Dr Love: Debu, how do you advise patients about pregnancy?

Dr Tripathy: The two large retrospective studies available do not suggest that pregnancy itself increases the risk of relapse (Table 1). These studies, looking at outcomes of patients who became pregnant compared to age and stage-matched patients who did not, did not show an excess risk of relapse, even in patients with ER-positive tumors. However, as clinicians, we know that some patients with ER-positive tumors associated with pregnancy seem to have more rapid tumor growth. I honestly don’t understand why that has not been seen in these studies. It is possible that these retrospective studies simply don’t have the sensitivity to detect what might be a true risk. Therefore, we cannot say absolutely that pregnancy is safe, but these studies have not shown any harm.

I advise patients to make decisions about pregnancy based on their individual risk of relapse. I agree with Andy that, in high-risk patients, most of the risk of relapse occurs within the first few years. The “watch-and-wait” approach allows them to put some of that risk behind them before making such an important decision.

However, different women make different decisions. For example, a woman with a support structure in place that would allow a child to be raised with security even without a mother might be more inclined to go forward with pregnancy sooner. The discussion needs to be individualized.

Dr Harth: I think the “watch-and-wait” approach is reasonable. Many of my young breast cancer patients have the option of waiting four or five years before becoming pregnant. I tell patients that we don’t know the absolute answer, and I generally recommend, if at all possible, that they wait at least five years before becoming pregnant.

Dr Tripathy: This makes sense, because they put some of the risk of relapse behind them in the first few years. However, there is sometimes the competing problem that these women are likely to go through menopause early — even in their 30s— because they received chemotherapy. With each successive year, their chances of fertility decrease. It’s a difficult decision.

Dr Love: One of the lessons here is that medical oncologists have a really, really difficult job. I applaud Dr Harth for presenting this case in which there is no good answer. That’s the nature of metastatic breast cancer and that’s what is involved in the practice of medical oncology. Dr Harth, what was it like for you to take care of this woman?

Dr Harth: I’ve been in practice for over 15 years now, and this was probably one of the most difficult cases with which I’ve dealt. Treating metastatic disease in young women is always hard, especially in cases like this. We become involved with our patients’ social issues, and it makes our jobs even tougher.

Dr Love: Taking care of women with metastatic breast cancer has an impact on the oncologist. What are some of the ways oncologists cope with these tragedies?

Dr Cohen: It helps to have a strong support system within your practice. We have very good social workers who run patient support groups targeted to the needs of different patients. We have an on-site psychiatrist who practices only oncologic psychiatry. These people help a tremendous amount.

Dr Brooks: Medical oncologists are a modern day manifestation of the myth of Prometheus — chained to the rock, and each day the big predatory bird eats away part of him, and overnight he regrows, just to be partially consumed again the next day. There are many things that we as oncologists can do to renew ourselves, including seeking support among colleagues. One thing I’ve also learned from your Breast Cancer Update audio series is that no one knows how to take care of some of these very challenging cases — and in a way, that is comforting. Even though it may be painful from time to time, there is comfort in the fact that we are all in the same large boat.

Dr Tripathy: When I’m dealing with a patient who is likely to die, I remind myself of the many beneficial things I do for them and their family. I explain what we can and can’t do and make them aware that we need to harness the capacity we all have to experience tremendous loss. I give examples of patients who have told me how comfortable they feel with their situation. They are at peace with themselves, even though they know they are dying. I share my amazement at this attitude with my patients and their families, and I confess that I myself, hope that I could reach this point if I were in their position.

Sharing these experiences with our patients and their families is rewarding. We have all had family members tell us, after patients die, how important we were, how much they appreciated our work and how they’ll never forget what we did. This is the reward that keeps us going. If this is our goal, death is not always a failure. Not helping the family to feel security is a failure. In this regard, there can always be some success no matter how terrible the outcome.

Dr Love: Debu, what advice would you give to a medical oncology fellow starting to deal with these difficult issues?

Dr Tripathy: As Dr Brooks pointed out, we need the support of our colleagues. We are all under a lot of stress, and we’ve all seen colleagues burn out. We’re faced with death all the time, but we have a lot of the same stresses that other people have. Oncologists are not alone in difficult jobs. Accountants and lawyers also burn out. We all have the ability to handle these kinds of stresses if we allow ourselves the support that we need.

We must understand the limits of what we can and can’t do. We must be proud of educating and advancing ourselves. We must hope that we can help our patients to the greatest extent possible, and we must take care of ourselves.

Case follow-up:
•	Patient received trastuzumab and vinorelbine with initial response, then progression
•	Pain increased requiring oral narcotics; pleural effusion recurred, leading to respiratory arrest (necessitating mechanical ventilation) and fetal demise
•	Continued treatment while on ventilator; was taken off ventilator and did reasonably well for several months until imaging studies revealed liver and bone metastases

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