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Case History

image A 29-year-old woman presented with a 6 month history of a left breast lump. She had no past medical history. She lived with her partner and 5-year-old son. Triple assessment revealed an invasive ductal carcinoma of the left breast: T2 with axillary node involvement, oestrogen receptor (ER) negative, progesterone receptor (PR) negative and human epidermal growth factor receptor 2 (HER2) positive.

Neoadjuvant treatment with chemotherapy and HER-2 directed therapy was discussed by the oncologist. She had no plans to have further children and was not using contraception. However, a staging CT scan showed evidence of liver metastases. Treatment with docetaxel, pertuzumab and trastuzumab was initiated and an interval scan confirmed disease response. Docetaxel was stopped after four cycles following radiological evidence of bowel perforation. The patient continued to receive treatment with maintenance pertuzumab and trastuzumab.

Further imaging showed a continued response in the liver but a small new pulmonary metastasis. She reported to her oncologist that she had been amenorrheic for 6 weeks and a pregnancy test was positive. At this point, she had received seven cycles of pertuzumab and trastuzumab. She was referred to the local obstetric service and a fetal scan confirmed she was 7 weeks pregnant.

Following a joint consultation between her oncologist and obstetrician, during which the risks to her health and the fetus were explained, the patient wished to continue with her pregnancy. The case was discussed in the MDT and it was decided that the antibody therapy should be discontinued and surveillance with clinical examination, blood tests and MRI liver without contrast was advised. She was seen in clinic at weeks 19 and 25 of pregnancy and her fetal scans were normal but MRI of the liver showed progressive disease.

She was commenced on cyclophosphamide and epirubicin for three cycles starting at week 25. Treatment was stopped at week 34. She had a planned caesarean section at week 38 and 4 weeks later recommenced trastuzumab as a CT scan showed further evidence of disease progression in the liver.

What is the evidence base for this patient’s first-line treatment?

How should this patient be counselled regarding continuing with her pregnancy?

How did pregnancy affect this patient’s cancer treatment and surveillance?

What were the risks to the fetus while receiving HER2 targeted treatment?

Why is the timing of chemotherapy important in relation to the expected delivery date?

What is the evidence base for this patient’s first line treatment?

The CLEOPATRA trial1 was a phase III study which enrolled 808 patients with metastatic HER-2 positive breast cancer. Participants were randomized 1:1 to receive pertuzumab, trastuzumab and docetaxel or placebo, trastuzumab and docetaxel. At least six cycles of docetaxel were recommended and trastuzumab and pertuzumab (or placebo) continued until disease progression or the occurrence of unmanageable toxicities. The addition of pertuzumab improved the median overall survival by 16.3 months (57.1 vs. 40.8). The 8 year overall survival ...

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