Preconception Issues And Care

Chemo Secrets From a Breast Cancer Survivor

Breast Cancer Survivors

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Women with a previous history of breast cancer who are contemplating pregnancy should seek advice from their obstetrician, breast surgeon and oncologist.

In general, a delay of two years post cancer treatment is recommended to allow for early recurrences to be detected5. Younger women (<33 years) may be advised to wait three years before conception as they have a higher relapse rate6. Women with a poor prognosis may be advised to avoid further pregnancy. Pregnancy does not appear to affect long-term survival after breast cancer, but women with a poor prognosis are likely to die while they have young children.

Women with previous early stage breast cancer and no signs of recurrence have a good prognosis following subsequent pregnancy, with survival rates of 71-90%7.

Pregnancy Issues

Breast cancer is the most common cancer found in pregnancy and accounts for 3% of all breast cancers7.

Pregnancy following breast cancer Pregnancy after treatment for breast cancer appears to be associated with a higher rate of miscarriage8. Current literature shows no evidence of previous use of cytotoxic drugs causing any adverse fetal or neonatal development effects. Consequently women with a previous history of breast cancer should be managed with regard to their pregnancy as normal.

Breast cancer diagnosed during pregnancy Prognosis may be worse in pregnancy, as diagnosis may be delayed due to normal physiological changes which may mask symptoms/signs of cancer. However, recent studies indicate that survival is unaffected in pregnant women with breast cancer when compared with non-pregnant women with the same stage of disease9,10.

Surgical intervention is the preferred management7, ideally performed after the first trimester in order to reduce risk of miscarriage. It may involve modified radical mastectomy or lumpectomy and axillary clearance with deferred reconstruction.

Chemotherapy is associated with risk of congenital malformations in the first trimester, with critical susceptible period of 5-10 weeks11. Chemotherapy in the second and third trimesters appears safe although there may be a link with IUGR and low birth weight12.

Radiotherapy and tamoxifen are usually avoided until post delivery. If radiotherapy is indicated, early delivery may be required to commence treatment as soon as possible12.

Medical Management and Care

For women with a previous history of breast cancer

• Manage pregnancy as normal

• Encourage surveillance for any signs of recurrence

For women diagnosed in pregnancy

• Diagnosis is as for non-pregnancy, but mammography is less useful due to pregnancy-induced changes in breast tissue13

• Discussion regarding continuation of pregnancy if diagnosis in first trimester14

• Whilst termination of pregnancy has not been shown to have any beneficial effect on outcomes it may require discussion if the treatment required is limited by continued pregnancy and/or for emotional and social reasons15

• Planned multi-disciplinary care including obstetricians, midwives, oncologists, anaesthetists, paediatricians and Macmillan nurses

• Negotiation about optimum time and mode of delivery depending upon need for treatment in pregnancy

• Steroid administration for fetal lung maturation and liaising with paediatricians if premature delivery is required

Midwifery Management and Care

For women with a previous history of breast cancer

• Encourage careful breast self-examination

• Educate about the normal physiological breast changes in pregnancy, but be alert to how these may mask symptoms

• Immediate referral to specialist obstetrician and oncology team if suspicious about these changes

• Provide psychological and emotional support for pregnant women who have experienced breast cancer; fears regarding future recurrence and issues around mortality may be heightened during pregnancy and impending parenthood

For women diagnosed in pregnancy

• Importance of maternal wishes are paramount; act as advocate and provide information for the woman and her family

• Extra vigilance regarding fetal growth, regular antenatal appointments and 'small for dates' recordings

• Advise about fetal movements

• Direct women to appropriate support networks (see Essential Reading)

• Basic nursing care may be required, especially if the mother has had recent surgery and requires wound care

• 'Parent-craft' education may have to be given on a one-to-one basis and include advice on lifting the baby if arm movement is impaired

Labour Issues

If mastectomy is required in the third trimester this could be combined with cae-sarean section, depending on gestation. The placenta requires histology, and the pathologist should examine for evidence of placental metastases.

Postpartum Issues

• Breast-feeding is contraindicated during chemotherapy and radiotherapy7

• Lactation might fail to occur as a consequence of radiation therapy

Medical Management and Care

• Delivery may be expedited early to allow radiotherapy or tamoxifen treatment to begin

Midwifery Management and Care

• Prepare for a potential pre-term delivery with a mother who might be physically 'run down' and anxious, and possibly post-operative

• Care with positioning of CTG monitor belts, and when assisting the mother to move; she may have weak arm movement if post surgery

• Send placenta to histology with detailed clinical history

Medical Management and Care

• Discuss contraception: the COCP is contraindicated after a diagnosis of breast cancer

Midwifery Management and Care

• Teach partner parenting skills

• Psychological and physical support; advise how to hold the baby

• Encourage breast-feeding if possible, or advise on formula feeds

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