S. Loibl et al.

Annals of Oncology

Table 1. Cytotoxic agents in relation to breast-feeding

Agent Protein binding (%) Half-life Waiting period suggested Comment References
between the last chemo
in pregnancy and breast-feeding
Doxorubicin 75 20-48 h 14 days d Codacci-Pisanelli et al.115
Epirubicin 55 40 h 14 days d d
Cyclophosphamide 13 w7.5 h 5 days Bone marrow suppression reported d
in 2 neonates while simultaneously
receiving chemotherapy
Docetaxel 95 11 h 3 days d Manufacturer
1 week
Paclitaxel w89-98 13-52h 15 days d d
Carboplatin 85-89 6h N/A d Manufacturer

incidence of perioperative fetal distress during cancer sur-
gery and the general feeling is that this is a very rare event.
Depending on the risk of prematurity and gestational age,
the obstetrician will decide on the need for steroids for fetal
lung ripening. Up until 24 weeks, pre-operative cervical
length screening can be considered before the procedure to
decide about risk of prematurity if the patient has a history
of preterm birth.
20 agree, 0 disagree, 4 abstain
100% consensus
QUESTION 22: In pregnancies complicated by BC and
treatment with chemotherapy before birth, how is lacta-
tion affected?
STATEMENT 22: Surgery involving the areola or nipple
complex will affect breast-feeding. If a patient has a mas-
tectomy, the infant can receive adequate milk from a single
breast. Patients receiving chemotherapy are currently
advised not to breast-feed because of the possible presence
of chemotherapy in breast milk and the cytotoxic effects to
the infant. During postpartum radiation therapy, it is ‘not’
recommended to breast-feed or stimulate milk production
from the treated breast. Depending on the gestational age
when chemotherapy started, and the number of cycles,
chemotherapy during pregnancy may affect the amount of
milk produced (V).
Discussion: Data on infant safety on oncological treatment
during breast-feeding are scarce.114 Patients receiving
chemotherapy are currently advised not to breast-feed
because of the possible presence of chemotherapy in
breast milk and the cytotoxic effects to the infant. In
addition, after chemotherapy during pregnancy, many
women report a decreased milk supply. The earlier gesta-
tional age at treatment and the increasing number of cycles
are significantly related to decreased breast milk produc-
tion. During postpartum radiation therapy, it is ‘not’ rec-
ommended to breast-feed or stimulate milk production in
any way from the treated breast. Radiation does not affect
the safety of the milk, but in the radiated breast mastitis is
difficult to treat and breast-feeding from the radiated breast
is not recommended.
If a patient is discouraged from breast-feeding due to the
need to receive chemotherapy, there is a benefit to the
infant (and to the mother’s birth experience) to provide the
infant with colostrum.
Table 1 gives an overview of the different agents and their
half-lives for women to decide if enough time has passed
between chemotherapy during pregnancy and delivery.
Recently, a study was carried out testing actual breast
milk for evidence of chemotherapy in three patients
providing milk for analysis while undergoing chemotherapy.
Damoiseaux et al.59 just recently in 2022 suggest that
breast-feeding in between cycles is an option as well. Three
patients collected 24-h samples of breast milk every day for
1, 2 or 3 weeks after chemotherapy, with a total of 210.
After determination of drug concentrations, the infant daily
dose, relative daily infant dose (RID%) and cumulative RID
were calculated. Cumulative RIDs in patients varied from
10% to values lower than 1%. Rich data allowed us to
design a table which gives predictions on the number of
days that breast milk has to be discarded to reach cumu-
lative RIDs below 5%, 1% and 0.1% for each compound. For
cyclophosphamide, paclitaxel and carboplatin, cumulative
RIDs below 1% or 0.1% are reached if breast milk is dis-
carded for 1-3 days after administration. However, still
safety data are very limited.
On an individual basis, the patient may be able to provide
colostrum to her infant before starting chemotherapy
postpartum.
22 agree, 1 disagree, 1 abstain
95.65% consensus
QUESTION 23: How do we address the additional psy-
chological support that may be required for pregnant
women with cancer and their families?
STATEMENT 23: Psychological support is required for the
families that are confronted with cancer during pregnancy.
The need is higher in case of lower coping strategy. Not all
women/families need this support; it is suggested to indi-
vidualize according to the patient’s and partner’s needs (V).
DISCUSSION: Since cancer or cancer treatment represents a
physical and psychological burden for pregnant women, this
can lead to stress during pregnancy and postpartum. Even
before the diagnosis of cancer, pregnant women are dealing
with increased stress in a major life transition involving
emotional and physical changes.116-121

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