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The Professors Vol. 1 2003: Case
1
Dr Love: Debu,
how do you advise patients about pregnancy?
Dr Tripathy: The two large retrospective
studies available do not suggest that pregnancy itself increases
the risk of relapse (Table 1). These studies, looking at outcomes
of patients who became pregnant compared to age and stage-matched
patients who did not, did not show an excess risk of relapse, even
in patients with ER-positive tumors. However, as clinicians, we
know that some patients with ER-positive tumors associated with
pregnancy seem to have more rapid tumor growth. I honestly don’t
understand why that has not been seen in these studies. It is possible
that these retrospective studies simply don’t have the sensitivity
to detect what might be a true risk. Therefore, we cannot say absolutely
that pregnancy is safe, but these studies have not shown any harm.
I advise patients to make decisions about pregnancy based on
their individual risk of relapse. I agree with Andy that, in high-risk
patients, most of the risk of relapse occurs within the first few
years. The “watch-and-wait” approach allows them to
put some of that risk behind them before making such an important
decision.
However, different women make different decisions. For example,
a woman with a support structure in place that would allow a child
to be raised with security even without a mother might be more
inclined to go forward with pregnancy sooner. The discussion needs
to be individualized.
Dr Harth: I think the “watch-and-wait” approach
is reasonable. Many of my young breast cancer patients have the
option of waiting four or five years before becoming pregnant.
I tell patients that we don’t know the absolute answer, and
I generally recommend, if at all possible, that they wait at least
five years before becoming pregnant.
Dr Tripathy: This makes sense,
because they put some of the risk of relapse behind them in the
first few years. However, there is sometimes the competing problem
that these women are likely to go through menopause early — even
in their 30s— because they received chemotherapy. With each
successive year, their chances of fertility decrease. It’s
a difficult decision.
Dr Love: One
of the lessons here is that medical oncologists have a really,
really difficult job. I applaud Dr Harth for presenting this case
in which there is no good answer. That’s the nature of metastatic
breast cancer and that’s what is involved in the practice
of medical oncology. Dr Harth, what was it like for you to take
care of this woman?
Dr Harth: I’ve been in
practice for over 15 years now, and this was probably one of the
most difficult cases with which I’ve dealt. Treating metastatic
disease in young women is always hard, especially in cases like
this. We become involved with our patients’ social issues,
and it makes our jobs even tougher.
Dr Love: Taking
care of women with metastatic breast cancer has an impact on the
oncologist. What are some of the ways oncologists cope with these
tragedies?
Dr Cohen: It
helps to have a strong support system within your practice. We
have very good social workers who run patient support groups targeted
to the needs of different patients. We have an on-site psychiatrist
who practices only oncologic psychiatry. These people help a tremendous
amount.
Dr Brooks: Medical
oncologists are a modern day manifestation of the myth of Prometheus — chained
to the rock, and each day the big predatory bird eats away part
of him, and overnight he regrows, just to be partially consumed
again the next day. There are many things that we as oncologists
can do to renew ourselves, including seeking support among colleagues.
One thing I’ve also learned from your Breast Cancer Update
audio series is that no one knows how to take care of some of these
very challenging cases — and in a way, that is comforting.
Even though it may be painful from time to time, there is comfort
in the fact that we are all in the same large boat.
Dr Tripathy: When I’m
dealing with a patient who is likely to die, I remind myself of
the many beneficial things I do for them and their family. I explain
what we can and can’t do and make them aware that we need
to harness the capacity we all have to experience tremendous loss.
I give examples of patients who have told me how comfortable they
feel with their situation. They are at peace with themselves, even
though they know they are dying. I share my amazement at this attitude
with my patients and their families, and I confess that I myself,
hope that I could reach this point if I were in their position.
Sharing these experiences with our patients and their families
is rewarding. We have all had family members tell us, after patients
die, how important we were, how much they appreciated our work
and how they’ll never forget what we did. This is the reward
that keeps us going. If this is our goal, death is not always a
failure. Not helping the family to feel security is a failure.
In this regard, there can always be some success no matter how
terrible the outcome.
Dr Love: Debu,
what advice would you give to a medical oncology fellow starting
to deal with these difficult issues?
Dr Tripathy: As Dr Brooks pointed
out, we need the support of our colleagues. We are all under a
lot of stress, and we’ve all seen colleagues burn out. We’re
faced with death all the time, but we have a lot of the same stresses
that other people have. Oncologists are not alone in difficult
jobs. Accountants and lawyers also burn out. We all have the ability
to handle these kinds of stresses if we allow ourselves the support
that we need.
We must understand the limits of what we can and can’t
do. We must be proud of educating and advancing ourselves. We must
hope that we can help our patients to the greatest extent possible,
and we must take care of ourselves.
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Case follow-up: |
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Patient received trastuzumab and vinorelbine
with initial response, then progression |
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Pain increased requiring oral narcotics; pleural
effusion recurred, leading to respiratory arrest (necessitating
mechanical ventilation) and fetal demise
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Continued treatment while on ventilator; was
taken off ventilator and did reasonably well for several
months until imaging studies revealed liver and bone metastases
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