News in Brief: Avoid chemotherapy in first 12 weeks of pregnancy; Review raises concerns about DCIS overtreatment; Specialists in top 10 for Australian incomes

Wednesday, 16 Jun 2021

Avoid chemotherapy in the first 12 weeks of pregnancy 

The risk of major congenital malformations from chemotherapy during pregnancy is highest when treatment is delivered during the first 12 weeks of pregnancy. But that risk falls to levels seen in the general population if chemotherapy is instead initiated 12 weeks after gestation, a cohort study shows.

The cohort – the largest and most detailed on congenital malformations following chemotherapy – included 755 pregnant women treated with chemotherapy between 1977 and 2019 from several sites across Europe.

According to lead investigator, Dr Frédéric Amant from the Center for Gynecological Oncology in Amsterdam, chemotherapy exposure prior to 12 weeks gestational age was associated with a high rate of major congenital malformations, at 21.7% (95% CI, 7.5%-43.7%).

But when chemotherapy was initiated after gestational age 12 weeks, the frequency of major congenital malformations was 3.0% (95% CI, 1.9%-4.6%) – similar to the expected rates in the general population, they note.

Meanwhile, minor malformations were comparable when exposure occurred before or after gestational age 12 weeks (4.3% [95% CI, 0.1%-21.9%] vs 1.8% [95% CI, 1.0-3.0])

Based on the findings the group suggests that when cancer is diagnosed in early pregnancy, chemotherapy can be initiated from 12 weeks onward. If an aggressive cancer diagnosis during early pregnancy does not allow treatment delay, parents should be counselled on foetal risks of malformations, they add.

The study also highlights how crucial accurate ultrasonographic dating is, with investigators also suggesting that clinicians consider the introduction of a 1-week safety period to further minimise the risk of chemotherapy-induced congenital malformations.

That advice is tempered however with their caution that ‘no rationale exists to delay the start of chemotherapy beyond 14 weeks of gestation.

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Review raises concerns about DCIS overtreatment

A review into the management of ductal carcinoma in situ (DCIS) has raised concerns about overtreatment with new data indicating a substantial number of women receive sentinal node biopsy (SNB) and just 0.4% of women with the condition in Australia and New Zealand do not undergo some form of surgery.

Researchers say the prevalence of SNB among women when it is not indicated should be monitored, adding that there is a need to inform treating specialists about the opportunities to deescalate treatment.

Investigating trends over the last decade researchers from Australia and Sweden assessed the frequency of surgical treatments, adjuvant therapies, and axillary surgery conducted in women with pure DCIS registered to the BreastSurgANZ Quality Audit (BQA) database.

Among 17 883 cases in 2007-16 some 44.9% of women presenting with a high-grade DCIS as well as 53.3% of women presenting with a DCIS tumour greater than 20 mm, had a SNB.

While in these cases, where the risk of finding invasive disease is expected to be higher, a SNB might be an appropriate management say researchers. But the team has questioned the appropriateness of its use in a number of other cases,

According to investigators some 19.6% of low-grade, 29.8% of intermediate-grade, and 23.2% of DCIS cases with a tumour size less than 20 mm had SNB. Meanwhile, 18.0% of the women who had breast conserving surgery also had a SNB. The findings may represent over treatment of a condition, which often, does not progress causing unnecessary intervention with potential harm.

While complications following SNB seem to be rare, ranging between 0.1% and 8.6% of women affected, they include axillary wound infection, axillary seroma, axillary hematoma, axillary paresthesia, decreased upper extremity motion, and lymphedema.

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Specialists in top 10 for Australian incomes

Doctors led by surgeons and anaesthetists hold five of the 10 top places for high-income earners in Australia, according to ATO statistics for the 2018-19 financial year.

Internal medicine specialists were in third spot, with average taxable income of $304,752, although earnings varied by jurisdiction, from $343,353 in Western Australia to $287,437 in NSW and $269,158 in the Northern Territory.

Surgeons were Australia’s most highly remunerated occupation, with an average taxable income of $394,303, followed by anaesthetists on $386,065. Psychiatrists were in 5th place on $235,558, while ‘other medical practitioners’, in 6th place, recorded average earnings of $222,933.

By way of comparison, the average taxable income for Australians was $62,549 overall, ($73,218 for males, $51,382 for females). Besides doctors other high income occupations included financial dealers in 4th place with $275,984, judges and lawyers (7th) with $188,798 and mining engineers (8th) with $184,507.

Australian CEOs and managing directors recorded average incomes of $164,896, (9th) and engineering managers rounded out the list with $159,940.

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