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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
[email protected]
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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
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Importance of Multidisciplinary Team
• Obstetrician / Perinatologist• Neonatologist• Surgeon• Radiation Oncologist• Medical Oncologist• Social work• Genetic Counselor• Clergy• Ethicist• Other
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Incidence by Age of the More Common Malignancies Seen in Pregnancy
American Cancer Society, Facts and Figures, 1995
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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.
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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
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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
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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
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Crucial Periods in Prenatal Development
Moore P (ed). The Developing Human, 6th Ed, 1998
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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.
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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
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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
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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
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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.
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Effects & Risks after Exposure to Ionizing Radiation in Utero
Tewari Ch 16, Clinical Gynecologic Oncology, 7th Ed, DiSaia & Creasman (eds) 2007
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SERUM TUMOR MARKERSPregnant & Non-Pregnant Patients
Tewari Ch 16, Clinical Gynecologic Oncology, 7th Ed, DiSaia & Creasman (eds) 2007
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= 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
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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
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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
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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.
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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.
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Thank You
[email protected] @chw.edu