Comment on "Advanced Breast Cancer in Yaoundé, Cameroon"

(Published in Network - Vol 7, Number 4, Winter 2007-08)

Case summary A 26 year old law student detected a breast lump in July 2005, which was eventually excised (February 2006) and reported as a fibroadenoma. In May 2006 she developed another large mass (8cm) in the same breast. Needle aspiration led to a diagnosis of breast cancer. The patient, however, was 14 weeks pregnant and declined a recommended termination. Chemotherapy was delayed until September 2006, and led to spontaneous delivery. The infant survived only one day. One month later an ultrasound examination suggested hepatic metastases. More chemotherapy was given and mastectomy recommended. The patient, however, declined surgery and resorted, instead, to traditional remedies. The tumor progressed, and in late December additional chemotherapy was given. She did not return for follow-up until June 2007 when local disease was very advanced (shown here). She was treated by mastectomy and radiation therapy, but in vain: local recurrence rapidly occurred in association with ascites. The patient was given palliative care.

This tragic case of pregnancy-associated breast cancer in a 26 year old woman illustrates the challenges of delivery proper multidisciplinary cancer care in low and middle income countries (LMCs). First, it should be emphasized that this case would be difficult in the best of circumstances and resources. At the point that cancer was definitively diagnosed at the end of her 1st trimester of pregnancy, she already had a locally advanced cancer – an 8cm mass eroding through skin (T4). The recommendation for induced abortion and neoadjuvant systemic therapy was correct and appropriate, although the necessity for abortion can be debated. Neoadjuvant chemotherapy with adriamycin and Cytoxan beginning in the second trimester of pregnancy can be safely delivered and is considered the standard of care in the United States. Unfortunately, the disagreement between patient and her clinicians regarding pregnancy termination led to delay in the initiation of systemic therapy for 3 - 4 months. It cannot be determined in retrospect whether prompt initiation of systemic therapy without therapeutic abortion would have changed the final outcome. Of note, the cancer continued to progress despite of systemic therapy, suggesting that this cancer was particularly aggressive and drug resistant. Furthermore, it cannot be determine whether the premature delivery resulted from the systemic chemotherapy or from the progressive cancer itself. Only a few weeks after the delivery, hepatic metasases were diagnosed, illustrating the unrelenting progression of disease and suggesting that the cancer may have played a role in the loss of the fetus. A second delay occurred after loss of the pregnancy when locoregional therapy with surgery and radiation was refused, whereby the possibility for local control of disease was lost leaving palliation of symptoms as the only treatment option.

What learning points can be gleaned from this terrible situation? At the core of this treacherous case is failed communication between the patient and her oncology team at the earliest point in her disease's course when a positive impact of therapy would be most likely to have had success. The medical team appears to have believed that abortion was a necessary prerequisite to the provision of care, an option that the patient was unwilling to accept. This disagreement caused an interruption of care during which her cancer progressed. The patient’s decision appears to have been based information received from her community suggesting that traditional medicine with local remedies and prayer could be as effective as systemic chemotherapy, surgery and radiation therapy. Thus, the critical importance of public education about the value of early detection and effectiveness of modern treatment cannot be overemphasized. From the professional side, there may have been a role for professional education regarding the use of neoadjuvant chemotherapy during pregnancy and also about communication with patients regarding methods of gaining patient trust. Had this patient conversed with a breast cancer survivor at the time of diagnosis, her trust might have been achieved earlier in the course of disease. While this case has had the worst possible outcome, future efforts directed at public and professional education could lead to - benefits for future cases.

Benjamin O. Anderson, Breast Health Global Initiative, Seattle, USA