While the majority of female cancer survivors have a good chance of having a healthy pregnancy, some will experience treatment-related side effects that impact their ability to become pregnant or cause complications during pregnancy. In this article, Jeff Chapa, MD, head of Maternal-Fetal Medicine, Ob/Gyn & Women’s Health Institute, discusses five important points related to female cancer survivors and fertility- and pregnancy-related complications they may face during childbearing years.
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What are the most common pregnancy-related complications associated with cancer treatment and its side effects?
Some chemotherapy agents are associated with damage to vital organs, including kidneys, heart and lungs. Patients may be able to live with such damage when they are not pregnant. However, some organs damaged by chemotherapy may be unable to support the significant physiological demands of pregnancy. The heart is a primary example. Pregnancy requires the mother’s heart to work about 50 percent harder to support both the mother and developing fetus. Chemotherapy can also affect the thyroid, which produces the appropriate levels of thyroid hormone needed for the fetus’ neurological development.
Pelvic radiation can damage the uterus, which may affect its blood supply. If the blood supply to the uterus isn’t robust, it may limit the placenta’s ability to implant, increasing the risk of miscarriage, growth restriction, preeclampsia and preterm delivery.
Women who undergo surgery for cervical cancer must have all or part of their cervix removed. This treatment can increase the risk of miscarriage or premature delivery.
Other considerations are hormonal treatments and recurrence. Survivors of some breast and other hormone-dependent cancers run the risk of recurrence once pregnancy hormones appear in the body. For breast cancer survivors, the risk of recurrence associated with pregnancy is especially concerning. While medical research has not proved that pregnancy increases breast cancer recurrence, most physicians recommend that patients wait a couple of years to stabilize before becoming pregnant. Tamoxifen, which helps prevent breast cancer recurrence following treatment, is teratogenic and should not be taking during pregnancy.
What steps can physicians and patients take to proactively manage pregnancy following cancer treatment?
Physicians should obtain a complete medical history from the patient, including a history of cancer diagnosis, treatment and remission. This may seem obvious, but it is very important since some patients relocate and seek pregnancy care in an area different from where they received cancer treatment. Physicians should use detailed medical records to help conduct a thorough evaluation and provide recommendations during preconception counseling with the patient.
We need to carefully evaluate and monitor the patient’s heart, lung and kidney function. We also need to evaluate and adjust medications as needed prior to conception. When potential concerns are noted, referral to an appropriate specialist is warranted.
As with all patients who have chronic diseases, cancer survivors should try to optimize their health prior to getting pregnant, and we can provide valuable advice and encouragement in this area.
Why is multidisciplinary care so important when it comes to pregnancy care for the cancer survivor?
While there is no established standard of care for managing pregnancy after cancer treatment, patients do best when they are managed using a collaborative approach. At Cleveland Clinic, multidisciplinary care includes working with the patient’s oncologist, primary care doctor and subspecialty physician or physicians. If complications arise during pregnancy, the team already has a collaborative relationship established with each other and with the patient.
Multidisciplinary care is also helpful in addressing inaccurate medical opinions. For example, a cancer survivor may be told by a provider that pregnancy is out of the question. However, the patient may be a reasonable candidate for pregnancy with the potential for a good outcome. Conversely, a patient may be cleared for conception by her primary care doctor when there is in fact a serious risk of complications. A multidisciplinary team is more likely to catch and address potential risks during the initial medical evaluation than a single doctor. Managing pregnancy after cancer treatment requires a collaborative effort to help the patient make an informed decision.
When is a maternal-fetal medicine specialist needed?
A maternal-fetal medicine specialist should be consulted when a cancer survivor has a high risk of recurrence or when there’s potential organ damage from previous cancer treatment. This specialist provides monitoring, evaluation and counseling to high-risk patients — no matter what the cause — before, during and after pregnancy. When there’s an increased risk of complications, close monitoring helps provide the best possible outcome and could even prevent some complications from recurring.
What are your recommendations for future pregnancy management for cancer survivors?
Many medical centers, including Cleveland Clinic, offer fertility programs to help cancer patients preserve fertility following cancer treatment. These programs may involve freezing eggs or ovarian tissue (including vitrification of ovarian tissue) as well as various in vitro or other fertilization techniques. At Cleveland Clinic, maternal-fetal medicine specialists and fertility specialists work together closely. The focus is not only on the patient’s ability to become pregnant, but also to assess her ability to support a healthy pregnancy without a high risk of complications. Discussions are then held with the patient regarding her reproductive options. Preconception counseling, coupled with collaborative care, is the key to optimizing pregnancy outcomes for cancer survivors.