ReviewCancer and pregnancy: Poena magna, not anymore
Introduction
Cancer diagnosed during pregnancy is a dramatic event with profound impact on the lives of the patient, offspring, family and physician. As women in developed societies defer child-bearing to the third or fourth decade of life, this rare association is likely to become more common. Curing the patient should still remain the top priority when this is deemed feasible. The dilemma of continuing pregnancy till birth of a viable foetus may turn out to be a complicated one and medical, social, personal, moral as well as religious factors interact to define the chosen course of action. Thorough evaluation of the patient and foetus, the biology and stage of the tumour and of therapeutic alternatives available are necessary for correct prioritization of goals and rationalization of management. The complex issues arising render this clinical condition extremely demanding for expertise and multidisciplinary care. In this article, data are reviewed and key aspects of epidemiology, diagnosis, management and outcome of pregnant women with cancer and embryos are presented.
Section snippets
Epidemiology and genetics
Cancer association with pregnancy (CAP) is poorly studied epidemiologically. The estimated incidence in developed societies is 1:1000 pregnancies, while it is probably lower in developing nations due to the younger age of pregnant women [1]. CAP is becoming more common over the last thirty years, the main reason being the increasing number of women child-bearing at older age [2]. The incidence of malignant diseases during the reproductive age has not increased over time but is known to be
Diagnostic work-up and radiological imaging
The diagnostic work-up of the pregnant woman with cancer should limit exposure to ionizing radiation and be restricted to procedures that do not endanger foetal health. Physical examination should be thorough with particular emphasis on search for palpable lymph nodes, skin lesions, breast abnormalities, enlarged liver or spleen. Gentle meticulous examination of the abdomen, pelvis and rectum is warranted in several clinical settings. In general, fine needle aspiration and excisional or
Safety of pharmacotherapy of the pregnant patient with cancer
Cytotoxic chemotherapy causes genetic damage in exposed somatic cells, including chromosomal breaks, translocations, deletions, gene mutations, aneuploidy and cell cycle disruption [27]. When administered during pregnancy, considerable concern has been generated by cell culture and animal data regarding the mutagenic, teratogenic and carcinogenetic effects on the developing embryo as well as the induced placental damage. Most cytotoxic drugs have a molecular weight less than 600 KDa, and can
Radiation therapy during pregnancy
The developing human embryo and foetus are extremely sensitive to ionizing radiation, which might cause pregnancy loss, malformations, growth retardation and neurobehavioral defects. Most such anomalies appear at foetal doses in excess of 200 mGy, though avoidance of exposure to doses higher than 100 mGy is advised because of the non-deterministic nature of radiobiological events 19, 24. Radiation doses used in cancer therapy are in the range of 30–70 Gy. However, the effective foetal dose depends
Basic principles of management of the pregnant cancer patient
Accumulating evidence suggests that during the first trimester, when treatment cannot be delayed or is administered, termination of pregnancy is advisable. Still, one must bear in mind that even in cases of uterine exposure to combination chemotherapy during the first gestational trimester, the chances of normal embryonal development are around 75%. Previous studies in leukaemic patients suggested that treatment during the first trimester can be accomplished safely. Therefore, any
Cervical cancer
Cervical cancer is probably the most common CAP of visceral organs. Median age at diagnosis of pregnant women is 30–35. Common presenting symptoms are vaginal bleeding, discharge or rarely, pelvic pain. The majority of women with cervical CAP are asymptomatic, diagnosed by abnormal cytology at early stages of the disease (stages IA–IIA in 80% of CAP cases) [58]. It is not yet known whether this presentation with early cancer is due to the frequent gynaecological examinations during prenatal
Placental and foetal metastases and subsequent pregnancies
Vertical transmission of malignant cells to the placenta or foetus is uncommon. In the most updated literature review in 2003, only 62 cases are included [122]. Placentofoetal malignant seeding takes place via hematogenous spread and less often via lymphatic spread or contiguous invasion (pelvic tumours). The malignant neoplasms more commonly affecting the placenta and foetus are melanomas (32% of reported cases), leukaemias/lymphomas (15%), breast cancer (13%), gastric cancer (3%), lung cancer
Psychosocial support of the pregnant patient and family
As experienced by the future mother, the coexistence of cancer with pregnancy is a dramatic circumstance when two irreconcilable realities: the process of creating life with the process of destroying life, meet. At a time of great joy and hope, comes a devastating blow along with the fear of death. As medical, psychological, religious, social and moral standards tower over them, both patient and physician will struggle to find the right balance that combines maximum patient benefit with minimum
Conflict of interest statement
None declared.
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