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Derived from podophyllotoxin, it is an inhibitor of mitosis. There is a high risk of serious side effects such as myelotoxicity (AEMPS 2015, Bristol MS 2010).
Indicated in certain leukemias, lung neoplasms and others; it is generally associated with other chemotherapeutic agents.
Intravenous or oral administration: 3 to 4 cycles of daily intravenous or several oral doses for 3 to 5 days followed by a 10 to 20 day break (AEMPS 2015, Bristol MS 2010).
Its high percentage of protein binding would explain the limited transfer to breastmilk (Azuno 1995). Due to its short half-life (T½), levels were undetectable in milk at 24 hours (Azuno 1995). The mother referred to in this publication (Azuno 1995), who also took mitoxantrone (T½ 1 to 9 days) and cytarabine (T½ 1 to 3 hours), waited 3 weeks before breastfeeding again; the infant did not present any problems in a follow-up at 16 months.
Given its serious side effects, it is prudent to interrupt breastfeeding during the period when the drug is still in the mother's body.
When it is possible to do so, detections in the breastmilk of each patient to determine the total elimination of the drug would be the best indicator of resuming breastfeeding between two cycles of chemotherapy.
It is known from pharmacokinetics that after 3 elimination half-lives (T½) 87.5% of the drug is eliminated from the body; after 4 T½ it is 94%, after 5 T½, 96.9%, after 6 T½, 98.4% and after 7 T½ it is 99%. From 7 T½ the plasma concentrations of the drug in the body are negligible. In general, a period of at least five half-lives can be considered a safe waiting period before breastfeeding again (Anderson 2016).
Expert authors recommend waiting 3 days (about 6 T½) after the last dose to resume breastfeeding. Meanwhile, express and discard milk from the breast regularly (Hale 2017 p.353, Pistilli 2013).
Some chemotherapeutic agents with antibiotic effects can alter the composition of the microbiota (bacterial cluster or bacterial flora) of the milk and the concentration of some of its components (Urbaniak 2014). This possibly occurs temporarily with subsequent recovery, although no harmful effects are expected nor have been reported in breastfed infants.
Given the strong evidence that exists regarding the benefits of breastfeeding for the development of babies and the health of mothers, it is advisable to evaluate the risk-benefit of any maternal treatment, including chemotherapy, individually advising each mother who wishes to continue with breastfeeding (Koren 2013).
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