pregnancy & breast cancer Flashcards
(30 cards)
wishing to breastfeed following treatment for
breast cancer?
- reassured: breastfeed from unaffected breast.
- no evidence increase recurrence risk , if completed treatment.
- better survival than bottlefeeding.
- Breast-conserving surgery: not inhibit lactation
- Radiotherapy fibrosis: lactation unlikely.
- Chemotherapy HX: not affects safety of breastfeeding.
- Midwifery support: helps encouraged
What is effect of adjuvant chemotherapy for breast cancer on fertility?
Chemotherapy-induced gonadotoxicity
- permanent amenorrhoea, complete loss of germ cells.
- transient amenorrhoea,
- menstrual irregularity and
- subfertility.
amenorrhea by age in adjuvant chemotherapy for breast cancer on fertility?
Amenorrhoea
- 20–70% of premenopausal women
- < 5% under 30 years
- 50% in 36–40 years.
effect of specific agents of adjuvant chemotherapy for breast cancer on fertility?
- Alkylating agents( cyclophosphamide) well-recognised gonadotoxicity,
- classic CMF regimen (cyclophosphamide, methotrexate, 5-fluorouracil) higher incidence of amenorrhoea than anthracycline (AN-thruh-SY-klin)-based regimens such as FEC (5-fluorouracil, epirubicin, cyclophosphamide).
- newer taxanes appear to be less gonadotoxic.
degree of effect of adjuvant chemotherapy for breast cancer on fertility?
degree dependent on
- specific agents used,
- cumulative dose administered and
- woman’s age.
What is effect of adjuvant hormonal therapy on fertility?
- not in themselves cause long-term effects on fertility.
- Tamoxifen (SERM) often menstrual irregularity and risk endometrial pathology; teratogenic, ‘washout period’ of 2–3 months
- GnRH analogues amenorrhoea and menopausal symptoms but reversible.
- Trastuzumab (monoclonal antibody binds selectively HER2 protein expressed by some breast cancers); no evidence impairs fertility, but pregnancy not advised during treatment.
What advice should be given to woman about postponement of pregnancy before embarking on further pregnancy?
- generally advised to postpone pregnancy for at least 2 years after treatment
- continue tamoxifen for 5 years.
- age and delay, poor ovarian function (chemotherapy) likely infertility.
- Women in 30s desiring pregnancy may discontinue after 2–3 years.Resuming not studied,but reasonable)
Can fertility be preserved before treatment?
- only minority of women
- scarcely any data on long-term outcome.
- routine co-treatment with GnRH analogues during chemotherapy
for ovarian protection in estrogen receptor positive breast cancer.
- therapeutic use in hormone-sensitive breast cancer, as ovarian suppression (low-estrogen state)
- insufficient level 1 data: protects oocyte pool from depletion?? uncertainties can be discussed with woman
- concerns: It may lessen tumour response to chemotherapy ER positive breast cancer.
Ovarian stimulation for egg or embryo freezing requires careful discussion in light of unknown long-term risks.
Embryo cryopreservation: success rates at least 20% per cycle, possible lower oocytes from cancer.
- may postpone chemotherapy,
- small risk of ovarian hyperstimulation.
- concern that elevated estrogen may deleterious in estrogen receptor positive breast cancer;
- Oocyte storage(without partner) Freeze–thaw techniques. only few hundred births worldwide.
- no long-term safety data.
- Harvesting immature oocytes without hormone-stimulated cycle
- not established technique.
what Modified stimulation regimes for women with estrogen-sensitive breast cancer.
- concern that elevated estrogen may deleterious in estrogen receptor positive breast cancer;
so stimulation with tamoxifen or letrozole, with gonadotrophins,
ovarian tissue storage (Cryopreservation of ovarian cortex or the whole ovary) for fertility preservation in women with breast cancer;
- insufficient data
- offered only context of research trial.
- experimental technique and
- tissue storage regulations UK restricted its use.
- small number of pregnancies after regrafting.
- disadvantage: need for surgical procedure
- advantage: not delay chemotherapy.
breast oncology service referral to fertility specialist
- How to avoid delay
- NICE recommendation
- Prompt referral essential; preparations for egg retrieval can during breast cancer diagnostic procedures and surgery to minimize delays in starting systemic treatment.
- NICE recommended universal access to sperm, egg and embryo storage for people undergoing gonadotoxic treatment.
breast oncology service referral to fertility specialist
- organisational aspects
NHS funding not in all areas, & dependent upon
- primary care trust &
- local infertility budget.
- service provision should not be dependent on local in vitro fertilistion funding arrangements.
- Oncology referral pathway (in cancer network) not necessarily coincide with local IVF arrangements.
- joint Royal Colleges working party recommended that adequate funding should be made available.
- Every breast oncology service should have designated pathway for prompt referral to fertility specialist able to offer assisted conception;
Assisted reproduction after treatment for breast cancer
Fertility treatment post-chemotherapy:limited (loss of ovarian reserve.)
- stimulation in IVF: theoretical risk hyperestrogenic state, but shorter duration than pregnancy.
- chemotherapy-induced menopause: donated eggs;
short-term HRT, theoretical risk. - Replacement of cryopreserved embryos: medicated HRT cycle.
- pregnancy contraindicated: surrogacy
who should care pregnancy following treatment for breast cancer?
- jointly by obstetrician, oncologist and breast surgeon.
- supervision of pregnancy be consultant led,but midwifery involvement will help to normalise care.
cardiac evaluation in pregnancy following treatment for breast cancer
- who at risk
- how frequent
- what functions
At risk
- received adjuvant chemotherapy with anthracyclines (doxorubicin, epirubicin), which can cause cumulative dose-dependent left ventricular dysfunction and,rarely, cardiomyopathy.
- cardiac complications during pregnancy are rare in cancer survivors,
- echocardiography: detect cardiomyopathy by resting left ventricular ejection fraction or echocardiographic fractional shortening.
complications in pregnancy following treatment for breast cancer?
A slightly increased risk of
- delivery complications and
- caesarean section
- Metastatic relapse may be harder to detect and
- common complaints in pregnancy such as backache can be difficult to assess.
what effect in breast treated by surgery/radiotherapy during pregnancy
- may not undergo hormonal change and
- woman may require temporary prosthesis.
If breast imaging is needed, in pregnancy following treatment for breast cancer
ultrasound (performed through breast multidisciplinary team) is preferred.
Women planning a pregnancy after treatment for breast cancer should consult their clinical oncologist, breast surgeon and obstetrician.
why to stop temoxifen before and how much before
- tamoxifen:stop 3 months before trying to conceive because of
1- long half-life of the drug,
2- any routine imaging before pregnancy to avoid suring.
Women planning a pregnancy after treatment for breast cancer should consult their clinical oncologist, breast surgeon and obstetrician.
Why - metastatic disease:advise against pregnancy
1- life expectancy is limited and
2 treatment of metastatic disease compromised.
Impact of pregnancy on risk of recurrence
estrogen receptor positive and endocrine responsive, in past advised against pregnancy because of concerns it worsen prognosis. but evidence show either no impact on survival or improved survival.
- Reassure: long-term survival after breast cancer is not adversely affected by pregnancy.
- prognosis good with subsequent pregnancy after early-stage breast cancer: survival 92% at 5 years & 86% at 10 years.
‘healthy mother effect’: healthy more likely to conceive
postulate an actual protective effect of pregnancy.
The impact of pregnancy on breast cancer survival benefit modified by tumour characteristics and BRCA
- does not seem to be for (e.g. size, hormone receptor status),
- but insufficient data to draw firm conclusions.
- BRCA gene mutations,the risks associated with subsequent pregnancy are uncertain.
