CANCER AND PREGNANCY: CONCERNS, CARE, AND CAVEATS Bradley J. Monk, MD, FACS, FACOG Professor and...

CANCER AND PREGNANCY: CONCERNS, CARE, AND CAVEATS

Bradley J. Monk, MD, FACS, FACOG

Professor and DirectorDivision of Gynecologic Oncology

Department of Obstetrics and GynecologyCreighton University School of Medicine atSt. Joseph’s Hospital and Medical Center,

a Member of Catholic Healthcare WestPhoenix, Arizona USA

[email protected]

Cancer in Pregnancy• No American Society of Clinical Oncology (ASCO)

cancer treatment guidelines in pregnancy• ASCO Recommendations on Fertility Preservation

in People Treated for Cancer. J Clin Oncol, Vol 24, No 18 (June 20), 2006: pp. 2917-2931

• Cancer, fertility and pregnancy: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Pentheroudakis G, Orecchia R, Hoekstra HJ, Pavlidis N; ESMO Guidelines Working Group. Ann Oncol. 2010 May;21 Suppl 5:v266-73.

• National Comprehensive Cancer Network (NCCN) only has guidelines for breast cancer

Importance of Multidisciplinary Team

• Obstetrician / Perinatologist• Neonatologist• Surgeon• Radiation Oncologist• Medical Oncologist• Social work• Genetic Counselor• Clergy• Ethicist• Other

Incidence by Age of the More Common Malignancies Seen in Pregnancy

American Cancer Society, Facts and Figures, 1995

Incidence of Tumor Types in Pregnant Women

Cancer, fertility and pregnancy: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.Pentheroudakis G, Orecchia R, Hoekstra HJ, Pavlidis N; ESMO Guidelines Working Group.Ann Oncol. 2010 May;21 Suppl 5:v266-73.

Oncologic Issues

• Timing of therapy

• Type of therapy

• Maternal effects of therapy

• Maternal outcomes

Berman, DiSaia & Tewari. Ch 58, Maternal-Fetal Medicine, 5th Ed, Creasy & Resnik (eds), 2004

Obstetrical Issues

• Fetal effects of therapy• Antepartum fetal surveillance• Corticosteroid use• Amniocentesis• Timing of delivery• Route of delivery


Ethical, Religious, LegalScioeconomic & Issues

• Pregnancy termination• Fetal advocate• Fetal viability• Maternal risk / future fertility• Health-care costs & expenditure• Right to autonomy• Mother’s overall prognosis


Crucial Periods in Prenatal Development

Moore P (ed). The Developing Human, 6th Ed, 1998

Gestational Age and Effects of Antineoplastic Therapy


Incidence of Abnormalities and of Prenatal & Neonatal Death in Mice given 200 cGy

Radiation

Tewari Ch 16, Clinical Gynecologic Oncology, 7th Ed, DiSaia & Creasman (eds) 2007

Surgical Considerations in Pregnancy

• 18-22 wks’ EGA• Check amniotic fluid volume & document FHTs pre-

operatively• Indocin per rectum pre and postoperative• Midline incisionTilt table left side down to move gravid

uterus off the IVC• “Hands off uterus”• Document FHTs in PACU• Tocodynometer x 2-3 days• DVT prophylaxis


Drug Safety Categoriesin Pregnancy

• A Safety established using human studies• B Presumed safety based on animal studies• C Uncertain safety; no human studies; animal

studies show adverse effect• D Unsafe; evidence of risk that may in certain

clinical circumstances be justifiable• X Highly unsafe

Cytotoxic Chemotherapy and Hormonal Therapy in Pregnancy


Effects & Risks after Exposure to Ionizing Radiation in Utero


SERUM TUMOR MARKERSPregnant & Non-Pregnant Patients


= Diagnosis during pregnancy or the first postpartum year

The most common cancer in pregnant/ postpartum women

Occurs in about 1/3000 pregnancies

Average age at the time of diagnosis: 32- 38 years

NCI: www.cancer.gov 2011

http://www.cancer.gov/

Background:PABC Delay in Diagnosis

Delay of diagnosis up to 5-15 mo after the onset of symptoms.

Patients present more often at an advanced stage than in non-pregnant, age-matched population.

Why?Physiologic changes of the pregnant/lactating breast may hinder diagnosis

Physician reluctance to perform biopsy antepartum

NCI: www.cancer.gov 2011Clark et al. Clin Oncol. 1989

http://www.cancer.gov/

Background: PABC

PABC has been associated with a poor prognosis

Most recent data show women with PABC have same survival stage for stage as non-pregnant women with breast cancer

Kelcher et al 2001

Rodriguez et al 2008

• Patients identified through the California Cancer Registry (1991-1999)

• 797 pregnant women compared with 4,177 age-matched non-pregnant controls

• PABC with higher death rate • (39.2% compared with 33.4% P=.002)• When controlled for stage, size of tumor,

hormone receptor status, age, race, type of surgery, survival is moderately worse in PABC (P=.046)

Obstet Gynecol. 2008 Jul;112(1):71-8.

Cardonick et al 2010

•Voluntary National Registry•130 patients diagnosed with breast

cancer and followed prospectively. •Women diagnosed with PABC can

receive treatment comparable to non-pregnant women

•Leads to similar survival when matched for stage at diagnosis

Cancer J. 2010 Jan-Feb;16(1):76-82.

Thank You

[email protected]@chw.edu

CANCER AND PREGNANCY: CONCERNS, CARE, AND CAVEATS Bradley J. Monk, MD, FACS, FACOG Professor and...

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