Pregnant women diagnosed with cancer are often advised to end their pregnancies or deliver early before the full range of treatment options is discussed, writes Elyce Cardonick, a maternal fetal medicine physician and founder of the Cancer and Pregnancy Registry.
Cardonick recounts treating two women with ovarian cancer early in her career. One, who was carrying twins, underwent imaging, evaluation of an ovarian cyst and chemotherapy during pregnancy. Her twins are now adults. The other woman’s treatment was delayed until the third trimester, and she died before her child’s second birthday. Cardonick says she does not know whether earlier surgery or chemotherapy would have changed the outcome, but the cases led her to question how cancer is managed during pregnancy.
According to Cardonick, cancer patients are frequently encouraged to terminate a pregnancy without being offered a detailed discussion of treatment during pregnancy. Women diagnosed in the second or early third trimester may instead be advised to undergo elective preterm delivery. However, she writes that chemotherapy can often be administered safely during pregnancy, allowing the infant to be delivered at term.
Delays can begin with diagnosis. Symptoms of pregnancy may overlap with symptoms of some cancers, while concerns about imaging during pregnancy can postpone biopsies and treatment. Cardonick also questions whether fear of litigation, limited experience with these cases or paternalistic counseling contributes to the reluctance to treat pregnant patients.
She notes that ending a pregnancy has not been shown to improve a woman’s cancer survival compared with continuing the pregnancy. Pregnant women with the same cancer generally have survival rates similar to those of nonpregnant women, she writes.
Cardonick helped develop a registry to collect cases of cancer during pregnancy and track outcomes for mothers and children. After 650 cases, she says the key questions remain how the cancer would be treated outside pregnancy, how long treatment can safely be delayed and whether a treatment has been used during other pregnancies.
Long-term research cited by Cardonick found that children exposed to chemotherapy during pregnancy performed similarly to unexposed children on developmental tests at ages ranging from 18 months through adolescence. The exposed children were three times more likely to need eyeglasses. Children who were electively delivered preterm to avoid maternal cancer treatment had poorer outcomes in the research described by Cardonick.
She emphasizes that every option carries risks, including early delivery, delaying treatment or administering chemotherapy during pregnancy. The decision requires balancing the health of the mother and fetus rather than focusing exclusively on avoiding fetal exposure to treatment.
Guidelines developed with the Society of Maternal-Fetal Medicine and the American Society of Clinical Oncology address avoiding diagnostic and treatment delays. They discuss the use of magnetic resonance imaging without contrast and computed tomography with contrast, necessary surgery at any stage of pregnancy and chemotherapy during the second and third trimesters, including timing treatment for delivery.
Cardonick argues that when cancer and pregnancy occur together, care should consider the health and survival of both the mother and child.
Sources: STAT News.