Female survivors of childhood cancer: preterm birth and low birth weight among their children

Development and evaluation of machine learning models for predicting large-for-gestational-age newborns in women exposed to radiation prior to pregnancy

INTRODUCTION

The correlation between radiation exposure before pregnancy and abnormal birth weight has been previously proven. However, for large-for-gestational-age (LGA) babies in women exposed to radiation before becoming pregnant, there is no prediction model yet.

MATERIAL AND METHODS

The data were collected from the National Free Preconception Health Examination Project in China. A sum of 455 neonates (42 SGA births and 423 non-LGA births) were included. A training set (n = 319) and a test set (n = 136) were created from the dataset at random. To develop prediction models for LGA neonates, conventional logistic regression (LR) method and six machine learning methods were used in this study. Recursive feature elimination approach was performed by choosing 10 features which made a big contribution to the prediction models. And the Shapley Additive Explanation model was applied to interpret the most important characteristics that affected forecast outputs.

RESULTS

The random forest (RF) model had the highest average area under the receiver-operating-characteristic curve (AUC) for predicting LGA in the test set (0.843, 95% confidence interval [CI]: 0.714-0.974). Except for the logistic regression model (AUC: 0.603, 95%CI: 0.440-0.767), other models' AUCs displayed well. Thereinto, the RF algorithm's final prediction model using 10 characteristics achieved an average AUC of 0.821 (95% CI: 0.693-0.949).

CONCLUSION

The prediction model based on machine learning might be a promising tool for the prenatal prediction of LGA births in women with radiation exposure before pregnancy.

Fertility preservation in patients undergoing gonadotoxic treatments: a Canadian Fertility and Andrology Society clinical practice guideline

The management of young patients with cancer presents several unique challenges. In general, these patients are ill prepared for the diagnosis and the impact on their fertility. With the improved survival for all tumour types and stages, the need for adequate fertility counselling and a multidisciplinary approach in the reproductive care of these patients is paramount. Recent advances in cryopreservation techniques allow for the banking of spermatozoa, oocytes, embryos and ovarian tissue without compromising survival. This Canadian Fertility and Andrology Society (CFAS) guideline outlines the current understanding of social and medical issues associated with oncofertility, and the medical and surgical technologies available to optimize future fertility.

Perinatal and childhood outcomes of children born to female cancer survivors in South Korea

Despite the increasing number of female cancer survivors, uncertainty remains regarding potential adverse health outcomes for their offspring. Comprehensive population-based studies would be invaluable for female cancer survivors in making decisions about their future. This study uses the National Health Information Database to investigate perinatal and long-term outcomes of offspring born to mothers with a history of cancer. In a South Korean cohort of 95,264 women aged 15-40 diagnosed with cancer between 2007 and 2010, we evaluated the outcomes of 15,221 children born to 11,092, cancer survivors. We selected 147,727 women without a history of cancer and 201,444 children as a control group. Our study found that children of female cancer survivors have a significantly higher odds ratio of primary outcomes including preterm birth, low birth weight, neonatal intensive care unit admission, and death. While there was no difference in the rate of death within 1 year of birth between the two groups, the total death rate during the follow-up period was significantly higher in children born to mothers with cancer. After adjusting for gestational age and birth weight, there was no statistically significant increased hazard ratio of secondary outcomes including cancer, chromosomal abnormalities, cerebral palsy, delayed development, epilepsy, language disorder, or hearing impairment.

Female reproductive health in pediatric, adolescent, and young adult cancer survivors

An estimated 500,000 cancer survivors of reproductive age in the United States will live to experience the long-term consequences of cancer treatment. Therefore, a focused aspect of cancer care has appropriately shifted to include quality of life in survivorship. Infertility is a late effect of therapy that affects 12% of female survivors of childhood cancer receiving any cancer treatment in large cohort studies and results in a 40% decreased likelihood of pregnancy in young adults of ages 18-39 years. Nonfertility gynecologic late effects such as hypoestrogenism, radiation-induced uterine and vaginal injury, genital graft-versus-host disease after hematopoietic stem cell transplant, and sexual dysfunction also significantly affect quality of life in survivorship but are underdiagnosed and require consideration. Several articles in the special edition "Reproductive Health in Adolescent and Young Adult Cancer Survivorship" address infertility, genital graft-versus-host disease, and psychosexual functioning in survivorship. This review article focuses on other adverse gynecologic outcomes of cancer therapies including hypogonadism and hormone replacement therapy, radiation-induced uterovaginal injury, vaccination and contraception, breast and cervical cancer screening, and pregnancy considerations in survivorship.

Reproductive late effects after hematopoietic stem cell transplant in pediatric, adolescent, and young adult cancer survivors

Reproductive late effects after hematopoietic stem cell transplant can have a significant impact on cancer survivors' quality of life. Potential late effects include gonadal insufficiency, genital graft-versus-host disease, uterine injury, psychosexual dysfunction, and an increased risk of breast and cervical cancer in patients treated with total body irradiation. Despite guidelines, screening and treatment are not standardized among at-risk patients. Provider barriers include lack of knowledge of at-risk therapies and evidenced-based guidelines. Patient barriers include a reluctance to report symptoms and lack of awareness of treatment options. System barriers include inefficient implementation of screening tools and poor dissemination of guidelines to providers who serve as the medical home for survivors. This review guides the clinician in identifying and managing reproductive late effects after hematopoietic stem cell transplant to improve outcomes.

Pregnancy and neonatal outcomes among women with early-onset colorectal cancer: a nationwide case-control study

Background

Early-onset colorectal cancer has risen worldwide, leaving more women with colorectal cancer at reproductive ages. We aimed to investigate the risk of adverse pregnancy and neonatal outcomes among women with early-onset colorectal cancer.

Methods

We conducted a nationwide, matched case-control study of maternal/pregnancy outcomes including pre-eclampsia and Cesarean delivery (C-section) as well as neonatal outcomes including preterm birth among 207 births in women with early-onset colorectal cancer (ages 18-49) and 1019 births in women without colorectal cancer in Sweden (1992-2019). Early-onset colorectal cancer cases were identified through the Cancer Register, and outcome data were retrieved through linkage to Medical Birth Register and National Patient Register. Using conditional logistic regression, we estimated multivariable-adjusted odds ratios (ORs) and 95% confidence intervals (CIs).

Findings

Between Jan 1, 1992, and Dec 31, 2019, women with early-onset colorectal cancer who gave birth had increased odds of pre-eclampsia (7.2% vs 3.2%; OR = 2.52, 95%CI = 1.25-5.08), any C-section (24.6% vs 19.4%; OR = 1.43, 95%CI = 1.00-2.06), particularly emergency C-section (17.4% vs 10.5%; OR = 1.79, 95%CI = 1.17-2.75), after adjustment for maternal education level, country of birth, body mass index and smoking in early pregnancy, and comorbidities. Maternal history of early-onset colorectal cancer was also associated with offspring preterm birth (12.1% vs 5.2%; OR = 2.31, 95%CI = 1.34-3.99), delineated as spontaneous (OR = 1.06, 95%CI = 0.47-2.39) or medically-indicated preterm birth (OR = 4.48, 95%CI = 2.05-9.79). There was no increased risk of congenital malformation or small for gestational age birth.

Interpretation

In this population-based study, maternal history of early-onset colorectal cancer was associated with risk of both adverse pregnancy (pre-eclampsia, C-section) and neonatal outcomes (preterm birth).

Funding

US National Institutes of Health, Swedish Society of Medicine, Swedish Cancer Foundation.

Radiotherapy exposure directly damages the uterus and causes pregnancy loss

Female cancer survivors are significantly more likely to experience infertility than the general population. It is well established that chemotherapy and radiotherapy can damage the ovary and compromise fertility, yet the ability of cancer treatments to induce uterine damage, and the underlying mechanisms, have been understudied. Here, we show that in mice total-body γ-irradiation (TBI) induced extensive DNA damage and apoptosis in uterine cells. We then transferred healthy donor embryos into ovariectomized adolescent female mice that were previously exposed to TBI to study the impacts of radiotherapy on the uterus independent from effects to ovarian endocrine function. Following TBI, embryo attachment and implantation were unaffected, but fetal resorption was evident at midgestation in 100% of dams, suggesting failed placental development. Consistent with this hypothesis, TBI impaired the decidual response in mice and primary human endometrial stromal cells. TBI also caused uterine artery endothelial dysfunction, likely preventing adequate blood vessel remodeling in early pregnancy. Notably, when pro-apoptotic protein Puma-deficient (Puma-/-) mice were exposed to TBI, apoptosis within the uterus was prevented, and decidualization, vascular function, and pregnancy were restored, identifying PUMA-mediated apoptosis as a key mechanism. Collectively, these data show that TBI damages the uterus and compromises pregnancy success, suggesting that optimal fertility preservation during radiotherapy may require protection of both the ovaries and uterus. In this regard, inhibition of PUMA may represent a potential fertility preservation strategy.

Maternal and perinatal outcomes following a diagnosis of Hodgkin lymphoma during or prior to pregnancy: A systematic review

BACKGROUND

The initial peak incidence of Hodgkin lymphoma (HL) occurs during reproductive years.

OBJECTIVES

Synthesise published literature on the relationship between HL and maternal and perinatal outcomes.

SEARCH STRATEGY

Systematic search of PubMed/Medline, Cochrane Library, Scopus, Embase and Science Direct from inception to June 2022, supplemented by hand-searching reference lists.

SELECTION CRITERIA

Two reviewers independently reviewed titles, abstracts and full-text articles. Published studies containing original data were eligible.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and appraised study quality. Outcomes for pregnant women with a previous/current diagnosis of HL were compared separately with women never diagnosed with HL. Where data permitted, meta-analyses of odds ratios and proportions were performed. Certainty of evidence was determined using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.

MAIN RESULTS

Of the 5527 studies identified, 33 met the inclusion criteria. In the groups with HL before pregnancy and HL during pregnancy, adjusted odds ratios were not statistically significant for congenital malformation (aOR 1.7, 95% CI 0.9-3.1, and aOR 1.84, 95% CI 0.81-4.15, respectively), preterm birth (PTB) (aOR 0.99, 95% CI 0.65-1.51, and aOR 6.74, 95% CI 0.52-88.03, respectively) and miscarriage (aOR 0.78, 95% CI 0.55-1.10, and aOR 0.38, 95% CI 0.05-2.72, respectively). The aORs for all other outcomes were not statistically significant, except for blood transfusion (aOR 1.38, 95% CI 1.05-1.82) and venous thromboembolism (VTE) (aOR 7.93, 95% CI 2.97-21.22) in the group for HL during pregnancy. The proportion of anaemia was also increased in this group (69%, 95% CI 57%-80% vs 4%, 95% CI 4%-5%, respectively). The GRADE certainty of findings ranged from low to very low.

CONCLUSIONS

Rates of most adverse pregnancy outcomes among women with a previous/current HL diagnosis are not increased significantly compared with the general pregnant population. Women with HL diagnosed during pregnancy may have a higher PTB rate and increased likelihood of VTE, anaemia and blood transfusion; however, small study numbers and the low to very low GRADE certainty of findings preclude firm conclusions.

Low-dose ionizing radiation and adverse birth outcomes: a systematic review and meta-analysis

OBJECTIVE

Ionizing radiation is a human carcinogen, and there is evidence that exposure to low-dose ionizing radiation increases the risk of adverse birth outcomes.

METHODS

We undertook a systematic review and meta-analysis to synthesize the research of maternal and paternal exposure to low-dose radiation on low birth weight, miscarriage, pre-term delivery, and stillbirth. Our literature search used four databases (PubMed, Environmental Index, GeoBASE, and the Cumulative Index to Nursing and Allied Health Literature). We included study populations exposed to occupational and medical sources of radiation, nuclear disasters, and those living near nuclear power plants. We considered papers published between January 1st, 1990, and June 30th, 2021. The quality of the studies was assessed, and we performed meta-analysis using random effects models to generate summary measures of association. Forest plots were created to assess the heterogeneity in these measures, and funnel plots were used to assess publication bias.

RESULTS

Overall, 26 studies were identified, and these yielded measures of association from 10, 11, and 8 studies for low birth weight, miscarriage, and stillbirth outcomes, respectively. It was not possible to perform meta-analyses for pre-term delivery due to a small number of studies. The meta-analysis summary relative risk (RR) of having a low-birth-weight infant among those ever exposed to radiation relative to those unexposed, after adjusting for publication bias, was 1.29 (95% CI 0.97-1.73). The corresponding risk estimates for miscarriage and stillbirth were 1.15 (95% CI 1.02-1.30), and 1.19 (95% CI 0.98-1.45), respectively.

CONCLUSIONS

Our findings suggest that ionizing radiation increases the risk of adverse birth outcomes. Future work should strive to provide data needed to better understand the shape of the exposure-response curve.

Pregnancy outcomes among female childhood, adolescent, and young adult cancer survivors assessed using internet-based nationwide questionnaire surveys in Japan

OBJECTIVE

Female cancer survivors planning to become pregnant are concerned about the impact of cancer treatment on their ability to maintain normal pregnancy and the negative impact on their offspring. However, studies on the pregnancy outcomes of cancer survivors in Japan are limited. Therefore, this study aimed to investigate the pregnancy outcomes of female cancer survivors by comparing them with women without a history of malignant tumors in Japan.

METHODS

This cross-sectional study included 3308 subjects, based on an internet-based questionnaire (self-reported) survey conducted in Japan. Differences in pregnancy outcomes, including multiple pregnancies, stillbirth, preterm birth (PTB), and infant birthweight, between cancer survivors and subjects without a history of malignant tumors, were evaluated using a generalized linear mixed-effects model with adjustment for possible confounding factors.

RESULTS

Of 3308 subjects included in this study, 629 (19.0%) were cancer survivors, among whom cervical (40.4%), breast (19.1%), and thyroid (7.0%) malignancies were most frequent. 71 (2.2%) and 53 (1.6%) participants had a history of multiple pregnancies and stillbirth, respectively; 385 (11.8%), 179 (5.5%), and 137 (4.2%) participants, respectively, had histories of PTB at less than 37, 34, and 32 weeks of gestation. Further, 302 (10.7%), 326 (11.6%), and 330 (11.7%) participants delivered to low birthweight (LBW), small-for-gestational-age (SGA), and large-for-gestational-age (LGA) infants, respectively. Subjects with a history of cervical or breast cancers had significantly higher odds of PTB at <37 weeks of gestation (adjusted odds ratios [ORs], 1.87 [95% CI: 1.25-2.81] and 2.61 [95% CI: 1.77-3.86], respectively), preterm LBW infants (adjusted ORs, 2.70 [95% CI: 1.39-5.24] and 2.76 [95% CI: 1.03-7.38], respectively), and LGA infants (1.98 [95% CI: 1.36-2.89] and 1.99 [95% CI: 1.14-3.49], respectively), compared to those without a history of a malignant tumor. Subjects with a history of thyroid cancer had significantly higher odds of stillbirth (adjusted OR, 5.11 [95% CI: 1.11-23.5]).

CONCLUSION

Cancer survivors had a higher risk of adverse pregnancy outcomes than those without a history of malignant tumors in Japan. Healthcare providers should consider the high likelihood of adverse pregnancy outcomes during preconception counseling for cancer survivors.

The risk of preterm birth among women with a history of leukemia or lymphoma

OBJECTIVE

Leukemia and lymphoma are top cancers affecting children, adolescents and young adults with high five-year survival rates. Late effects of these cancers are a concern in reproductive-age patients, including pregnancy outcomes such as preterm birth. Our study aimed to evaluate whether diagnosis of leukemia or lymphoma prior to pregnancy was associated with preterm birth (<37 weeks gestation).

METHODS

We conducted a cross-sectional study using a population-based dataset from California with linked birth certificates to hospital discharge records and an Iowa-based sample that linked birth certificates to Surveillance, Epidemiology, and End Results (SEER) cancer registry data. Preterm birth was defined using birth certificates. We ascertained history of leukemia and lymphoma using discharge diagnosis data in California and SEER registry in Iowa.

RESULTS

Prevalence of preterm birth in California and Iowa was 14.6% and 12.0%, respectively, in women with a history of leukemia/lymphoma compared to 7.8% and 8.2%, respectively, in women without a cancer history. After adjusting for maternal age, race, education, smoking, and plurality, Women with history of leukemia/lymphoma were at an increased risk of having a preterm birth in California (odds ratio (OR) 1.89; 95% confidence interval (CI) 1.56-2.28) and Iowa (OR 1.61; 95% CI 1.10-2.37) compared to those with no cancer history.

CONCLUSION

In both California and Iowa, women with a history of leukemia or lymphoma were at increased risk for preterm birth. This suggests the importance of counseling with a history of leukemia/lymphoma prior to pregnancy and increased monitoring of women during pregnancy.

Life Span, Cause of Death and Neoplasia in B6C3F1 Mice Exposed In Utero to Low- and Medium-Dose-Rate Gamma Rays

Previously, we reported that while low-dose-rate (LDR) gamma-ray exposure to 20 mGy/day for the entire gestation period (gestation days 0-18) did not result in any significant effect in B6C3F1 pups up to 10 weeks of age when compared to the non-irradiated controls, exposure to medium-dose-rates (MDR, 200 and 400 mGy/day) resulted in growth retardation and gonadal hypoplasia, in addition to delayed ossification (only at 400 mGy/day). In the present work, we investigated the late effects of continuous in utero exposure to gamma rays at LDRs (0.05, 1.0 and 20 mGy/day) and at an MDR of 400 mGy/day, on life span, causes of death, neoplastic and non-neoplastic disease incidences in B6C3F1 mice. Reproductive parameters such as litter size and weaning rates was not significantly different among the LDR groups, but was significantly decreased in the MDR group, when compared to the non-irradiated controls. Mean life spans were not significantly different among the LDR exposed groups compared to the non-irradiated controls, whereas the life spans of those exposed to the MDR were significantly shorter than the non-irradiated controls. There was no significant difference in tumor spectra between the non-irradiated and LDR nor MDR irradiated groups. In mice exposed to MDR in utero, the over-all incidence rates shifted with increased incidences in the number of neoplasms of liver (both sexes) and endocrine (adrenals, pituitary and ovaries in females) origin with corresponding decreases in the incidence of malignant lymphomas (both sexes) and lung neoplasms (males). Multiple primary neoplasms were significantly increased only in females exposed to MDR. Results show that B6C3F1 mice exposed to gamma-rays in utero at LDRs of 0.05, 1 and 20 mGy/day for the entire gestation period (18 days) does not significantly alter lifespan, cause of death, neoplasm incidence rates and tumor spectra.

Dosimetric Evaluation of the Uterus in Patients Receiving Total Body Irradiation with Ovarian Shielding

Infertility is a well-known late complication in patients receiving hematopoietic stem cell transplantation (HSCT). We previously reported that total body irradiation (TBI) with ovarian shielding reduces the radiation dose to the ovaries to 2.4 Gy - one-fifth of the dose compared to conventional TBI - and preserves fertility without increasing the risk of relapse. Exposure to the uterus and ovaries can reportedly affect pregnancy and childbirth. However, the dose constraint of the uterus that causes infertility remains unknown. Herein, we report the pregnancy and birth outcomes of 2 patients who gave birth following TBI with ovarian shielding and evaluated the dose to the uterus using a dose-volume histogram. Case 1 involved a 30-year-old woman with acute myeloid leukemia who underwent HSCT at 21 years of age with a uterus mean dose (D _mean) of 7.0 Gy. She had a natural pregnancy and elective cesarean section at 38 weeks of gestation due to hypertensive disorders of pregnancy. She gave birth to a normal-birthweight infant. Case 2 involved a 32-year-old woman with T-cell acute lymphoblastic leukemia who underwent HSCT at 30 years of age with a uterus D _mean of 7.6 Gy. Her baby was delivered at full term with normal birthweight. These results indicate that a uterus D _mean between 7.0 and 7.6 Gy does not have a significant impact on pregnancy and delivery with the ovarian function being preserved for patients who received TBI with ovarian shielding after puberty.

The Use of Assisted Reproductive Technology by European Childhood Cancer Survivors

CCS often wish to have biological children yet harbour concerns about fertility impairment, pregnancy risks and the general health risks of prospective offspring. To clarify these concerns, health outcomes in survivor offspring born following ART (n = 74, 4.5%) or after spontaneous conception (n = 1585) were assessed in our European offspring study by descriptive and bivariate analysis. Outcomes were compared to a sibling offspring cohort (n = 387) in a 4:1 matched-pair analysis (n = 1681). (i) Survivors were more likely to employ ART than their siblings (4.5% vs. 3.7%, p = 0.501). Successful pregnancies were achieved after a median of one cycle with, most commonly, intracytoplasmic sperm injection (ICSI) using non-cryopreserved oocytes/sperm. (ii) Multiple-sibling births (p < 0.001, 29.7% vs. 2.5%), low birth weight (p < 0.001; OR = 3.035, 95%-CI = 1.615−5.706), and preterm birth (p < 0.001; OR = 2.499, 95%-CI = 1.401−4.459) occurred significantly more often in survivor offspring following ART utilisation than in spontaneously conceived children. ART did not increase the prevalence of childhood cancer, congenital malformations or heart defects. (iii) These outcomes had similar prevalences in the sibling population. In our explorative study, we could not detect an influence on health outcomes when known confounders, such as multiple births, were taken into account.

Successful term pregnancy following cervical cerclage for uterine atrophy secondary to childhood radiotherapy

Pelvic radiotherapy can lead to scarring and atrophy of reproductive organs including the uterus. This may lead to complications, such as preterm birth, during pregnancy. The mechanism by which preterm birth is associated with pelvic radiation is believed to be due to inefficient uterine stretch or a deficient cervix. We report a case of cervical shortening during the second trimester in a pregnant woman with a history of pelvic radiotherapy in childhood. Ultrasound surveillance and cervical cerclage inserted in the shortening cervix successfully prevented preterm labour in this case. Cerclage insertion led to a longer cervix and lower fibronectin. Although cervical cerclage does not influence uterine stretch, it may be able to prevent cervical dilatation and therefore prevent ascending infections and subsequent inflammatory sequelae which results in preterm labour. We recommend cervical surveillance and targeted cerclage interventions to prevent preterm labour in women with prior childhood pelvic radiotherapy.

Effects of early maternal cancer and fertility treatment on the risk of adverse birth outcomes

BACKGROUND

Early maternal cancer and fertility treatment each increase the risk for adverse birth outcomes, but the joint effect of these outcomes has not yet been reported. Thus, the aim was to assess the individual and joint effect of maternal cancer and fertility treatment on the risk for adverse birth outcomes.

METHODS

This population-based cohort study included 5487 live-born singletons identified in the Danish Medical Birth Register (1994-2016) of mothers with previous cancer (<40 years) recorded in the Danish Cancer Registry (1955-2014). We randomly selected 80,262 live-born singletons of mothers with no cancer <40 years matched to mothers with cancer by birth year and month. We calculated odds ratios (ORs) for preterm birth, low birth weight (LBW) (<2500 g) and small for gestational age (SGA), mean differences in birth weight in grams, and additional cases of preterm birth (gestational age<259 days) per 100,000 person-years. Multiplicative and additive interaction of maternal cancer and fertility treatment was compared with outcomes of children conceived naturally to mothers with no maternal cancer (reference group).

FINDINGS

Among 84,332 live-born singletons, increased ORs for preterm birth were observed among children born to mothers with previous cancer (1·48, 95% confidence interval [CI] 1·33-1.65) or after fertility treatment (1·43, 95% 1·28-1-61), with 22 additional cases of preterm birth among both group of children (95% CI 15-29; 95% CI 14-30). In the joint analyses, the OR for SGA for children born after fertility treatment to mothers with previous cancer was similar to that of the reference group (OR 1·02, 95% CI 0·72-1·44, P for interaction=0·52). Children with both exposures had increased ORs for LBW (1·86, 95% CI 1·17-2·96, P for interaction=0·06) and preterm birth (2·31, 955 CI 1·66-3·20, P for interaction = 0·56), with 61 additional cases of preterm birth (95% CI 27-95, P for interaction=0.26) over that of children in the reference group. The mean birth weight was also lower in children born to mothers with both exposures (-140 g, 95% CI -215; -65) (P for interaction=0.06) but decreased to -22 g (95% CI -76; 31) after adjustment for GA.

INTERPRETATION

Although we did not find any statistically significant additive interaction between maternal cancer and fertility treatment, children born after fertility treatment of mothers with previous cancer were at increased risk for adverse birth outcomes. Thus, pregnant women with both exposures need close follow-up during pregnancy.

FUNDING

The Danish Cancer Society and the Danish Childhood Cancer Foundation.

Development and Evaluation of a Machine Learning Prediction Model for Small-for-Gestational-Age Births in Women Exposed to Radiation before Pregnancy

Exposure to radiation has been associated with increased risk of delivering small-for-gestational-age (SGA) newborns. There are no tools to predict SGA newborns in pregnant women exposed to radiation before pregnancy. Here, we aimed to develop an array of machine learning (ML) models to predict SGA newborns in women exposed to radiation before pregnancy. Patients’ data was obtained from the National Free Preconception Health Examination Project from 2010 to 2012. The data were randomly divided into a training dataset (n = 364) and a testing dataset (n = 91). Eight various ML models were compared for solving the binary classification of SGA prediction, followed by a post hoc explainability based on the SHAP model to identify and interpret the most important features that contribute to the prediction outcome. A total of 455 newborns were included, with the occurrence of 60 SGA births (13.2%). Overall, the model obtained by extreme gradient boosting (XGBoost) achieved the highest area under the receiver-operating-characteristic curve (AUC) in the testing set (0.844, 95% confidence interval (CI): 0.713–0.974). All models showed satisfied AUCs, except for the logistic regression model (AUC: 0.561, 95% CI: 0.355–0.768). After feature selection by recursive feature elimination (RFE), 15 features were included in the final prediction model using the XGBoost algorithm, with an AUC of 0.821 (95% CI: 0.650–0.993). ML algorithms can generate robust models to predict SGA newborns in pregnant women exposed to radiation before pregnancy, which may thus be used as a prediction tool for SGA newborns in high-risk pregnant women.

Family size and duration of fertility in female cancer survivors: a population-based analysis

OBJECTIVE

To assess family size and timescale for achieving pregnancy in women who remain fertile after cancer.

DESIGN

Population-based analysis.

SETTING

National databases.

PATIENT(S)

All women diagnosed with cancer before the age of 40 years in Scotland, 1981-2012 (n = 10,267) with no previous pregnancy; each was matched with 3 population controls.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The number and timing of pregnancy and live birth after cancer diagnosis, to 2018.

RESULT(S)

In 10,267 cancer survivors, the hazard ratio for a subsequent live birth was 0.56 (95% confidence interval, 0.53-0.58) overall. In women who achieved a subsequent pregnancy, age at live birth increased (mean ± SD, 31.2 ± 5.5 vs. 29.7 ± 6.1 in controls), and the family size was lower (2.0 ± 0.8 vs. 2.3 ± 1.1 live births). These findings were consistent across several diagnoses. The interval from diagnosis to last pregnancy was similar to that of controls (10.7 ± 6.4 vs. 10.9 ± 7.3 years) or significantly increased, for example, after breast cancer (6.2 ± 2.8 vs. 5.3 ± 3.3 years) and Hodgkin lymphoma (11.1 ± 5.1 vs. 10.1 ± 5.8 years).

CONCLUSION(S)

These data quantify the reduced chance of live birth after cancer. Women who subsequently conceived achieved a smaller family size than matched controls, but the period of time after cancer diagnosis across which pregnancies occurred was similar or, indeed, increased. Thus, we did not find evidence that women who were able to achieve a pregnancy after cancer had a shorter timescale over which they have pregnancies.

Obstetrical and Perinatal Outcomes in Female Survivors of Childhood and Adolescent Cancer: A Population-Based Cohort Study

BACKGROUND

The likelihood of pregnancy and risk of obstetrical or perinatal complications is inadequately documented in female survivors of pediatric cancer.

METHODS

We assembled a population-based cohort of female survivors of cancer diagnosed at age 21 years and younger in Ontario, Canada, between 1985 and 2012. Survivors were matched 1:5 to women without prior cancer. Multivariable Cox proportional hazards and modified Poisson models assessed the likelihood of a recognized pregnancy and perinatal and maternal complications.

RESULTS

A total of 4062 survivors were matched to 20 308 comparisons. Median (interquartile range) age was 11 (4-15) years at cancer diagnosis and 25 (19-31) years at follow-up. By age 30 years, the cumulative incidence of achieving a recognized pregnancy was 22.3% (95% confidence interval [CI] = 20.7% to 23.9%) among survivors vs 26.6% (95% CI = 25.6% to 27.3%) among comparisons (hazard ratio = 0.80, 95% CI = 0.75 to 0.86). A lower likelihood of pregnancy was associated with a brain tumor, alkylator chemotherapy, cranial radiation, and hematopoietic stem cell transplantation. Pregnant survivors were as likely as cancer-free women to carry a pregnancy >20 weeks (relative risk [RR] = 1.01, 95% CI = 0.98 to 1.04). Survivors had a higher relative risk of severe maternal morbidity (RR = 2.31, 95% CI = 1.59 to 3.37), cardiac morbidity (RR = 4.18, 95% CI = 1.89 to 9.24), and preterm birth (RR = 1.57, 95% CI = 1.29 to 1.92). Preterm birth was more likely in survivors treated with hematopoietic stem cell transplantation (allogenic: RR = 8.37, 95% CI = 4.83 to 14.48; autologous: RR = 3.72, 95% CI = 1.66 to 8.35).

CONCLUSIONS

Survivors of childhood or adolescent cancer are less likely to achieve a pregnancy and, once pregnant, are at higher risk for severe maternal morbidity and preterm birth.

Cancer and Pregnancy: National Trends

OBJECTIVE

Cancer and pregnancy are likely increasing; however, updated estimates are needed to optimally address the unique needs of this patient population. The study aims to estimate the prevalence of cancer and cancer survivorship at delivery, to test the change in odds of cancer and cancer survivorship at delivery over the 10-year period, and to compare medical conditions, serious events, and obstetric complications between pregnancies with and without cancer at delivery.

STUDY DESIGN

We conducted a retrospective analysis of the National Inpatient Sample (NIS), the largest all-payer inpatient health database in the United States. We identified delivery admissions from 2004 to 2013 with a concurrent diagnosis of cancer using International Classification of Disease, ninth revision (ICD-9) codes. Multivariable logistic regression was used to test the change in prevalence of concurrent cancer, cancer survivorship, and pregnancy and to compare outcomes between deliveries with and without cancer. All analyses were adjusted for NIS-provided population weights and strata.

RESULTS

During the study period, the NIS represented a national estimate of 40,855,208 deliveries. The odds of cancer increased from 3.41/10,000 deliveries in 2004 to 4.33/10,000 in 2013. This trend was statistically significant, including after adjustment for maternal age (adjusted odds ratio [aOR] = 1.03 [95% confidence interval (CI): 1.01-1.04]). Cancer survivorship at delivery increased significantly (aOR = 1.07 [95% CI: 1.06-1.08]). Women with cancer more often experienced one or more of the following: death, ventilation, cardiac arrest, sepsis, or acute respiratory or renal failure during delivery (aOR for composite outcome 10.7 [95% CI: 6.6-17.2]), even after adjustment in a multivariable logistic regression model.

CONCLUSION

The odds of cancer and cancer survivorship at delivery increased from 2004 to 2013, independent of maternal age. Women with cancer were more likely to experience medical or obstetric complications during their delivery compared with women without cancer. These findings highlight the importance of obstetric and oncologic clinical and research collaboration to improve patient care.

KEY POINTS

· The odds of cancer at delivery increased.. · Women with cancer may have delivery complications.. · Cancer survivorship at delivery increased..

Dyadic support across contraceptive decision-making among young adult breast cancer survivors and their partners

OBJECTIVE

The purpose of this study is to explore the role of dyadic support across the contraceptive decision-making process between young adult breast cancer (YABC) survivors and their partners.

RESEARCH APPROACH

Semi-structured interviews with YABC survivors and their partners.

PARTICIPANTS

Twenty-five young adult breast cancer survivors and their partners (n = 50). Survivors reported an average age of 36.9 years (SD = 4.30) and the majority self-identified as white (86.2%).

METHODOLOGICAL APPROACH

Thematic analysis approach with dyads as the primary unit of analysis, guided by the dyadic decision-making framework and the Theory of Gender and Power.

RESULTS

Perceived lack of contraceptive options due to a history of hormone-sensitive cancer, perceived infertility, and contraception as a result of cancer treatment (e.g., hysterectomy) contributed to the contraceptive decision context for survivors and their partners. Contraceptive support varied across couples depending on the cancer-specific context, where communication, sharing responsibility, and respecting bodily autonomy revealed as supportive behaviors. Other social influences including survivors' desire to conceive biologically and family planning desires also related to partner supportive behaviors.

INTERPRETATIONS

YABC survivors face specific challenges to contraceptive decision-making where partners can offer supportive behaviors. Health care providers can also support couples by engaging in triadic communication about contraception and family planning.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS OR POLICY

Psychosocial providers can support couples by encouraging them to talk together about contraception and highlighting the importance of triadic communication with a healthcare provider to support shared decision-making and alignment of contraceptive decisions with family planning desires.

Four Ways to Decrease Late Toxicity From Pelvic Radiation Therapy in Children and Young Adults

The use of curative-intent multimodality therapy with chemotherapy, surgery, and radiation results in late toxicities in almost two-thirds of patients with pediatric cancer. When pelvic radiation is used for pediatric malignancies such as rhabdomyosarcoma, lymphoma, neuroblastoma, Ewing sarcoma, and Wilms tumor, the associated late toxicities can affect many normal tissues and may include growth asymmetries, cystitis, infertility, and sexual dysfunction. We describe 4 recommendations of how to prevent or minimize late toxicities from pelvic radiation and review the literature of these pediatric late toxicities.

A case of placenta previa with increta with a history of pelvic radiation

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No documented pregnancy has occurred with history of pelvic radiation > 45 Gy prior to this case report.

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Severe pregnancy complications that can occur after pelvic radiation.

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Detailed counseling teams to be available to patients considering conception with history of pelvic radiation.

Background

Prior pelvic radiation increases risks of pregnancy complications that can be life threatening. No documented pregnancy has successfully occurred with pelvic radiation dosing of >45 Gy. This case report describes a successful conception after receiving 54 Gy with subsequent severe pregnancy complications.

Case

34 yo G4P2012 with a history of pelvic radiation who presented with painless vaginal bleeding at 12w6d gestation resulting from a donor egg embryo transfer. She was subsequently diagnosed with a subchorionic hemorrhage, complete placenta previa, and placenta increta leading to a gravid hysterectomy at 23w0d due to concern for hemodynamic instability.

Conclusion

History of pelvic radiation increases risk of severe life-threatening pregnancy complications. This case report details the complications that can arise to provide assistance for counseling and management for future providers.

Pregnancy outcomes in children, adolescents, and young adults that survived cancer: A nationwide survey in Japan

AIM

Recent advances in cancer treatment have improved the prognosis of child, adolescent, and young adult (CAYA) cancer survivors. This study aimed to examine the current status of pregnancy outcomes among female cancer survivors in Japan.

METHODS

The first questionnaire was sent to 633 major tertiary institutions certified by the Japan Society of Obstetrics and Gynecology to identify institutions managing cases of pregnant cancer survivors between January 2011 and December 2015. The second questionnaire was sent only to institutions with pregnant cancer survivors during the study period.

RESULTS

We analyzed 2242 singleton deliveries of cancer survivors based on the responses received in the second questionnaire (199/255 responses; 78.0%). The three most frequent types of malignant tumors were uterine cervical (23.4%), breast (17.6%), and thyroid cancers (17.5%). Conception was aided by the use of assisted reproductive technology in 17.0% of the patients. The proportions of mothers aged 35-39.9 and ≥ 40 years were 36.5% and 11.8%, respectively. The prevalence of preterm birth (PTB) at <37, <34, and < 32 weeks' gestation were 16.7%, 6.8%, and 4.3%, respectively. The proportion of infants with low birth weight (LBW) was 18.9%.

CONCLUSION

The present study findings suggest that advanced maternal age was common among pregnant cancer survivors and these survivors often gave birth to PTB and LBW infants in Japan. The likelihood of adverse pregnancy outcomes should be considered by healthcare providers when planning counseling and perinatal care for cancer survivors.

Involved Site Radiotherapy Extends Time to Premature Menopause in Infra-Diaphragmatic Female Hodgkin Lymphoma Patients - An Analysis of GHSG HD14- and HD17-Patients

Introduction

Consolidation radiotherapy in intermediate stage Hodgkin´s lymphoma (HL) has been the standard of care for many years as involved field radiotherapy (IFRT) after chemotherapy. It included initially involved region(s). Based on randomized studies, radiation volumes could be reduced and involved site radiation therapy (ISRT) became the new standard. ISRT includes the initially affected lymph nodes. In young adults suffering from HL, infertility and hypogonadism are major concerns. With regard to these questions, we analyzed the influence of modern radiotherapy concepts such as consolidating ISRT in infradiaphragmatic involvement of HL after polychemotherapy.

Patients and Methods

Five hundred twelve patients treated within German Hodgkin Study Group (GHSG) HD14 and HD17 trials were evaluated. We analyzed log-adjusted follicle-stimulating-hormone (FSH)- and luteinizing-hormone (LH)-levels of HD14-patients with infradiaphragmatic radiotherapy (IDRT) in comparison with HD14-patients, who had a supradiaphragmatic radiotherapy (SDRT). In a second step, we compared IFRT with ISRT of female HD17 patients regarding the effects on ovarian function and premature menopause.

Results

We analyzed FSH- and LH-levels of 258 female and 241 male patients, all treated with IFRT. Of these 499 patients, 478 patients had SDRT and 21 patients had IDRT. In a multiple regression model, we could show that log-adjusted FSH (p=0.0006) and LH values (p=0.0127) were significantly higher after IDRT than after SDRT. The effect of IDRT on gonadal function was comparable to two cycles of escalated bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPPesc). We compared the effect of IFRT with ISRT in thirteen female HD17 patients with infradiaphragmatic (ID) involvement. The mean ovarian dose after ISRT was significantly lower than after IFRT. The calculated proportion of surviving non-growing follicles (NGFs) increased significantly from 11.87% to 24.48% in ISRT compared to IFRT, resulting in a significantly longer calculated time to menopause. The younger the age at therapy, the greater the absolute time gain until menopause.

Conclusion

Infradiaphragmatic IFRT impairs gonadal function to a similar extent as two cycles of BEACOPPesc. In comparison, the use of ISRT target volume definition significantly reduced radiation dose to the ovaries and significantly extends the time interval from treatment to premature menopause.

A narrative review of pregnancy after malignancies in young women that don't originate in the female genital organs or in the breast

While cancer during pregnancy and its treatment has grown to be a popular topic in recent years, little is known on how to advise patients looking to conceive or conceiving after cancer treatment. The aim of this paper is to review the available literature on the impact of pregnancy on survivors of the most common childhood cancers, brain cancer, haematological malignancies, thyroid cancer, melanomas and sarcomas. Its main objective is to be a source of information for clinicians looking to counsel patients in these delicate moments exploiting all the available literature, albeit scarce. Given the available literature, we conclude that the presence of a multidisciplinary team is of great importance in supporting the patient and her loved ones when facing pregnancy with a previous cancer diagnosis.

Fertility Preservation and Long-Term Monitoring of Gonadotoxicity in Girls, Adolescents and Young Adults Undergoing Cancer Treatment

Chemo- and radio-therapy can often affect reproductive organs impairing hormonal regulation, fertility, and sexual function. As cancer treatments become more effective and many patients have long term survival, concerns related to patient's quality of life and reproductive health become relevant. It is especially important for girls and young females facing cancer therapy who have not yet started family planning. Chemotherapy protocols using alkylating agents and abdominal radiotherapy, which are frequently used in the treatment of childhood and adolescent cancer, can cause gonadal injury. The most common clinical manifests are ovarian hormone insufficiency, premature ovarian insufficiency, early menopause and infertility. In this review we assess current literature and summarize current recommendations on the reproductive function of girls and young females undergoing cancer treatment and their follow-up. Fertility preservation methods are discussed, including psychological and ethical considerations and barriers. Improvement of reproductive health and quality of life of adolescents and young adults (AYA) undergoing cancer treatment is an important issue. Further research should be continued to develop efficient and accessible methods for fertility preservation in young patients. An expert panel including oncologists, radiation oncologists, endocrinologists and gynecologists should always consider fertility preservation in pediatric, adolescent and AYA cancer patients, minding patients' medical condition, cancer staging and potential risk of treatment-related gonadotoxicity.

Counseling and surveillance of obstetrical risks for female childhood, adolescent, and young adult cancer survivors: recommendations from the International Late Effects of Childhood Cancer Guideline Harmonization Group

Female childhood, adolescent, and young adult cancer survivors have an increased risk of adverse pregnancy outcomes related to their cancer- or treatment-associated sequelae. Optimal care for childhood, adolescent, and young adult cancer survivors can be facilitated by clinical practice guidelines that identify specific adverse pregnancy outcomes and the clinical characteristics of at-risk subgroups. However, national guidelines are scarce and vary in content. Here, the International Late Effects of Childhood Cancer Guideline Harmonization Group offers recommendations for the counseling and surveillance of obstetrical risks of childhood, adolescent, and young adult survivors. A systematic literature search in MEDLINE database (through PubMed) to identify all available evidence published between January 1990 and December 2018. Published articles on pregnancy and perinatal or congenital risks in female cancer survivors were screened for eligibility. Study designs with a sample size larger than 40 pregnancies in childhood, adolescent, and young adult cancer survivors (diagnosed before the age of 25 years, not pregnant at that time) were eligible. This guideline from the International Late Effects of Childhood Cancer Guideline Harmonization Group systematically appraised the quality of available evidence for adverse obstetrical outcomes in childhood, adolescent, and young adult cancer survivors using Grading of Recommendations Assessment, Development, and Evaluation methodology and formulated recommendations to enhance evidence-based obstetrical care and preconception counseling of female childhood, adolescent, and young adult cancer survivors. Healthcare providers should discuss the risk of adverse obstetrical outcomes based on cancer treatment exposures with all female childhood, adolescent, and young adult cancer survivors of reproductive age, before conception. Healthcare providers should be aware that there is no evidence to support an increased risk of giving birth to a child with congenital anomalies (high-quality evidence). Survivors treated with radiotherapy to volumes exposing the uterus and their healthcare providers should be aware of the risk of adverse obstetrical outcomes such as miscarriage (moderate-quality evidence), premature birth (high-quality evidence), and low birthweight (high-quality evidence); therefore, high-risk obstetrical surveillance is recommended. Cardiomyopathy surveillance is reasonable before pregnancy or in the first trimester for all female survivors treated with anthracyclines and chest radiation. Female cancer survivors have increased risks of premature delivery and low birthweight associated with radiotherapy targeting the lower body and thereby exposing the uterus, which warrant high-risk pregnancy surveillance.

Do cancer therapies damage the uterus and compromise fertility?

BACKGROUND

As cancer survival rates improve, understanding and preventing the adverse off-target and long-term impacts of cancer treatments, including impacts on fertility, have become increasingly important. Cancer therapy-mediated damage to the ovary and depletion of the primordial follicle reserve are well characterised. However, our knowledge of the full extent of damage to the rest of the female reproductive tract, in particular the uterus, is limited.

OBJECTIVE AND RATIONALE

Improving our understanding of the off-target effects of cancer therapies on the entire female reproductive tract is a critical step towards developing truly effective strategies to protect the fertility of cancer survivors. The objective of this narrative review was to critically evaluate the available literature regarding the capacity for the uterus to sustain a healthy pregnancy following exposure to radiotherapy or chemotherapy.

SEARCH METHODS

The authors performed PubMed (Medline) searches using the following key words: uterus, cancer survivors, radiotherapy, chemotherapy, pregnancy outcome, fertility preservation, infertility. There were no limits placed on time of publication.

OUTCOMES

Overall, there were major limitations to the current available literature, meaning that interpretations should be taken with caution. Despite these drawbacks, data suggest that the uterus may sustain off-target damage, with the extent of damage dependent on the type of cancer treatment and patient age. Specifically, uterine growth is stunted and resistant to hormone replacement therapy in prepubertal girls receiving abdominal, pelvic or whole-body radiotherapy. In contrast, females treated with radiotherapy post-puberty can benefit from hormone replacement therapy, as demonstrated by increased uterine volume and function. No live births have been reported in women previously exposed to radiotherapy after transplantation of cryopreserved ovarian tissue, even when menstruation returns. However, this technique has proven to be a successful fertility preservation method for women previously treated with chemotherapy. Obstetricians commonly report that women who maintain sufficient ovarian function can achieve pregnancy naturally following radiotherapy, but they have thin and/or fibrotic myometrium at delivery, compromising safe delivery and subsequent pregnancy. Furthermore, women exposed to either radiotherapy or chemotherapy have a higher prevalence of preterm birth and low birth weight infants, even in those with normal ovarian function or when oocyte donation is utilised. The mechanisms of potential uterine damage are poorly understood. While the myometrium, vasculature and endometrial progenitor cells are possibly targets, further studies are clearly required and well-controlled animal models could provide the best avenue for these types of future investigations.

WIDER IMPLICATIONS

Female cancer survivors experience greater rates of early pregnancy loss and complications, suggesting that cancer therapy-induced damage to the uterus contributes to infertility. Despite clinical reports dating back to 1989, we highlight a surprising lack of detail in the literature regarding the precise nature and extent of off-target damage inflicted to the uterus in response to cancer therapies. Young women requiring cancer treatment, and the clinicians treating them, must be equipped with accurate information to aid informed decision-making regarding cancer treatment regimens as well as the development and use of effective fertility preservation measures. As the current literature on the impacts of cancer treatments is limited, we hope that our narrative review on this subject will stimulate more research in this important field.

Early-life cancer, infertility, and risk of adverse pregnancy outcomes: a registry linkage study in Massachusetts

PURPOSE

Investigate the relationship between history of cancer and adverse pregnancy outcomes according to subfertility/fertility treatment.

METHODS

Deliveries (2004-2013) from Massachusetts (MA) Registry of Vital Records and Statistics were linked to MA assisted reproductive technology data, hospital discharge records, and Cancer Registry. The relative risks (RR) and 95% confidence intervals of adverse outcomes (gestational diabetes (GDM), gestational hypertension (GHTN), cesarean section (CS), low birth weight (LBW), small for gestational age (SGA), preterm birth (PTB), neonatal mortality, and prolonged neonatal hospital stay) were modeled with log-link and Poisson distribution generalized estimating equations. Differences by history of subfertility/fertility treatment were investigated with likelihood ratio tests.

RESULTS

Among 662,630 deliveries, 2,983 had a history of cancer. Women with cancer history were not at greater risk of GDM, GHTN, or CS. However, infants born to women with prior cancer had higher risk of LBW (RR: 1.19 [1.07-1.32]), prolonged neonatal hospital stay (RR: 1.16 [1.01-1.34]), and PTB (RR: 1.19 [1.07-1.32]). We found clinically and statistically significant differences in the relationship between cancer history and SGA by subfertility/fertility treatment (p value, test for heterogeneity = 0.02); among deliveries with subfertility or fertility treatment, those with a history of cancer experienced a greater risk of SGA (RRsubfertile: 1.36 [1.02-1.83]).

CONCLUSIONS

Women with a history of cancer had greater risk of some adverse pregnancy outcomes; this relationship varied by subfertility and fertility treatment.

Clinical summary guide: reproduction in women with previous abdominopelvic radiotherapy or total body irradiation

STUDY QUESTION

What is the evidence to guide the management of women who wish to conceive following abdominopelvic radiotherapy (AP RT) or total body irradiation (TBI)?

SUMMARY ANSWER

Pregnancy is possible, even following higher doses of post-pubertal uterine radiation exposure; however, it is associated with adverse reproductive sequelae and pregnancies must be managed in a high-risk obstetric unit.

WHAT IS KNOWN ALREADY

In addition to primary ovarian insufficiency, female survivors who are treated with AP RT and TBI are at risk of damage to the uterus. This may impact on its function and manifest as adverse reproductive sequelae.

STUDY DESIGN SIZE DURATION

A review of the literature was carried out and a multidisciplinary working group provided expert opinion regarding assessment of the uterus and obstetric management.

PARTICIPANTS/MATERIALS SETTING METHODS

Reproductive outcomes for postpubertal women with uterine radiation exposure in the form of AP RT or TBI were reviewed. This included Pubmed listed peer-reviewed publications from 1990 to 2019, and limited to English language..

MAIN RESULTS AND THE ROLE OF CHANCE

The prepubertal uterus is much more vulnerable to the effects of radiation than after puberty. Almost all available information about the impact of radiation on the uterus comes from studies of radiation exposure during childhood or adolescence.An uncomplicated pregnancy is possible, even with doses as high as 54 Gy. Therefore, tumour treatment doses alone cannot at present be used to accurately predict uterine damage.

LIMITATIONS REASONS FOR CAUTION

Much of the data cannot be readily extrapolated to adult women who have had uterine radiation and the publications concerning adult women treated with AP RT are largely limited to case reports.

WIDER IMPLICATIONS OF THE FINDINGS

This analysis offers clinical guidance and assists with patient counselling. It is important to include patients who have undergone AP RT or TBI in prospective studies to provide further evidence regarding uterine function, pregnancy outcomes and correlation of imaging with clinical outcomes.

STUDY FUNDING/COMPETING INTERESTS

This study received no funding and there are no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Pregnancy after chemoradiotherapy in childhood: Complications and recommendations - about one case

The question of pregnancy prognosis after radio chemotherapy is unaddressed. We report here the case of three successive spontaneous pregnancies 17 years after the management of a thigh rhabdomyosarcoma treated by radiochemotherapy. In 2018 the patient aged 22 presented with a spontaneous miscarriage. In 2019, she obtained a new spontaneous pregnancy. At 21 W G, she presented with threatened late miscarriage and gave birth to a live girl who would die. Three months after delivery, she had spontaneous pregnancy. At 18 W G, emergency cervical cerclage was performed. At 35 W G the ultrasound found severe intrauterine growth retardation. Cesarean section was performed allowing the birth of a girl in good health status. Childbirth was complicated by 1L8 postpartum hemorrhage secondary to uterine atony, controlled after surgical revision. To conclude, pregnancy in a patient with a history of pelvic irradiation in childhood must be considered high-risk pregnancy and its management must be multidisciplinary.

The Likelihood of Adverse Pregnancy Outcomes and Genetic Disease (Transgenerational Effects) from Exposure to Radioactive Fallout from the 1945 Trinity Atomic Bomb Test

The potential health consequences of the Trinity nuclear weapon test of 16 July 1945 at Alamogordo, New Mexico, are challenging to assess. Population data are available for mortality but not for cancer incidence for New Mexico residents for the first 25 y after the test, and the estimates of radiation dose to the nearby population are lower than the cumulative dose received from ubiquitous natural background radiation. Despite the estimates of low population exposures, it is believed by some that cancer rates in counties near the Trinity test site (located in Socorro County) are elevated compared with other locations across the state. Further, there is a concern about adverse pregnancy outcomes and genetic diseases (transgenerational or heritable effects) related to population exposure to fallout radiation. The possibility of an intergenerational effect has long been a concern of exposed populations, e.g., Japanese atomic bomb survivors, survivors of childhood and adolescent cancer, radiation workers, and environmentally exposed groups. In this paper, the likelihood of discernible transgenerational effects is discounted because (1) in all large-scale comprehensive studies of exposed populations, no heritable genetic effects have been demonstrated in children of exposed parents; (2) the distribution of estimated doses from Trinity is much lower than in other studied populations where no transgenerational effects have been observed; and (3) there is no evidence of increased cancer rates among the scientific, military, and professional participants at the Trinity test and at other nuclear weapons tests who received much higher doses than New Mexico residents living downwind of the Trinity site.

Risk of Being Born Preterm in Offspring of Cancer Survivors: A National Cohort Study

Background: With the increased number of cancer survivors, it is necessary to explore the effect of cancer and its treatments on pregnancy outcomes, such as preterm birth, which seriously endangers the health of offspring. We aimed to explore the risk of being born preterm among offspring of cancer survivors.

Materials and Methods: This is a retrospective cohort study. All singleton live births between 1973 and 2014 in Sweden with information of birth outcomes were retrieved from the Swedish Medical Birth Register. By linking to several Swedish registers, we identified all parents of children and parental cancer diagnosis. Logistic regression was used to estimate odds ratios and 95% confidence intervals.

Results: As compared to the children without parental cancer, the risk of being born preterm was significantly higher among children of overall female cancer survivors born after cancer diagnosis with an adjusted OR of 1.48 (95 CI% = 1.39–1.59), in particular those diagnosed with childhood cancer and cancer in female genital organs. Besides, the risk might continuously decline with time at the first 8 years after maternal diagnosis. A higher risk of being born preterm was found among offspring of male survivors diagnosed with central nervous system cancer (Adjusted OR = 1.26, 95% CI = 1.04–1.53).

Conclusions: Our study provides evidence for a higher risk of being born preterm among children of female cancer survivors and male survivors with central nervous system tumor, as well as indicates that the effect on female reproductive system from cancer and related-treatments might decline with time.

Spatiotemporal association of low birth weight with Cs-137 deposition at the prefecture level in Japan after the Fukushima nuclear power plant accidents: an analytical-ecologic epidemiological study

BACKGROUND

Perinatal mortality increased in contaminated prefectures after the Fukushima Daichi Nuclear Power Plant (FDNPP) accidents in Japan in 2011. Elevated counts of surgeries for cryptorchidism and congenital heart malformations were observed throughout Japan from 2012 onward. The thyroid cancer detection rate (2011 to 2016) was associated with the dose-rate at the municipality level in the Fukushima prefecture. Since the birth weight is a simple and objective indicator for gestational development and pregnancy outcome, the question arises whether the annual birth weight distribution was distorted in a dose-rate-dependent manner across Japan after Fukushima.

METHODS

The Japanese Ministry of Health, Labour, and Welfare provides prefecture-specific annual counts for 26.158 million live births from 1995 to 2018, of which 2.366 million births (9.04%) with weights < 2500 g. Prefecture-specific spatiotemporal trends of the low birth weight proportions were analyzed. Logistic regression allowing for level-shifts from 2012 onward was employed to test whether those level-shifts were proportional to the prefecture-specific dose-rates derived from Cs-137 deposition in the 47 Japanese prefectures.

RESULTS

The overall trend of the low birth weight prevalence (LBWp) in Japan discloses a jump in 2012 with a jump odds ratio (OR) 1.020, 95%-confidence interval (1.003,1.037), p-value 0.0246. A logistic regression of LBWp on the additional dose-rate after the FDNPP accidents adjusted for prefecture-specific spatiotemporal base-line trends yields an OR per μSv/h of 1.098 (1.058, 1.139), p-value < 0.0001. Further adjusting the logistic regression for the annual population size and physician density of the prefectures, as well as for the counts of the dead, the missing, and the evacuees due to earthquake and tsunami (as surrogate measures for medical infrastructure and stress) yields an OR per μSv/h of 1.109 (1.032, 1.191), p-value 0.0046.

CONCLUSIONS

This study shows increased low birth weight prevalence related to the Cs-137 deposition and the corresponding additional dose-rate in Japan from 2012 onward. Previous evidence suggesting compromised gestational development and pregnancy outcome under elevated environmental ionizing radiation exposure is corroborated.

Risk of being born preterm in offspring of survivors with childhood or adolescent central nervous system tumor in Sweden

An increasing number of patients with central nervous system (CNS) tumor could survive to reproductive age. However, it is largely unknown whether the history of CNS tumor might affect pregnancy outcome. We aimed to explore the risk of being born preterm among children of CNS tumor survivors. By linking several nationwide registers in Sweden, we identified 1,369 children whose parents were childhood or adolescent CNS tumor survivors. Children whose parents did not have CNS tumor were matched randomly with a 5:1 ratio to generate the reference group. Conditional logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (CI). The prevalence of preterm birth (PTB) was 6.9% among children of survivors with CNS tumor and 5.2% among the matched controls. Children of survivors had an increased risk of PTB (adjusted OR = 1.29, 95%CI 1.01-1.65) compared to the matched controls. This risk was increased specifically among offspring of those diagnosed in childhood (adjusted OR = 1.53, 95%CI 1.14-2.06) but not adolescence (adjusted OR = 0.89, 95%CI 0.56-1.41). For families with more than one child, the risk was slightly lower among the second child as compared to the first child. The risk was negatively associated with time interval between parental diagnosis and childbirth. Parental medulloblastoma and ependymoma were most strongly associated with a higher risk of PTB. Children of survivors with CNS tumor experienced an elevated risk of PTB. However, the risk diminishes gradually after parental diagnosis of CNS tumor. Offspring of childhood CNS tumor survivors and medulloblastoma or ependymoma survivors may have the highest risk of PTB.

Uterine irradiation as a determinant of infertility and pregnancy losses in young cancer survivors

Several concerns exist regarding the impact of anticancer treatments on fertility and pregnancy outcome. The detrimental effects of both chemotherapy and radiotherapy on the ovaries are well reported in the available literature. Fewer data are focused on the importance of a functioning uterus to conceive and carry on a healthy pregnancy. The aim of this paper is to provide a narrative review of the current literature to assess the role of uterine irradiation as a potential determinant of infertility and poor obstetrical outcomes. This review addresses the need for multidisciplinary counselling in order to face the poor reproductive and obstetrical outcomes of women who had uterine radiation, according to the different backgrounds (radiotherapy during adulthood versus childhood; total body irradiation versus pituitary, spinal and/or abdominal-pelvic irradiation).

Looking beyond the ovary for oncofertility care in women: uterine injury as a potential target for fertility-preserving treatments

Treatment for cancer has the potential to significantly diminish fertility and, further, to negatively impact the obstetrical outcomes of pregnancies that do occur. Cancer survivors have decreased rates of fertility and increased rates of pregnancy complications, such as preterm birth and low birth weight, after exposure to chemotherapy. To date, research on the impact of chemotherapy and radiotherapy on fertility and pregnancy outcomes has focused largely on the gonadotoxic effect of cancer treatments on ovaries, while the uterus and endometrium have not been extensively studied. It is intuitive, however, that decreased fertility and poorer obstetrical outcomes may be substantially mediated through injury to a highly mitotic tissue like the endometrium, which is also central to embryo implantation and utero-placental exchange. Pregnancy complications in cancer survivors might be due to compromised blood supply to the endometrium and myometrium affecting placentation or altered remodeling of the pregnant uterus secondary to radiation fibrosis. Alterations in endometrial receptivity at the molecular level could affect pregnancy implantation and early pregnancy loss, but later complications also can occur. This review focuses on understanding the unintended effects of chemotherapy and radiotherapy on uterine function in female cancer survivors and the impact on pregnancy, and summarizes mechanisms to protect and treat the uterus before and after cancer chemotherapy and radiotherapy.

Concepts in preterm birth research: Interview with a stakeholder

Preterm birth continues to be a clinical problem of vast significance all over the world [1,2]. The complexities of the biology of preterm birth suggest a syndrome with multiple factors that synchronize rupture of membranes, uterine contraction, cervical dilation, and labor. Multiple genetic, environmental, and basic biological factors are associated with preterm birth. Despite many years of effort, we still do not completely understand preterm birth, the basic mechanisms underlying parturition, or the relationship(s) between the two. My position has always been that breakthroughs in this area will come from an inclusive, integrative, and interdisciplinary approach that hears the voices of multiple stakeholders, encompasses "outside the box" thinking and utilizes novel methodologies. To document the voices of stakeholders, alternative thinking and the seeds of development of novel methodologies, I have begun to interview stakeholders in preterm birth. This is an interview with Ramkumar Menon, MS, PhD, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine & Perinatal Research, The University of Texas Medical Branch at Galveston. Dr. Menon is past president and current Executive Director of PREBIC Global. He has surmounted considerable challenges to not only produce outstanding science from his own laboratory, but also to bring together collaborators and support from all over the world to bear upon the problem of preterm birth. What follows is an interview I did with him in 2014.

Pregnancy, time to pregnancy and obstetric outcomes among female childhood cancer survivors: results of the DCOG LATER-VEVO study

Purpose

To evaluate pregnancy rates, time to pregnancy (TTP) and obstetric outcomes in female childhood cancer survivors (CCSs) and to identify specific diagnosis- and treatment-related factors associated with these outcomes.

Methods

The study is part of the DCOG LATER-VEVO study, a nationwide multicenter cohort study evaluating fertility among long-term Dutch female CCSs. Data were collected by questionnaire. The current study included 1095 CCSs and 812 controls, consisting of sisters of CCSs and a random sample of women from the general population.

Results

Among the subgroup of women who ever had the desire to become pregnant, the chance of becoming pregnant was significantly lower for CCSs than controls (OR 0.5, 95%CI 0.4–0.8). Moreover, TTP was 1.1 times longer for CCSs compared to controls (p = 0.09) and was significantly longer in survivors of CNS and renal tumours. Overall, no differences were found between CCSs and controls regarding the probability of ever having had a miscarriage, still birth, or induced abortion. However, CCSs had a significantly increased risk of delivering preterm (OR 2.2, 95%CI 1.3–3.7) and delivering via caesarean section (OR 1.8, 95%CI 1.2–2.6). Treatment with lower abdominal/pelvic radiotherapy was strongly associated with several adverse obstetric outcomes.

Conclusion

CCSs are less likely to have ever been pregnant. Among those who do become pregnant, certain subgroups of CCSs are at increased risk of longer TTP. Moreover, as pregnant CCSs, especially those treated with lower abdominal/pelvic radiotherapy, are more likely to develop various adverse obstetric outcomes, appropriate obstetric care is highly advocated.

Electronic supplementary material

The online version of this article (10.1007/s00432-020-03193-y) contains supplementary material, which is available to authorized users.

Gynecological cancer among adolescents and young adults (AYA)

Adolescents and young adults (AYA) patients with cancer show specific biological, sociodemographic and behavioral features, with lower survival rates than younger group. Gynecologic malignancies that occur among AYA requires a multidisciplinary management and a tailored model of care, in order to enhance the early diagnosis, the adherence to the treatment, the enrollment in clinical trials, the rate of survival and the quality of life (QoL). In this article, we review the main gynecological tumors that may occur in AYA, with a focus on the clinical signs at the diagnosis and the modality of treatment. In addition, we proposed a model of multidisciplinary and personalized care for AYA with gynecological tumors, which can help the clinicians to manage the specific gynecologic concerns, such as ovarian failure, contraception, fertility, late psychosocial effects.

Placenta Accreta in a Woman with Childhood Uterine Irradiation: A Case Report and Literature Review

The pregnancies of childhood cancer survivors who have received uterine irradiation are associated with a high risk of several obstetrical complications, including placenta accreta. The present case was a 26-year-old pregnant woman with a history of myelodysplastic syndrome treated with umbilical cord blood transplantation following chemotherapy and total body irradiation at the age of 10. Despite every possible measure to prevent preterm labor, uterine contractions became uncontrollable and a female infant weighing 892 g was vaginally delivered at 27⁺⁴ weeks of gestation. Under the postpartum ultrasonographic diagnosis of placenta accreta, we selected to leave the placenta in situ. Although emergency bilateral uterine artery embolization was required, complete resorption of the residual placenta was accomplished on the 115^th day postpartum. Our experience highlighted the following points. (1) The expectant management of placenta accreta arising in an irradiated uterus may not only fulfill fertility preservation, but may also reduce possible risks associated with cesarean hysterectomy. (2) Due to extreme thinning of and a poor blood supply to the myometrium, reaching an antepartum diagnosis of placenta accreta in an irradiated uterus is difficult. (3) The recurrence of placenta accreta in subsequent pregnancies needs to be considered after successful preservation of the uterus.

Surprisingly, the Result of an Unplanned Pregnancy after Cranial Radiotherapy: A Case Report (Successful Childbirth after Brain Astrocytoma)

The present study aimed to present a rare case of successful pregnancy within 6 months from cranial mass surgery and postsurgical radiotherapy. A 32-year-old female with gestational age of 19 weeks had been refereed with a past medical history of recently treated brain astrocytoma. Close obstetric monitoring had been planned; the pregnancy was complicated with severe preeclampsia at the gestational age of 36 weeks, which leads to successful delivery. Pregnancy in patients with a history of cancer has been the focus of studies today and in many cancers it is recommended to delay pregnancy for at least 2 years. The prognosis of such a patient after unplanned pregnancy conception could be more complex; and the present case report aimed to explain about it. The goal of this presentation was to emphasis on the possibility of fertility preservation in the patient with malignancy even after cranial mass surgery and radiotherapy.

Pregnancy outcomes among leukemia survivors: a population-based study on 14.5 million births

PURPOSE

Leukemia is the most common cancer among children and young adults and an increasing number of affected patients can expect a full recovery and long-term survival. The study objective was to determine the prevalence of leukemia survivors among pregnant women and to examine the maternal and fetal outcomes of this population.

MATERIALS AND METHODS

We conducted a retrospective population-based cohort study on all births recorded in the Health - Care Cost and Utilization Project - Nationwide Inpatient Sample between 1999 and 2014. We measured the prevalence of leukemia survivors in pregnancy and performed multivariate logistic regression to calculate adjusted odds ratios for maternal and fetal outcomes among this group compared to a nonaffected one.

RESULTS

Our cohort consisted of 14,513,587 births, of which 1,269 were to women with a history of leukemia or leukemia in remission, corresponding to a prevalence of 8.74 per 100,000 births. The prevalence rose steadily over the 16-year study period. Pregnant women who were leukemia survivors were more likely to experience gestational diabetes (OR 1.36, 95% CI 1.08-1.70), threatened preterm labor (1.50, 1.09-2.08), venous thromboembolism (4.40, 2.86-6.78), and to require blood transfusions (1.89, 1.24-2.88). Preterm deliveries (1.25, 1.02-1.54) and congenital anomalies (2.32, 1.39-3.86) among their newborns were also more common.

CONCLUSION

The prevalence of leukemia survivors among pregnant women has been steadily rising. While the disease may no longer be active during their pregnancy, leukemia survivors appeared to have increased risks of several adverse outcomes and as such, should be monitored closely in centers with access to specialized care.

Oncofertility: Meeting the Fertility Goals of Adolescents and Young Adults With Cancer

Adolescents and young adults aged 15 to 39 years who are diagnosed with cancer (AYA survivors) undergo a range of therapies for cancer cure but subsequently may be at risk of treatment-related infertility, and for female AYA survivors, adverse pregnancy outcomes. Future fertility is important to AYA survivors. Meeting their fertility goals requires awareness of this importance, knowledge of cancer treatment-related fertility risks, appropriate fertility counseling on these risks, and access to fertility care. Epidemiologic and dissemination and implementation research are needed to estimate more precise risks of traditional and novel cancer therapies on fertility and pregnancy outcomes and improve the delivery of fertility care.

Perceived infertility and contraceptive use in the female, reproductive-age cancer survivor

OBJECTIVE

To estimate the association between perceived fertility potential and contraception use and to characterize factors important in contraceptive decision making in reproductive-age, female cancer survivors.

DESIGN

Cross-sectional study.

SETTING

Participants were from two state cancer registries, physician referrals, and cancer survivor advocacy groups in the United States.

PATIENT(S)

A total of 483 female survivors aged 18-40 years.

INTERVENTION(S)

Online questionnaire.

MAIN OUTCOME MEASURE(S)

Contraception use.

RESULT(S)

Eighty-four percent of participants used contraception; 49.7% used highly effective, World Health Organization tiers I and II methods (surgical sterilization, intrauterine devices, contraceptive implant, combined hormonal contraceptives, medroxyprogesterone acetate, progestin-only pills, contraceptive diaphragm). Contraception non-use was more common among survivors who perceived themselves to be infertile, compared with survivors who perceived themselves to be as or more fertile than similarly aged peers (prevalence ratio 4.0, 95% confidence interval 2.5-7.4). In mediation analysis that adjusted for clinical infertility, 59% of the association between prior chemotherapy and contraception non-use was explained by perceived infertility. Contraception efficacy (n = 62, 25.8%) and ease of use (n = 50, 20.8%) were the most cited reasons for using tier I/II methods; compared with lack of hormones (n = 81, 49.7%) as the predominant reason for using less-effective, tier III/IV methods.

CONCLUSION(S)

Although female, reproductive-age cancer survivors had high uptake of contraception, those who perceived themselves to be infertile were less likely to use contraception. Throughout survivorship, clinicians should counsel survivors on fertility potential in the context of their prior cancer treatments and on factors, including contraceptive efficacy and hormone-free contraception, that inform reproductive decision making in this population.