Source: Jpn J Clin Hematol  |  Posted 5 years ago

By Ed Susman

HOLLYWOOD, FL -- March 13, 2006 -- The first guidelines for treatment of pregnant women with breast cancer were released here at the 11[^]th[] annual conference of the National Comprehensive Cancer Network (NCCN).

The guidelines, used as treatment algorithms by the 19 member institutions of the NCCN and hundreds of other institutions nationally and internationally, define options for treatment by each trimester of pregnancy.

"We were reluctant to attempt these guidelines because we thought they would be difficult to produce, but once we started it turned out to be fairly straightforward," said Robert Carlson, MD, Professor of Medicine, Stanford University, California, United States.

"If a woman is in her first trimester, the guidelines suggest the doctor and the patient discuss possible termination of the pregnancy," said Dr. Carlson. "If she decided to continue the pregnancy, then the guidelines come into place."

The guideline considers only woman with early stage breast cancer. If the woman is in her first trimester and decides to continue the pregnancy, she is then scheduled for surgery -- a mastectomy with axillary lymph nodes dissection. Following surgery, the guideline suggests beginning adjuvant chemotherapy in the second trimester. Radiation and endocrine therapy would begin post-partum.

"Considerations and selection of optimal local therapy and systemic therapy are similar to that recommended in non-pregnancy associated breast cancer," noted Richard Theriault, DO, Professor of Breast Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, United States. Dr. Theriault wrote the guidelines before it was reviewed by the entire breast cancer guideline committee.

Dr. Carlson said that there is no clinical trial evidence for the basis of the guideline. Lacking this so-called "Level 1" evidence, the breast cancer guideline writing committee, which he heads, assigned Level 2A evidence to the treatment suggestions.

"That means that while we have no hard evidence for these recommendations, there was unanimous agreement among those of us on the committee that the guideline represents the best treatment for these women," Dr. Carlson said.

If cancer is discovered during the second trimester or in the early part of the third trimester, women are offered either a mastectomy or breast conserving therapy -- a lumpectomy -- along with lymph node dissection, or the woman can begin chemotherapy as well as undergoing surgery.

If the woman selects breast conserving therapy, radiation is delayed until after delivery of the child, as is endocrine therapy.

Women in the third trimester are offered mastectomy or lumpectomy along with lymph node dissection. Again, radiation and endocrine therapy would follow post-partum.

"Chemotherapy should not be administered during the first trimester of pregnancy and radiation therapy should not be administered during any time of the pregnancy," Dr. Theriault wrote in preparing the guidelines.

He said that after the child is delivered, standard chemotherapy can be offered. During pregnancy, patients have usually been treated with combinations of doxorubicin, cyclophosphamide and 5-fluorouracil. The guideline does not indicate dosing of those drugs during pregnancy.

[Presentation title: Update: Breast Cancer Guidelines]