NCCN VERSION 2 2015

NCCN Guidelines Version 2.2015 Breast Cancer

NCCN Guidelines Index Breast Cancer Table of Contents Discussion

4, doxorubicin 50 mg/m 2 by IV infusion over 72 hours, and cyclophosphamide 500 mg/m 2 IV day 1) may be given with relative safety during the second and third trimesters of pregnancy. 549 Ondansetron, lorazepam, and dexamethasone can be used as part of the pre-chemotherapy antiemetic regimen. As reported by Gwyn et al, the median gestational age at delivery was 38 weeks, more than 50% of the patients had vaginal delivery, and there have been no fetal deaths. 537 An update of this experience reported on 57 women treated with FAC in the adjuvant or neoadjuvant setting. There were 57 live births. A survey of parents/guardians reported on the health of 40 children. There was one child with Down’s syndrome and two with congenital abnormalities (club foot; congenital bilateral ureteral reflux). The children are reported to be healthy and progressing well in school. 549,552 Ondansetron, lorazepam, and dexamethasone can be used as part of the pre-chemotherapy antiemetic regimen. There are limited data on the use of taxanes during pregnancy. 553-556 If used, the NCCN Panel recommends weekly administration of paclitaxel after the first trimester if clinically indicated by disease status. There are only case reports of trastuzumab use during pregnancy. 557-564 The majority of these case reports indicated oligo- or anhydramnios with administration of trastuzumab; fetal renal failure occurred in one case. If trastuzumab is otherwise indicated, it should be administered in the postpartum period; the panel recommends against its use during pregnancy. A single case report of first trimester exposure to lapatinib during treatment for breast cancer reported an uncomplicated delivery of a healthy female neonate. 565

be on-site and immediately available in the event of precipitous delivery of a viable fetus. Although there are a limited number of isolated case reports and small retrospective studies evaluating use of SLN biopsy in pregnant patients, 542,543 the sensitivity and specificity of the procedure has not been established in this setting. Thus, there are insufficient data on which to base recommendations for its use in pregnant woman. Decisions related to use of SLN biopsy in pregnancy should be individualized. A review of the relative and absolute contraindications to sentinel node biopsy concluded that sentinel node biopsy should not be offered to pregnant women under 30 weeks gestation. 544 There are limited data with only case reports and estimations of fetal radiation dose regarding use of radioactive tracer (eg, technetium 99m sulfur colloid). 545-547 Isosulfan blue or methylene blue dye for sentinel node biopsy procedures is discouraged during pregnancy. The indications for systemic chemotherapy are the same in the pregnant patient as in the non-pregnant breast cancer patient, although chemotherapy should not be administered at any point during the first trimester of pregnancy. The largest experience in pregnancy has been with anthracycline and alkylating agent chemotherapy. 548,549 Collected data of chemotherapy exposure in utero indicate that the first trimester has the greatest risk of fetal malformation. 550,551 Fetal malformation risks in the second and third trimester are approximately 1.3%, not different than that of fetuses not exposed to chemotherapy during pregnancy. If systemic therapy is initiated, fetal monitoring prior to each chemotherapy cycle is appropriate. Chemotherapy during pregnancy should not be given after week 35 of pregnancy or within 3 weeks of planned delivery in order to avoid the potential for hematologic complications during delivery. Data from a single-institution prospective study indicate that FAC chemotherapy (5-FU 500 mg/m 2 IV days 1 and

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