Pregnancy should not delay treatment of cancer. Treatment is often similar to that in nonpregnant women, except for rectal and gynecologic cancers.
Diagnosis and management of cancer during pregnancy or the postpartum period require a multidisciplinary team including oncologists and maternal-fetal medicine specialists. Patient education and shared decision making is important to ensure the patient can make an informed decision.
Breast cancer
Gestational breast cancer is defined as cancer during pregnancy, in the first year postpartum, and/or during lactation. Breast hypertrophy and engorgement during pregnancy may make recognizing breast cancer difficult. Any solid or cystic breast mass should be evaluated.
Usually, breast cancer should be treated immediately. Data are mixed regarding whether being diagnosed with breast cancer during pregnancy negatively impacts prognosis (1, 2).
Cervical cancer
Pregnancy does not appear to worsen the prognosis of cervical cancer (3).
Cervical cancer can develop during pregnancy, and an abnormal Papanicolaou (Pap) test should not be attributed to the pregnancy itself. Abnormal Pap tests are followed by colposcopy and directed biopsies when indicated. Colposcopy does not increase risk of an adverse pregnancy outcome. Biopsies are done only if high-grade cervical intraepithelial neoplasia or cervical cancer is suspected. If biopsy is required, expert colposcopic evaluation and consultation with the pathologist are recommended because the biopsy may cause hemorrhage and preterm labor.
For carcinoma in situ (Federation of Gynecology and Obstetrics [FIGO] stage 0—see table FIGO Clinical Staging of Cervical Cancer Carcinoma) and microinvasive cancer (stage IA1), treatment is often deferred until after delivery because at these stages, cancer progresses very slowly and pregnancy can be completed safely without affecting the woman's prognosis.
If invasive cancer (FIGO stage IA2 or higher) is diagnosed, pregnancy should be managed in consultation with a gynecologic oncologist. If invasive cancer is diagnosed during early pregnancy, immediate therapy appropriate for the cancer is usually recommended. If invasive cancer is diagnosed after 20 weeks and if the woman accepts the unquantified increase in risk, treatment can be deferred until into the 3rd trimester (eg, 32 weeks) to maximize fetal maturity but not delay treatment too long. For patients with invasive cancer, cesarean delivery with radical hysterectomy rather than vaginal delivery is done.
Other gynecologic cancers
After 12 weeks gestation, ovarian, fallopian tube, and peritoneal cancers are difficult to detect, because after 12 weeks gestation the ovaries, with the uterus, rise out of the pelvis and are no longer easily palpable. If advanced, ovarian cancer during pregnancy may be fatal before completion of the pregnancy. Affected women require bilateral oophorectomy as soon as possible.
Uterine cancer rarely occurs during pregnancy.
Rectal cancer
Rectal cancers may require hysterectomy to ensure complete tumor removal. Cesarean delivery may be done as early as 28 weeks, followed by hysterectomy so that aggressive cancer treatment can be started.
Leukemia and Hodgkin lymphoma
Leukemia and Hodgkin lymphoma are uncommon during pregnancy.
Antineoplastic agents typically used to treat lymphoma increase risk of fetal loss and congenital malformations.
Because leukemias can become fatal rapidly, treatment is given as soon as possible, without any significant delay to allow the fetus to mature.
If Hodgkin lymphoma is confined to above the diaphragm, radiation therapy may be used; the abdomen must be shielded. If lymphoma is below the diaphragm, abortion may be recommended.
References
1. Amant F, von Minckwitz G, Han SN, et al: Prognosis of women with primary breast cancer diagnosed during pregnancy: results from an international collaborative study. J Clin Oncol 31(20):2532-2539, 2013. doi:10.1200/JCO.2012.45.6335
2. Shao C, Yu Z, Xiao J, et al: Prognosis of pregnancy-associated breast cancer: a meta-analysis. BMC Cancer 20(1):746, 2020. doi:10.1186/s12885-020-07248-8
3. Johansson ALV, Fredriksson I, Mellemkjaer L, et al. Cancer survival in women diagnosed with pregnancy-associated cancer: An overview using nationwide registry data in Sweden 1970-2018. Eur J Cancer 155:106-115, 2021. doi:10.1016/j.ejca.2021.07.008
