Oncological management and obstetric and neonatal outcomes for women diagnosed with cancer during pregnancy: a 20-year international cohort study of 1170 patients

Maternal death by cancer in pregnancy: A descriptive study of the International Network on Cancer, Infertility and Pregnancy

OBJECTIVE

To characterise pregnant women diagnosed with primary or recurrent cancer who died during pregnancy, during delivery or within 1 year postpartum.

DESIGN

A descriptive study.

SETTING

The registry of the International Network on Cancer, Infertility and Pregnancy (INCIP).

POPULATION

Women diagnosed with cancer during pregnancy between 2000 and 2022.

METHODS

Using the INCIP registry database, we compared the characteristics of all women with cancer who died during pregnancy, delivery or within 1 year postpartum with those of all women with cancer who survived the first year postpartum.

MAIN OUTCOME MEASURES

Maternal and tumour characteristics and obstetrical and neonatal outcomes.

RESULTS

Of the 2359 women registered in INCIP, there were 131 cases (5.6%) of maternal mortality. Lung cancer (9/14, 64.3% of all registered women with lung cancer), gastro-oesophageal cancer (13/21, 61.9%) and acute leukaemia (17/105, 16.2%) had the highest rates of maternal mortality. Maternal mortality was associated with fewer live births compared with the control group without maternal mortality (99/131, 75.6%, vs 1952/2163, 90.0%; P < 0.001), more elective caesarean sections (64/104, 60.4%, vs 756/1836, 41.2%; P < 0.001) and a lower gestational age at (induced) delivery (34.0 vs 37.1 weeks; P < 0.001), resulting in more preterm births.

CONCLUSIONS

Maternal mortality occurred in 5.6% of cancer-in-pregnancy cases and is associated with adverse perinatal outcomes.

Multidisciplinary Management of Pregnancy-Associated Breast Cancer

Breast cancer during pregnancy is uncommon; however, it is one of the most common malignancies affecting pregnant women. Pregnancy-associated breast cancer (PABC) is a complex entity characterized by unique risk factors, presentation, and pathology. Furthermore, although management generally aims to mirror that for nonpregnant patients, there are distinct aspects of oncologic care delivery specific to PABC. The focus is on optimizing maternal outcomes while maximizing maternal and fetal safety. A multidisciplinary approach is key, and the timing of various treatment modalities is critical. Postdelivery care and counseling are also imperative to address issues such as contraception, breastfeeding, and future fertility. In the present review, we discuss the current knowledge base and the diagnostic and treatment landscape for PABC, including recent literature and practice pattern updates.

Pregnancy and Breast Cancer: A Challenge for the Multidisciplinary Team. A Single Center Experience and Narrative Review

Purpose

The diagnosis of breast cancer during pregnancy is a rare event, but it is more frequent in our daily clinical practice due to the progressing aging of pregnant women. The management of a woman affected by pregnancy-associated breast cancer (PABC) remains a challenge for the clinician as it is related to ethical and psychological decisions.

Patients and Methods

Here, we retrospectively described 10 cases of PABC in women treated at our Institution. All cases were discussed in the multidisciplinary team. We reviewed available literature data on the topic.

Results

Nine out 10 patients were diagnosed with localized breast cancer. The remaining patients were presented with metastatic de novo disease. Median age was 37.5 years (range 26-42). Seven patients presented with grade 3 tumor and 9 patients had Ki-67 value higher than 30%. All but 2 patients received neoadjuvant chemotherapy consisting of sequential anthracyclines and cyclophosphamide followed by weekly paclitaxel during pregnancy. No safety concerns or complications during delivery for both the mothers and the babies were reported.

Conclusion

Breast cancer during pregnancy is a challenging clinical situation and all the decisions need to consider both the patients and the fetus safety. Data from our series and from literature confirm the safety of standard chemotherapy approach starting from the second trimester of gestation. More research and effort are needed to offer these patients excellent outcomes and it is mandatory that cases should be closely followed up by a multidisciplinary team.

Maternal and obstetric outcomes in women with pregnancy-associated haematological malignancies: an observational nationwide cohort study

BACKGROUND

Pregnancy-associated haematological malignancy is a rare event; therefore, data available to guide the treatment are scarce. We aimed to evaluate the incidence, overall survival, and maternal morbidity and mortality of women with pregnancy-associated haematological malignancies.

METHODS

We conducted a nationwide observational cohort study using the French National Healthcare Data System (SNDS), a health-care administrative database covering up to 99% of the French population. We included all pregnancies in France ending between Jan 1, 2012, and Dec 31, 2022. Pregnancies with terminations or miscarriages managed on an outpatient basis, and women with a history of haematological malignancies before pregnancy were excluded. A Cox proportional hazards model was used to assess overall survival, defined as the date of haematological malignancy diagnosis to either death or the end of the study follow-up, in the haematological malignancy during pregnancy group (pregnancies with a diagnosis of haematological malignancy during pregnancy) compared with the haematological malignancy post-pregnancy group (pregnancies with a diagnosis of haematological malignancy in the year following pregnancy). Severe maternal morbidity was compared in the haematological malignancy during pregnancy group versus the reference group (pregnancies without a history of haematological malignancy or a diagnosis of pregnancy-associated haematological malignancy). Births were classified as very preterm (<32 weeks of pregnancy), preterm (32-36 weeks), and term (≥37 weeks) and compared in the haematological malignancy during pregnancy group versus the reference group. Inverse probability weighting (IPW) was used for confounder adjustment, using maternal age (categorised), comorbidities, socioeconomic status, and year of delivery (as a category).

FINDINGS

Of 9 996 523 pregnancies in 5 995 235 women, 1366 pregnancy-associated haematological malignancies were identified: 413 during pregnancy (4·13 per 100 000 pregnancies) and 953 (9·53 per 100 000 pregnancies) within 12 months of the end of pregnancy (post-pregnancy). No significant differences in overall survival were observed between the haematological malignancy during and post-pregnancy groups across all types of haematological malignancy (IPW-adjusted hazard ratio 0·91 [95% CI 0·62-1·34], p=0·63), specifically for Hodgkin lymphoma (0·56 [0·07-4·53], p=0·59), aggressive B-cell non-Hodgkin lymphoma (0·52 [0·12-2·38], p=0·40), and acute leukaemia alone (0·84 [0·50-1·41], p=0·51). Severe maternal morbidity was more frequent in the haematological malignancy during pregnancy group than in the reference group (86 [26·2%] of 328 completed pregnancies vs 120 335 [1·5%] of 7 945 909 completed pregnancies; IPW-adjusted odds ratio 22·71 [95% CI 17·72-29·10], p<0·0001). We observed an increase in very preterm birth (32 [9·8%] vs 92 712 [1·2%]; IPW-adjusted odds ratio 11·90 [95% CI 7·91-17·91], p<0·0001) and preterm birth (116 [35·4%] vs 430 472 [5·4%]; 11·76 [9·34-14·81], p<0·0001) in the haematological malignancy during pregnancy group compared with the reference group.

INTERPRETATION

This nationwide observational study examines pregnancy-associated haematological malignancies in France, revealing no significant difference in overall survival between women diagnosed during pregnancy and post-pregnancy. Our data highlight an increased frequency of severe maternal morbidity and obstetric complications among women diagnosed during pregnancy. Notably, the study underscores the necessity for specialised care to manage these complex cases effectively.

FUNDING

None.

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.

Prenatal cell-free DNA testing of women with pregnancy-associated cancer: a retrospective cross-sectional study

Background

Incidentally, the non-invasive prenatal test (NIPT) shows chromosomal aberrations suspicious of a maternal malignancy, especially after genome-wide testing. The aim of this study is to determine how many cases of cancer in pregnancy are diagnosed or missed with NIPT and whether in retrospect subtle changes in NIPT results could have detected cancer.

Methods

We identified Dutch patients diagnosed in 2017-2021 with pregnancy-associated cancer from the International Network on Cancer, Infertility and Pregnancy (INCIP) Registry, who underwent NIPT in the Dutch NIPT implementation study (TRIDENT-2). We retrospectively assessed how many of these women showed a malignancy suspicious-NIPT, their tumour types and -stages, and the time interval between NIPT and cancer diagnosis.

Findings

Of 143 women with pregnancy-associated cancer, we included 65 patients that underwent an NIPT. Fifty-four women had a solid tumour and 11 a haematological malignancy. Sixteen (24.6%) NIPTs were malignancy suspicious (15 genome-wide, one targeted). All 10 haematological cancer patients with genome-wide NIPT had a malignancy suspicious-NIPT, irrespective of the disease stage. Only five patients with a solid tumour had a genome-wide malignancy suspicious-NIPT (4/5 advanced cancer stage III or IV). The mean time between date of NIPT and cancer diagnosis was significantly shorter after a malignancy suspicious-NIPT compared to a non-suspicious-NIPT, respectively 49.9 days (± SD 31.8) and 100.7 days (± SD 74.9), p = 0.001.

Interpretation

All genome-wide NIPT in women with pregnancy-associated haematological malignancies were malignancy suspicious. Women with a solid tumour showed a malignancy suspicious-NIPT in only a minority of cases, mainly the advanced stages.

Funding

None.

Giant ovarian yolk sac tumor during late pregnancy: a case report and literature review

The manifestation of a giant ovarian yolk sac tumor during late pregnancy is relatively rare. A yolk sac tumor is a highly malignant germ cell tumor that originates from primitive germ cells. It is characterized by yolk sac differentiation in vitro. The frequency of prenatal examinations should be appropriately increased for ovarian tumors discovered during pregnancy. Furthermore, regular follow-up ultrasound should be performed, and tumor markers should be dynamically detected. If needed, imaging examinations such as computed tomography and magnetic resonance imaging should be combined to comprehensively investigate disease progression. If the tumor diameter and tumor marker levels rapidly increase during pregnancy, the possibility of malignancy increases. Therefore, exploratory laparotomy should be immediately performed to further improve subsequent treatment modalities, early diagnosis, early treatment, and prognosis. Herein, we report the case of a 28-year-old pregnant woman whose pregnancy was terminated at 29 weeks and 5 days. She complained of lower abdominal pain for 2 days. A pelvic mass was detected for 1 week, accompanied by increased levels of tumor markers such as serum alpha-fetoprotein, cancer antigen 125, carbohydrate antigen 724, and human epididymis protein 4. Imaging revealed the presence of a pelvic mass. At 32 weeks and 3 days of pregnancy, a cesarean section was performed, with a transverse incision in the lower uterine segment. Furthermore, pelvic adhesiolysis, omentectomy, right adnexectomy, right pelvic lymph node dissection, and pelvic metastasis peritonectomy were performed. The postoperative pathological diagnosis was yolk sac tumors of the ovary (stage IIB). Postoperatively, a five-cycle chemotherapy regimen comprising bleomycin, etoposide, and cisplatin was administered. During postoperative follow-up, the patient's general condition was noted to be good, with the newborn and pregnant women ultimately achieving good outcomes. We reviewed the relevant literature to increase clinical doctors' understanding of ovarian malignancy during pregnancy, guide treatment selection, and facilitate early intervention for associated diseases.

Cancer Diagnosis During Pregnancy and Livebirth Outcomes in the Adolescent and Young Adult Horizon Study

Objective: To describe patterns of cancer treatment and live birth outcomes that followed a cancer diagnosis during pregnancy. Study Design: The Adolescent and Young Adult (AYA) Horizon Study is an observational study evaluating outcomes in survivors of the five most common types of cancer in this age group (15-39 years old). Of the 23,629 individuals identified diagnosed with breast, lymphoma, thyroid, melanoma, or gynecological cancer in North Carolina (2000-2015) and California (2004-2016), we identified 555 live births to individuals who experienced cancer diagnosis during pregnancy. Births to individuals diagnosed with cancer during pregnancy were matched ∼1:5 on maternal age and year of delivery to live births to individuals without a cancer diagnosis (N = 2,667). Multivariable Poisson regression was used to compare birth outcomes between pregnancies affected by a cancer diagnosis and unaffected matched pregnancies. Results: Cancer diagnosis during pregnancy was associated with an increased risk of preterm delivery (prevalence ratio [PR] 2.70; 95% confidence interval [CI] 2.24, 3.26); very preterm delivery (PR 1.74; 95% CI 1.12, 2.71); induction of labor (PR 1.48; 95% CI 1.27, 1.73); low birth weight (PR 1.97; 95% CI 1.55, 2.50); and cesarean delivery (PR 1.18; 95% CI 1.04, 1.34) but not associated with low Apgar score (PR 0.90; 95% CI 0.39, 2.06). In our sample, 41% of patients received chemotherapy, half of whom initiated chemotherapy during pregnancy, and 86% received surgery, 58% of whom had surgery during pregnancy. Of the 19% who received radiation, all received radiation treatment following pregnancy. Conclusion: We identified an increased risk of birth outcomes, including preterm and very preterm delivery, induction of labor, low birth weight, and cesarean delivery, to those experiencing a cancer diagnosis during pregnancy. This analysis contributes to the available evidence for those experiencing a cancer diagnosis during pregnancy.

Protective effect of alpha‑lipoic acid against in utero cytarabine exposure-induced hepatotoxicity in rat female neonates

Cytarabine, an anti-metabolite drug, remains the mainstay of treatment for hematological malignancies. It causes various toxic effects including teratogenicity. Alpha lipoic acid (ALA) is a natural antioxidant reported to offer protection against hepatotoxicity induced by various pathological conditions, drugs, or chemicals. We investigated the protective effect of ALA against prenatal cytarabine exposure-induced hepatotoxicity in rat female neonates. A total of 30 dams were randomly assigned to five groups and received normal saline, ALA 200 mg/kg, cytarabine 12.5 mg/kg, cytarabine 25 mg/kg, and cytarabine 25 mg/kg + ALA 200 mg/kg, respectively, from gestational day (GD)8 to GD21. Cytarabine and ALA were administered via intraperitoneal and oral (gavage) routes, respectively. On postnatal day (PND)1, all the live female neonates (pups) were collected and weighed. The blood and liver from pups were carefully collected and used for histopathological, and biochemical evaluations. A significant and dose-dependent decrease in maternal food intake and weight gain was observed in the pregnant rats (dams) of the cytarabine groups as compared to the dams of the control group. The pups exposed to cytarabine showed a significant and dose-dependent (a) decrease in body weight, liver weight, hepatosomatic index, catalase, superoxide dismutase, glutathione, glutathione peroxidase, serum albumin levels and (b) increase in malondialdehyde, alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase, AST/ALT ratio, and histopathological anomalies. Maternal co-administration of ALA ameliorated these biochemical changes and histopathological abnormalities by combating oxidative stress. Future studies are warranted to explore the molecular mechanisms involved in the ALA's protective effects against prenatal cytarabine-induced hepatotoxicity.

Beyond the decision: Reproductive justice and cervical cancer care in a post-Dobbs era

Cervical cancer is among the most commonly diagnosed cancers in pregnancy and for some patients, abortion may be desired or recommended. The Dobbs v Jackson decision has the potential to limit choice while exacerbating disparities in cervical cancer care. We highlight the necessity of employing a reproductive justice framework to both clinical care and research for cervical cancer care in pregnancy to increase access to reproductive choice and to address inequities.

Additive genotoxic effects in cord blood cells upon indirect exposure to chemotherapeutic compounds crossing an in vitro placental barrier

Prenatal exposure to toxins can adversely affect long-term health outcomes of the offspring. Though chemotherapeutics are now standard of care for treating cancer patients during pregnancy, certain compounds are known to cross the placenta and harm placental tissue. The consequences for the fetus are largely unexplored. Here we examined the responses of newborn cord blood mononuclear cells in tissue culture to two chemotherapeutic drugs, cyclophosphamide and epirubicin, when either directly exposed to these drugs, or indirectly after crossing a placenta trophoblast bilayer barrier. Cord blood mononuclear cells exposed to the conditioned media obtained from cyclophosphamide-exposed trophoblast barriers showed a significant 2.4-fold increase of nuclear ROS levels compared to direct exposure to cyclophosphamide. Indirect exposure to epirubicine-exposed trophoblast barriers not only enhanced nuclear ROS levels but also significantly increased the fraction of cord blood cells with double strand breaks, relative to directly exposed cells. Neither apoptosis nor proliferation markers were affected in cord mononuclear blood cells upon direct or indirect exposure to cyclophosphamide or epirubicin. Our data suggests that trophoblast cells exposed to cyclophosphamide or epirubicine may induce an indirect 'bystander' effect and can aggravate genotoxicity in the fetal compartment.

Procedural abortion, provider-initiated preterm delivery and survival in pregnant people with cancer: A population-based cohort study

OBJECTIVE

To assess whether procedural-induced abortion or provider-initiated preterm delivery are associated with improved survival in pregnant people with cancer.

DESIGN

Retrospective population-based cohort study.

SETTING

Provinces of Alberta and Ontario, Canada, 2003-2016.

POPULATION

Females aged 18-50 years diagnosed with cancer at <20 weeks' (for the assessment of procedural-induced abortion) or <37 weeks' gestation (for the assessment of provider-initiated delivery).

METHODS

Cox proportional hazard models assessed all-cause mortality in relation to procedural-induced abortion and provider-initiated preterm delivery, adjusting for cancer site, stage at diagnosis and age. Meta-analysis pooled the results across both provinces.

MAIN OUTCOME MEASURES

All cause mortality.

RESULTS

There were 512 pregnant people diagnosed with cancer at <20 weeks' gestation and 782 diagnosed with cancer at <37 weeks' gestation. Neither procedural-induced abortion (adjusted hazard ratio [aHR] = 1.39, 95% CI: 0.32-6.17) nor provider-initiated preterm delivery (aHR = 1.17, 95% CI: 0.76-1.81) were associated with improved survival following adjustment for age, stage at diagnosis and cancer site.

CONCLUSIONS

Neither procedural-induced abortion nor provider-initiated preterm birth was associated with improved survival in pregnant people diagnosed with cancer; however, these obstetric interventions are highly personal decisions best decided by the pregnant person in consultation with their care providers.

Knockdown of YTHDF2 initiates ERS-induced apoptosis and cancer stemness suppression by sustaining GLI2 stability in cervical cancer

Cervical cancer ranks fourth in women in terms of incidence and mortality. The RNA-binding protein YTH N6-methyladenosine RNA-binding protein F2 (YTHDF2) contributes to cancer progression by incompletely understood mechanisms. We show how YTHDF2 controls the fate of cervical cancer cells and whether YTHDF2 could be a valid target for the therapy of cervical cancer. Sphere formation and alkaline phosphatase staining assays were performed to evaluate tumor stemness of cervical cancer cells following YTHDF2 knockdown. Apoptosis was detected by flow cytometry and TUNEL assay. The compounds 4PBA and SP600125 were used to investigate the correlation between JNK, endoplasmic reticulum stress, tumor stemness, and apoptosis. Data from The Cancer Genome Atlas (TCGA) databases and Gene Expression Omnibus (GEO) revealed that GLI family zinc finger 2 (GLI2) might be the target of YTHDF2. The transcription inhibitor actinomycin D and dual-luciferase reporter gene assays were employed to investigate the association between the GLI2 mRNA and YTHDF2. Nude mouse xenografts were generated to assess the effects of YTHDF2 knockdown on cervical cancer growth in vivo. Knockdown of YTHDF2 up-regulated the expression of GLI2, leading to JNK phosphorylation and endoplasmic reticulum stress. These processes inhibited the proliferation of cervical cancer cells and their tumor cell stemness and promotion of apoptosis. In conclusion, the knockdown of YTHDF2 significantly affects the progression of cervical cancer cells, making it a potential target for treating cervical cancer.

Screening and Diagnostic Mammography During Pregnancy and Lactation: A Systematic Review of the Literature

In recent years, the age of childbearing has been increasing in Western countries, and consequently the need to conduct mammography during pregnancy and lactation is also increasing. The aim of the present study was to systematically review the existing evidence regarding the overall use of mammography during pregnancy and lactation. A systematic review of the literature was conducted in PubMed, Epistemonikos, and clinicaltrials.gov, by using the search terms "pregnancy" AND "mammography", and "lactation" AND "mammography". The review protocol was prospectively registered in PROSPERO (CRD42024543971). Initially, 1,038 articles were identified; the titles and abstracts of 441 studies were screened; 40 studies were retrieved; after assessment of full texts, 20 studies were included for data extraction and further analysis. All 20 studies were retrospective; 14 studies included women with pregnancy-associated breast cancer, five studies included women with breast symptoms during pregnancy and/or lactation and one study included young breast cancer patients under age 40. Overall, 420 diagnostic and one incidental screening mammography examinations were performed during pregnancy and/or lactation with a 78.6% cumulative detection rate of breast cancer. The role of mammography was confounded by the use of breast ultrasound in most studies. In conclusion, the use of mammography during pregnancy and lactation is based on empirical data from retrospective studies, not directly addressing this issue. Hence, well-designed, focused, prospective clinical studies are needed in order to improve existing evidence regarding the use of diagnostic and screening mammography during pregnancy and lactation.

Lived Experiences of Pregnant Women With Cancer in South Korea: A Qualitative Study

PURPOSE

The incidence of cancer during pregnancy is increasing, presenting several challenges to the treatment of cancer in pregnant women. However, research focusing on the lived experiences of pregnant women with cancer in South Korea is limited. This study aimed to explore and describe the day-to-day lived experiences of women diagnosed with or treated for cancer during pregnancy and their husbands.

METHODS

The study employed a qualitative descriptive design and utilized purposive sampling to recruit participants. The participants comprised six women living in Korea diagnosed with cancer during pregnancy and one husband of a female participant. In-depth semi-structured interviews were conducted, audiotaped, and transcribed. Five of the participants agreed to a second interview, resulting in a total of 12 individual interviews. A thematic analysis was then performed. The participants' ages ranged from 31 to 40 years, and their diagnoses during pregnancy were either breast or thyroid cancer.

RESULTS

Four main themes were identified: (1) Participants faced various heart-breaking difficulties maintaining their pregnancies throughout cancer treatment; (2) Pregnant women with cancer experienced complex but responsible feelings toward their children; (3) Patients with cancer also fulfilled their roles as parents even with their own diseases; and (4) Family support had a significant impact on the pregnant women to overcome the path.

CONCLUSIONS

These findings provide a comprehensive understanding of the lived experiences of being diagnosed with cancer during pregnancy. A recommended strategy is to develop a nursing education program for pregnant women with cancer to provide necessary information and support, and to help them cope positively with their situation.

Gastric cancer in pregnancy: a review

Malignant tumors including gastric cancer (GC) are the leading cause of deaths among reproductive women. Physiological morning sickness can mask the clinical manifestations of GC, whereas the clinical presence of metastatic tumors in the abdominal cavity may be easily mistaken for abdominal swelling caused by fetal growth. Pregnancy and delivery processes in young females could accelerate the growth of GC, leading to its rapid development and grave prognosis. Therefore, early diagnosis is critical and gastrointestinal endoscopy is recommended for any suspected pregnant woman with long-term morning sickness. Treatment strategies, including chemotherapy, resection surgery and radiotherapy, will be determined based on a comprehensive consideration of the status of both the fetus and the mother. Rational management, especially clinical multidisciplinary collaboration may significantly benefit such patients.

Intestinal perforation due to colorectal cancer during pregnancy: case report and literature review

Colorectal cancer (CRC) in pregnancy is sporadic. We reported a case of a woman at 23 + 4 weeks of gestation who presented with abdominal pain. The patient underwent an ultrasound and MRI, during which a colonic mass was noted. Considering a probable incomplete intestinal obstruction, a colonoscopy, biopsy, and colonic stenting were performed by a multidisciplinary team. However, sudden hyperthermia and CT demonstrated intestinal perforation, and an emergency caesarean section and colostomy were conducted. The histological analysis confirmed moderately high-grade adenocarcinoma.

Evaluation of consumer self-selection of a proposed over-the-counter, progestin-only daily oral contraceptive

OBJECTIVES

In an effort to switch a norgestrel 0.075 mg progestin-only pill (Opill) from prescription to over-the-counter, we conducted this study to assess whether consumers can use the drug facts label alone to guide appropriate self-selection.

STUDY DESIGN

Two studies assessed self-selection: (1) an all-comers, actual-use study evaluating self-selection before purchasing and using norgestrel 0.075 mg and (2) the Targeted Breast Cancer Self-Selection Study evaluating theoretical self-selection among participants with a history of breast cancer.

RESULTS

In the actual-use study, based on the label, 1670/1772 participants (94%) were appropriate for use of norgestrel 0.075 mg; 102 (6%) were not appropriate. Of the 102, 66 (65%) correctly did not select and 36 (35%) responded it was okay for them to use norgestrel 0.075 mg. Of the 36 participants who incorrectly self-selected, one had a history of breast cancer and thus might have been adversely affected had they taken norgestrel 0.075 mg. In the Targeted Breast Cancer Self-Selection Study (N = 206), 97% of participants correctly stated norgestrel 0.075 mg was not appropriate for them.

CONCLUSIONS

The proposed over-the-counter label enables 98% of potential users to self-select norgestrel 0.075 mg appropriately. Only 2% of potential purchasers may have bought and started to use norgestrel 0.075 mg inappropriately. For two-thirds of these, the potential benefits of their use of the method outweighed any theoretical risks. Adverse clinical consequences of norgestrel 0.075 mg use are unlikely even in those rare cases when the drug facts label was not followed.

IMPLICATIONS

The balance of the risk of inappropriate selection to the benefit of taking an over-the-counter progestin-only pill appears to be very much in favor of an overall benefit in terms of unintended pregnancy prevention.

CAnceR IN PreGnancy (CARING) - a retrospective study of cancer diagnosed during pregnancy in the United Kingdom

BACKGROUND

The incidence of cancer diagnosed during pregnancy is increasing. Data relating to investigation and management, as well as maternal and foetal outcomes is lacking in a United Kingdom (UK) population.

METHODS

In this retrospective study we report data from 119 patients diagnosed with cancer during pregnancy from 14 cancer centres in the UK across a five-year period (2016-2020).

RESULTS

Median age at diagnosis was 33 years, with breast, skin and haematological the most common primary sites. The majority of cases were new diagnoses (109 patients, 91.6%). Most patients were treated with radical intent (96 patients, 80.7%), however, gastrointestinal cancers were associated with a high rate of palliative intent treatment (63.6%). Intervention was commenced during pregnancy in 68 (57.1%) patients; 44 (37%) had surgery and 31 (26.1%) received chemotherapy. Live births occurred in 98 (81.7%) of the cases, with 54 (55.1%) of these delivered by caesarean section. Maternal mortality during the study period was 20.2%.

CONCLUSIONS

This is the first pan-tumour report of diagnosis, management and outcomes of cancer diagnosed during pregnancy in the UK. Our findings demonstrate proof of concept that data collection is feasible and highlight the need for further research in this cohort of patients.

Challenges and opportunities for proton therapy during pregnancy

During pregnancy, the use of radiation therapy for cancer treatment is often considered impossible due to the assumed associated fetal risks. However, suboptimal treatment of pregnant cancer patients and unjustifiable delay in radiation therapy until after delivery can be harmful for both patient and child. In non-pregnant patients, proton-radiation therapy is increasingly administered because of its favorable dosimetric properties compared with photon-radiation therapy. Although data on the use of pencil beam scanning proton-radiation therapy during pregnancy are scarce, different case reports and dosimetric studies have indicated a more than 10-fold reduction in fetal radiation exposure compared with photon-radiation therapy. Nonetheless, the implementation of proton-radiation therapy during pregnancy requires complex fetal dosimetry for the neutron-dominated out-of-field radiation dose and faces a lack of clinical guidelines. Further exploration and standardization of proton-radiation therapy during pregnancy will be necessary to improve radiotherapeutic management of pregnant women with cancer and further reduce risks for their offspring.

Weekly Paclitaxel for Pregnancy Associated Breast Cancer

BACKGROUND

Pregnancy associated breast cancer is the most common cancer diagnosed during pregnancy. When chemotherapy is indicated, although it is more common to use anthracycline-based chemotherapy as a first treatment, we suggest weekly paclitaxel as a valid alternative both in the adjuvant and neoadjuvant setting, as this allows for weekly assessment of maternal-fetal well-being and a quicker maternal and fetal bone marrow recovery in cases of unexpected preterm delivery.

PATIENTS AND METHODS

We present a case series of pregnant breast cancer patients treated with weekly paclitaxel between 2016 and 2022. Patient demographics and tumor characteristics, data on management, delivery, and maternal-neonatal outcomes were extrapolated from institutional electronic databases.

RESULTS

Eighteen patients underwent weekly paclitaxel for breast cancer during pregnancy (PrBC); 17 were primary diagnoses and 1 was a recurrence. None of the patients had severe adverse reactions to CT. Two cases of preterm prelabour rupture of membranes were reported while in 1 case treatment was stopped due to threatened preterm birth. Two babies were born large for gestational age, 2 were small for gestational age and 2 babies were growth restricted at birth. At a mean follow up of 42.9 months, 1 patient died, 1 patient was diagnosed with disease recurrence and another patient was diagnosed with disease progression.

CONCLUSION

Weekly paclitaxel can be safely administered during pregnancy and should be included in the current therapeutic options for PrBC.

Risk factors for the increasing incidence of pregnancy-associated cancer in Sweden - a population-based study

INTRODUCTION

The incidence of cancer during pregnancy and within first year post-delivery, ie pregnancy-associated cancer (PAC), is increasing in many countries, but little is known about risk factors for these trends. This study quantified incidence of PAC by trimesters and post-delivery periods, and assessed the role of maternal age, parity, immigrant status, education, smoking and body mass index for the risk and incidence trends of PAC.

MATERIAL AND METHODS

We used data from the national birth and cancer registers in Sweden during 1973-2017 to define a register-based cohort of women aged 15-44 years. Incidence rates of PAC during pregnancy and up to 1 year post-delivery were calculated per 100 000 deliveries per year. Poisson regression with multiple imputation estimated incidence rate ratios with 95% confidence intervals adjusted by year, age, previous parity, immigrant status, education, smoking and BMI during 1990-2017, when information on risk factors was available.

RESULTS

Among 4 557 284 deliveries, a total of 1274 (during pregnancy) and 3355 (within 1 year post-delivery) cases of PAC were diagnosed, with around 50 cases/year diagnosed during pregnancy and 110 cases/year during the first year post-delivery in the latest period 2015-2017. The most common cancer types during pregnancy were malignant melanoma, breast and cervical cancer, together accounting for 57% of cases during pregnancy and 53% during the first year post-delivery. The numbers of PAC were lower during pregnancy than during post-delivery for all tumor types with lowest numbers during first trimester. The PAC incidence rates increased over calendar time. High maternal age at diagnosis, smoking, nulliparity and non-immigrant background were associated with significantly higher risks of PAC. The increasing PAC incidence was in part explained by higher maternal age over time, but not by the other factors.

CONCLUSIONS

High maternal age is the strongest risk factor for PAC. We show for the first time that smoking, nulliparity and non-immigrant background are also contributing risk factors for PAC. However, only high maternal age contributed significantly to the increasing incidence. Further studies on other potential risk factors for PAC are warranted, since our results indicate that age on its own does not fully explain the increase.

Breast cancer during pregnancy-The oncologist's point of view

Breast cancer is the most common malignancy diagnosed during or directly after pregnancy. Differences in pathogenesis and prognosis identify two distinct patient groups, those with breast cancer during pregnancy and those with postpartum breast cancer which, for reasons not completely understood, is associated with worse outcomes. Compared with breast cancer in the non-pregnant patient, several limitations in terms of both local and systemic therapy are applied to limit fetal harm. Treatment is nevertheless delivered with curative intent, therefore avoiding harmful delays in therapy initiation, unnecessary therapy de-escalation or chemotherapy dose modifications is strongly recommended. In this short commentary, we briefly review current evidence and treatment guidelines and provide recommendations for optimal oncologic management of pregnancy-related breast cancer.

Middle cerebral artery peak systolic velocity monitoring of fetal anemia during chemotherapy in pregnancy

INTRODUCTION

Chemotherapy during pregnancy can increase the risk of fetal anemia. Severe fetal anemia can lead to the development of hydrops fetalis and potentially fetal demise. Hence, it is imperative to implement consistent monitoring methods in the context of chemotherapy treatment. This study aimed to diagnose and monitor fetal anemia using middle cerebral artery peak systolic velocity (MCA-PSV) as a diagnostic tool during chemotherapy in pregnant women.

MATERIAL AND METHODS

The study employed a prospective analysis involving a case series of 15 patients diagnosed with cancer during pregnancy and subsequently underwent chemotherapy. MCA-PSV was used to identify fetal anemia. The patients were scheduled for ultrasound examinations of the MCA-PSV. The first examination was performed on the same day as the administration of chemotherapy, while the second occurred on the 10th day after chemotherapy. The measurement technique used in the study was based on the methodology proposed by Mari and Barr. The multiples of the median were calculated using the calculators provided by Medicina Fetal Barcelona. Based on these values anemia severity was determined. When moderate or severe anemia was identified, chemotherapy was individually modified. Additionally, a blood count analysis was conducted immediately after the delivery of the newborn.

RESULTS

Five patients were diagnosed with fetal or newborn anemia. With MCA-PSV, we identified moderate fetal anemia in two patients and severe fetal anemia in one. The complete blood count testing of newborns revealed mild anemia in three patients. One case was unrelated to chemotherapy-induced anemia. During treatment, fetal anemia did not corelate with maternal anemia.

CONCLUSIONS

In four cases of anemia the combination of cisplatin and iphosphamide was used as a chemotherapy agent. No anemia was observed in other drug combinations. Our findings suggest that MCA-PSV is a reliable method for identifying anemia and should be included in the treatment protocol for chemotherapy-induced fetal anemia.

Risk of obstetric and perinatal complications in women presenting with breast cancer during pregnancy and the first year postpartum in Sweden 1973-2017: A population-based matched study

INTRODUCTION

For women presenting with breast cancer during pregnancy, treatment guidelines were historically restricted to only surgical treatment. Over the past decades, chemotherapy administered during pregnancy has been gradually introduced. Although breast cancer treatments during ongoing pregnancy have been deemed safe, detailed information on potential obstetric risks is lacking. We aimed to assess the risk of adverse obstetric and perinatal outcomes of breast cancer in pregnancy and within 1 year postpartum and in relation to trimester at breast cancer diagnosis, tumor stage, and cancer treatment during pregnancy.

MATERIAL AND METHODS

Population-based matched study. Women diagnosed with breast cancer during pregnancy in 1973-2017 were identified in the Swedish Cancer Register and the Medical Birth Register, with additional information from the National Quality Register for Breast Cancer. Each birth with maternal breast cancer (n = 208 pregnant, n = 672 postpartum) was matched by age, calendar year, and birth order to 10 unexposed births from cancer-free women in the population (n = 2080 and n = 6720). Adjusted conditional logistic and multinomial regression models were used to estimate odds ratios and relative risk ratios, commonly denoted relative risks (RR) with 95% confidence intervals (CI), of adverse obstetric and perinatal outcomes.

RESULTS

Breast cancer during pregnancy was associated with higher risks of preterm birth, both planned (RR 67.1, 95% CI 33.2-135.6) and spontaneous preterm birth (RR 3.8, 95% CI 2.0-7.5), and low birthweight (<2500 g: RR 7.5, 95% CI 4.9-11.3). The associated risks were higher if the breast cancer was diagnosed in the second trimester, and of similar magnitude irrespective of stage and treatment groups. There was a higher risk of low birthweight for gestational age (<25th centile) if breast cancer was diagnosed in the first trimester (RR 2.8, 95% CI 1.1-7.3). Risks of other pregnancy complications were similar to those of unexposed women, as were risks of neonatal mortality and malformations. Postpartum breast cancer was only associated with bleeding during pregnancy (RR 1.6, 95% CI 1.0-2.8).

CONCLUSIONS

Preterm birth and related adverse outcomes were more common in women diagnosed with breast cancer during pregnancy. Reassuringly, breast cancer was not associated with other maternal pregnancy complications or adverse outcomes in children.

Pregnancy-associated gynecological cancer in New South Wales, Australia 1994-2013: A population-based historical cohort study

INTRODUCTION

Pregnancy-associated gynecological cancer (PAGC) refers to cancers of the ovary, uterus, fallopian tube, cervix, vagina, and vulva diagnosed during pregnancy or within 12 months postpartum. We aimed to describe the incidence of, and perinatal outcomes associated with, invasive pregnancy-associated gynecological cancer.

MATERIAL AND METHODS

We conducted a population-based historical cohort study using linked data from New South Wales, Australia. We included all women who gave birth between 1994 and 2013, with a follow-up period extending to September 30, 2018. Three groups were analyzed: a gestational PAGC group (women diagnosed during pregnancy), a postpartum PAGC group (women diagnosed within 1 year of giving birth), and a control group (women with control diagnosis during pregnancy or within 1 year of giving birth). We used generalized estimation equations to compare perinatal outcomes between study groups.

RESULTS

There were 1 786 137 deliveries during the study period; 70 women were diagnosed with gestational PAGC and 191 with postpartum PAGC. The incidence of PAGC was 14.6/100 000 deliveries and did not change during the study period. Women with gestational PAGC (adjusted odds ratio [aAOR] 6.81, 95% confidence interval [CI] 2.97-15.62) and with postpartum PAGC (aOR 2.65, 95% CI 1.25-5.61) had significantly increased odds of a severe maternal morbidity outcome compared with the control group. Babies born to women with gestational PAGC were more likely to be born preterm (aOR 3.11, 95% CI 1.47-6.59) and were at increased odds of severe neonatal complications (aOR 3.47, 95% CI 1.45-8.31) compared with babies born to women without PAC.

CONCLUSIONS

The incidence of PAGC has not increased over time perhaps reflecting, in part, the effectiveness of cervical screening and early impacts of human papillomavirus vaccination programs in Australia. The higher rate of preterm birth among the gestational PAGC group is associated with adverse outcomes in babies born to these women.

Long-term outcomes of children after prenatal exposure to maternal cancer and its treatment

The incidence of antenatal cancer is increasing, prompting a medical-ethical evaluation. The International Network on Cancer, Infertility, and Pregnancy (INCIP) was established to study cancer treatment safety during pregnancy and its impact on maternal and child health. Pivotal research has led to a paradigm shift in clinical management, demonstrating the feasibility and safety of most antenatal oncological treatments. Short-term outcomes reveal normal growth and cardiac function in the exposed offspring, but caution is advised against first-trimester chemotherapy. Psychological impact studies highlight the elevated levels of distress in pregnant cancer patients, underscoring the need for personalized information and ongoing psychological support. Long-term follow-up studies address gaps in postnatal impacts, while research into specific chemotherapeutic agents continues. Despite generally reassuring outcomes, continued monitoring is crucial, especially in families, such as those where the child was born premature after cancer (treatment) during pregnancy or where mothers are frequently absent due to continued illness or have died from. The ongoing INCIP child follow-up initiative aims to further elucidate knowledge gaps, emphasizing the importance of large-scale studies and personalized patient care.

Results of an international survey on the current organization of care for pregnant women with cancer

The global incidence of cancer is increasing, including its incidence in women of reproductive age. Still, physicians encounter this situation rarely, which could lead to substandard care. This research sought to explore opportunities to improve future care for pregnant women with cancer, by describing the outcomes of a survey distributed to physicians all over the world focusing on clinical experience with pregnant women with cancer, the organization of care and current gaps in knowledge. We included 249 responses from physicians working across 36 countries. Responses demonstrate a wide variation in the organization of care - generally lacking centralization, and the physicians' acknowledgement of insufficient knowledge on the management of pregnant women with cancer. There is a need for improvement through national centralization and/or establishing advisory boards for cancer in pregnancy. Seeing the paucity of cancer in pregnancy experience, the importance of global multidisciplinary collaboration is emphasized.

Cancer during pregnancy: Twenty-two years of experience from a tertiary referral center

INTRODUCTION

Cancer complicating pregnancy is a rare but potentially life-threatening condition for both the mother and her child. The aim of the present study was to assess the outcomes for mothers and children after pregnancy complicated by malignancy and to investigate which parameters are important for their 1-year survival.

MATERIAL AND METHODS

The study included 84 pregnant women diagnosed with malignant tumors during pregnancy from 2001 to 2022. The pregnancy course and outcome, as well as parameters that could influence the survival and condition of the mother and child were evaluated. Mothers and children were followed up for 1 year after delivery to assess their condition/complications and overall survival.

RESULTS

Most malignancies were gynecological (31%) or hematological (23.8%) and were diagnosed and surgically treated in the second trimester. Most children (69%) showed adequate growth and development throughout pregnancy but were delivered before term (53.6%) to allow mothers to receive therapy. Adjuvant therapy during pregnancy mostly caused a transitory deterioration of the child's condition, while surgery did not significantly impact the pregnancy course. Deliveries, on average, occurred during the 33.01 ± 6.16 gestational week (range: 20-40) and mostly by cesarean section (76.2%). For mothers, the pregnancy survival rate was 95.2% and survival after 1 year was 87.5%. However, 37.5% of women were still ill and required additional therapy 1 year postpartum. The pregnancy survival rate for children was 94%, whereas the 1-year survival rate was 76.2%. Most children had a favorable condition (alive, adequately growing and developing, and without complications) at birth (81%) as well as at the 1-year follow-up (63.7%). Regression analysis identified the following predictors of favorable 1-year maternal condition: applying therapy during pregnancy, no progression of the malignancy during pregnancy, and delivery at a later gestational week. Predictors of favorable 1-year condition of children were lower histopathological grade of malignancy, surgery as therapy for malignancy, obtaining higher birthweight, and delivery by cesarean section.

CONCLUSIONS

If the malignancy is not progressing, pregnancy should be continued as long as possible for the child to obtain adequate birthweight. Both surgery and chemotherapy were safe therapeutic choices, as most pregnancies continued successfully after therapy.

Cancer in pregnancy - The obstetrical management

Cancer in pregnancy, defined as a cancer diagnosed during pregnancy, is a rare but severe condition presenting both clinical and ethical challenges. During the last two decades a paradigm shift has occurred towards recommending similar staging and treatment regimens of pregnant and non-pregnant cancer patients. This strategy is a result of an increasing number of reassuring reports on chemotherapy treatment in pregnancy after the first trimester. The management of cancer in pregnancy should be managed in a multidisciplinary team where staging, oncological treatment, social and mental care, timing of delivery, and follow-up of the infant should be planned. Due to the rarity, centralization is recommended to allow experience accumulation. Furthermore, national and international advisory boards are supportive when there is a lack of expertise.

Evaluating offspring Genomic and Epigenomic alterations after prenatal exposure to Cancer treatment In Pregnancy (GE-CIP): a multicentric observational study

INTRODUCTION

Around 1 in 1000-2000 pregnancies are affected by a cancer diagnosis. Previous studies have shown that chemotherapy during pregnancy has reassuring cognitive and cardiac neonatal outcomes, and hence has been proposed as standard of care. However, although these children perform within normal ranges for their age, subtle differences have been identified. Given that chemotherapeutic compounds can cross the placenta, the possibility that prenatal chemotherapy exposure mutates the offspring's genome and/or epigenome, with potential deleterious effects later in life, urges to be investigated.

METHODS AND ANALYSES

This multicentric observational study aims to collect cord blood, meconium and neonatal buccal cells at birth, as well as peripheral blood, buccal cells and urine from infants when 6, 18 and/or 36 months of age. Using bulk and single-cell approaches, we will compare samples from chemotherapy-treated pregnant patients with cancer, pregnant patients with cancer not treated with chemotherapy and healthy pregnant women. Potential chemotherapy-related newborn genomic and/or epigenomic alterations, such as single nucleotide variants, copy number variants and DNA-methylation alterations, will be identified in mononuclear and epithelial cells, isolated from blood, buccal swabs and urine. DNA from maternal peripheral blood and paternal buccal cells will be used to determine de novo somatic mutations in the neonatal blood and epithelial cells. Additionally, the accumulated exposure of the fetus, and biological effective dose of alkylating agents, will be assessed in meconium and cord blood via mass spectrometry approaches.

ETHICS AND DISSEMINATION

The Ethics Committee Research of UZ/KU Leuven (EC Research) and the Medical Ethical Review Committee of University Medical Center Amsterdam have approved the study. Results of this study will be disseminated via presentations at (inter)national conferences, through peer-reviewed, open-access publications, via social media platforms aimed to inform patients and healthcare workers, and through the website of the International Network on Cancer, Infertility and Pregnancy (www.cancerinpregnancy.org).

Survival in pregnancy-associated breast cancer patients compared to non-pregnant controls

BACKGROUND

Pregnancy-associated breast cancer (PABC) is a rare entity whose prognosis has previously been studied and is subject to controversy.

METHODS

Survival of patients with PABC diagnosed between 2009 and 2021 with breast cancer during pregnancy or until 1 year after childbirth was compared with non-pregnant patients with breast cancer from the same period at La Paz University Hospital. Cox proportional hazards regression was used to compare disease-free (DFS) and overall (OS) survival between the groups, adjusting for grade and pathologic stage.

RESULTS

Among the 89 included patients with breast cancer, 34 were diagnosed during pregnancy, and 55 were not pregnant. The pregnant patients were more likely to have grade 3 tumors (61.3% vs 37%, p = 0.023) and an advanced stage (pathologic stage III-IV: 44.1% vs 17.6%, p = 0.008). Median follow-up was 47 months for the pregnant group and 46 months for the control group. After adjustments for tumor grade and pathologic stage, OS was comparable between the groups (HR 2.03; 95% CI 0.61 to 6.79; P = 0.25).

CONCLUSIONS

The outcome of women diagnosed with PABC is comparable to young non-pregnant controls. However, it should be taken into account that PABC has a more aggressive phenotype.

Influence of cancer in pregnancy on obstetric and neonatal outcomes: an observational retrospective cohort study

OBJECTIVE

The study aimed to review the oncological characteristics and treatment of pregnancy-associated cancers and analyze the obstetric and neonatal outcomes to provide evidence-based recommendations for reproductive function preservation, oncological treatment, and obstetric management.

METHODS

We conducted an observational retrospective cohort study among pregnant patients with cancer in 7 Chinese tertiary A hospitals from 2003 to 2021. We conducted multiple logistic regression to determine the influence of various factors on preterm birth and small-for-gestational-age infants, log-binomial regression to analyze temporal changes, and χ² tests to explore the effects of cancer type/treatment.

RESULTS

Of 204 women, 17% terminated their pregnancies; 59% received pre-delivery treatment. Every 6 years, the rates of pregnancy termination (relative risk [RR]=0.48; 95% confidence interval [CI]=0.35-0.67) and iatrogenic preterm births (RR=0.73; 95% CI=0.54-0.98) reduced, and that of pre-delivery treatment increased, mainly due to increased rates of surgery (RR=1.87; 95% CI=1.31-2.67). Maternal systemic diseases were related to small-for-gestational-age infants (odds ratio [OR]=12.02; 95% CI=1.82-79.43). Chemotherapy with taxanes plus platinum-based agents was related to adverse obstetric outcomes (OR=1.87; 95% CI=1.42-2.46; p<0.05). Thyroid (OR=0.36; 95% CI=0.22-0.57) and ovarian cancer (OR=0.70; 95% CI=0.50-0.98) were associated with fewer cesarean sections. Thyroid cancer was associated with fetal growth restriction (OR=5.21; 95% CI=1.21-22.55).

CONCLUSION

Rates of pregnancy termination in cancer declined. Taxane plus platinum-based chemotherapy was associated with adverse obstetric outcomes. Cancer type influenced outcomes.

TRIAL REGISTRATION

Chinese Clinical Trial Register Identifier: ChiCTR2100044292.

Diagnostic, Management, and Neonatal Outcomes of Colorectal Cancer during Pregnancy: Two Case Reports, Systematic Review of Literature and Metanalysis

OBJECTIVE

Colorectal cancer (CRC) during pregnancy is a rare occurrence, with a reported incidence of 0.8 cases per 100,000 pregnancies. Managing CRC during pregnancy poses substantial challenges for clinicians: the diagnosis is often complicated and delayed due to symptom overlap with pregnancy-related manifestations, and medical imaging is constrained by safety concerns for the foetus.

METHODS

This article presents two cases of advanced CRC diagnosed and managed during pregnancy. Additionally, we conducted a systematic review of the literature to assess diagnostic and prognostic factors involved in CRC in pregnant individuals. The systematic review, with pre-registration and approval through Prospero, involved an extensive search of medical databases (Pubmed, Web of Science, Scopus and Scholar) and statistical analysis using t-test for continuous variables and chi square for dichotomous variables.

RESULTS

A total of 1058 studies were identified. After applying exclusion criteria, sixty-six studies were included. Women whose initial symptoms were severe abdominal pain not responsive to common medical treatments and constipation (acute abdomen) had a mean gestational age at delivery lower than those who presented with paucisymptomatic onset. In our study groups, women who underwent chemotherapy during pregnancy had a higher mean gestational age at delivery and did not experience worse neonatal outcomes compared to those who did not undergo chemotherapy.

CONCLUSIONS

CRC during pregnancy poses unique diagnostic and therapeutic challenges. Collaborative efforts among various medical disciplines are essential to manage CRC during pregnancy.

An uncommon case of metastatic undifferentiated pleomorphic soft tissue sarcoma during pregnancy: Literature review and case report

Soft tissue sarcomas accounts for 1-2% of adult malignancies. Undifferentiated pleomorphic sarcoma (UPS) is a rare subtype that lack immunohistochemical markers for a specific definition. About 18% of sarcomas are at a locally advanced stage, often requiring several cycles of chemotherapy and radiotherapy, in addition to surgery. For a young woman, this can mean delaying pregnancies with a high risk of therapy-induced ovarian damage. For this reason, proper counseling on fertility preservation plays a key role. In addition, all women of childbearing age with cancer, should be informed about the importance of planning a pregnancy to improve maternal and neonatal outcomes. We report a rare case of a 40-year-old woman with a UPS who, during CT scan after chemotherapy to decide on surgery, find out she was pregnant. After counseling, the patient decides to go ahead with the pregnancy.

The Future Direction of Women in Nuclear Medicine and Nuclear Medicine in Women's Health

This work discusses the role of Nuclear Medicine for women's health, the role of women in the development of this emerging field and the various issues which arise from both. It emphasizes the importance of young women and their competing needs due to factors like pregnancy and work-related challenges. The objectives of this overview include improving imaging techniques, preserving fertility during cancer treatment, diagnosing pelvic and uterine conditions, developing radiopharmaceuticals for women's health, protecting female employees in Nuclear Medicine, and considering the role of artificial intelligence.

Taxanes for the treatment of breast cancer during pregnancy: an international cohort study

INTRODUCTION

The addition of taxanes to anthracycline-based chemotherapy is considered standard of care in the treatment of breast cancer. However, there are insufficient data regarding the safety of taxanes during pregnancy. The aim of this study was to describe the incidence of obstetric and neonatal adverse events associated with the use of taxane-containing chemotherapy regimens for the treatment of breast cancer during pregnancy.

METHODS

This is a multicenter, international cohort study of breast cancer patients treated with taxanes during pregnancy. A descriptive analysis was undertaken to synthetize available data.

RESULTS

A total of 103 patients were included, most of whom were treated with paclitaxel and anthracyclines given in sequence during gestation (90.1%). The median gestational age at taxane initiation was 28 weeks (range = 12-37 weeks). Grade 3-4 adverse events were reported in 7 of 103 (6.8%) patients. The most common reported obstetric complications were intrauterine growth restriction (n = 8 of 94, 8.5%) and preterm premature rupture of membranes (n = 5 of 94, 5.3%). The live birth rate was 92 of 94 (97.9%), and the median gestational age at delivery was 37 weeks (range = 32-40 weeks). Admission to an intensive care unit was reported in 14 of 88 (15.9%) neonates, and 17 of 70 (24.3%) live births resulted in small for gestational age neonates. Congenital malformations were reported in 2 of 93 (2.2%).

CONCLUSION

Obstetric and neonatal outcomes after taxane exposure during pregnancy were generally favorable and did not seem to differ from those reported in the literature with standard anthracycline-based regimens. This study supports the use of taxanes during gestation when clinically indicated.

Pregnancy, delivery and neonatal outcomes in women with gastrointestinal system cancer in pregnancy. An evaluation of a population database

OBJECTIVES

Gastrointestinal system (GIS) cancer in pregnancy is a rare disease. Our aim was to evaluate the association between this type of cancer and pregnancy, delivery and neonatal outcomes.

METHODS

We conducted a retrospective population-based cohort study using the Healthcare Cost and Utilization Project, Nation-wide Inpatient Sample (HCUP-NIS). We included all women who delivered or had a maternal death in the US between 2004 and 2014. We compared women with an ICD-9 diagnosis of GIS cancer to those without. Pregnancy, delivery, and neonatal outcomes were compared between the two groups.

RESULTS

A total of 9,096,788 women met inclusion criteria. Amongst them, 194 women (2/100,000) had a diagnosis of GIS cancer during pregnancy. Women with GIS cancer, compared to those without, were more likely to be Caucasian, older than 35 years of age, and to suffer from obesity, chronic hypertension, pregestational diabetes and thyroid disease. The cancer group had a lower rate of spontaneous vaginal delivery (aOR 0.2, 95 % CI 0.13-0.27, p<0.001), and a higher rate of preterm delivery (aOR 1.85, 95 % CI 1.21-2.82, p=0.04), and of maternal complications such as blood transfusion (aOR 24.7, 95 % CI 17.11-35.66, p<0.001), disseminated intravascular coagulation (aOR 14.56, 95 % CI 3.56-59.55, p<0.001), venous thromboembolism (aOR 9.4, 95 % CI 2.3-38.42, p=0.002) and maternal death (aOR 8.02, 95 % CI 2.55-25.34, p<0.001). Neonatal outcomes were comparable between the two groups.

CONCLUSIONS

Women with a diagnosis of GIS cancer in pregnancy have a higher incidence of maternal complications including maternal death, without any differences in neonatal outcomes.

The impact of urban spatial environment on COVID-19: a case study in Beijing

Epidemics are dangerous and difficult to prevent and control, especially in urban areas. Clarifying the correlation between the COVID-19 Outbreak Frequency and the urban spatial environment may help improve cities' ability to respond to such public health emergencies. In this study, we firstly analyzed the spatial distribution characteristics of COVID-19 Outbreak Frequency by correlating the geographic locations of COVID-19 epidemic-affected neighborhoods in the city of Beijing with the time point of onset. Secondly, we created a geographically weighted regression model combining the COVID-19 Outbreak Frequency with the external spatial environmental elements of the city. Thirdly, different grades of epidemic-affected neighborhoods in the study area were classified according to the clustering analysis results. Finally, the correlation between the COVID-19 Outbreak Frequency and the internal spatial environmental elements of different grades of neighborhoods was investigated using a binomial logistic regression model. The study yielded the following results. (i) Epidemic outbreak frequency was evidently correlated with the urban external spatial environment, among building density, volume ratio, density of commercial facilities, density of service facilities, and density of transportation facilities were positively correlated with COVID-19 Outbreak Frequency, while water and greenery coverage was negatively correlated with it. (ii) The correlation between COVID-19 Outbreak Frequency and the internal spatial environmental elements of neighborhoods of different grades differed. House price and the number of households were positively correlated with the COVID-19 Outbreak Frequency in low-end neighborhoods, while the number of households was positively correlated with the COVID-19 Outbreak Frequency in mid-end neighborhoods. In order to achieve spatial justice, society should strive to address the inequality phenomena of income gaps and residential differentiation, and promote fair distribution of spatial environments.

Neonatal outcomes and follow-up of children born to women with pregnancy-associated cancer: a prospective observational study

BACKGROUND

During the last decade, there has been a growing number of cases of children born from pregnancy-associated cancer (PAC), however there are currently insufficient data on the follow up to be observed in this category of newborns. Objective of the study was to evaluate the neonatal outcomes of infants born to mother with PAC, the potential adverse effect of chemotherapy during pregnancy and the risk of metastasis to the fetus.

METHODS

Maternal clinical data and neonatal outcomes of child born to mothers diagnosed with PAC were collected; infants were divided into those were and were not exposed to chemotherapy during fetal life and their outcomes were compered.

RESULTS

A total of 37 newborn infants from 36 women with PAC were analyzed. Preterm delivery occurred in 83.8% of the cases. No significant differences in neonatal outcomes were found between infants who were and were not exposed to chemotherapy during pregnancy. The median follow-up period was 12 months.

CONCLUSIONS

PAC treatment during the second or third trimester does not seem to be dangerous for the fetus, however infants born from PAC must be carefully evaluated for to rule out the consequences of chemotherapy and exclude the presence of metastasis. Long-term follow-up, especially in children exposed to chemotherapy, should be encouraged to obtain relevant data on long-term toxicity.

Obstetric and neonatal outcomes following taxane use during pregnancy: a systematic review

BACKGROUND

The use of taxanes following the first trimester of pregnancy is endorsed by current clinical guidelines. However, evidence regarding their safety in terms of obstetric and neonatal outcomes is limited.

METHODS

A comprehensive literature search was performed using the MEDLINE, CENTRAL and Web of Sciences databases from their inception up to 12/16/2022. Eligibility criteria included gestational taxane use, presentation of original findings, and individual case data presented. A descriptive statistical analysis was undertaken.

RESULTS

A total of 159 patients treated with taxane-containing regimens during pregnancy were identified, resulting in 162 fetuses exposed in utero. The majority of patients had breast cancer (n = 88; 55.3%) or cervical cancer (n = 45; 28.3%). The most commonly employed taxane was paclitaxel (n = 131; 82.4%). A total of 111 (69.8%) patients were also treated with other cytotoxic drugs during pregnancy, including platinum salts (n = 70; 63.0%) and doxorubicin/cyclophosphamide (n = 20; 18.0%). While most patients received taxanes during the second trimester of pregnancy (n = 79; 70.0%), two were exposed to taxanes in the first trimester. Obstetric outcomes were reported in 105 (66.0%) cases, with the most frequent adverse events being preterm contractions or premature rupture of membranes (n = 12; 11.4%), pre-eclampsia/HELLP syndrome (n = 6; 5.7%), and oligohydramnios/anhydramnios (n = 6; 5.7%). All cases with pregnancy outcome available resulted in live births (n = 132). Overall, 72 (54.5%) neonates were delivered preterm, 40 (30.3%) were classified as small for gestational age (SGA), and 2 (1.5%) had an Apgar score of < 7 at 5 min. Perinatal complications included acute respiratory distress syndrome (n = 14; 10.6%), hyperbilirubinemia (n = 5; 3.8%), and hypoglycemia (n = 2; 1.5%). In addition, 7 (5.3%) cases of congenital malformations were reported. At a median follow-up of 16 months, offspring health status was available for 86 (65.2%), of which 13 (15.1%) had a documented complication, including delayed speech development, recurrent otitis media, and acute myeloid leukemia.

CONCLUSIONS

Taxanes appear to be safe following the first trimester of pregnancy, with obstetric and fetal outcomes being similar to those observed in the general obstetric population. Future studies should aim to determine the most effective taxane regimen and dosage for use during gestation, with a specific focus on treatment safety.

Physiologically-based pharmacokinetic model to predict doxorubicin and paclitaxel exposure in infants through breast milk

Limited information is available concerning infant exposure and safety when breastfed by mothers receiving chemotherapy. Whereas defining distribution to breast milk is important to infer drug exposure, infant pharmacokinetics also determine to what extent the infant will be exposed to potential toxic effects. We aimed to assess the impact of chemotherapy containing breast milk on infants by predicting systemic and local (intestinal) exposure of paclitaxel and doxorubicin in infants through breast milk using a physiologically-based pharmacokinetic (PBPK) approach. Whole-body PBPK models of i.v. paclitaxel and doxorubicin were extended from the literature, with an oral absorption component to enable predictions in infants receiving paclitaxel or doxorubicin-containing breast milk. For safety considerations, worst-case scenarios were explored. Finally, paclitaxel and doxorubicin exposures in plasma and intestinal tissue of infants following feeding of breast milk from paclitaxel- or doxorubicin-treated mothers were simulated and breast milk discarding strategies were evaluated. The upper 95th percentile of the predicted peak concentrations in peripheral venous blood were 3.48 and 0.74 nM (0.4%-1.7% and 0.1%-1.8% of on-treatment) for paclitaxel and doxorubicin, respectively. Intestinal exposure reached peak concentrations of 1.0 and 140 μM for paclitaxel and doxorubicin, respectively. Discarding breast milk for the first 3 days after maternal chemotherapy administration reduced systemic and tissue exposures even further, to over 90% and 80% for paclitaxel and doxorubicin, respectively. PBPK simulations of chemotherapy exposure in infants after breastfeeding with chemotherapy containing breast milk suggest that particularly local gastrointestinal adverse events should be monitored, whereas systemic adverse events are not expected.

Pregnancy and neonatal outcomes following malignancy in pregnancy at a tertiary care Canadian center: a retrospective chart review

Objective: Data on pregnancy-associated cancers (PACs) are lacking. The objectives of this study were to determine the incidence of PACs and describe the characteristics and outcomes of pregnancies affected by malignancy at a single tertiary care center in Ottawa, Canada.Methods: This was a retrospective chart review of individuals with PAC at The Ottawa Hospital (TOH) between 2011-2022. Eligible cases were identified from the TOH Data Warehouse, the TOH instance of the Better Outcomes Registry & Network Ontario, and the TOH Division of Maternal Fetal Medicine's Perinates database. Chart reviews were conducted to confirm case eligibility and to extract demographic, oncologic, obstetrical, and neonatal measures. The annual incidence of PAC over the 11-year period was reported per 1000 deliveries. Descriptive statistics were used to describe the sample, including frequency (n) and proportions (%) for categorical variables and mean and standard deviation (SD) for continuous variables.Results: The final cohort included 59 individuals with PAC at TOH between 2011-2022. The annual incidence of PAC ranged from 0.47 to 1.54 per 1000 deliveries. The most common PACs were breast cancer (28.8%), Hodgkin lymphoma (10.2%), and thyroid cancer (8.5%). Common interventions during pregnancy included chemotherapy (33.9%) and surgical intervention (32.2%). A total of 19 individuals (32.2%) did not undergo PAC-related treatment during pregnancy. There were 55 livebirths (91.7%), 2 spontaneous abortions (3.3%), 3 induced abortions (5.0%), and no stillbirths. Among livebirths, the mean gestational age was 37.4 ± 2.8 weeks and the mean birthweight was 2920.3 ± 650.0 g. All neonates had reassuring 5-minute Apgar scores, 18 (32.7%) were admitted to the Neonatal Intensive Care Unit/Special Care Nursery (NICU/SCN), and 8 (14.5%) were noted to have a mild congenital abnormality.Conclusion: This study shows promising perinatal outcomes for patients with PAC and their neonates. Ongoing surveillance of PAC is needed to better inform care for this patient population.

From Infection to Malignancy: Tracing the Impact of Human Papillomavirus on Uterine Endometrial Cancer in a Nationwide Population-Based Cohort Study

Uterine endometrial cancer (EC) is the most common gynecological malignancy in Taiwan. This study aimed to investigate the association between human papillomavirus (HPV) infection and the development of uterine EC among Taiwanese women. A nationwide population cohort research approach was employed, leveraging longitudinal health insurance databases (LHID 2007 and 2015) from the National Health Insurance Research Database alongside data from the Taiwan Cancer Registry datasets. A comparative analysis examined 472,420 female patients with HPV infection and 944,840 without HPV infection. The results demonstrated that the HPV cohort exhibited a significantly elevated risk of uterine EC, as evidenced by an adjusted hazard ratio (aHR) of 1.588 (95% CI: 1.335-1.888). Furthermore, this elevated risk extended to type 1 EC with an aHR of 1.671 (95% CI: 1.376-2.029), specifically the endometrioid adenocarcinoma subtype with an aHR 1.686 (95% CI: 1.377-2.065). Importantly, these findings were statistically significant (p < 0.001). In conclusion, this research unveils a potential association between HPV infection and an increased risk of uterine EC, particularly the type 1 endometrial cancer subtype, within the Taiwanese female population. These findings have implications for preventive measures and screening programs targeting HPV infection to reduce the risk of this prevalent gynecological malignancy in Taiwan.

Spontaneous and induced abortions in women with a diagnosis of gestational related neoplasm: a population-based linkage study in Lombardy, 2010-2020

BACKGROUND

A diagnosis of cancer during pregnancy or within one year after the end of pregnancy is a major clinical and public health issue. The current study aimed at estimating the incidence of pregnancy-associated cancer (PAC) and assessing whether the risk of abortion is increased in women diagnosed with cancer.

METHODS

This population-based cohort study used the regional healthcare utilization (HCU) databases of Lombardy, the largest region in Italy, to identify the women who delivered between 2010 and 2020. PAC were identified by oncological ICD-9-CM codes reported in the hospital discharge forms. We computed the ratio of PAC cases to the total number of pregnancies. Following a diagnosis of PAC, the prevalence ratio (PR) of abortion and the corresponding 95% confidence interval (CI), was estimated using a log-binomial model adjusted for maternal age.

RESULTS

During the study period, 926 women who gave birth (1.29 cases per 1000 births) and 341 women who had an abortion (1.52 cases per 1000 abortions) were diagnosed with PAC. Regardless of the outcome of pregnancy, the risk of PAC increased with increasing age. The rate of PAC was initially lower among births, but it came very close to the rate of PAC among abortions in the last two calendar years. The proportion of abortions among women with PAC gradually decreased from 27.7% in 2010-2012 to 18.5% in 2019-2020 (p-value < 0.001). Overall, a diagnosis of PAC was related to an approximately 10% increased risk of abortion (PR = 1.11, 95%CI:1.01-1.22). However, no association was observed in 2019-2020 (PR = 0.87, 95%CI:0.65-1.17). Considering only diagnoses made during the first trimester of pregnancy, the risk of abortion was about 2.5 times higher (PR = 2.53, 95%CI:2.05-3.11) and the risk of induced abortion was almost 4 times higher (PR = 3.71, 95%CI:2.82-4.90).

CONCLUSION

In this population the risk of abortion was about 10% higher in women with PAC than in women without PAC. However, this association tended to decrease in more recent calendar periods. This trend seemed to be influenced more by spontaneous than by induced abortions.

Cancer and Pregnancy in the Post-Roe v. Wade Era: A Comprehensive Review

Cancer during pregnancy, affecting 1 in 1000 pregnancies, is rising in incidence due to delayed childbearing and improved detection. Common types include breast cancer, melanoma and cervical cancer and Hodgkin's Lymphoma. There are several physiological changes that occur during pregnancy that make its management a challenge to clinicians. Managing it requires multidisciplinary approaches and cautious test interpretation due to overlapping symptoms. To minimize fetal radiation exposure, non-ionizing imaging is preferred, and the interpretation of tumor markers is challenging due to inflammation and pregnancy effects. In terms of treatment, chemotherapy is avoided in the first trimester but may be considered later. Immunotherapy's safety is under investigation, and surgery depends on gestational age and cancer type. Ethical and legal concerns are growing, especially with changes in U.S. abortion laws. Access to abortion for medical reasons is vital for pregnant cancer patients needing urgent treatment. Maternal outcomes may depend on the type of cancer as well as chemotherapy received but, in general, they are similar to the non-pregnant population. Fetal outcomes are usually the same as the general population with treatment exposure from the second trimester onwards. Fertility preservation may be an important component of the treatment discussion depending on the patient's wishes, age and type of treatment. This article addresses the complicated nature of a diagnosis of cancer in pregnancy, touching upon the known medical literature as well as the ethical-legal implications of such a diagnosis, whose importance has increased in the light of recent judicial developments.

ESMO Expert Consensus Statements on the management of breast cancer during pregnancy (PrBC)

The management of breast cancer during pregnancy (PrBC) is a relatively rare indication and an area where no or little evidence is available since randomized controlled trials cannot be conducted. In general, advances related to breast cancer (BC) treatment outside pregnancy cannot always be translated to PrBC, because both the interests of the mother and of the unborn should be considered. Evidence remains limited and/or conflicting in some specific areas where the optimal approach remains controversial. In 2022, the European Society for Medical Oncology (ESMO) held a virtual consensus-building process on this topic to gain insights from a multidisciplinary group of experts and develop statements on controversial topics that cannot be adequately addressed in the current evidence-based ESMO Clinical Practice Guideline. The aim of this consensus-building process was to discuss controversial issues relating to the management of patients with PrBC. The virtual meeting included a multidisciplinary panel of 24 leading experts from 13 countries and was chaired by S. Loibl and F. Amant. All experts were allocated to one of four different working groups. Each working group covered a specific subject area with two chairs appointed: Planning, preparation and execution of the consensus process was conducted according to the ESMO standard operating procedures.

Breast Cancer in Pregnant Young Women: Clinicopathological Profile, Survival, and Pregnancy Outcomes

Background Breast cancer is one of the most common cancer types diagnosed during pregnancy; the presence of any neoplasm in pregnant women faces clinical dilemmas and challenges in cancer and pregnancy management. Pregnancy-associated breast cancer (PABC) is defined as breast cancer diagnosed during pregnancy or within one year after delivery. The aim of this study was to describe tumor clinicopathological characteristics and pregnancy outcomes in PABC patients. Materials and methods This is a retrospective cohort assessing PABC patients. Qualitative variables were compared using Fisher's exact test. Kaplan-Meier method was used to calculate survival. Cox regression and logistic regression methods were used to estimate the hazard ratio (HR) and odds ratio (OR), respectively. Results We assessed 16 PABC patients. Women ≤ 35 years of age were mainly diagnosed at advanced stage (88.8%) with ER-negative disease (77.8%). Patients with >4 pathological lymph nodes (25%; p = 0.001) and ER-negative disease (50%; p = 0.646) showed poor five-year overall survival (OS). In the multivariate analysis, nodal involvement was the main predictor associated with poorer OS (HR = 1.4, 90% confidence interval [CI]: 1.14 to 1.8). The following risk factors might influence the risk of preterm delivery: maternal older age, gestational age at diagnosis, and intrauterine exposure to chemotherapy, but an adjusted OR of 0.61 (90% CI: 0.34 to 1), 0.80 (90% CI: 0.66 to 0.9), and 0.013 (90% CI: 0.00 to 0.9), respectively, did not statistically support such an effect. Conclusions Younger women with PABC had a more aggressive pathological profile that might partly explain the poor OS. Obstetrical adverse events related to preterm delivery should be avoided with better planning of specialized strategies.

Choosing the appropriate pharmacotherapy for breast cancer during pregnancy: what needs to be considered?

INTRODUCTION

Breast cancer is the most commonly diagnosed malignancy during pregnancy. Breast cancer during pregnancy is a challenging clinical condition requiring proper and timely multidisciplinary management.

AREAS COVERED

This review focuses on the management of breast cancer during pregnancy with a focus about the current state-of-the-art on the feasibility and safety of pharmacotherapy approaches in this setting.

EXPERT OPINION

Multidisciplinary care is key for a proper diagnostic-therapeutic management of breast cancer during pregnancy. Engaging patients and their caregivers in the decision-making process is essential and psychological support should be provided. The treatment of patients with breast cancer during pregnancy should follow the same recommendations as those for breast cancer in young women outside pregnancy but taking into account the gestational age at the time of treatment.Anthracycline-, cyclophosphamide-, and taxane-based regimens can be safely administered during the second and third trimesters with standard protocols, preferring weekly regimens whenever possible. Endocrine therapy, immune checkpoint inhibitors, and targeted agents are contraindicated throughout pregnancy, also due to the very limited data available to guide their administration in this setting. During treatment, careful fetal growth monitoring is mandatory, and even after delivery proper health monitoring for the children exposed in utero to chemotherapy should be continued.