Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Pregnancy after breast cancer - at what risk to their offspring ?
- Corinne Jones (28 January 2007)
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Uncertainty about teratogenic potential of tamoxifen to be shared with the patient
- Ludger Barthelmes, Eifion Vaughan Williams, Christopher A Gateley (1 February 2007)
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Breastfeeding after Breast Cancer
- Andrew D Lynk (12 February 2007)
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Corinne Jones, Consultant Breast and Thyroid Surgeon Pilgrim Hospital, Sibsey Road, Boston, Lincolnshire. PE21 9QS
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Banks and Reeves (1) have provided a good summary of the Western Australian study by Ives et al (2) indicating that after breast cancer 'the effect of pregnancy on survival and the best time to conceive are uncertain'. Ives et al have concluded that their study 'does not support the current medical advice given to premenopausal women with a diagnosis of breast cancer to wait two years before attempting to conceive'. Both groups of authors have concentrated on the issue of conception and childbirth after breast cancer treatment as it pertains to the mother. This is a very delicate issue at the time of breast cancer diagnosis and treatment, and as so succinctly described, management needs to be tailored to the individual. It is also important to include in these discussions the risk of breast cancer to their offspring. This risk is very real, as are the concerns of their offspring. Currently in the UK women are considered at moderate risk of developing breast cancer if they have one first degree relative treated for breast cancer at less than 40 years. All clinicians who deal with such women have a greater sense of concern for those whose mothers were very young, less than 30, when they developed breast cancer. The only way to answer the question of breast cancer risk in the offspring is to include all such children in long term outcome studies. Hopefully Ives et al intend to undertake this analysis to help provide valuable, future answers. 1. Banks E, Reeves G. Pregnancy in women with a history of breast cancer. BMJ 2007;334:166-7 2. Ives A, Saunders C, Bulsara M, Semmens J. Pregnancy after breast cancer:population based study. BMJ 2007;334:194-196 Competing interests: None declared |
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Ludger Barthelmes, Specialist registrar Royal Glamorgan Hospital CF72 8XR, Eifion Vaughan Williams, Christopher A Gateley
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We concur with Banks and Greeves that the improved prognosis of breast cancer allows the focus to shift to issues of quality of life. They state that women with oestrogen receptor positive disease need to consider the effects of deferring or curtailing the use of tamoxifen if they wanted to conceive (1). We have previously reported the dilemma these women are faced with (2). By stopping tamoxifen before attempting pregnancy they are deprived of its potential benefit and they may not become pregnant. Of 6 case reports of tamoxifen use during pregnancy, four women delivered healthy babies.(3) (4) (5) One child was born with abnormalities of the genital tract suggestive of a tamoxifen effect on the foetus (6). In another case, the foetus was exposed to a number of other potentially toxic agents as well as tamoxifen (7). AstraZeneca - the manufacturer of tamoxifen – is aware of 50 pregnancies associated with tamoxifen use. 10 were associated with foetal or neonatal disorders, 2 of them resembling those seen in animal experiments. The long-term effect on offspring exposed to tamoxifen in- utero are regrettably unknown which would be of particular importance due to the chemical resemblance of tamoxifen to diethylstilbestrol. Daughters of women who used diethylstilbestrol during pregnancy developed clear cell carcinoma of the cervix in their late teenage years. Corinne Jones highlighted the need for more information about the long-term outcome of offspring of breast cancer patients in the rapid response section. On the other hand, in 85 pregnancies of women receiving prophylactic tamoxifen in a chemoprevention trial no abnormalities were seen (8). Publication bias may favour reporting adverse effects of tamoxifen while normal pregnancy outcomes are less likely to be published. Tamoxifen is licensed for ovulation induction. It has been successfully used for egg retrieval for in vitro fertilization in breast cancer patients (9). We agree with Banks and Greeves that it is essential to acknowledge and communicate uncertainties to the patient. It is prudent to stop tamoxifen before attempting pregnancy because of reports of congenital abnormalities after tamoxifen exposure during pregnancy and the lack of long-term data on outcome. However, some women may not want to miss out on the therapeutic advantage of tamoxifen nor defer pregnancy as chances of becoming pregnant are reduced with age and after chemotherapy. They may be prepared to accept the unknown risk of a congenital abnormality or a teratogenic effect later on in the life of their offspring if they become pregnant. Ludger Barthelmes
Eifion Vaughan-Williams
Christopher A Gateley
References 1 Banks E, Reeves G. Pregnancy in women with a history of breast cancer. BMJ 2007; 334:166-167, doi:10.1136/bmj.39098.376181.BE 2 Barthelmes L, Gateley CA. Tamoxifen and pregnancy. Breast 2004; 13: 446 -51, doi:10.1016/j.breast.2004.08.007 3 Koizumi K, AonoT. Pregnancy after combined treatment with bromocriptine and tamoxifen in two patients with pituitary prolactinomas. Fertil Steril 1986; 46 (2): 312-4 4 Isaacs RJ, Hunter W, Clark K. Tamoxifen as systemic treatment of advanced breast cancer during pregnancy – case report and literature review. Gynecol Oncol 2001; 80 (3): 405 - 8 5 Oksuzoglu B, Guler N. An infertile patient with breast cancer who delivered a healthy child under adjuvant tamoxifen therapy. Eur J Obstet Gynecol Reprod Biol 2002; 104 (1): 79 6 Tewari K, Bonebrake RG, Asrat T, Shanberg AM. Ambiguous genitalia in infant exposed to tamoxifen in utero. Lancet 1997; 350 (9072): 183 7 Cullins SL, Pridjian G, Sutherland CM. Goldenhar’s syndrome associated with tamoxifen given to the mother during gestation. J Am Med Assoc 1994; 271 (24): 1905 – 6 8 Clark S. Prophlactic tamoxifen. Lancet 1993; 342: 168 9 Oktay K, Buyuk E, Davis O, Yermakova I, Veeck L, Rosenwaks Z. Fertility preservation in breast cancer patients: IVF and embryo cryopreservation after ovarian stimulation with tamoxifen. Human Reproduction; 18 (1): 90-5, 2003 Competing interests: CAG has received funding by AstraZeneca for attending conferences and courses. |
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Andrew D Lynk, Consultant Pediatrician Sydney, Nova Scotia
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As a practical point, women who wish to breastfeed after having had breast cancer need to know that follow-up diagnostic imaging (mammography, MRI, ect) will be rendered difficult by virtue of natural changes in the lactating breast(s), and depending on the risk for recurrence, the timing of weaning may need to be shortened. Competing interests: None declared |
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