INITIAL EVALUATION. Ductal carcinoma in situ 2 (DCIS) See Ductal Carcinoma In Situ Breast Cancer Non-Invasive Algorithm

Transcription

1 Pregnancy and Breast Cancer Page of 5 INITIAL EVALUATION Palpable mass greater than 2 weeks History and physical Bilateral mammogram with fetal shielding/ultrasound of breast and nodal basins Core biopsy Pathology Ductal carcinoma in situ 2 (DCIS) Invasive Breast Cancer See Ductal Carcinoma In Situ Breast Cancer n-invasive Algorithm See Clinical Stages on Pages 2-3 Special considerations: If metastatic disease at diagnosis, individualized treatment with multidisciplinary planning 2 Patients with DCIS should not receive chemotherapy.

2 Pregnancy and Breast Cancer Page 2 of 5 Clinical Stage I Surgical consult for primary treatment Maternal Fetal Medicine (MFM) consult to determine fetal age and delivery date Individualized care as clinically indicated including primary surgery, if preoperative chemotherapy is not indicated and if fetal age is less than 23 weeks gestation at MD Anderson If primary surgery is necessary between 23 weeks and delivery, surgery to be performed at outside facility with complete obstetrics unit available Pathology review: Is patient a candidate for postoperative systemic therapy? Individualized surveillance program based on clinical indication Medical Oncology consult Systemic therapy: anthracycline or taxane chemotherapy as medically appropriate once fetal age is greater than or equal to 2 weeks Response? MFM follow-up prior to each anthracycline chemotherapy or every 3-5 weeks prior to taxane chemotherapy Consider holding chemotherapy by week 35 of gestational age or 3 weeks prior to a planned delivery Individualized therapy based on multidisciplinary conference recommendation Surveillance Continue systemic therapy until completed After delivery of baby, individualized care as clinically indicated Special Considerations: Anthracycline therapy prior to taxane therapy is the preference

3 Pregnancy and Breast Cancer Page 3 of 5 CLINICAL STAGES Clinical Stage II or III or suspicion of distant metastatic disease Ultrasound of liver Chest x-ray with fetal shielding MRI thoracic and lumbar spine screening MFM consult to determine fetal age and delivery date Surgical consult and Medical Oncology consult to determine preferred sequencing of systemic and local therapy Surgical resection Systemic therapy Pathology review: Fetal age greater than or equal to 2 weeks? MFM follow-up prior to each anthracycline chemotherapy or prior to starting taxol and every 3-5 weeks during taxol therapy Consider holding chemotherapy by week 35 of gestational age or 3 weeks prior to a planned delivery Initiation of systemic therapy should be delayed until fetal age greater than or equal to 2 weeks Evaluate tumor response as clinically indicated, consider at least after 4 cycles of anthracycline- based chemotherapy or 2 cycles of taxanebased chemotherapy Tumor response? Continue systemic therapy until completed, followed by Surgical resection, followed by Radiation therapy (after delivery of baby) Individualized therapy based on multidisciplinary conference recommendation Surveillance Special Considerations: Anthracycline therapy prior to taxane therapy is the preference. 2 Following the delivery of baby: Additional chemotherapy, endocrine, biologic therapy and/or radiation as clinically indicated. Review labor, delivery, and neonatal records

4 Pregnancy and Breast Cancer Page 4 of 5 SUGGESTED READINGS Amant, F., Halaska, M. J., Fumagalli, M., Steffensen, K. D., Lok, C., Van Calsteren, K.,... & Maxwell, C. (204). Gynecologic cancers in pregnancy: guidelines of a second international consensus meeting. International Journal of Gynecological Cancer, 24(3), Amant, F., von Minckwitz, G., Han, S. N., Bontenbal, M., Ring, A. E., Giermek, J.,... & Neven, P. (203). Prognosis of women with primary breast cancer diagnosed during pregnancy: results from an international collaborative study. Journal of Clinical Oncology, 3(20), Azim, H. A., Santoro, L., Russell-Edu, W., Pentheroudakis, G., Pavlidis, N., & Peccatori, F. A. (202). Prognosis of pregnancy-associated breast cancer: a meta-analysis of 30 studies. Cancer Treatment Reviews, 38(7), Beadle, B. M., Woodward, W. A., Middleton, L. P., Tereffe, W., Strom, E. A., Litton, J. K.,... & Perkins, G. H. (2009). The impact of pregnancy on breast cancer outcomes in women 35 years. Cancer, 5(6), Berry DL, Theriault RL, Holmes FA, et al. (999). Multidisciplinary management of breast cancer during pregnancy: An 8 year experience using a standardized protocol. J Clin Oncol, 7: Fanale, M. A., Uyei, A. R., Theriault, R. L., Adam, K., & Thompson, R. A. (2005). Treatment of metastatic breast cancer with trastuzumab and vinorelbine during pregnancy. Clinical Breast Cancer, 6(4), Hahn, K. M., Johnson, P. H., Gordon, N., Kuerer, H., Middleton, L., Ramirez, M.,... & Theriault, R. L. (2006). Treatment of pregnant breast cancer patients and outcomes of children exposed to chemotherapy in utero. Cancer, 07(6), Kuerer, H. M., Gwyn, K., Ames, F. C., & Theriault, R. L. (2002). Conservative surgery and chemotherapy for breast carcinoma during pregnancy. Surgery, 3(), Keleher, A. J., Theriault, R. L., Gwyn, K. M., Hunt, K. K., Stelling, C. B., Singletary, S. E.,... & Kuerer, H. M. (2002). Multidisciplinary management of breast cancer concurrent with pregnancy. Journal of the American College of Surgeons, 94(), Litton, J. K., Warneke, C. L., Hahn, K. M., Palla, S. L., Kuerer, H. M., Perkins, G. H.,... & Theriault, R. L. (203). Case control study of women treated with chemotherapy for breast cancer during pregnancy as compared with nonpregnant patients with breast cancer. The Oncologist, 8(4), Middleton, L. P., Amin, M., Gwyn, K., Theriault, R., & Sahin, A. (2003). Breast carcinoma in pregnant women. Cancer, 98(5), Mir, O., Berveiller, P., Goffinet, F., Treluyer, J. -., Serreau, R., Goldwasser, F., & Rouzier, R. (200). Taxanes for breast cancer during pregnancy: A systematic review. Annals of Oncology, 2(2), doi:0.093/annonc/mdp57 Murthy, R. K., Theriault, R. L., Barnett, C. M., Hodge, S., Ramirez, M. M., Milbourne, A.,... & Litton, J. K. (204). Outcomes of children exposed in utero to chemotherapy for breast cancer. Breast Cancer Research, 6(6), 500. Theriault R, Hahn K. (2007). Management of Breast Cancer in Pregnancy. Curr Oncol Rep, 9:7-2. Yang, W. T., Dryden, M. J., Gwyn, K., Whitman, G. J., & Theriault, R. (2006). Imaging of Breast Cancer Diagnosed and Treated with Chemotherapy during Pregnancy. Radiology, 239(), Invited Articles Litton, J. K., & Theriault, R. L. (200). Breast cancer and pregnancy: current concepts in diagnosis and treatment. The Oncologist, 5(2), Theriault, R. L., & Litton, J. K. (203). Pregnancy during or after breast cancer diagnosis: What do we know and what do we need to know? Journal of Clinical Oncology, 3(20), doi:0.200/jco

5 Pregnancy and Breast Cancer Page 5 of 5 DEVELOPMENT CREDITS This practice algorithm is based on majority expert opinion of the Breast Medical Oncology Faculty at the University of Texas MD Anderson Cancer Center. It was developed using a multidisciplinary approach that included input from the following: Olga N. Fleckenstein Henry Mark Kuerer, MD Jennifer Litton, MD Vicente Valero, MD Gloria Trowbridge, BSN, RN Clinical Effectiveness Development Team