Data are limited regarding the optimal management of breast cancer in pregnancy. We aimed to compare strategies for the management of estrogen or progesterone hormone receptor-positive (HR+) tumors, and to determine the optimal gestational age for induction in regards to chemotherapy status and maternal-fetal outcomes.METHODS:
A decision-analytic model was designed comparing 32 different strategies for scheduled delivery between 24-39 weeks gestation, with chemotherapy induction either at 24 weeks or delayed until after delivery. Baseline estimates of stage-specific mortality and the impact of delayed chemotherapy on survival rates were obtained from the literature. Our model included the risk of intrauterine fetal demise, spontaneous delivery, respiratory distress syndrome, cerebral palsy, and neonatal demise at each gestational age.RESULTS:
For women receiving antenatal chemotherapy, delivery at 39 weeks yielded the highest maternal and overall QALYs at all cancer stages. For women with stage I disease deferring chemotherapy until after delivery, no significant increase in 5-year mortality occurred until after 30-31 weeks gestation; induction at 37 and 38 weeks yielded the highest quality-adjusted life years (QALYs) from the maternal and societal perspectives, respectively. For women with stage II and III disease deferring chemotherapy, overall QALYs were maximized at 37 and 31 weeks, respectively. In univariate and multivariate sensitivity analyses, our model remained robust across reasonable ranges for all variables of interest.CONCLUSION:
For women with operable HR+ breast cancer diagnosed in early pregnancy, antenatal chemotherapy and delivery at term are recommended; however, delaying chemotherapy until the postpartum period is reasonable for early stage disease.