There are no previous reports of standardized breast cancer therapy for pregnant women. This report reviews experience gained over the past 8 years, when a group of breast surgeons and medical and radiation oncologists reached consensus management decisions. Twenty-four pregnant women with primary or, in two cases, recurrent breast cancer were treated under the protocol and received outpatient chemotherapy, surgery alone, or both surgery and radiotherapy as clinically indicated.
Breast masses were imaged by ultrasound and/or mammography with abdominal shielding. A palpable mass was biopsied by the core-needle or fine-needle aspiration technique under local anesthesia. If nondiagnostic or if an impalpable mass was located, an excisional biopsy was done under local anesthesia. Two chest views were obtained, also with shielding, and renal and liver function were evaluated. Women were offered genetic counseling, focusing on possible fetal effects of chemotherapy. Most resectable tumors were managed by modified radical mastectomy with axillary node dissection, regardless of gestational age. Patients with stage III tumors received up to four cycles of neoadjuvant chemotherapy before locoregional treatment. Chemotherapy was used to treat stage I lesions. Cycles of fluorouracil, doxorubicin, and cyclophosphamide were given at 3- to 4-week intervals on an outpatient basis after the first trimester. Fetal growth was monitored ultrasonically every 3 to 4 weeks or as clinically indicated. Nonstress testing was done starting at 28 weeks' gestation.
Eighteen of the 22 primary cancers were removed by modified radical mastectomy without complications, during pregnancy in 14 women and after delivery and chemotherapy in 4 others. Four patients required first-trimester surgery, but none of them aborted. No operation was associated with fetal compromise or preterm labor. Two patients had antepartum segmental mastectomy with axillary node dissection, followed by chemotherapy and postpartum radiotherapy. Three patients with stage I disease were not operated on, and one patient refused surgery. Two thirds of patients were node-positive at the time of surgery. Chemotherapy was tolerated in full dosage without major problems. In no case did leukopenia require intervention. There were no unexpected antepartum maternal problems. The median gestational age at delivery was 38 weeks, and no newborn infant had any unusual complication. All the infants had a 5-minute Apgar score of 9 or above. There were no congenital malformations. The three women who presented with a recurrent or stage I tumor died of disease within 2 years. Six of nine patients with stage II disease were alive and well after a median of 44 months. Nine of 11 stage II patients were alive after a median follow-up of 3 years, 8 of them without disease. A single patient with stage I disease had a recurrence. Pregnancy in a woman diagnosed as having invasive breast cancer may confidently be continued provided that a comprehensive multidisciplinary treatment approach is available.