Relapse of cancer after pregnancy
Dr Ang Peng Tiam explains how pregnancy can speed up the growth of cancer cells and why cancer patients need to understand the risks even if “ cancer-free ”
She walked into my room beaming from ear to ear . “ I ’ m pregnant !” she announced joyfully . Seven years earlier in August 2006 , when Jane was 33 years old , she was diagnosed with Stage 2 breast cancer .
At the time , she had gone to see her local doctor when she noticed a lump in her left breast . An ultrasound showed a tumour with an enlarged lymph node in the armpit . Upon hearing the diagnosis of possible cancer , she came to see me for a second opinion .
The lump in the breast measured about 2 cm in size . It was easily palpable . I stuck a fine needle into the lump and aspirated some cells . Within an hour , the pathologist confirmed that it was cancer . Thankfully , investigations didn ’ t show any evidence of cancer spread .
As the tumour was small , she had the option of removing the whole breast ( a mastectomy ) or only the part of the breast with the cancer ( partial mastectomy or wide excision ). As the lymph nodes were clinically involved , all the lymph nodes in the axilla ( armpit ) had to be removed ( axillary clearance ) at the same time .
Jane opted for a wide excision with axillary clearance , and this was carried out in August 2006 .
The final pathology confirmed that the cancer was 2 cm in size , and only one out of the 17 axillary lymph nodes that were removed contained cancer cells . The cancer cells stained positive for both estrogen and progesterone receptors , meaning that they were to some extent “ driven ” by hormones .
After the surgery , Jane went for eight cycles of chemotherapy . She also received radiotherapy to the breast as this is a requirement for patients who have opted not to have a mastectomy . By March 2007 , she was essentially done with the major part of her treatment .
As Jane had hormone-receptor positive breast cancer , she was prescribed Tamoxifen , an antiestrogen tablet , to be taken daily . She came back for follow-up reviews every three to four months . Tamoxifen was continued for five years until March 2012 when we discussed various options .
One was to continue taking Tamoxifen , and another was to switch to an enhanced hormone therapy which involved injections to stop her menses completely . The last option was to stop hormone therapy and do nothing , which she chose .
Jane had a son who was three and a half years old when she was first diagnosed with breast cancer . The child was conceived after she had gone for IVF treatment . One of the reasons Jane wanted to stop Tamoxifen after five years was that she was considering having a second child .
There was no certainty that she would be able to conceive again . Factors working against her getting pregnant included a history of extensive chemotherapy , age ( she was already 40 years old ), and her previous need for IVF treatment to conceive the first time around when she was only 30 .
Despite these odds , two years later during a followup visit in March 2014 , Jane told me of her pregnancy . Naturally , she was very happy . In July 2014 , she gave birth to a baby girl . With one boy and one girl , she felt blessed and complete .
In November 2014 , after she stopped breast feeding , she came back to see me for her annual check-up , which consisted of a mammogram , chest X-ray , ultrasound , and bone scan . All was well .
Busy with the newborn baby , Jane missed her regular follow-up appointments and showed up only in June 2015 . At first , I wasn ’ t too perturbed by the delay . After all , Jane had remained cancer-free for almost asdf nine years since her surgery . The term “ cancerfree ” is used when we cannot detect any evidence
58 APRIL 2021 GlobalHealthAsiaPacific . com