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Case History

image A 37-year-old woman presented with a right breast lump. She had no significant past medical history or family history. On examination there was a 50 × 50 mm right breast mass with palpable right axillary lymphadenopathy. A biopsy showed a grade 3 carcinoma, which was oestrogen receptor positive (ER 8/8), progesterone receptor positive (PR 4/8) and HER2-negative. She received primary chemotherapy with four cycles of docetaxel, followed by four cycles of epirubicin and cyclophosphamide. Following this she underwent a right wide local excision and axillary node clearance. Histology showed 10 mm of residual tumour and 1/10 positive lymph nodes. She received adjuvant radiotherapy to the right breast and supraclavicular fossa. Following this hormone therapy was commenced with zoladex (LHRH analogue) and exemestane. Unfortunately, she was unable to tolerate this combination and after 4 months was switched to tamoxifen. After 2 years she stopped her Tamoxifen as she wished to become pregnant. Staging investigations (mammogram, CT scan and bone scan) were all negative for metastatic disease. She conceived naturally and had a live birth with no complications. Following 3 months of breastfeeding she recommenced tamoxifen.

After 1 year of hormone therapy, the patient wished to become pregnant. What would you advise?

How long should she stop tamoxifen for prior to attempting conception?

Should patients undergo staging investigations prior to attempting conception?

Should the patient be advised to breastfeed following giving birth?

After restarting tamoxifen how long should she be advised to continue it for?

After 1 year of hormone therapy, the patient wished to become pregnant. What would you advise?

There is no particular timepoint at which it is considered optimal to allow patients to become pregnant following cancer treatment, with multiple factors needing to be considered. Women should be made aware that there is a lack of evidence to support the early interruption of tamoxifen. However, age is a major determinant of fertility and further delay with already poor ovarian function secondary to chemotherapy is likely to lead to infertility. Therefore, the Royal College of Obstetricians and Gynaecologists (RCOG) and European Society of Medical Oncology (ESMO) advise that most women should wait at least 2 years before attempting conception.1,2 This period of time is when the risk of relapse is highest, and also allows adequate recovery of ovarian function.1 A small Australian population-based study included 62 women who conceived after treatment for breast cancer. They concluded that for women with localized disease conception as early as 6 months after completing treatment is unlikely to reduce survival.3 A similar American study showed a small non-significant adverse effect among women who conceived within 12 months of diagnosis.4 POSITIVE is a large international prospective study that is currently underway and aims to evaluate the safety of temporary interruption of endocrine therapy to allow conception.5 Until this question is better answered, women should be advised according to ...

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