COMMENTARY

Managing Cancer During Pregnancy

Peter Kovacs, MD, PhD

Disclosures

October 29, 2014

Cancer and Pregnancy: An Overview for Obstetricians and Gynecologists

Salani R, Billingsley CC, Crafton SM
Am J Obstet Gynecol. 2014;211:7-14

Background

It is devastating for anyone to receive the diagnosis of cancer, but it is especially devastating for a pregnant woman when she has to worry about not only herself but the safety of her baby as well. The incidence of cancer during pregnancy is around 1:1000 to 1:2000, and an increase over the past decades can be seen.[1] This is most likely due to the more advanced mean age of women during pregnancy; cancer incidence is known to be higher with increased age.

The most common cancers among women in general are breast cancer, lung cancer, colorectal cancer, uterine cancer, thyroid cancer, and lymphoma. The most common cancers diagnosed during pregnancy are breast cancer, lymphoma, leukemia, and cervical cancer. This expert review summarized the diagnostic and therapeutic choices for the most common types of cancers detected during pregnancy.

The Study

The authors start by reviewing the diagnostic dilemmas that occur during pregnancy. The symptoms that can be associated with early or advanced cancer (eg, breast tenderness, nausea, abdominal pain) can easily be attributed to the pregnancy itself. Therefore, it is important to remain suspicious when symptoms persist or occur in a phase of pregnancy when it no longer is considered typical. A physical exam can always be helpful. Ultrasound and MRI are safe to use. Exposure to higher-dose x-ray may be associated with anomalies, decreased IQ, and childhood malignancies. Laboratory testing of tumor markers may be affected by the normal changes during pregnancy.

Depending on the type of cancer surgery, chemotherapy or radiation therapy is typically offered, but management close to term may be acceptable. Depending on gestational age, local regulations, and the type of treatment needed, it is also important to consider the maternal benefits of pregnancy termination.

Breast cancer typically is treated surgically with adjuvant chemotherapy. Chemotherapy can be considered in the second and third trimester, but radiation and hormonal treatments should be delayed into the postpartum period.

In the case of an abnormal Pap smear, further testing using human papillomavirus screening, colposcopy and directed biopsy can be carried out. Endocervical curettage, however, is contraindicated. If required, even cone biopsy can be carried out with careful follow-up. Microinvasive and invasive disease can be managed by trachelectomy. Neoadjuvant chemotherapy can be considered, but radiation therapy needs to be avoided during pregnancy.

Ovarian tumors are managed surgically with subsequent chemotherapy. The standard platinum and taxane-based protocols can be used during pregnancy as well.

Hematologic cancers that occur during pregnancy are typically managed by chemotherapy. When surgery is performed, well-being should be monitored beyond 24 fetal weeks. Preterm delivery is possible either during the surgery or in the subsequent period.

Chemotherapy administered within the first 2 weeks after implantation has an all-or-nothing effect on the pregnancy. During organogenesis, it may induce malformations, however, and should be avoided. Beyond week 8 of pregnancy, it may interfere with fetal growth, result in fetal hematologic suppression, and increase the risk for prematurity and, rarely, in utero death. Exposure to radiation in doses exceeding 20 rads is teratogenic and could result in pregnancy loss.

Viewpoint

When cancer is discovered during pregnancy, the health of the mother needs to be considered, but the prognosis for the fetus becomes increasingly important as one gets closer to term.

Because cancer is rare among young women, the general suspicion is low for it. The typical pregnancy-related symptoms and physiologic changes make it even more difficult to diagnose cancer in pregnant women. When the suspicion is raised and is supported by physical findings, there is still the dilemma about the proper diagnostic tests. Certain tests can be safely used (ultrasound, MRI), while others should be limited or avoided (CT, x-ray). The gestational age and the body area of interest also may affect the test that one uses. Radiation that directly reaches the embryo or fetus may cause dose-dependent teratogenic effects. Tumor markers are often used during the work-up of ovarian cancers. Cancer antigen (CA)-125, human chorionic gonadotropin, and alpha-fetoprotein are affected by the pregnancy itself, but CA19-9, carcinoembryonic antigen, and lactate dehydrogenase can still be used. Biopsy can be obtained from any solid or cystic lesion when needed without affecting the pregnancy.

Once the diagnosis has been made, one has to face treatment dilemmas:

Does the pregnancy affect the prognosis?

Is the pregnancy viable already?

What would be the standard treatment for the given cancer, and how does that treatment affect the pregnancy?

Can the treatment be delayed into the postpartum period?

In general, in very early pregnancies (first trimester), the termination of the pregnancy to allow proper oncologic care needs to be considered. Once the pregnancy reaches the gestational age of viability (24 weeks), the physician has to decide how long the treatment can be delayed and how soon the delivery can be induced. Oncologic treatment carries the risk for malformation when used before week 8. This risk decreases as the pregnancy gets past this gestational age. Fetal growth and the duration of the pregnancy still may be affected, and adverse fetal physiologic changes may be induced that the neonatologist needs to be aware of.

In order to provide the best possible care, a multidisciplinary approach involving an obstetrician, maternal-fetal medicine specialist, oncologist, radiologist, and neonatologist is required. The couple also needs to be informed about the complexity of the problem and needs to be involved in the decision-making. It is equally important to share experience as current recommendations are often based on case series and expert views with little high-quality research.

Abstract

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