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Breast cancer chemotherapy during pregnancy does not preclude healthy birth
High-risk women may no longer be required to terminate their pregnancies during chemotherapy.
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Pregnant women with breast cancer can receive chemotherapy and still deliver healthy children, breast cancer specialists reported this summer.
Richard L. Theriault, DO, FACP, presented his encouraging data at an American Medical Association press briefing. “Treating these women can result in happy mothers and a healthy baby,” he said. Theriault is a professor of medicine in the department of breast medical oncology at the University of Texas MD Anderson Cancer Center, Houston.
Although Theriault’s study enrolled a small cohort of 57 pregnant women, American Cancer Society president Carolyn D. Runowicz, MD, predicted the study would change the way all pregnant women with breast cancer are treated.
“In the past, many women were encouraged to terminate their pregnancy or avoid any sort of cancer treatment until after the delivery of their child,” Runowicz said. “It became an ethical dilemma — should there be a focus on the health of the unborn child or the health of the mother?”
Questions and concerns
About one in 3,000 women in the United States will be diagnosed with cancer while pregnant, according to the NCI. Experts expect this incidence to increase as women delay child bearing, according to Theriault. There are many obstacles to caring for these high-risk patients. Few physicians have experience treating these women, so there is a need for a standardized ethical framework. Centers should incorporate a team-oriented approach to treatment. The decision-making team should include the patient, obstetrician, oncologist, a nurse and other specialists, Theriault said.
Attitudes toward cancer and pregnancy can serve as obstacles to quality care, as well. Some physicians might feel as though they cannot treat the cancer because of the pregnancy, Theriault said. Pregnant women also need to be counseled. Many worry that the cancer could spread to the unborn child or that pregnancy hormones could stimulate cancer growth. Additional concerns include fetal death, intrauterine growth retardation, premature delivery, fetal malformations and potential long-term adverse events.
Some physicians recommend that women with breast cancer terminate the pregnancy, however those who have had trouble becoming pregnant in the first place will not accept this solution. Other women opt for surgical resection with fetal monitoring which is safe during all trimesters, according to Theriault. Surgeons will try to conserve as much of the breast as possible and will not administer radiotherapy until after delivery.
Radiotherapy generally is not recommended for pregnant women at any time. However the fetus is at increased risk as it matures because it moves closer to the site of breast radiation.
There are limited data regarding the administration and success of chemotherapy during pregnancy, as pregnant women are not typically enrolled in clinical trials. Data are exceptionally sparse for newer targeted therapies as well, according to Theriault.
Chemotherapy while pregnant
Theriault explained how he and his colleagues at MD Anderson typically treat pregnant women with breast cancer.
First, they evaluate the patient and her family’s values, beliefs and needs. All women undergo a physical examination, mammography and a breast ultrasound. Next, clinicians check for metastases. If the cancer has spread to a site proximal to the uterus, the patient and health care team discuss further treatment options.
Clinicians perform standard tumor-node-metastases staging. Most patients under Theriault’s care present with stage-II and -III disease and most are hormone-receptor–negative and negative for the HER2/neu oncogene.
It is important that all women receive standard prenatal care. Clinicians should perform a baseline fetal ultrasound prior to treatment and evaluate fetal growth before each cycle of chemotherapy. The timing of delivery is important, as well, Theriault said. Patients should deliver three weeks after they complete their last course of chemotherapy. If the fetus is mature, an obstetrician will induce labor or perform a Cesarean delivery.
At MD Anderson, Theriault and colleagues examined 57 pregnant women with invasive breast cancer and a mean age of 33.5 years. After the first trimester, women received standard IV 5-fluorouracil, adriamycin and cyclophosphamide (FAC) every 21 to 28 days: 500 mg/m2 of 5-fluorouracil on days one and four, 50 mg/m2 of adriamycin and 500 mg/m2 of cyclophosphamide on day one.
Healthy deliveries
The mean age at the time of delivery was 37 weeks. About half of live births in the Unites States are of a 37- to 39-week gestational age, Theriault said. The average baby weighed in at 6.4 lbs, whereas most babies born 37 to 39 weeks are between 6.8 lbs and 8.7 lbs.
In the current cohort, 57% of babies were delivered vaginally and 39% were delivered Cesarean. Four percent of women are still pregnant, Theriault said.
Of the women who delivered, 63% reported no neonatal complications. Twenty-eight percent of newborns had breathing difficulties.
Three congenital anomalies occurred. One child had Down’s syndrome and another child had a clubbed foot; both anomalies were not attributable to chemotherapy, Theriault said. The third child presented with congenital bilateral ureteral reflux, which could have been due to the chemotherapy, but researchers were not sure. Between 3% and 4% of newborns have an abnormality in the kidneys or ureters.
The longest follow-up has been 15 years, according to the study. Overall, 97% of parents or guardians have reported normal development compared with siblings or other children. Five percent have reported attention deficit disorder in their children.
The mothers have experienced positive outcomes as well, with 75% alive without recurrence. There was one death due to a pulmonary embolism following a Caesarean delivery. In general, there was no apparent difference in treatment outcomes compared with nonpregnant patients with similar disease characteristics.
Theriault’s initial interest in breast cancer during pregnancy arose when his clinic began seeing pregnant women who did not want to terminate their pregnancy because of their breast cancer.
“They wanted information on what we knew about treatment, and how we can help them without jeopardizing their pregnancy,” he said. “We formalized a program in the hope of tracking these women and collecting as much data as possible to make the decision-making process easier,” Theriault said.