Download Invited Speaker Parallel session 10: Cancer and pregnancy

Invited Speaker
Parallel session 10: Cancer and pregnancy – current knowledge and future perspectives
Cancer and pregnancy – obstetrical view
Joachim W. Dudenhausen
Berlin, Germany
The frequency of diagnosed malignancies is overall the same in pregnant versus non-pregnant
women of the same age. However, in the industrialized world, we are experiencing an increase in the
incidence of malignant diseases in pregnancy. This increase is attributable to demographic
developments bringing changes in childbearing behavior and increasing numbers of older pregnant
women. Looking ahead, this trend foreshadows ongoing growth in the coincidence of neoplasia and
pregnancy.
Given this trend, we have to acknowledge that specifically and especially in pregnancy the level of
knowledge on the course and prognosis of malignant diseases is low. Our therapeutic decisions are
mostly based only on case reports and retrospective studies. Representative data on fetal outcome in
neoplasia and pregnancy is usually missing, as is data on the complications of cancer treatment
during pregnancy, the consequences of this treatment for the neonate, and its impact on long-term
development.
When we counsel a pregnant woman with a malignant disease, not only have the pregnancy and the
child to be considered, but also the influence of the malignancy on the pregnancy and, on the other
hand, the influence which the pregnancy has on the malignant disease. It seems that our current
knowledge can be summarized as follows: The tumor biology of malignancies is not changed by the
pregnancy, and the disease prognosis depends on stage-related therapy.
The diagnosis and the therapy of malignancies in pregnancy are necessarily interdisciplinary
challenges. From the obstetrical perspective, two aspects should be considered equally: The
consequences for prematurity, and the effects of adjuvant and surgical procedures on the fetus and
the pregnant woman.
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Invited Speaker
Parallel session 10: Cancer and pregnancy – current knowledge and future perspectives
Effect of conservative cervical surgery on pregnancy outcome
Lynn Sadler
Auckland, New Zealand
There is now a considerable published literature of observational studies reporting an association
between cervical surgery and increased risk of preterm birth. This accumulated evidence is
supportive of a causal relationship despite the uncertainty that confounding due to unknown or poorly
measured shared risk factors for CIN and preterm birth could explain the observed increase in risk.
Large linkage studies from Scandinavia have demonstrated that the increased risk of preterm birth
occurs at all gestations and the increase in risk remains, although attenuated, when a control group
of women giving birth prior to cervical treatment is used. Cold knife cone and LLETZ/LEEP are
consistently associated with increased risk and ablative therapies generally not associated with
increased risk. The absence of risk associated with ablative therapies is further evidence that the
association with excisional therapies is causal. Data supporting a dose response relationship
between height of cone and risk of preterm birth are also accumulating.
The importance of this research includes providing evidence to support studies of conservative
approaches to cervical screening (such as delaying to age 25), development of more specific
screening tests, evaluation of delaying referral and intervention for low grade abnormalities in young
women, and natural history studies of the rates of regression or progression of HPV related disease.
In many countries, “see and treat” protocols are no longer recommended. Few studies have explored
the mechanisms mediating the effects of cervical treatments on pregnancy outcome. This should be
a focus for future research and has the potential to elucidate the pathophysiological mechanisms of
preterm birth.
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Invited Speaker
Parallel session 10: Cancer and pregnancy – current knowledge and future perspectives
Cervical cancer in pregnancy
Achim Schneider, Giovanni Favero, Vito Chiantera, Christhardt Köhler
Berlin, Germany
In recent years, an elevated incidence of cancer during gestation has been detected, probably
related to the tendency of increasing maternal age. Cervical cancer (CC) classically occurs in young
patients, with a median age of 45 years and is considered the most common cancer associated with
pregnancy. The estimated incidence is approximately 1 per 200 to 10000 pregnancies, depending on
whether pre-cancer is included. In parallel, a significant decrease of parity has changed completely
the maternal profile. Thus, when cervical cancer complicates gestation, this pregnancy may
represent the only opportunity of the patient to become a mother.
Cervical cancer in pregnancy is a challenge for the patient, her family and the medical staff. In the
past, for a diagnosis before 20 weeks of gestation, the standard management was termination of
pregnancy in order to not delay cancer treatment. However, recent studies attesting the safety of
cancer treatment delay to reach fetal viability and the fact that gestation does not seem to have a
negative impact on oncologic prognosis have changed this concept. Although CC treatment
guidelines for non-gravid patients are well defined based on several randomized trials, there is a
noticeable absence of reliable studies and data in this group to support a standard therapy. Currently,
both maternal and fetal factors, such as cancer clinical stage, lesion size and gestational age
determine management.
In early stage cervical cancer, lymph node metastases are found in up to 20% of patients, which is
considered the most important negative prognostic factor. To date, all non-invasive diagnostic
procedures do not precisely reflect nodal status. Histopathologic evaluation of the lymph nodes
mainly before 20 weeks of gestation, is a crucial parameter to select the most appropriate treatment
strategy. Maintenance of pregnancy appears to be safe in a lymph node negative patient, whereas
delay of oncologic therapy for fetal benefit in a patient with a nodal metastasis should not be
recommended.)
We performed laparoscopic lymphadenectomy in 13 patients in the first half of pregnancy and report
no complication to the mother or to the fetus related to the surgery. The knowledge of the tumor
biology gives a sound basis for the management of mother and fetus which can vary between
expectative observation till term, neoadjuvant chemotherapy, or immediate treatment with termination
of pregnancy.
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