Epstein Richard J
Division of Haematology/Oncology, Department of Medicine, The University of Hong Kong, Pokfulam, Hong Kong.
BMC Cancer. 2007 May 30;7:92. doi: 10.1186/1471-2407-7-92.
Diagnosis of breast cancer during pregnancy was formerly considered an indication for abortion. The pendulum has since swung to the other extreme, with most reviews now rejecting termination while endorsing immediate anthracycline-based therapy for any pregnant patient beyond the first trimester. To assess the evidence for this radical change in thinking, a review of relevant studies in the fields of breast cancer chemotherapy, pregnancy, and drug safety was conducted.
Accumulating evidence for the short-term safety of anthracycline-based chemotherapy during late-trimester pregnancy represents a clear advance over the traditional norm of therapeutic abortion. Nonetheless, the emerging orthodoxy favoring routine chemotherapy during gestation should continue to be questioned on several grounds: (1) the assumed difference in maternal survival accruing from chemotherapy administered earlier--i.e., during pregnancy, rather than after delivery--has not been quantified; (2) the added survival benefit of adjuvant cytotoxic therapy prescribed within the hormone-rich milieu of pregnancy remains presumptive, particularly for ER-positive disease; (3) the maternal survival benefit associated with modified adjuvant regimens (e.g., weekly schedules, omission of taxanes, etc.) has not been proven equivalent to standard (e.g., post-delivery) regimens; and (4) the long-term transplacental and transgenerational hazards of late-trimester chemotherapy are unknown.
Although an incrementally increased risk of cancer-specific mortality is impossible to exclude, mothers who place a high priority on the lifelong well-being of their progeny may be informed that deferring optimal chemotherapy until after delivery is still an option to consider, especially in ER-positive, node-negative and/or last-trimester disease.
孕期乳腺癌的诊断曾被视为堕胎的指征。此后情况却转向了另一个极端，大多数综述如今都反对终止妊娠，同时支持对任何妊娠中期以后的孕妇立即进行以蒽环类药物为基础的治疗。为评估这一思维上的彻底转变的证据，我们对乳腺癌化疗、妊娠及药物安全领域的相关研究进行了综述。
越来越多的证据表明妊娠晚期以蒽环类药物为基础的化疗具有短期安全性，这显然是相对于传统的治疗性堕胎规范的一种进步。尽管如此，对于孕期常规化疗这一新兴的正统观念，仍应基于以下几点继续提出质疑：（1）早期（即孕期而非产后）进行化疗所带来的假定的母体生存差异尚未得到量化；（2）在富含激素的孕期环境中进行辅助细胞毒性治疗所带来的额外生存获益仍只是推测，尤其是对于雌激素受体阳性的疾病；（3）改良辅助治疗方案（如每周给药方案、省略紫杉烷类等）与母体生存获益相关联，这一点尚未被证实等同于标准方案（如产后方案）；（4）妊娠晚期化疗的长期经胎盘和跨代危害尚不清楚。
尽管无法排除癌症特异性死亡率逐渐增加的风险，但对于那些高度重视其后代终身福祉的母亲，可以告知她们，将最佳化疗推迟至产后仍是一个可考虑的选择，尤其是对于雌激素受体阳性、淋巴结阴性和/或妊娠晚期疾病。
