pregnancy and cancer - association of cancer physicians · lmwh in patients with cancer and...
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Pregnancy and Cancer
Kate Harding
October 2019
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Incidence
Overall 1-2 per 1,000
• Breast
• Melanoma
• Cervical
• Haematological
Possible increased incidence over time
BJOG 2012 Lee et al Australian data
Journal of clinical oncology 2010 Calsteren et al
Cancer 2015 Anderson et al
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Pregnancy complications in 215 women with cancer
Treatment Number Pregnancy complications %
No treatment 58 PIH/PET 3 3%
Chemotherapy 33 Sepsis1PPROM3Premature delivery 6
30%
Chemotherapy & surgery
25 Sepsis 1Premature delivery 2
12%
Surgery alone 49 IUGR 1Sepsis 1
4%
Radiotherapy 10 IUGR 1 10%
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Previous Cancer
• Fertility*
• Germline
• Malformations
• IUGR
• Premlabour
• Risk of IUD/Stillbirth
• Maternal side effects*
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Cervical competance
• LLETZ
• Cone biopsy
• Trachelectomy
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Previous childhood cancer
• Increasing numbers (600 survivors annually)
• Possible increased IUGR , miscarriage and IUD following pelvic radiation
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Risk of Recurrence
• Little good evidence of increase
• Delay to demonstrate recurrence unlikely
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New diagnosis/ recurrence
• Diagnosis
• Initial management
• Discussions
• Support
• Timing of treatment
• Timing of delivery
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Diagnosis
• Ultrasound
• CT Adverse fetal effects associated with radiation exposure include
microcephaly, mental retardation, intellectual deficits, or induction of
• childhood malignancies
• MRI
• Tumour markers
• Diagnostic surgery
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Imaging
Fetal Radiation Exposure in mGys• Ultrasound 0
• MRI 0
• CXR, mammography, CT head and neck, cervical spine0.001-0.1
• Xray abdo/pelvis, lumbar spine, CT Chest
0.1-1.0
• Adominal CT, technetium-99 bone scan 1-10
• CT Pelvis, PET-CT FDG 10-50
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Initial management
• Multi-disciplinary
• Rapid access
• Appropriate, informed advice
• Psychological support
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Discussion
• Affect on fetus
• What treatment would be offered if not pregnant
• Does timing of delivery affect prognosis
• Affect of surgery on pregnancy
• Affect of chemotherapy on pregnancy
• Can radiotherapy be used
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Who has a TOP?
• Individual
• Little evidence of benefit
• May allow different treatment regime
• Those with very high risk of early mortality might
• Family circumstances
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Surgery
• Timing
• Anaesthesia
• Risk of miscarriage
• Ease of operating
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Chemotherapy
• Generally avoided in first trimester
• Variety of differing malformations described
• Possible increased risk of IUGR
• Risk of maternal pancytopenia may be minimised with growth factors
• Generally avoid breast feeding as risk of neonatal neutropenia
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Total 175 patients rate 14.9%
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Radiotherapy
• Generally avoided
• Can be used with careful shielding after first trimester
• Useful for boney metastases with imminent spinal cord compression
• Affect depends on dose to fetus and gestation
• Miscarriage if >20cGy
• Mental retardation if >18cGy at 8-15 weeks
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Timing of delivery
• At term, timed between chemo cycles (usually 2 weeks after a course to minimise maternal and neonatal neutropenia)
• Early so baby does not get chemotherapy at all
• Early allow further treatment (eg radiotherapy)
• Timed to allow mother time with her baby (in extremis)
• Spontaneous
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Fetal affects
• Placental spread
• Chemotherapy
• Radiotherapy
• ?IUGR
• Prematurity
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Thromboprophylaxis
• NEJM 1992 showed increased risk of cancer in patients with idiopathic thrombosis (OR 2.3) most in first year
• Increased risk of VTE in breast cancer in combination with chemotherapy or tamoxifen (5.4vs 1.8%)
• Increased risk with central lines
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Thromboprophylaxis guidelines
American college of Physicians Guidelines 2005
LMWH in patients with cancer and surgery, chemotherapy or central lines
American Haematology Society Dec 2010
AN and Postnatal prophylaxis for women with cancer and pregnancy
RCOG Greentop 2009
Cancer counts as one risk factor. Thus if 3 or more for AN prophylaxis. If 2 or more treat as in patient and for 7 days postnatally
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Breast feeding
• Important
• Contraindicated with chemotherapy (neonatal immunosupression)
• ?reduces risk of breast Ca
• May be possible for a short time
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Contraception
• Important
• Usually non-hormonal if Breast Cancer
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