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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
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
Berman, DiSaia & Tewari. Ch 58, Maternal-Fetal Medicine, 5th Ed, Creasy & Resnik (eds), 2004
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
Berman, DiSaia & Tewari. Ch 58, Maternal-Fetal Medicine, 5th Ed, Creasy & Resnik (eds), 2004
Crucial Periods in Prenatal Development
Moore P (ed). The Developing Human, 6th Ed, 1998
Gestational Age and Effects of Antineoplastic Therapy
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.
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
Berman, DiSaia & Tewari. Ch 58, Maternal-Fetal Medicine, 5th Ed, Creasy & Resnik (eds), 2004
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
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.
Effects & Risks after Exposure to Ionizing Radiation in Utero
Tewari Ch 16, Clinical Gynecologic Oncology, 7th Ed, DiSaia & Creasman (eds) 2007
SERUM TUMOR MARKERSPregnant & Non-Pregnant Patients
Tewari Ch 16, Clinical Gynecologic Oncology, 7th Ed, DiSaia & Creasman (eds) 2007
= 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
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
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