TEALE FENNING

Jullien Brady · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 39

A nice easy medical disorder of pregnancy to start you off.

A woman has had a breast cancer a year previously. She is considering pregnancy. She has consulted you for pre-pregnancy counselling.

What factors would you need to ascertain to assess the severity of her disease status? (4 marks)

What are the implications of her diagnosis on pregnancy? (5 marks)

If the patient decided to embark upon pregnancy, what modifications would you suggest to her care? (11 marks)

I will post the marking scheme in the week.

Good writing, and keep up the hard work to all.
_________________
Jullien Brady B.Sc. MB.BS. MRCOG.
Teale Fenning Administrator

Abik · Posted: Sat Feb 17, 2007 8:34 pm Post subject:

Thanks Jullien, this is a great idea and a tricky first question.
Just as a rough and starter for ten...

Assess severity?

History main part.
Diagnosis - stage important, as reflects prognosis.
Treatment given incl. surgery/chemo/radio.
when treatment was finished is vital.
any recurrance already?
symptoms now from disease or treatment?
Get assessed by oncologist/surgeon invlolved ion her care.
Menstruation returned? or ever stopped?

implications?

this stem says disease on pregnancy rather than pregnancy on disease.
Fertility issues to discuss, menstruation doesn't always mean fertile. contraception here too?
BF OK
Generally prognosis of pregnancy thought to be positive
risk to foetus from previous treatment negligable.
Increased surveillance of pregnancy and disease needed.
Should delay pregnancy according to stage - ideally 2 years but longer if advanced and not at all if recurrance.

Have to go for dinner now!!

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

Thanks Jullien

What factors would you need to ascertain to assess the severity of her disease status? (4 marks)

- Stage of disease at diagnosis and prognosis. Is she going to survive to bring up her baby? Is she going to be in a good condition to look it after?
- Positive estrogen or progesterone receptors? Theoretically pregnancy can exacebrate disease, meta or cause recurrence
- Treatment that has recieved so far. Is treatment complete? Chemo can cause POF and some are contraindicated in pregnancy. Radiotherapy also.
- Is she on tamoxifen? Tamoxifen is teratogenic

What are the implications of her diagnosis on pregnancy? (5 marks)

- Pregnancy is usually not adviced for the first 2 years after treatment as recurrences will mostly happen then
- Monitoring of the disease might be difficult due to physiological changes to the breast
- Chemotherapy (alkyliating agents) can cause ovarian failure and subfertility
- Psycological impact is also significant
- Generally the pregnancy outcome though is good

If the patient decided to embark upon pregnancy, what modifications would you suggest to her care? (11 marks)

- Another stubborn patient...
- If disease is active and chemotherapy/radiotherapy advised, discuss TOP.
- Pregnancy has little effect on the course of the disease
- MDT care with obstetrician, midwife, oncologist, gen surgeon, oncology nurse.
- FNA to any suspicious lumps/ mammography (although reduced sensitivity due to increased blood supply to breasts)/ excisional biopsy/ mastectomy are all generally safe to perform
- Methotrexate BAD- stop, all chemo agents should be stopped in first trimester, cyclophsosphamide can be continued after organogenesis but levels and liver function should be checked (i think)
- There is also no place for hormonal treatment
- Radiotherapy very bad.
- Anomaly scan in 2nd trimester
- No need for serial growth scans or increased fetal monitoring as there is no effect of the disease to the fetus
- Consider earlier delivery (when maturity is achieved ?32 weeks) if suspicion of relapse. Give steroids
- Breast feeding if practicalities allow is safe (?)
- Post natal MDT review/assesment for further treatment

Abik · Posted: Mon Feb 19, 2007 9:35 am Post subject:

What do people think about Wolverine's question regarding whether this woman will survive to raise her child?
Personally, if I was the examiner and you wrote this I would be verty cross and would not want to give you any more marks!!!!!!
I don't think it's relevant or any concern of ours.
I certainly hope you weren't planning on asking her!

As for the rest, well done Wolverine. Another great essay bubbling. I think the second part of the question is hard- is this disease on pregnancy and pregnancy on disease?
Where should we mention folate/alcohol/rubella!!?

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

agree with abi, wouldn't want to go into life expectancy, atleast not at the start of the essay, that is a social issue, but is out of our sphere of duty.

the folate/alcohol/rubella bit i may put at the very end or with the MDT bit.

Very Happy

_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

...during the MDT meeting you mean?

Jullien Brady · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 39

Posted: Mon Feb 26, 2007 8:52 am Post subject: Answer for the breast cancer question.

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Here is the answer for the first essay of the week on breast cancer:

A woman has had a breast cancer a year previously. She is considering pregnancy. She has consulted you for pre-pregnancy counselling.
What factors would you need to ascertain to assess the severity of her disease status? (4 marks)
What are the implications of her diagnosis on pregnancy? (5 marks)
If the patient decided to embark upon pregnancy, what modifications would you suggest to her care? (11 marks)

What do we know?
Had treated breast cancer 1 year previously.
Is considering pregnancy, so not yet pregnant.

What do we not know?
How breast cancer was treated and was it successful?
Has treatment finished?
Age of patient.
Previous obstetric history etc.

Category.
Obstetrics, medical disorder.

Approach.
Counselling, modified management.

Impact.
Obstetricians likely to see more cases, due to increased incidence but falling mortality of breast cancer.

Concept.
Patient should be counselled in light of information on previous treatment and bearing on possible pregnancy.

What factors would you need to ascertain to assess the severity of her disease status? (4 marks)
If the patient is still undergoing treatment for her breast cancer pregnancy is contra-indicated.
The treatments used on any treated breast cancer should be established.
Chemotherapy treatment may have caused a premature menopause.
Regular menstruation and ovulation should be investigated if indicated, but resumption of menstruation following chemotherapy does not confirm restoration of fertility.

What are the implications of her diagnosis on pregnancy? (5 marks)
Long term survival rates after breast cancer do not appear to be affected by subsequent pregnancies.
Fertility may have been compromised by chemotherapy.
There appears to be an increased chance of pregnancy loss and miscarriage following treatment for breast cancer.
There is no evidence that cytotoxic drugs used in the treatment of breast cancer prior to pregnancy produce any adverse effects on fetal development or the neonate.

If the patient decided to embark upon pregnancy, what modifications would you suggest to her care? (11 marks)
Deferring pregnancy.
It is recommended that pregnancy be deferred until 2 years after treatment, to allow differentiation of those patients with a better chance of long term survival from those with more aggressive disease. Younger women have significantly lower survival rates, and higher local and distal relapse rates, so those women under the age of 33 are advised to defer pregnancy for 3 years to reduce the risk of relapse.
The final decision on deferring pregnancy should be the patients.
Ante-natal care.
Standard pre-conceptual advice regarding diet, exercise, smoking, folic acid, and rubella status should be given.
Normal ante-natal screening should be offered.
Intra-partum care.
Vaginal delivery is not contra-indicated, and decisions for delivery should be conducted on obstetric grounds.
Post-partum care.
There is no evidence to contra-indicate breast feeding from the unaffected breast. With regard to the affected breast, conserving surgery may allow for feeding, but irradiation causes fibrosis and makes lactation unlikely.
Suitable contraceptive advice should be given, with the avoidance of oestrogen containing methods that may compromise breast feeding and increase recurrent breast disease risk.
_________________
Jullien Brady B.Sc. MB.BS. MRCOG.
Teale Fenning Administrator
_________________
Jullien Brady B.Sc. MB.BS. MRCOG.
Teale Fenning Administrator

Nick Raine-Fenning · Posted: Wed Feb 28, 2007 4:26 pm Post subject:

Nick Raine-Fenning · Posted: Wed Feb 28, 2007 4:27 pm Post subject:

Jullien Brady · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 39

Those are all valid points, but perhaps a little to detailed for something that is only worth 4 marks.

The marking scheme reflects a more wide reaching approach.
_________________
Jullien Brady B.Sc. MB.BS. MRCOG.
Teale Fenning Administrator

mrcog2010 · Joined: 08 Jul 2008 Posts: 32

this was the old question
A woman has had a breast cancer a year previously. She is considering pregnancy. She has consulted you for pre-pregnancy counselling.

What factors would you need to ascertain to assess the severity of her disease status? (4 marks)

What are the implications of her diagnosis on pregnancy? (5 marks)

If the patient decided to embark upon pregnancy, what modifications would you suggest to her care? (11 marks)

but my question is, what if a lady discover that she has a breast cancer while she's pregnant ?..what will be her mangment?

mrcog2010 · Joined: 08 Jul 2008 Posts: 32

i donno what is ur point of view nick, but here iam opening the old thread and adding my topic...can we discuss now Idea

mrcog2010 · Joined: 08 Jul 2008 Posts: 32

did the RCOG publish any guideline for this ?

Nick Raine-Fenning · Posted: Wed Sep 10, 2008 4:51 pm Post subject:

Nick Raine-Fenning · Posted: Wed Sep 10, 2008 4:53 pm Post subject:

mrcog2010 · Joined: 08 Jul 2008 Posts: 32

thanks nick i'll check it and try to re-formulate the answer Smile