Pregnancy and Cancer Treatment

In an important presentation at the annual meeting of the Society for Maternal-Fetal Medicine, Dr. Elyce Cardonick of Thomas Jefferson Medical College in Philadelphia told attendees that pregnant women with cancer symptoms need to be diagnosed and treated promptly. Although extreme caution should be taken, she said, cancer treatment can often commence safely without waiting until after delivery.

It has been estimated that 1 out of every 1,000-1,500 live births are complicated by maternal cancer (breast, ovarian, etc.), causing a significant dilemma for both the patient and her physician.

Cardonick and her colleagues reported on two studies of women who underwent chemotherapy during pregnancy. In the first study, they found no increase in preterm delivery or growth restriction in any of the women as a result of the cancer treatment. In the second study, they found that infants exposed to chemotherapy after the first trimester were not at risk of preterm delivery, low birth weight, neutropenia, alopecia, myocarditis, or rashes.

The first study included 42 pregnant patients with a variety of cancers: 18 of the women had breast cancer. The mean age of the fetus was 17.2 weeks at the time of diagnosis. Six of the women were advised to terminate their pregnancies; four subsequently did. Of the remaining women, four had preterm deliveries; two were induced at 31 and 32 weeks to avoid fetal exposure to cancer treatment; one was induced at 35 weeks because of pre-eclampsia; one spontaneously delivered twins at 29 weeks.

The second study involved another 18 women who underwent chemotherapy during their pregnancy. The mean gestational age of the fetuses was 15.8 weeks at the time of diagnosis. All of these patients were treated with chemotherapy after the first trimester.

Only one birth defect occurred in all of the pregnancies, an infant who was born with syndactyly of the right hand. The child was apparently exposed to multi-agent chemotherapy at 14.6 weeks while the mother was being treated for Hodgkin's lymphoma. The only other pregnancy complication was uterine contractions due to dehydration. However, this did not result in delivery.

Cardonick acknowledged that cancer treatment is more complicated during pregnancy, but she asserted that it should be considered in most cases. The problem with cancer in pregnancy, she said, is that the patient is understandably afraid-and often the physician too.

She pointed out several diagnostic procedures that are safe to perform as early as 12 weeks, including mammography and biopsies of several types of tissue. And she told attendees that chemotherapy can be given after the first trimester without an increased risk of birth defects, mental retardation or a compromise in immune function.

In a recent question fielded in the "Ask the Experts" column of Medscape Oncology, Dr. Harold Burstein responded to a query about a 32-year-old woman diagnosed with breast cancer who was 15 weeks pregnant. To complicate matters, her cancer was found to have spread to six lymph nodes. What impact would cancer treatment have on the pregnancy? Should the treatment regimen be altered?

Burstein cited an earlier study conducted at the M.D. Anderson Cancer Center in Houston where 24 women with breast cancer were treated with surgery (modified radical mastectomy), followed by adjuvant chemotherapy until the time of delivery. There were no unexpected antepartum complications; 12% had preterm labor, and 4% had pre-eclampsia. Postpartum lactation was impaired in all patients, and patients were advised not to breastfeed on account of chemotherapy exposure.

Importantly, none of the 24 children had congenital abnormalities; 23 of the 24 had birth weights above the 10th percentile. No unusual neonatal complications were noted, although 1 baby had transient leukopenia.

Burstein nonetheless cautioned: "It is hard to overestimate the uncertainties and challenges of managing patients such as the one presented in this case. Ultimately, physicians and patients must acknowledge the potential risks and the potential benefits, and work together to make the best treatment decisions for each individual."

SOURCE:
22nd Annual Meeting of the Society for Maternal-Fetal Medicine, January 23, 2002, New Orleans, LA
"Ask the Experts on ... Treatment of Breast Cancer During Pregnancy?" Medscape Oncology (http://oncology.medscape.com)

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