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Adjuvant chemotherapy for pregnant breast cancer patients.

Adjuvant chemotherapy for pregnant breast cancer patients. Case report:. (PABC; pregnancy-associated breast cancer). 2014/10/13 張嘉顯. Patient information: (2014/10/10 OPD). visited Jen-Ai Hospital for help. Core biopsy revealed an invasive ductal carcinoma. Modified radical mastectomy.

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Adjuvant chemotherapy for pregnant breast cancer patients.

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  1. Adjuvant chemotherapy for pregnant breast cancer patients. Case report: (PABC; pregnancy-associated breast cancer). 2014/10/13 張嘉顯

  2. Patient information: (2014/10/10 OPD)

  3. visited Jen-Ai Hospital for help. • Core biopsy revealed an invasive ductal carcinoma. • Modified radical mastectomy. • Set port-A. • Pregnancy termination. (pregnacy for12 wks) History of present illness: Found bloody nipple discharge on right breast. And also found she had pregnacy. • Visited KFSYCC. • Examination revealed • infiltration ductal carcinoma • (NG3,ER0,PR0, HER +++) • KSFYSCC OPD follow-up. • Arrange the further treatment. Early 2014/8 2014/9/9 2014/8/25 2014/9/17

  4. Patient information: (2014/10/10 OPD)

  5. Breast cancer. • Gastric ulcer. Problem list If the patient were not performed pregnant termination… How to perform the further treatment for the pregnant breast cancer patient?

  6. Cure or palliative ? • To Cure the patient is our goal. Goal

  7. Definition of PABC : • Breast cancer is diagnosed •  during pregnancy. • in the first postpartumyear. •  any time during lactation. • The most common malignancy occuring pregnancy. • Incidence rate: 1 in 3000 pregnancise. PABC EUROPEAN JOURNAL OF CANCER 46(2020)3158-3168. UPTODATE: Gestitional breast cancer: Treatment. 2014.

  8. Compared PABC with non-PABC: •  For PABC in the first postpartum: • Death risk : PABC > non-PABC. •  For PABC during pregnancy: • OS, DFS : PABC ≒ non-PABC. PABC vs non-PABC UPTODATE: Gestitional breast cancer: Treatment. 2014.

  9. Treatments for PABC are generally the same as non-PABC, but they need some modification to protect fetus. Treatment principles for PABC:

  10. Local treatment. • Systemic treatment: • Timing. • Regimen. • Supportive treatment. Treatment principles for PABC:

  11. Local treatment: • The local treatment available for the non-PABC patients can also be performed for the PABC patients, • ex. Mastectomy. • Exception: Radiation therapy. Local treatment for PABC:

  12. Timing of treatment about delay chemotherapy: Systemic treatment for PABC: • Decrease disease-free survival. • Increase risk of metastasis. • (↑5-10 %Delay chemotherapy for 3-6 months).

  13. Timing of treatment about trimester Systemic treatment for PABC: General concepts about pregnancy: - Gestational age: last normal menstrual period (LMP) to the time during pregnancy. - Full term pregnancy: Gestational age ≥ 37 wks. - Pregnancy consists of 3 trimesters:  The 1st trimester: 0-13 wks.  The 2nd trimester: 14-26 wks.  The 3rd trimester: 27-40 wks.

  14. Timing of treatment (head?) : Systemic treatment for PABC: The 1st trimester: 0-13 wks. The 2nd trimester: 14-26 wks. The 3rd trimester: 27-40 wks. The important organogenesis period. Less vulnerable to chemotherapy. More vulnerable to chemotherapy. It is recommended to begin chemotherapy after the 13th wks. EUROPEAN JOURNAL OF CANCER 46(2020)3158-3168.

  15. Timing of treatment (tail?): Systemic treatment for PABC: To allow the bone marrow to recover and to minimise the risk of maternal and fetal neutropenia  Delivery should be planned 3 wks after the last chemotherapy. (Stop chemotherapy about at the 35th wk). EUROPEAN JOURNAL OF CANCER 46(2020)3158-3168.

  16. For PABC patient, delayed chemotherapy can: • Decrease disease-free survival. • Increase risk of metastasis. (↑5-10 %). • The suitable period for taking chemotherapy: • The 2nd and 3rd trimester. (about 14-35 wk). • To reduce the interference for oganogenesis. • To reduce the risk of myelosuppression at birth. Summary : Timing for treatment: EUROPEAN JOURNAL OF CANCER 46(2020)3158-3168.

  17. Amost common regimens in PABC now. • (with more sufficient data compared with other regimens). • A prospective single-arm study (Cancer 2006; 107:1219). • (other smaller retrospective anthracycline-based chemotherapy have similar findings.): FAC/ACregimen for PABC:

  18. Safety outcome (Cancer 2006; 107:1219): • No stillbirth/miscarriage. FAC/ACregimen for PABC: • The majority of the children didn’t have any significant neonatal complications and seem to be similar to reported norms for the general population. • Caution: no long-term safety data.(Follow-up:2-152 months)

  19. Compared with FAC/AC, the taxane regimens are less sufficient data. • 2010 systematic review of 40 case reports of taxane administration during pregnancy: (Annals of Oncology 21: 425-433, 2010) • 38 patients: taking taxane Tx in 2nd & 3rd trimester. • 27 patients were PABC patient. • Result: • - No spontaneous abortion/intrauterine death reported. • - 2 case exposed to paclitaxel were prematurity (30 & 32 wks, respectively) and developed acute respiratory distress. • - 1 case with pyloric stenosis (the mother took multiagent chemotherapy). • Caution: no long-term safety data. Taxaneregimen for PABC:

  20. How about other regimens? UPTODATE: Gestitional breast cancer: Treatment. 2014.

  21. The 2nd and 3rd trimester is much safer period for taking chemotherapy. • FAC/AC regimen is the first choice for PABC currently due to its more sufficient data. • Taxane regimen may be the choice for PABC patients. • Short-term toxicity data seem to be safe. • (Prematurity and neutropenia need more caution.) • Lorm-term toxicity data are insufficient and need further follow-up. • Trathuzumab, lapatinib, MTX, tamixifen are not recommeded for the pregnant patients. Summary : regimen for PABC:

  22. The following items can be administrated for pregnant patient? • Antiemetics. • G-CSF. • Steroid. Supportive treatment for PABC:

  23. Antiemetics: Antiemetics for PABC: • [1]. Int J Gynecol Cancer 2009; 19: S1-S12. • [2]. EUROPEAN JOURNAL OF CANCER 46(2020)3158-3168. • [3]. UPTODATE: Drug information.

  24. G-CSFPregnancy risk factor: B[3] Antiemetics for PABC: • [1]. Int J Gynecol Cancer 2009; 19: S1-S12. • [2]. EUROPEAN JOURNAL OF CANCER 46(2020)3158-3168. • [3]. UPTODATE: Drug information.

  25. Steroid for PABC: [1]. Int J Gynecol Cancer 2009; 19: S1-S12. [2]. EUROPEAN JOURNAL OF CANCER 46(2020)3158-3168.

  26. Breast cancer: T1N1M0, ER(-), PR(-), HER2(+). • The patient performed MRM on 9/17, and the gestational age is 12 wks). Back to the patient (9/17):

  27. Timing consideration: • -We can perform the further chemotherapy after 2 wks and should be stopped at GA 35 wks. • For the patient: 2014/10/1~ 2015/2/25 is the pregnant period can be performed chemotherapy. • The FAC/AC may be suitable chemotherapy for the patient. • Although the patient is HER-2 positive, Trastuzumab can not be taken during pregnacy. Back to the patient (9/17):

  28. Back to the patient (9/17): • Because the high emetic risk for FAC regimen, • the combinaiton of N1K antagonist, 5-HT3 antagonist and steroid should be taken. • Hydrocortisone, methylprednisolone, prednisolone are preferred steroid. • G-CSF can be taken during the pregnancy. • If the neonate is neutropenia after birth, G-CSF can be taken to prevent infection for the baby. • No breast feeding during chemotherapy.

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