Commentary (Cardonick): Care of the Pregnant Patient With Cancer

Cancer occurs in approximately 1 per 1,000 pregnancies. For the woman and her family, the diagnosis creates an emotional upheaval of hopes and fears and raises the issue of immortality and mortality simultaneously. The treatment proposed to save the mother can appear in direct conflict with the desire to protect the developing fetus.

Sue Rimes and colleagues have provided an excellent review of the counseling and management of patients faced with this difficult clinical dilemma. The article details the coordination of care between members of the multidisciplinary team necessary to manage these patients, including participants from oncology, perinatology, and neonatology.

In the majority of cancers, pregnant vs nonpregnant women matched for age and stage have comparable 5-year survival rates, provided there is not a delay in diagnosis. Delay of cancer treatment for leukemia during pregnancy does not benefit mother or developing child. Live birth rates and overall maternal survival were both lower for 7 untreated pregnant women diagnosed with leukemia compared with the perinatal and survival outcomes of 40 pregnant women who received chemotherapy prior to delivery.[1]

Other types of cancer diagnosed during pregnancy may not require immediate treatment for the health of the mother, and the pregnancy can be continued without cancer treatment for a period of time. Management depends on the gestational age at cancer diagnosis.

A total of 59 patients with stage I squamous cell carcinoma of the cervix complicating pregnancy safely delayed surgical treatment for up to 14 weeks to achieve fetal maturity without a significant effect on maternal survival or significant difference in recurrence rate. Neonates demonstrated a significant improvement in survival and morbidity.[2–10]

To date, a total of 447 reports of women receiving chemotherapy during pregnancy have been published, the majority treated after the first trimester. Three hundred forty-three have been previously summarized in a review in Lancet Oncology.[11]

Aviles and Neri[12] extensively followed children exposed in utero to chemotherapy. Sixty-two children born to mothers treated during pregnancy for hematologic malignancies were followed until the oldest was 19 years of age. Thirty were exposed in the first trimester without congenital malformations. All children were normal physically and neurologically. School performances and standardized intelligence testing were not significantly different from controls (unrelated matched children and unexposed siblings).

Laboratory testing showed normal tolerance of infections. For the older children, normal secondary sexual development was documented. Twelve second-generation children were born to these exposed cases. Birth weights, learning, and educational performances were normal. No congenital, neurological, or psychological abnormalities were observed. No cases of acute leukemia or other cancers were diagnosed.[12]

Surgery can be performed safely at any gestational age. Anesthesiologists should be comfortable with managing the pregnant patient; they should avoid hypotension, hypovolemia, and hypoxia, and should position the patient with left lateral uterine displacement after 20 weeks’ gestation. Preoperative steroids can be given for fetal lung maturity if surgery is performed at a gestational age when premature delivery is a possible complication.

Depending on the cancer stage and the gestational age of the pregnancy at the time of diagnosis, treatment can be timed and tailored to meet the survival needs of the mother, while minimizing the risk to the fetus. Resources for patients are detailed by Rimes and colleagues as well. Newly diagnosed pregnant women can find support in talking with other women diagnosed with cancer during a past pregnancy who have already delivered their children or can share information about why they may have chosen to terminate the pregnancy. (Newly diagnosed patients also can be referred to the website pregnantwithcancer.org as a resource for information and support.)

Only another woman who has been given the diagnosis of cancer during pregnancy can truly understand what our patients are experiencing. We can only do our best to offer our guidance, expertise, and treatment options similar to how nonpregnant women with cancer are treated, with some modifications to protect the fetus without compromising maternal chance of cure.

Financial Disclosure: The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

1. Catanzarite VA, Ferguson JE: Acute leukemia and pregnancy: A review of management and outcome, 1972-1982. Obstet Gynecol Surv 39(11):663–678, 1984.
2. Prem KA, Makowski EL, McKelvey JL: Carcinoma of the cervix associated with pregnancy. Am J Obstet Gynecol 95(1):99–108, 1966.
3. Lee RB, Neglia W, Park RC: Cervical carcinoma in pregnancy. Obstet Gynecol 58(5):584–589, 1981.
4. Nisker JA, Shubat M: Stage IB cervical carcinoma and pregnancy: Report of 49 cases. Am J Obstet Gynecol 145(2):203–206, 1983.
5. Hopkins MP, Morley GW: The prognosis and management of cervical cancer associated with pregnancy. Obstet Gynecol 80(1):9–13, 1992.
6. Jones WB, Shingleton HM, Russell A, et al: Cervical carcinoma and pregnancy: A national patterns of care study of the American College of Surgeons. Cancer 77(8):1479–1487, 1996.
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8. Sorosky JI, Squatrito R, Ndubisi BU, et al: Stage I squamous cell cervical carcinoma in pregnancy: Planned delay in therapy awaiting fetal maturity. Gynecol Oncol 59(2):207–210, 1995.
9. Sood AK, Sorosky JI, Krogman S, et al: Surgical management of cervical cancer complicating pregnancy: A case-control study. Gynecol Oncol 63(3):294–298, 1996.
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11. Cardonick E, Iacobucci A: Use of chemotherapy during human pregnancy. Lancet Oncol 5(5):283–291, 2004.
12. Aviles A, Neri N: Hematological malignancies and pregnancy: A final report of 84 children who received chemotherapy in utero. Clin Lymphoma 2(3):173–177, 2001.