Trastuzumab administration during pregnancy: un update

Biology, care, and outcomes of gestational breast cancers: a review

PURPOSE

The incidence of gestational breast cancers, breast cancers diagnosed during pregnancy, is increasing. There is a critical need to understand the pathophysiology, treatment recommendations, and remaining questions regarding care and therapeutics for this complex condition.

METHODS

Here, we review existing data regarding evaluation and management of gestational breast cancer, including safe imaging modalities, timing and choice of chemotherapy, evidence regarding targeted therapies during pregnancy. We highlight the importance of multidisciplinary care including oncologic, obstetric, and psychosocial care.

RESULTS

Gestational breast cancers are associated with unique biologic and clinicopathologic features that are impacted by physiologic changes of pregnancy such as upregulation of target genes associated with cell proliferation and immune regulation. Patients with gestational breast cancers more often present at advanced stages, are more likely to have aggressive tumor subtypes (i.e., triple negative or HER2 positive), and overall have worse prognoses than patients with non-gestational breast cancers. In this review, we synthesize recommendations for treatment strategies based on pregnancy trimester, optimal timing and choice of surgery, chemotherapy, targeted therapies, and psychosocial support.

CONCLUSION

Developing a framework for clinical care and treatment of patients with gestational breast cancers is integral to improving outcomes for patients with gestational breast cancers. Optimal treatment includes collaborative management with a multidisciplinary team dedicated to both maternal and fetal care.

Physicians' knowledge, practice, and attitudes on fertility and pregnancy-related issues in young women with advanced breast cancer: results of the ABC6 and ABC7 survey

BACKGROUND

Fertility and pregnancy-related issues are critical for young patients with breast cancer. No proper evidence exists on physicians' knowledge, practice, and attitudes on dealing with these concerns in the specific group of patients with advanced disease.

METHODS

A 26-item questionnaire was administered via e-mail in December 2023 to physicians who attended the ABC6 consensus conference (virtually, November 2021) and those who were registered for the ABC7 consensus conference (Lisbon, November 2023). The questionnaire was divided into 3 main sections: 1) demographic, medical training, and background information; 2) knowledge, practice, and attitudes of physicians towards fertility preservation and pregnancy-related issues in patients with advanced breast cancer; 3) approach to hypothetical clinical cases.

RESULTS

A total of 133 physicians completed the survey. Most reported discussing always (40.6 %) or usually (36.1 %) the possible treatment-related loss of ovarian function in patients with advanced breast cancer. Regarding fertility preservation and pregnancy-related issues, 23.3 % would always feel comfortable discussing these topics with patients, and 45.9 % would feel comfortable depending on the clinical situation. 20.3 % reported not prescribing any type of contraception, and 10-20 % would prescribe treatments that are contraindicated during pregnancy.

CONCLUSIONS

Our survey showed that many concerns exist when discussing and dealing with fertility and pregnancy-related issues in patients with advanced breast cancer. It is essential to increase physicians' awareness on how to address fertility and pregnancy-related issues in patients with advanced breast cancer, especially as oncological treatments continue to improve, resulting in longer survival and, in some cases, potential cure.

Pharmacovigilance study of adverse reactions of anti-HER-2 drugs for the treatment of HER-2-positive breast cancer based on the FAERS database

OBJECTIVE

There are three categories of drugs that treat human epidermal growth factor receptor type 2 (HER-2) positive breast cancer: monoclonal antibodies (mAbs), antibody-drug conjugates (ADCs), and tyrosine kinase inhibitors (TKIs). The purpose of this study is to analyze and compare the adverse reactions of three classes of anti-HER-2 drugs to various body systems in patients based on the FDA Adverse Event Reporting System (FAERS).

METHODS

All data reports were extracted from the FAERS between 2004 and 2024. Data mining of adverse events associated with anti-HER-2 drugs was carried out using disproportionality analysis. A multivariate logistic regression analysis was conducted to explore the risk factors associated with AEs leading to hospitalization.

RESULTS

A total of 47,799 patients were screened for the three classes of drugs, among which ADC drugs caused the largest proportion of deaths. MAb has the strongest ADR signals associated with "cardiac disorders". Moreover, trastuzumab was associated with a greater risk of cardiotoxicity. Logistic regression analysis revealed that the treatment with mAbs should be wary of serious adverse reactions in "infections and infestations" and "metabolism and nutrition disorders". Moreover, "endocrine disorders" were the factor associated with the highest risk of prolonged hospitalization due to trastuzumab deruxtecan (T-DXd). The safety of tucatinib among TKI drugs is greater than that of other drugs.

CONCLUSION

In general, from the perspective of the effects of the three classes of drugs on the various body systems of patients, we should focus on mAb-associated "cardiac disorders", ADC-associated "hepatobiliary disorders", "respiratory, thoracic and mediastinal disorders", and TKI-associated "gastrointestinal disorders.

Chemo- and Radiotherapy of Gastrointestinal Tumors during Pregnancy

Background

Gastrointestinal cancers account for approximately one-fourth of all cancer cases and one-third of all tumor-related deaths worldwide. For the most frequent gastrointestinal tumor entities including colorectal, gastric, esophageal, and liver cancer, the incidence is expected to increase by more than 50% until 2040. While most gastrointestinal cancers are diagnosed beyond the age of fertility and predominantly in men, the increasing incidence of gastrointestinal malignancies in patients below the age of fifty suggests a growing importance in women of childbearing age. While localized cancers in pregnant women can either be monitored or treated surgically, more advanced stages might require radio- or chemotherapy to control tumor growth until delivery. Under these circumstances, critical decisions have to be made to preserve maternal health on the one side and minimize harm to the infant on the other side.

Summary

Here we summarize data from case reports, meta-analyses, and registries of women undergoing radio- or chemotherapy during pregnancy and provide guidance for therapeutic decision-making in pregnant women suffering from gastrointestinal cancers.

Key Message

After the first trimester, most chemotherapeutic regimens can be safely administered to pregnant patients with gastrointestinal cancers. With appropriate safety measures, both radiotherapy and radiochemotherapy can be applied to pregnant patients with rectal cancers.

Diagnosis and Management of Cancers in Pregnancy: The Results of a Dual Battle Between Oncological Condition and Maternal Environment-Literature Review

Cancer during pregnancy presents considerable challenges that arise from various factors, including the diagnostic, prognostic and therapeutic implications of managing cancer in this unique patient population. There is a crucial need for an integrated approach that aligns medical interventions for both the pregnant patient and the developing embryo or fetus. Furthermore, the distinct characteristics associated with each stage of gestation may significantly influence the treatment protocols that can be proposed. Due to all of these factors, the importance of collaboration among healthcare professionals from different specialties (to ensure that both mother and child receive optimal care throughout the pregnancy) is often neglected. This review is designed to provide a thorough overview of the current standard procedures regarding the diagnosis and treatment options for cancer in pregnant patients in order to ensure the safety of mother and child. Furthermore, the review describes the feasibility of current fertility preservation methods, highlights the psychological effects of cancer during pregnancy and examines the risks and benefits of breastfeeding.

Weekly Paclitaxel for Pregnancy Associated Breast Cancer

BACKGROUND

Pregnancy associated breast cancer is the most common cancer diagnosed during pregnancy. When chemotherapy is indicated, although it is more common to use anthracycline-based chemotherapy as a first treatment, we suggest weekly paclitaxel as a valid alternative both in the adjuvant and neoadjuvant setting, as this allows for weekly assessment of maternal-fetal well-being and a quicker maternal and fetal bone marrow recovery in cases of unexpected preterm delivery.

PATIENTS AND METHODS

We present a case series of pregnant breast cancer patients treated with weekly paclitaxel between 2016 and 2022. Patient demographics and tumor characteristics, data on management, delivery, and maternal-neonatal outcomes were extrapolated from institutional electronic databases.

RESULTS

Eighteen patients underwent weekly paclitaxel for breast cancer during pregnancy (PrBC); 17 were primary diagnoses and 1 was a recurrence. None of the patients had severe adverse reactions to CT. Two cases of preterm prelabour rupture of membranes were reported while in 1 case treatment was stopped due to threatened preterm birth. Two babies were born large for gestational age, 2 were small for gestational age and 2 babies were growth restricted at birth. At a mean follow up of 42.9 months, 1 patient died, 1 patient was diagnosed with disease recurrence and another patient was diagnosed with disease progression.

CONCLUSION

Weekly paclitaxel can be safely administered during pregnancy and should be included in the current therapeutic options for PrBC.

Immune Checkpoint Inhibitor Use During Pregnancy and Outcomes in Pregnant Individuals and Newborns

Importance

With the widespread use of immune checkpoint inhibitors (ICIs), concerns about their pregnancy outcomes through maternal exposure have emerged, and clinical comparative data are lacking.

Objective

To assess the risk of pregnancy-, fetal-, and/or newborn-related adverse outcomes associated with exposure to ICIs compared with exposure to other anticancer agents.

Design, Setting, and Participants

In this cohort study, all reports mentioning a pregnancy-related condition and an antineoplastic agent (Anatomical Therapeutic Chemical classification group L01) used for a cancer indication registered in the World Health Organization international pharmacovigilance database VigiBase up to June 26, 2022, were extracted.

Exposure

Anticancer agents, including ICIs, used during pregnancy for a cancer indication. Immune checkpoint inhibitors included blockers of programmed cell death 1 (PD1) or its ligand (PD-L1) or cytotoxic T-lymphocyte-associated protein 4 (CTLA4).

Main Outcomes and Measures

The main outcome was the reporting odds ratio (ROR) for maternal, fetal, or newborn complications in patients treated with ICIs vs any other anticancer drug. Adverse events, categorized into 45 individual maternofetal adverse outcomes, were directly mapped to Medical Dictionary for Regulatory Activities preferred terms in VigiBase.

Results

A total of 3558 reports (ICI: 91 [2.6%]; other anticancer drugs: 3467 [97.4%]) were included in the analysis. In the ICI group, most reports were from the US (60 [65.9%]), and the mean (SD) patient age was 28.9 (10.2) years; in 24 of 55 reports with data on cancer type (43.6%), patients were treated for melanoma. The molecules involved in the ICI group were anti-PD1 (58 reports [63.7%]), anti-PD1 plus anti-CTLA4 (15 [16.5%]), anti-CTLA4 (13 [14.3%]), anti-PD-L1 (4 [4.4%]), and anti-PD1 plus anti-lymphocyte activation gene 3 (1 [1.1%]). An ICI was used in combination with a non-ICI anticancer agent in 10 participants (11.0%). Compared with other anticancer drugs, none of the 45 adverse outcomes identified were overreported in the group exposed to ICIs. However, preterm birth was significantly overreported for the anti-PD1 plus anti-CTLA4 combination compared with other anticancer drugs (12 of 15 [80.0%] vs 793 of 3452 [23.0%]; ROR, 13.87; 95% CI, 3.90-49.28; P < .001) but not for anti-PD-L1 or anti-CTLA4 monotherapy. Three reports of possibly immune-related maternofetal events were identified: 1 case of maternal antiphospholipid syndrome leading to spontaneous abortion, 1 case of pneumonitis leading to neonatal respiratory distress syndrome and death, and 1 case of transient congenital hypothyroidism.

Conclusions and Relevance

In this cohort study of 91 individuals exposed to ICIs during pregnancy, ICI exposure was not associated with overreporting of specific adverse pregnancy, fetal, and/or newborn outcomes compared with other anticancer treatments. However, due to possible rare immune-related neonatal adverse events, ICI use in pregnant women should be avoided when possible, especially the anti-PD1 plus anti-CTLA4 combination.

Caring for Pregnant Patients with Cancer: A Framework for Ethical and Patient-Centred Care

(1) Background: Caring for pregnant cancer patients is clinically and ethically complex. There is no structured ethical guidance for healthcare professionals caring for these patients. (2) Objective: This concept paper proposes a theoretically grounded framework to support ethical and patient-centred care of pregnant cancer patients. (3) Methodological approach: The framework development was based on ethical models applicable to cancer care during pregnancy-namely principle-based approaches (biomedical ethics principles developed by Beauchamp and Childress and the European principles in bioethics and biolaw) and relational, patient-focused approaches (relational ethics, ethics of care and medical maternalism)-and informed by a systematic review of clinical practice guidelines. (4) Results: Five foundational discussion themes, summarising the key ethical considerations that should be taken into account by healthcare professionals while discussing treatment and care options with these patients, were identified. This was further developed into a comprehensive ethics checklist that can be used during clinical appointments and highlights the need for a holistic view to patient treatment, care and counselling while providing ethical, patient-centric care. (5) Conclusion: The proposed framework was further operationalised into an ethics checklist for healthcare professionals that aims to help them anticipate and address ethical concerns that may arise when attending to pregnant cancer patients. Further studies exploring clinicians' attitudes towards cancer treatment in the course of pregnancy and patient experiences when diagnosed with cancer while pregnant and wider stakeholder engagement are needed to inform the development of further ethical, patient-centred guidance.

Treatments During Pregnancy Targeting ERBB2 and Outcomes of Pregnant Individuals and Newborns

Importance

Targeted therapies directed against ERBB2 are the cornerstone of medical treatment for ERBB2-positive breast cancers but are contraindicated during pregnancy.

Objectives

To describe the association of exposure to anti-ERBB2 agents during pregnancy with pregnancy and fetal or newborn outcomes, and to compare the risk and types of adverse outcomes reported more frequently in this context than after exposure to other anticancer agents.

Design, Setting, and Participants

For this case-control study, All reports with a pregnancy-related condition and an antineoplastic agent (Anatomical Therapeutic Chemical classification group L01) registered in the World Health Organization international pharmacovigilance database VigiBase up to June 26, 2022, were extracted. All reports with a pregnancy, an antineoplastic treatment during pregnancy, and a cancer were retained. Reports with anticancer agents prescribed for nononcologic purposes were not included.

Exposure

The exposure group was defined as reports that mention anti-ERBB2 agents compared with exposure to other anticancer agents.

Main Outcome and Measures

The main outcome was the reporting odds ratio (ROR) for maternofetal complications in the group exposed to anti-ERBB2 agents compared with other anticancer agents, as determined using a disproportionality analysis.

Results

A total of 3558 reports (anti-ERBB2 agents, 328; other anticancer agents, 3230) were included in the analysis. In the group exposed to anti-ERBB2 agents, most reports were from the US (159 [48.5%]), the mean (SD) age of participants was 30.8 (10.4) years, and 209 patients (97.7%) were treated for breast cancers. The molecules most frequently involved in cases with anti-ERBB2 agents were trastuzumab (n = 302), pertuzumab (n = 55), trastuzumab-emtansine (n = 20), and lapatinib (n = 18). The outcomes overreported in these cases included oligohydramnios (ROR, 17.68 [95% CI, 12.26-25.52]; P < .001), congenital respiratory tract disorders (ROR, 9.98 [95% CI, 2.88-34.67]; P < .001), and neonatal kidney failure (ROR, 9.15 [95% CI, 4.62-18.12]; P < .001). Sensitivity and multivariable analyses found similar results. Toxic effects were also significantly overreported for trastuzumab-emtansine (cardiovascular malformation: ROR, 4.46 [95% CI, 1.02-19.52]) and lapatinib (intrauterine growth restriction: ROR, 7.68 [95% CI, 3.01-19.59]).

Conclusions and Relevance

In this case-control study of 328 individuals exposed to anti-ERBB2 agents during pregnancy, exposure was associated with a severe specific adverse pregnancy and fetal or newborn outcomes compared with exposure to other anticancer treatments.

First Reported Case of Successful Conception and Delivery During Stage IV Breast Cancer Treatment: A Case Report and Literature Review

We herein report a case involving a woman with metastatic human epidermal growth factor receptor 2 (HER-2)-positive breast cancer (BC) who became pregnant while undergoing active anticancer therapy with Trastuzumab-Pertuzumab for her advanced BC disease at our institution. To our knowledge, this is the first reported case of pregnancy and successful delivery in a stage IV BC patient during anticancer therapy. A multidisciplinary approach for such a complex case is a must to evaluate the mother's medical condition by an experienced oncology team along with a maternal-fetal team, with support from a psychiatric and psychological evaluation for the mother. The use of effective contraception during anticancer therapy is essential to avoid such a scenario.

Choosing the appropriate pharmacotherapy for breast cancer during pregnancy: what needs to be considered?

INTRODUCTION

Breast cancer is the most commonly diagnosed malignancy during pregnancy. Breast cancer during pregnancy is a challenging clinical condition requiring proper and timely multidisciplinary management.

AREAS COVERED

This review focuses on the management of breast cancer during pregnancy with a focus about the current state-of-the-art on the feasibility and safety of pharmacotherapy approaches in this setting.

EXPERT OPINION

Multidisciplinary care is key for a proper diagnostic-therapeutic management of breast cancer during pregnancy. Engaging patients and their caregivers in the decision-making process is essential and psychological support should be provided. The treatment of patients with breast cancer during pregnancy should follow the same recommendations as those for breast cancer in young women outside pregnancy but taking into account the gestational age at the time of treatment.Anthracycline-, cyclophosphamide-, and taxane-based regimens can be safely administered during the second and third trimesters with standard protocols, preferring weekly regimens whenever possible. Endocrine therapy, immune checkpoint inhibitors, and targeted agents are contraindicated throughout pregnancy, also due to the very limited data available to guide their administration in this setting. During treatment, careful fetal growth monitoring is mandatory, and even after delivery proper health monitoring for the children exposed in utero to chemotherapy should be continued.

Patient-Centered Care in the Management of Cancer During Pregnancy

The management of cancer during pregnancy requires a patient-centered, multidisciplinary approach to balance maternal and fetal well-being given the rarity of this clinical scenario and lack of substantial data. Involvement of oncology and nononcology medical specialists and ethical, legal, and psychosocial supports, as needed, is instrumental in navigating the complexities of care for this patient population. Critical periods of fetal development and physiological changes in pregnancy must be considered when planning diagnostic and therapeutic approaches during pregnancy. The complexity of symptom recognition and interventional approaches contributes to diagnostic delays of cancers during pregnancy. Ultrasound and whole-body diffusion-weighted magnetic resonance imaging are safe throughout pregnancy. Surgery can be safely performed throughout pregnancy, with the early second trimester preferred for intra-abdominal surgery. Chemotherapy can be safely administered after 12-14 weeks of gestation until 1-3 weeks before the anticipated delivery. Most targeted and immunotherapeutic agents are contraindicated during pregnancy because of limited data. Pelvic radiation during pregnancy is absolutely contraindicated, while if radiation to the upper body is needed, administration should only be considered early in pregnancy. To ensure that the total cumulative fetal exposure to ionizing radiation does not exceed 100 mGy, early inclusion of the radiology team in the care plan is required. Closer prenatal monitoring is recommended for maternal and fetal treatment-related toxicities. Delivery before 37 weeks of gestation should be avoided if possible, and vaginal delivery is preferred unless obstetrically indicated or specific clinical scenarios. Postpartum, breastfeeding should be discussed, and the neonate should receive blood work to assess for acute toxicities with follow-up arranged for long-term monitoring.

Women at heart: Introducing gender cardio-oncology

As cardio-oncology imposed itself as the reference specialty for a comprehensive cardiovascular approach to all patients with cancer, a more specific and careful cardiac evaluation of women entering their journey into cancer care is needed. Gender medicine refers to the study of how sex-based biological and gender-based socioeconomic and cultural differences influence people's health. Gender-related aspects could account for differences in the development, progression, and clinical signs of diseases as well as in the treatment of adverse events. Gender also accounts for major differences in access to healthcare. As for medicine and healthcare in general, gender-related characteristics have gained significance in cardio-oncology and should no longer be neglected in both clinical practice and research. We aimed to review the most relevant cardiovascular issues in women related to the cardio-oncology approach to offer a specific gender-related point of view for clinicians involved in the care process for both cancer and cardiovascular disease.

Strategies for Mitigating Antibody-Drug Conjugate Related Adverse Events for Precision Therapy

ABSTRACT

Antibody-drug conjugates (ADCs) have been revolutionary in improving personalized therapy of cancer. Through combining monoclonal antibodies, which are targeted to tumor-specific antigens, and cytotoxic agents, ADCs lead to selective delivery of active components, also called payloads, to cancerous cells while sparing healthy body cells from possible collateral damage. Adverse events, however, can still develop because of early release of the payload or cross-expression of targets by normal cells leading to collateral damage. In this review, we elaborate on the common and serious adverse events for the currently US Food and Drug Administration-approved ADCs in solid tumors and discuss mitigating strategies and dose modification guidance for optimizing efficacy and toxicity.

Pregnancy in Breast Cancer Survivors; Is It Safe?

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Pregnancy and perinatal outcomes following exposure to antineoplastic agents around pregnancy within the US FDA Adverse Event Reporting System

Objective: To review pregnancy and perinatal outcomes associated with exposure to antineoplastic drugs around pregnancy as reported within the US FDA Adverse Event Reporting System (FAERS). Methods: The FAERS database was accessed and reports of exposure to antineoplastic drugs before/during pregnancy 2000-2020 were reviewed. An analysis of the frequency of different adverse pregnancy outcomes and perinatal outcomes was conducted for all agents as well as for specific categories of antineoplastic agents. Results: A total of 5312 reports of pregnancy exposure to antineoplastic drugs within the FAERS database were found to be eligible and were included in the current study. The most frequent adverse pregnancy outcomes included premature delivery (21.8%) and abortion (11.9%). The most frequent adverse perinatal outcomes included congenital malformations (15.9%) and fetal/neonatal death (12.9%). Conclusions: Within the limitations of the study (especially the lack of an accurate denominator), premature delivery, abortion, fetal/neonatal death and congenital malformations seemed to be the main risks associated with pregnancy exposure to antineoplastic drugs.

Treatment of Breast Cancer in Young Adults

Although breast cancer is rare and understudied in adults age 40 and younger, recent epidemiologic data show an increasing incidence of breast cancer among young women in the United States and ongoing inferior long-term outcomes. Given breast cancers arising at a young age are more likely to present at advanced stages and to have aggressive biology, multimodal treatments are often indicated. Elevated local recurrence risks and greater propensity for germline cancer predisposition mutations can impact local therapy choices. Recently, escalated systemic therapy regimens for triple-negative breast cancer incorporating immunotherapy, de-escalated anti-HER2 therapy, and emerging targeted agents, including CDK4/6 inhibitors and PARP inhibitors, for early-stage disease may be employed in younger and older patients alike, with some special considerations. Prognostic genomic signatures can spare low-risk young women with hormone receptor-positive breast cancer adjuvant chemotherapy, but management of intermediate-risk patients remains controversial. Ovarian function suppression and extended endocrine therapy are improving outcomes in hormone receptor-positive breast cancer, but treatment adherence is a particular problem for young patients. Young women may also face greater challenges in long-term survivorship, including impaired fertility, difficulties in psychosocial adjustment, and other treatment-related comorbidities. Consideration of these age-specific issues through dedicated multidisciplinary strategies is necessary for optimal care of young women with breast cancer.

Current status of AYA-generation breast cancer: trends worldwide and in Japan

Breast cancer (BC) is the most common cancer worldwide among women. In Japan, the incidence of BC gradually increased. The recent number of adolescent and young adult (AYA)-BC patients is approximately 4,000-5,000 every year, accounting for 5% of all BC cases. BC in young people has been attracting attention since Japan's third basic plan to promote cancer control programs incorporated cancer control measures for pediatric (age ≤ 14 years) and adolescent and young adult (AYA)-generation (age 15-39 years) cancers in 2018. Attention is needed to detect AYA-BC because of the presence of dense breasts. AYA-BC patients are clinically characterized by larger tumor size, more lymph node metastases, advanced stages, and a higher rate of aggressive phenotypes, such as triple-negative or HER2-positive subtypes, and are strongly associated with family history and genetic germline alterations, including hereditary breast and ovarian cancers. Given that AYA-BC patients show a poorer prognosis than older BC patients, they often require intensive therapies, including surgery, radiation, chemotherapy, and endocrine therapy. We must solve many survivorship-associated problems in AYA-BC patients, including fertility preservation, comorbidity after treatment, and long-term follow-up. Under these circumstances, national and local governments and various academic societies have started addressing these problems by formulating laws and guidelines, establishing medical systems, and offering financial support to conquer cancer and maintain a better quality of life. This review summarizes the current trends of AYA-BC worldwide and in Japan. Further Japan-specific data on AYA-BC are required to clarify its characteristics and improve prognosis and survivorship.