Cancer during pregnancy

1. CANCER IN PREGNANCY
Semarya Berhe (Asst. Professor)

2. OUTLINE
 Incidence
 Investigations and management issues
 Counseling
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3. OVERVIEW
 The incidence of cancer in pregnancy is increasing.
 Cancer during pregnancy is a rare event, occurring
approximately once per 1,000 pregnancies
annually, corresponding to 0.07% to 0.1% of all
malignant tumors
 The most frequent malignancies include breast and
cervical cancers.
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4. CONT.
 The pathophysiology of cancer associated to
pregnancy is not fully understood.
 However, hormonal changes, immunological
suppression and increased permeability and
vascularization are implied.
 As frequency is expected to increase, due to trends
in delayed childbearing .
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5. DIAGNOSIS
 Diagnosis of cancer is vital for successful treatment
regardless of pregnancy status.
 Diagnosis of cancer in pregnancy is, unfortunately,
often delayed;
 This is in part because many symptoms of
malignancy are similar to the symptoms of
pregnancy,
 including nausea/vomiting, breast changes, abdominal
pain, anemia, and fatigue.
 Breast changes and the pregnant uterus may make
physical examination difficult
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6. CONT.
 In addition, the clinician may be more hesitant to
assign the appropriate tests because of concerns
that laboratory results may be inaccurate or that
radiologic testing is harmful.
 Diagnostic work-up, including tumor markers, can
be influenced by the physiology of pregnancy.
 Owing to its rarity, cancer might not be considered
in the differential diagnosis.
 This delay in diagnosis can lead to late
presentation, complex treatment, and poor
prognosis
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7. LABORATORY TESTING
 Tumor markers should be used with caution owing to
pregnancy-induced elevation.
 The sensitivity and specificity of tumor markers may be
lower during pregnancy.
 Physiological changes in pregnancy and accompanying
alteration of commonly used laboratory values may
complicate the diagnosis of malignancy.
 Hemoglobin and hematocrit values are typically lower,
whereas
 alkaline phosphatase and lactate dehydrogenase are typically
higher in pregnancy.
 CA 15-3 used in breast cancer, CA 125 used in epithelial
ovarian cancer, and alpha-fetoprotein used in germ cell tumors
are physiologically elevated in pregnancy.
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8. DILEMMA
 Save the mother ? Save the baby?
 Is the potential life of an unborn child more
important than prolonging a life of a young woman?
And whose decision is this ?
 Fetus Mother Pregnancy Risk
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9. IF
 Save the baby Malignant disease in pregnancy
complicates the management of both cancer and
the pregnancy.
 There are not many options and none of them are
ideal Management of cancer in pregnancy
 For women diagnosed with cancer waiting for 40
weeks could be a death sentence particularly with
high-grade, aggressive or metastatic cancers.
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10. To delay treatment until the child can be safely
delivered
• For mother this poses the risk that may be
hard to quantify
• It also means that she will have to care for a
very premature baby while coping with the
side-effects of cancer treatment
First option
This option is more viable
the lower the risk posed
by the cancer and the
more advanced the
pregnancy
To terminate the pregnancy to allow normal
treatment to go ahead
• This may be the safest option for the mother
s health
• Unacceptable to some mothers
Second option
More likely to be
considered early in
pregnancy
To treat the cancer as effectively as possible
while continuing the pregnancy and trying to
minimize the risk for the fetus
Third option
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11. IMAGING
 Imaging in pregnancy to diagnose and stage cancer
may create conflict between maternal benefit and
fetal risk.
 Therefore, the following issues need to be taken
into account when choosing the appropriate
imaging technique:
 Safety of the fetus.
 Risk of metastasis.
 Viability of the fetus.
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12. CONT.
 Radiation exposure above 100 mGy is associated
with fetal malformation and childhood cancer.
 If X-rays are needed, proper abdominal shielding
should be provided.
 Mammogram images are increasingly difficult to
interpret owing to physiological hypervascularity
and density of the breast tissue.
 Computed tomography (CT scan) is best avoided
during pregnancy because of the unacceptable
cumulative radiation and contrast doses.
 Positron-emission tomography (PET) imaging in
pregnancy is debatable owing to the risk to the
fetus of radiation exposure
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13. CONT.
 Ultrasound as a tool for diagnosis and staging is used
worldwide.
 It is noninvasive and helps to perform guided biopsies of the
breast and lymph nodes.
 Magnetic resonance imaging (MRI) is safe in all trimesters of
pregnancy.
 It is the imaging technique of choice for diagnosis and
staging.
 Histopathology of tissues provides definitive diagnosis of
tumor type and grading.
 The pathologist should always be informed of the patient's
pregnancy status to avoid incorrect diagnosis resulting from
pregnancy-associated tissue changes.
 Aside from the changes to the uterine corpus and ovaries,
pregnancy has various effects on benign conditions that may
mimic malignancy.
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14. CANCER TREATMENT IN PREGNANCY
 Treatment of cancer can often be safely
administered with good maternal and fetal
outcomes.
 Chemotherapy, radiotherapy, and surgery must be
adapted to the pregnancy state.
 Counseling and emotional support are an essential
part of management.
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15. CONT.
 After the first trimester, most chemotherapeutic
agents can be used with relative safety.
 Trans-placental transport of chemotherapeutic
agents differs widely, with some agents such as
 paclitaxel crossing the placenta at a low rate,
 anthracyclines crossing the placenta at an intermediate
rate, and
 carboplatin at a high rate.
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16. PLACENTAL AND FETAL TUMOR INVOLVEMENT
 Metastatic disease to the placenta and the fetus is
rare.
 The most likely tumors to metastasize to the
placenta include melanomas and hematological
malignancies.
 In all cases where malignant spread is possible, the
placenta should be submitted for careful histologic
evaluation.
 The fetus should be examined carefully at birth and
at regular intervals after birth for any signs of
metastatic disease.
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17. COUNSELING
 Cancer during pregnancy represents both a
psychological and biological dilemma given that
treatment should be directed to save two lives:
maternal and fetal.
 Using a multidisciplinary approach, counseling can
help to reduce the distress of the patient and her
family.
 It is essential that the obstetrician, oncologist,
pediatrician, and psychotherapist take leading roles.
 The patient and her family should be actively involved
in the decision-making process, which will enhance
confidence and support.
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18. BREAKING BAD NEWS
 Receiving bad news is painful for any patient.
 Counseling should always include information on
the ongoing pregnancy and impact of the disease
on the mother and baby.
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19. CERTAIN GUIDELINES SHOULD BE ADHERED TO:
 Assess the mental state of the patient.
 Ensure privacy.
 Take adequate time to assess the situation.
 Be honest.
 Provide accurate information.
 Show empathy.
 Arrange for family members to be present.
 Provide evidence-based treatment options.
 Inform about other supportive services.
 Clearly indicate that the patient has the final decision regarding
their care.
 Briefly explain the process by which the diagnosis was reached.
 Provide varied methods to convey the information, for example,
written material and video.
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20. CONT.
 A realistic and honest approach is essential to
maintain the patient's confidence and support.
 Providing too much information using medical
jargon, hiding news, false reassurance, and a
paternalistic approach disregarding the patient's
concerns all reduce their confidence.
 The basis of shared decision making is to
exchange information in a clear, evidence-
based, and unbiased manner, giving due
consideration to the patient's values, concerns,
beliefs, and priorities in life.
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