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August 16, 2018/Cancer

The Secrets to Balancing Cancer and Pregnancy Care

Collaborative, personalized approach optimizes patient outcomes

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When pregnancy and cancer occur at the same time, it can catch patients and their physicians off guard. Although this situation presents some unique challenges, the right treatment at the right time can yield positive results.

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For example, a 36-year-old female with a history of acute myeloid leukemia (AML) became pregnant after being in clinical remission for several months. At 28 weeks gestation, she had a routine blood count and a peripheral smear, which showed evidence of AML relapse. She was admitted to Cleveland Clinic for further evaluation and treatment. A lumbar puncture revealed leukemic involvement of the cerebral spinal fluid. An ultrasound of the fetus demonstrated that the baby was growing and developing normally.

Before recommending treatment, her multidisciplinary medical team had extensive discussions about the risks, benefits and alternatives, considering the impact on both mother and fetus. Her physicians agreed upon immediate treatment of the relapse with chemotherapy (cytarabine and daunorubicin).

They also administered twice weekly intrathecal chemotherapy via lumbar punctures. After allowing time for recovery from the effects of chemotherapy and further fetal maturity, labor was induced at approximately 34 weeks gestational age, and she delivered a healthy baby girl. Her infant did well in the NICU following delivery.

The timing of the delivery allowed the mother to proceed with more definitive treatment for her leukemia. She continued intrathecal chemotherapy until the leukemic cells were cleared. One month after delivery, she underwent a bone marrow transplant. Both mother and child continue to do well over a year later.

In this article, Jeff Chapa, MD, head of Maternal-Fetal Medicine, Ob/Gyn & Women’s Health Institute, discusses how a collaborative approach with cancer-related specialists, including oncology and radiation therapy colleagues from Cleveland Clinic Cancer Center, ensures the best possible outcome for a mother and her child.

Q: Cancer during pregnancy is more common than we think and is increasing. Why?

A: Cancer affects about one in 1,000 pregnancies. The incidence of malignancy increases with age, so the incidence of cancer during pregnancy is expected to rise since women are having children at older ages. As cancer treatments improve, more patients are surviving and with a higher quality of life after treatment. Thus, for women of childbearing age with a history of cancer, pregnancy is an increasingly common event.

Q: Which cancers are most often diagnosed during pregnancy?

A: These include breast cancer, cervical cancer, lymphoma/leukemia and melanoma.

Q: What are some of the challenges involved in diagnosing cancer during pregnancy?

A: Even during pregnancy, the standard oncologic diagnostic process should be used to obtain as much information as possible. However, several issues make this challenging. For example, common symptoms of pregnancy can overlap symptoms of cancer. In addition, some physicians may delay performing diagnostic procedures or imaging studies to evaluate a complaint because of the fear of the effects of radiation exposure, delaying the diagnosis. In some cases, the physician may be unable to fully stage or diagnose the patient because of the pregnancy.

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Q: How do you balance using radiation or chemotherapy during pregnancy and protecting the fetus?

A: Radiation exposure early in a pregnancy can lead to miscarriage and birth defects. Later in a pregnancy, it can lead to developmental and neurological delays as well as microcephaly. With chemotherapy or radiation exposure, there’s also an increased risk of developing childhood malignancy after birth.

However, most cancer treatments are options during pregnancy, as long as we adjust the modality or timing. For example, some chemotherapy agents are safer to use than others. Also, oncologists usually avoid administering treatment during the final six weeks prior to delivery, since it can suppress the fetus’ immune system. During certain types of radiation treatment, radiation oncologists can shield the abdomen or adjust dosing so that radiation doesn’t reach the fetus.

In some cases, we can initiate treatment at an early stage of pregnancy and finish it after delivery for optimal results.

Q: How does cancer care during pregnancy impact patient outcomes?

A: It may surprise many Ob/Gyn specialists to learn that providing mothers with proper cancer care and evaluation during pregnancy actually yields better outcomes for both mothers and their babies. In fact, most cancer treatments don’t result in adverse pregnancy outcomes. Many babies can be delivered at or close to term and are healthy. It’s actually the exception that physicians would recommend delaying treatment or terminating the pregnancy. In general, avoiding or delaying treatment in pregnancy leads to additional health problems and complications for both mother and child.

Q: What should a primary care physician or Ob/Gyn do when cancer is suspected in a pregnant patient?

A: The key to a good outcome is collaboration and a team-based approach to care. It is essential to refer the patient to a center where there is skilled coordination between oncology and Ob/Gyn staffs. When planning cancer care for a pregnant patient, the Ob/Gyn and oncology teams must work together to develop an individualized plan that takes into account the type of cancer, cancer stage, prognosis, gestational age and patient preferences.

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