Following are the authors’ top 6 key points to consider in caring for women with breast cancer during pregnancy.

1. “Ultrasonography is the first-line imaging modality. If concerning mass identified, bilateral mammography with appropriate shielding is recommended.”

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  • Ultrasonography
    • Can differentiate between solid and cystic lesions
    • Lacks ionizing radiation, which is associated with birth defects
    • High sensitivity to detect benign and malignant lesions
    • Guided core biopsy can be used to perform tissue diagnosis
  • Mammography can help determine “extent of disease, visualize suspicious microcalcifications, and evaluate the contralateral breast”
  • Not recommended: MRI with contrast or contract-enhanced CT

2. “Surgery can be safely performed at any time during pregnancy, but second trimester is preferred. Lumpectomy and mastectomy are both reasonable surgical approaches.”

  • While awaiting results of genetic testing to guide surgical planning, neoadjuvant chemotherapy can be administered
  • Surgical planning should include gestational age at breast cancer diagnosis
  • Breast-conservation surgery is safe in patients who are pregnant
  • When administering anesthesia during surgery, consider the safety of both the mother and the fetus
  • Premature labor and delivery can be initiated by the stress of surgery during the third trimester
  • Dose and duration of any narcotics used for pain control “should be closely monitored to minimize infant dependency”

3. “The recommended method of lymphoscintigraphy is with 99m-Tc sulfur colloid alone.”

4. “Chemotherapy should not be administered in the first trimester of pregnancy; anthracycline-based chemotherapy can be safely initiated in the second and third trimesters of pregnancy.”

  • “Perhaps one of the most important consideration in the selection and timing of systemic therapy is the effect of chemotherapy on fetal development”
  • Timing of chemotherapy should take into consideration stage at diagnosis, grade and lymph node and receptor status; “gestational age at breast cancer diagnosis, and the likelihood of promoting a full-term delivery in an effort to maximize both maternal and fetal outcomes”
  • The largest experience with chemotherapy in the second and third trimesters of pregnancy for maternal and fetal outcomes is with anthracycline-containing regimens; taxanes and platinum agents should be used only if anthracyclines are not feasible
  • Congenital abnormalities in children exposed to chemotherapy in utero is approximately 3%, similar to the national average

5. “Chemotherapy should be stopped approximately 3–4 wk before delivery to avoid hematologic nadir during delivery that may result in infectious or bleeding complications.”

6. “Dosing of chemotherapy in pregnant patient should be similar to that in nonpregnant patient (i.e., based on actual body surface area).”