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Track 2

DR LOVE: John, would you use chemotherapy for this woman in an attempt to shrink the tumor so she could undergo lumpectomy?

PROF CROWN: You can consider arguments for mastectomy in her case. You’d have to go through all the issues with her carefully, regarding whether she would receive induction chemotherapy or undergo mastectomy. You might also obtain a second surgical opinion about whether breast-conserving surgery is feasible right now.

In general, life is a little easier when you’re pregnant if you undergo surgery first and delay the chemotherapy until a little later. My default position here would always be trying to perform surgery first and use chemotherapy later.

DR LOVE: Julie, is it safe for the fetus if the mother receives chemotherapy in this situation?

DR GRALOW: I believe reasonable data exist for doxorubicin/cyclophosphamide, not in any studies but with long-term follow-up of both the patients and babies. I don’t believe we have the data to use growth factors. I’d probably avoid using a taxane, although they have been accidentally used in some reported cases.

We know she will receive chemotherapy. She has node-positive, triple-negative disease. If we think we might have a chance of converting her surgery to breast conservation, then I believe it’s reasonable to start with chemotherapy.

DR LOVE: Kevin, chemotherapy in this situation is basically for cosmesis — it’s not a life-threatening situation. Do we know for sure if chemotherapy is safe to offer here?

DR FOX: At ASCO 2005, the group from MD Anderson presented the largest collection of women who had received chemotherapy for early-stage breast cancer while pregnant (Johnson 2005). They have subsequently published their data. About 55 women received FAC, because that was the regimen in use at the time (Hahn 2006; [2.1]).

They didn’t examine the patient outcomes but rather the outcomes of the children who were born. They followed some of them out to seven years. No signals indicated that the children suffered from the chemotherapy or that peripartum mortality or morbidity for the women was increased. The collective opinion was that FAC was safe (Hahn 2006; [2.1]).

So administering doxorubicin/cyclophosphamide to this woman to achieve the surgical goal that she wishes for, I believe, is also safe. I believe it will do her no harm, and it will do her child, in all likelihood, no harm either.

This comes back to John’s point earlier. For a young woman with triple-negative breast cancer and a genetic mutation, I would have counseled this patient to take into consideration her long-term concerns and it might have changed her view of breast conservation, although it might not have.

DR HUDIS: The advantage of operating on her and then using conventional postoperative therapy is that she can be induced to deliver when she is closer to 36 weeks. Then she can receive dose-dense therapy or a third-generation regimen, if you prefer one of the others, and you’re offering her a state-of-the-art outcome.

DR LOVE: What happened with this patient?

DR ALLISON: She has received three cycles of FAC. She’s going to receive her fourth one next week, and then she’ll be induced at week 37.

After the first cycle, the tumor shrank from four centimeters to two centimeters. Three weeks ago, only thickening was found — it melted away.