Coordinating Breast Cancer Care for a Patient in Early Pregnancy

When a woman in her early 30s presented to NYU Langone Health’s Perlmutter Cancer Center in the first trimester of pregnancy with a new diagnosis of breast cancer, her multidisciplinary care team—involving maternal–fetal medicine (MFM) and surgical and medical oncology—aligned on one shared priority: optimizing maternal care while ensuring fetal safety.

Breast cancer treatment in the first trimester is particularly complex. “We always start by asking, ‘What would we do if this patient was not pregnant?’” says MFM subspecialist Justin S. Brandt, MD, who partners closely with oncologists to support pregnant patients navigating cancer care. “We want to avoid unnecessary delays or deviation from standard cancer care, while managing the pregnancy to reduce complications such as prematurity.”

“At NYU Langone, we’re seeing more breast cancer cases in pregnant women because we have the multidisciplinary support it takes to care for both mom and baby,” says breast surgeon Mary L. Gemignani, MD, MPH, director of the Early Onset Cancer Program. “Survivorship has really evolved into a holistic, individual, and personal experience, and our program honors that.”

Surgery First

The patient’s cancer was ER-positive and HER2-positive. Though the team anticipated a need for endocrine therapy, that would need to wait until after delivery. Breast surgery, on the other hand, can be performed safely in any trimester of pregnancy, generally without major risk of obstetric complications.

“There is no trimester when surgery is absolutely contraindicated,” says Dr. Brandt. “When we have a choice, we plan it for early in the second trimester. And for this patient, we timed surgery for the end of the first trimester to enable chemotherapy as soon as possible in the second, when it is generally considered safest for the fetus.”

With timing confirmed, the question of surgical approach remained. Options discussed included lumpectomy or mastectomy, as well as whether chemotherapy would be given before delivery.

Although lumpectomy can be performed early in pregnancy, the required postoperative radiation would need to be deferred until after delivery. With concerns about this delay in radiation therapy, the treatment recommendation shifted to mastectomy. In addition, mastectomy would simplify breast surveillance during the pregnancy, as imaging such as breast MRI with contrast is generally not recommended.

“Given the early pregnancy, and delay in administering radiation therapy post lumpectomy, we shifted to mastectomy as the best surgical treatment option,” notes Dr. Gemignani.

The patient underwent a unilateral mastectomy and reconstruction with a tissue expander. A sentinel node biopsy for cancer staging was performed using radiotracer alone and avoiding blue dye, which is contraindicated in pregnancy due to fetal risks and the potential for an anaphylactic reaction. Dr. Brandt provided pre-surgical and post-surgical fetal monitoring.

Scheduling Chemotherapy

Concurrently, medical oncologist Elizabeth Comen, MD, devised a chemotherapy plan to maximize safety while preserving curative intent. “In a nonpregnant patient with HER2-positive disease, we likely would have advised neoadjuvant therapies with agents, such as trastuzumab, that are contraindicated in pregnancy,” Dr. Comen explains. “Instead, we selected safer therapeutic agents for the duration of the pregnancy, with a plan to add HER2 inhibitors post-delivery.”

Since the baby was at risk of preterm labor later in the pregnancy—and the mother was intermittently contracting, a common side effect of chemotherapy—Dr. Brandt and Dr. Comen adjusted the schedule to avoid fetal myelosuppression. “You want to stop chemotherapy about four weeks before delivery,” Dr. Brandt explains, “to allow the patient and fetus time to recover blood counts and optimize delivery outcomes.”

The patient carried to term, delivering vaginally after a successful trial of labor after cesarean. “Vaginal delivery reduces the risk of thromboembolism, facilitates quicker recovery, and enables us to resume cancer treatment sooner,” says Dr. Brandt.

Ongoing Care

Following delivery, the patient completed HER2-directed therapy and hormone therapy as planned. While HER2-positive disease carries a higher risk of recurrence, her treatment was considered curative and her prognosis positive.

“For a pregnant patient, ‘optimal care’ means ensuring fetal safety while providing the best treatments available, tailored to the patient’s condition and life,” reflects Dr. Comen. “We are uniquely equipped here at Perlmutter Cancer Center to provide this level of care, with a range of experts that treat the patient, not just the disease.”

“Maternal–fetal medicine is part of every decision—medication timing, anesthesia, positioning, postpartum recovery,” adds Dr. Brandt. “You need that integration to make complex cases like this successful.”