Pregnancy-Associated What?!?

During medical training, I learned a lot about post-partum breast cancer. In particular, I learned postpartum breast cancer is generally diagnosed early, is generally treated as an outpatient, and patients generally do well. On my notes from my scientific basis of medicine lecture during second year, I wrote the following regarding pre-menopausal breast cancer: "high grade, generally advanced stage, extremely poor prognosis." The good news is that new treatments, particularly for Her-2 positive disease, have markedly changed the landscape for some pre-menopausal women. When I was in medical school, the major trial on herceptin as an adjunctive chemotherapy agent was ongoing; this drug has proven to be extremely effective for patients with the Her-2/neu receptor. Since then, two more monoclonal antibodies have been developed (kadcyla and pertuzumab) and both show great promise. In addition, data from more recent years shows that, after adjusting for stage of disease at diagnosis, age is not an independent risk factor for poor outcomes, at least for Her2-positive disease.

However, despite all of my medical training, I had never even heard of pregnancy-associated, or post-partum breast cancer.

Conventional wisdom is that pregnancy, particularly prior to age 30, reduces the life-time risk of breast cancer. The dirty little secret: While pregnancies clearly reduce life-time risk, there is actually a slight increase in breast cancer during the intra- and post-partum periods. In fact, approximately 1 out of every 3000 pregnancies will cause breast cancer. Further, there is epidemiologic evidence that pregnancy-associated breast cancer may actually be increasing. This increase has largely been attributed to increasing maternal age, but the underlying cause remains unclear.

One in 3000 is a very small number-- but it is not zero -- and it is a risk that every pregnant and breastfeeding woman should know about. Finding lumps during the intra- and post-partum periods is difficult, because breasts are dense, and clogged ducts are common. However, if a lump is found, it is very, very important to get it checked out-- up to 20% of lumps during pregnancy and lactation turn out to be malignant, and, in general, pregnancy-associated breast cancer is aggressive and nasty-- so early diagnosis is particularly important to ensure the best possible outcome (Note that, after adjusting for stage at diagnosis, the 95% confidence interval crosses one, which means there is no statistically significant difference).

TCH #5 of 6: The Home Stretch!

Infusion #5 in— which means I am getting very close to the end! At this point, I have figured out ways to keep most of my chemo-related symptoms in check and I am obsessively rubbing my head to monitor for new hair growth (it is there!). I am also still going to the gym 3-4 times per week, including one strength-training workout with my trainer per week (I wear an arm sleeve during the exercise, but am not sure this is actually necessary).

At this point, the allergists have worked out a regimen that works well, including a slow infusion and pre-treatment with singulair and the tried-and-true aspirin. I have not had any problems since, but do get quite bored with the 10-hours of infusion time.

Side effects of TCH & Management

In general, the steroids part of the regimen remains the worst part for me (and my husband) because they make me batty. However, this only lasts for three days, and, because of the desensitization unit, I am no longer getting high-dose IV steroids, which helps a lot.

Other than the steroids, the other nagging symptom is the metallic taste on my tongue—it is fairly predictable, and very difficult to manage. The two strategies I have come up with are masking the taste (mint gum works well) and acupuncture. Acupuncture does not cure the symptom entirely, but I think it helps and is better than doing nothing.

Here are the rest of the symptoms I have experienced, and what has helped:

Bone pain (from neulasta): The major intervention that has helped with the bone pain is going to the gym. I do not do a hard work out, just relatively light and short cardio, but this keeps my joints from getting stiff and significantly reduces the bone pain. Plus, it was recently shown that regular exercise during chemotherapy and radiation is beneficial to cancer patients-- even during therapy. So there are many reasons to do it! Although in the past, the medical establishment has been reluctant to recommend exercise during acute illness, in nearly every setting in which it has been studied (post-MI, intensive care patients, others), exercise improves outcomes.

In addition to going to the gym, I have maintained pre-treatment with Claritin and naproxen, then Claritin x 4 days after injection and naproxen twice day for four days after injection.  I am not sure that all of this is actually necessary, but now that I have a system that works, I am reluctant to change it.

Dry eyes: Use of preservative-free eye drops on rare occasion, and acupuncture, which was recently written up in a major ophthalmology journal as one of the optimal treatments for this condition. Acupuncture has been demonstrated in many clinical trials to be a very useful adjunct treatment in chemotherapy symptom control; click on the links for a list of WHO-recommended uses and clinical trial summaries.

Peripheral Neuropathy: I definitely experienced some peripheral neuropathy in my infusion arm after the first infusion. This has been very well controlled (I have almost none at this point) with both B-complex vitamins and acupuncture.

Nausea: Overall, I have had very little nausea, but I am given aloxi prior to every infusion. What little nausea I do get is very well controlled by acupuncture.

Reflux: Pepcid once per day on the day of chemotherapy, and once per day for four days following each infusion.

Hair, Redux: A Few Days Prior to TCH Cycle #5

2.5 weeks after TCH cycle #4

We had a great time at a wedding this weekend- I was even able to find a deco-style headband with some flare to wear with my dress! My mother very kindly took me shopping for more headbands, and we were even able to find some fabulous ones in leopard print (which normally I would never wear unless it is Halloween!). I think that the added flare helps to add a distractor to my very thin hair, and sends the message that I am not sick. 

Last week, in clinic, I was wearing a scarf, and my patient told me at the end of the visit that she would pray for me. While it was a nice sentiment, I hate being treated as if I am sickly—that is not the sort of attention that I want! I am still grateful to my friend who took one look at me in the scarf and said, “Take that off- it looks terrible!” That was exactly what I needed to hear to gain the courage to just walk around as I am! Perhaps I will wear the leopard print to see patients next week instead.