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Case history

image A 40-year-old woman in her second pregnancy was diagnosed at 24 weeks' gestation with a clinically node-positive grade 3 invasive ductal breast cancer measuring 6.5 cm in diameter. It had initially been thought to be a blocked milk duct. The tumour was oestrogen receptor (ER)-, progesterone receptor (PR)- and human epidermal growth factor receptor 2 (HER2)-negative. On the basis of size, neoadjuvant chemotherapy was recommended. Staging was performed with a liver ultrasound and a chest radiograph. Chemotherapy with fluorouracil, epirubicin and cyclophosphamide was commenced. There was close liaison with obstetric services.

The chemotherapy was well tolerated and there was clinical evidence of response with tumour shrinkage. A planned induction of labour took place at 37 weeks' gestation, 3 weeks after completion of four cycles of chemotherapy. Labour was induced with a prostaglandin vaginal tablet. The delivery was uncomplicated. The patient gave birth to a healthy baby son weighing 3.7 kg. The baby was fed with donor breast milk.

Shortly after the birth the patient restarted chemotherapy with planned docetaxel treatment. The breast tumour was barely palpable at this point. The chemotherapy was associated with significant fatigue and nausea and she required prolonged bed rest. She began to suffer migraines for the first time.

Following her seventh chemotherapy session the patient became very unwell and was admitted to hospital with severe migraines, dehydration, sickness and blurred vision and a Glasgow Coma Score of 13. Contrast-enhanced MRI showed meningeal thickening consistent with leptomeningeal disease. The diagnosis was confirmed on subsequent lumbar puncture. There was some brief improvement with dexamethasone but then further and rapid deterioration. After a 12 day admission she was transferred to her local hospice. She died there peacefully 3 days later surrounded by her family. Her son was 2 months old and her daughter was 3 years old. The patient and her family were supported throughout the process by the charity Mummy's Star and a named midwife and breast care nurse.

How does the treatment of pregnancy-associated breast cancer differ from standard care?

How should obstetric/antenatal services and oncology services combine in these cases?

How can charities or third sector partners help in cases of pregnancy-associated cancer?

What opportunities are there to collect and share data on these relatively rare cases?

How does the treatment of pregnancy-associated breast cancer differ from standard care?

The incidence of pregnancy-associated breast cancer is rising due to the trend for later pregnancies and the increasing incidence of breast cancer with age (53% of all live births in England and Wales in 2015 were to mothers aged 30 and over).1 There is European consensus guidance for the treatment of pregnancy-associated breast cancer:2 as no randomized data were available, evidence was taken from retrospective datasets, which appear to demonstrate that pregnancy does not worsen cancer prognosis.3

It has been suggested that the hormonal changes of pregnancy and the lactational breast changes may be ...

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