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Malignancies in pregnancy

https://doi.org/10.1016/j.bpobgyn.2015.10.004Get rights and content

Highlights

  • •

    We review the epidemiology and outcomes of malignancy in pregnancy in general.

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    We provide a general overview of the treatment of malignancy in pregnancy with chemotherapy and radiation.

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    The more common malignancies seen in pregnancy are reviewed in detail.

  • •

    Outcomes and survival of malignancy in pregnancy are similar to nonpregnant patients.

  • •

    Timing of delivery is dependent on the type and stage of the malignancy, and the gestational age at diagnosis.

Malignancy complicating pregnancy is fortunately rare, affecting one in 1000 to one in 1500 pregnancies. Optimal treatment involves balancing the benefit of treatment for the mother while minimizing harm to the fetus. This balance is dependent on the extent of the disease, the recommended course of treatment, and the gestational age at which treatment is considered.

Both surgery and chemotherapy are generally safe in pregnancy, whereas radiation therapy is relatively contraindicated. Iatrogenic prematurity is the most common pregnancy complication, as infants are often delivered for maternal benefit. In general, however, survival does not differ from the nonpregnant population.

These patients require a multidisciplinary approach for management with providers having experience in caring for these complex patients. The aim of this review was to provide an overview for obstetricians of the diagnosis and management of malignancy in pregnancy.

Introduction

Cancer in pregnancy is, fortunately, rare. However, when a woman is diagnosed with cancer during her pregnancy, many complicated questions arise. The underlying dilemma to which all other questions can be traced is how best to balance the health of the mother with the health of her unborn child. Every woman, partner, and family is likely to have a different viewpoint on this underlying dilemma, making these questions, at times, extraordinarily complex. Once the diagnosis of cancer in pregnancy is established, the patient should be referred to an institution with experience in dealing with such cases, where she can receive multidisciplinary care by a team whose main objective was to guide and support care decisions that reflect the wishes of the woman and her support system.

The aim of this review was to give clinicians a framework for how to approach some of these complex issues, with a focus on how the pregnancy affects cancer progression and treatment, and, conversely, how cancer progression and treatment affect the pregnancy.

Section snippets

Epidemiology of cancer in pregnancy

Cancer affects approximately one in 1000 to one in 1500 pregnancies ∗[1], [2]. This estimate is an increase from one in 2000 in 1964 [3], and it is thought to reflect not only higher rates of cancer in general but also a delay in childbearing to the third or fourth decades of life by an increasing number of women [4]. The most common cancers that occur concurrent with pregnancy include hematologic malignancies, breast cancer, thyroid cancer, colon cancer, cervical cancer, ovarian cancer, and

Diagnosis of cancer in pregnancy

Prompt diagnosis of cancer is paramount to successful treatment regardless of pregnancy status. Unfortunately, the diagnosis of cancer in pregnancy is often delayed. Diagnosis during pregnancy is complicated by the fact that many symptoms of malignancy are similar to symptoms of pregnancy, including nausea/vomiting, breast changes, abdominal pain, anemia, and fatigue. Breast changes and the gravid uterus may make the physical examination of a pregnant woman difficult. In addition, clinicians

Surgery

Cancer surgery during pregnancy may be either diagnostic or therapeutic. When surgery is considered the optimal method for either diagnosis or treatment, it should not be significantly delayed because of the pregnancy, but, if possible without compromising care, it should be performed in the second trimester. At this time, the pregnancy is well established, but in most cases the uterus is not so large as to make surgery technically difficult. In the first trimester, although the administration

Breast cancer

Breast cancer in pregnancy is fortunately rare. However, unfortunately, breast cancer in pregnancy is most often axillary lymph node-positive, and it presents with a larger primary tumor size than outside of pregnancy. Histologically, the tumors are often poorly differentiated, are more frequently estrogen and progesterone receptor-negative, and approximately 30% are HER2/neu-positive [56], [57]. Approximately 65–90% of pregnant patients are diagnosed with stage II or III breast cancer compared

Pregnancy diagnosed while undergoing cancer treatment

All premenopausal women undergoing any form of systemic cancer treatment should be advised to use an effective form of contraception. If pregnancy occurs while on chemotherapy or hormone therapy, the patient should be informed of the increased risk of fetal malformations related to first trimester exposure. An exception is patients who are being treated with monoclonal antibodies, because these do not cross the placenta early in gestation [142]. Data from the HERA trial and additional case

Pregnancy in cancer survivors

On average, pregnancy rates are 40% lower among female cancer survivors compared with the general population; however, this is highly dependent on cancer type [144]. The rates of pregnancy after thyroid cancer or melanoma are similar to the general population, whereas the rate of pregnancy after breast cancer is almost 70% lower when compared with the general population. This is likely secondary to not only treatment with gonadotoxic agents and prolonged tamoxifen use but also the general

Summary

Receiving a diagnosis of cancer in pregnancy is devastating for families, and it is challenging for physicians. To manage these complex cases, the well-being of both the mother and the fetus needs to be considered; maternal treatment needs to be optimized while attempting to minimize the fetal impact. Just as important as the medical assessment, appropriate decision making requires working closely with the patient and her family to understand their wishes. Due to the relative rarity of cancer

Conflict of interest

The authors report no conflicts of interest.

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