Download CANCER AND PREGNANCY

CANCER AND PREGNANCY:
CONCERNS, CARE, AND CAVEATS
Bradley J. Monk, MD, FACS, FACOG
Professor and Director
Division of Gynecologic Oncology
Department of Obstetrics and Gynecology
Creighton University School of Medicine at
St. Joseph’s Hospital and Medical Center,
a Member of Catholic Healthcare West
Phoenix, Arizona USA
[email protected]
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
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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
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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, Legal
Scioeconomic & Issues
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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 Categories
in Pregnancy
• A
• B
• C
• D
• X
Safety established using human studies
Presumed safety based on animal studies
Uncertain safety; no human studies; animal studies
show adverse effect
Unsafe; evidence of risk that may in certain clinical
circumstances be justifiable
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 MARKERS
Pregnant & 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 2011
Clark 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 nonpregnant 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 agematched 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]