Malignancy in pregnancy — structured oral station (12 minutes)

Opening prompt — "Take me through your management from this point."

Model response — say it in this order: [1][2]

• "This is a breast cancer diagnosed in pregnancy, and the principle that governs everything from here is that cancer treatment in pregnancy is possible and should not be deferred solely because of pregnancy when the prognosis is curative."
• "I would convene the multidisciplinary team — maternal–fetal medicine, medical and surgical oncology, anaesthesia, neonatology, perinatal mental health, a pathologist and the woman herself. If my unit does not have local expertise, I would refer to the Advisory Board on Cancer, Infertility and Pregnancy, which provides a virtual on-demand tumour board."
• "My immediate next steps are staging imaging with the pregnancy in mind, surgical planning with sentinel node biopsy, and systemic therapy planning with the timing rules — chemotherapy after the first trimester, stopped by 34 weeks."[1]

Probe 1 — "She needs staging imaging. How do you approach this in pregnancy?"

• "Ultrasound and non-contrast MRI are the first-line modalities in pregnancy (SMFM GRADE 2B). For this woman, breast MRI without contrast is reasonable for local staging, and chest imaging would use low-dose CT protocols."
• "If clinically indicated, CT with or without contrast, gadolinium-enhanced MRI, and 18-FDG-PET/CT should not be withheld (SMFM GRADE 1C). Modern dose-sparing protocols keep the fetal dose well below the threshold for deterministic harm."
• "Abdominal shielding is no longer recommended for diagnostic imaging with ionising radiation in pregnancy — LeJeune 2025 showed it can increase scatter dose to the fetus and degrade image quality."[6]

Probe 2 — "What is your surgical approach, and what is the evidence for sentinel node biopsy in pregnancy?"

• "Surgery is safe at any gestation (SMFM GRADE 1C). For a 2.8 cm HER2-positive tumour, the operation is mastectomy or wide local excision with sentinel node biopsy, decided jointly with the breast surgeon and the woman."
• "Sentinel node biopsy using 99mTc-labelled nanocolloid is supported by the INCIP series of 145 pregnant women — a low axillary recurrence rate of 0.7% at 48-month follow-up, comparable to non-pregnant women, with no neonatal adverse events. Blue dye is avoided because of anaphylaxis risk."[4]
• "Radiotherapy is deferred to postpartum; if it would be required during pregnancy, mastectomy is preferred to avoid an inadequate operation."

Probe 3 — "Tell me about the systemic therapy, including what you would not give."

• "Anthracycline- and taxane-based chemotherapy after the first trimester — the first trimester is the malformation window. The INCIP comparison of pregnant breast cancer patients treated with chemotherapy versus non-pregnant controls showed comparable outcomes, so standard regimens continue in pregnancy."[5]
• "Stop most chemotherapy by 34 weeks for marrow recovery before delivery, with a treatment-free window of around three weeks before birth."[5]
• "I would not give tamoxifen — it is contraindicated for clinical use in pregnancy, with barrier contraception during treatment and for three months after stopping. Trastuzumab is avoided because of oligohydramnios and fetal renal injury. Checkpoint inhibitors are avoided in pregnancy because of fetomaternal immune-tolerance disruption."

Probe 4 — "She asks whether her pregnancy has worsened her prognosis. What do you tell her?"

This is the counselling the station is built around — the literature answer that frees the woman to choose her own course. [3]

• "I would tell her honestly: the international collaborative study (Amant 2013) of 311 women with breast cancer during pregnancy compared with 865 age-matched non-pregnant controls found similar overall survival — a hazard ratio for death of 1.19, 95% CI 0.73 to 1.93. Pregnancy does not, in itself, worsen the prognosis of breast cancer when treatment is appropriate."
• "I would explain that the option to treat with continuation of pregnancy is supported by the data, and that the decision about continuation is hers, made with the multidisciplinary team."[3]

Probe 5 — "Describe the delivery planning and the aftercare."

• "Avoid planned delivery before 37 weeks unless medically indicated. If she is on chemotherapy, stop by 34 weeks for marrow recovery; aim for a treatment-free window of around three weeks before birth."
• "Send the placenta to pathology in every case of cancer during pregnancy (SMFM GRADE 1C) — it is the only way to detect placental metastasis."
• "Postpartum: complete cancer treatment; decide on lactation based on the timing of the last chemotherapy dose; contraception counselling; surveillance imaging; and a structured debrief. Address future fertility explicitly — this woman is 34, and the conversation about her next pregnancy belongs in the treatment plan, not an afterthought."[5]

Communication probe — "She is in tears and says she is terrified of dying and leaving her baby."

This is a scored domain, not a courtesy. Demonstrate it out loud: [1]

• Move to her eye level, use her name, acknowledge the fear without minimising it: "I can see how frightening this is. The data we have — and there is a lot of it now — tell us that being pregnant does not make your cancer worse, and that we can treat you safely while you are pregnant. You are not choosing between yourself and your baby."
• Allocate a named support person — partner, family member, perinatal mental health clinician — to be with her through the appointments.
• Commit to a structured follow-up: a written plan, a named coordinator, a debrief after every treatment decision. The fear of dying is real; the antidote is information, continuity and a team she trusts.[1]