Birth outcome in women with breast cancer, cutaneous malignant melanoma, or Hodgkin's disease: a review

Obstetric complications at time of delivery amongst breast cancer survivors: A population-based cohort study

PURPOSE

Our aim was to determine whether breast cancer survivors are at increased risk of obstetric and maternal complications at time of delivery.

METHODS

The USA 'National Inpatient Sample' database was queried for hospitalizations associated with deliveries, between 2015 and 2018. The incidence of maternal and fetal complications was compared between women with, and without, a personal history of breast cancer.

RESULTS

Of the 2,103,216 birth related admissions, 617 (0.03%) of the women were breast cancer survivors, with the proportion increasing over time (from 0.02% in 2015 to 0.04% in 2018). Breast cancer survivors had a higher socioeconomic status (p < 0.001) and were significantly older compared to other mothers (34 vs. 28 years, p < 0.001). Additionally, they were more likely to suffer from preexisting chronic diseases including cardiopulmonary disease and diabetes mellitus, and had a higher incidence of multiple gestation (4.4% vs. 1.6%) [OR 2.7, 95% CI 1.9-4.0, p < 0.001]. The incidence of acute adverse events at time of delivery including fetal distress, preterm labor, cesarean section and maternal infection was higher amongst the breast cancer survivors. On multivariate analysis age, ethnic group, comorbidities, multiple gestations, and a previous breast cancer diagnosis, but not cancer treatment, were associated with an increased risk of an obstetric adverse event.

CONCLUSION

Breast cancer survivors have more comorbidities and are at increased risk of acute obstetrical complications at time of delivery. Further studies are required to validate these findings, and evaluate the ability of interventions to improve obstetrical outcomes amongst breast cancer survivors.

In-Hospital Complications in Pregnant Women With Current or Historical Cancer Diagnoses

OBJECTIVE

To assess the temporal trends, characteristics and comorbidities, and in-hospital cardiovascular and obstetric complications and outcomes of pregnant women with current or historical cancer diagnosis at the time of admission for delivery.

METHODS

We analyzed delivery hospitalizations with or without current or historical cancer between January 1, 2004, and December 31, 2014, from the US National Inpatient Sample database.

RESULTS

We included 43,132,097 delivery hospitalizations with no cancer, 39,118 with current cancer, and 67,336 with historical diagnosis of cancer. The 5 most common types of current cancer were hematologic, thyroid, cervical, skin, and breast cancer. Women with current and historical cancer were older (29 years and 32 years vs 27 years) and incurred higher hospital costs ($4131 and $4078 vs $3521) compared with women without cancer. Most of the cancer types were associated with preterm birth (hematologic: adjusted odds ratio [aOR], 1.48 [95% CI, 1.35 to 1.62]; cervical: aOR, 1.47 [95% CI, 1.32 to 1.63]; breast: aOR, 1.93 [95% CI, 1.72 to 2.16]). Current hematologic cancer was associated with the highest risk of peripartum cardiomyopathy (aOR, 12.19 [95% CI, 7.75 to 19.19]), all-cause mortality (aOR, 6.50 [95% CI, 2.22 to 19.07]), arrhythmia (aOR, 3.82 [95% CI, 2.04 to 7.15]), and postpartum hemorrhage (aOR, 1.31 [95% CI, 1.11 to 1.54]). Having a current or historical cancer diagnosis did not confer additional risk for stillbirth; however, metastases increased the risk of maternal mortality and preterm birth.

CONCLUSION

Women with a current or historical diagnosis of cancer at delivery have more comorbidities compared with women without cancer. Clinicians should communicate the risks of multisystem complications to these complex patients.

Counseling young women with early breast cancer on fertility preservation

PURPOSE

Women with early-stage breast cancer may still have a future child wish, while chemotherapy may impair fertility. To pursue on fertility preservation shortly after breast cancer diagnosis is complex. This review holds a critical reflection on all topics that need to be counseled to give them the opportunity to make a well-informed decision before starting any oncological treatment.

METHODS

A comprehensive literature review was performed on papers published in English language on breast cancer in young women, risk of chemotherapy-induced infertility, fertility preservation techniques, impact of possible mutation carriership, and future pregnancy outcome.

RESULTS

Below 40 years of age, the risk of permanent chemotherapy-induced ovarian function failure is approximately 20%, where taxanes do not significantly add to this risk. Overall, 23% of reported women who performed fertility preservation by cryopreserving oocytes or embryos returned for embryo transfer. Of these, 40% gave live birth. Both fertility preservation in women diagnosed with breast cancer and pregnancy after treatment seem safe with respect to breast cancer survival. Women who have a genetic predisposition for breast cancer like BRCA gene mutation should also be informed about the possibility of pre-implantation genetic diagnosis.

CONCLUSIONS

Women with an early stage of breast cancer and a possible future child wish should be referred to an expertise center in breast cancer, fertility preservation, and genetics in this complex decision-making process, shortly after diagnosis.

Obstetrical outcomes in women with history of breast cancer: a systematic review and meta-analysis

PURPOSE

Potential risk of adverse obstetrical outcomes has been shown among breast cancer survivors. Therefore, the aim of this systematic review and meta-analysis was to evaluate the relationship between history of breast cancer (BC) and obstetrical outcomes.

METHODS

PubMed, EMBASE, and Medline were searched from the inception of each database to April 2019. Selection criteria included prospective and retrospective cohort studies of BC pregnant survivors. The meta-analysis was performed by computing odds ratios (ORs) using both fixed and random-effects models. Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale and the review was registered with PROSPERO number CRD42019127716.

RESULTS

Four studies, including 1466 cases of BC survivors and 6,912,485 controls, were included. Compared with controls, a higher incidence of obstetrical complication was found in women with history of BC. The incidence of preterm birth (PTB) in the study group was 11.05% compared with 7.79% in the control group (1.68, 95% confidence interval 1.43-1.99). Breast cancer history was also associated with low birth weight (LBW) (study group: 9.26% vs. control group: 5.54%, 1.88, CI 95% 1.55-2.27), cesarean section (CS) (study group: 19.76% vs. control group 10.81%, 1.78, CI 95% 1.39-2.27), intrauterine fetal death (IUFD) (study group: 0.004% vs. control group 0.36%, of 1.25 CI 95% 0.36-4.35), and fetal anomalies (study group: 5.8% vs. control group: 4.26%, 1.45 CI 95% 1.01-2.09).

CONCLUSIONS

History of BC was associated with adverse obstetrical outcomes.

Pregnancy-associated cancers and birth outcomes in children: a Danish and Swedish population-based register study

OBJECTIVES

This study aims to estimate the association between pregnancy-associated maternal cancers, diagnosed both prenatally and postnatally, and birth outcomes.

DESIGN

Population-based register study.

SETTING

National registers of Denmark and Sweden.

PARTICIPANTS

A total of 5 523 365 children born in Denmark (1977-2008) and Sweden (1973-2006).Primary and secondary outcome measures: gestational age, birth weight, size for gestational age, Apgar score, caesarean section and sex were the outcomes of interest. ORs and relative risk ratios (RRR) with 95% CIs were estimated using logistic regression and multinomial logistic regression, respectively.

RESULTS

In this study, 2% of children were born to mothers with a diagnosis of cancer. Children whose mothers received a prenatal cancer diagnosis had higher risk of being born preterm (RRR: 1.77, 95% CI 1.64 to 1.90); low birth weight (RRR 1.84, 95% CI 1.69 to 2.01); low Apgar score (OR 1.36, 95% CI 1.20 to 1.56); and by caesarean section (OR: 1.69, 95% CI 1.59 to 1.80). Associations moved towards the null for analyses using postnatal diagnoses, but preterm birth (RRR: 1.13, 95% CI 1.09 to 1.17) and low birth weight (RRR: 1.14, 95% CI 1.09 to 1.18) remained statistically significant, while risk of caesarean section became so (OR: 0.95, 95% CI 0.91 to 0.98). Additionally, statistical significance was reached for large for gestational age (RRR: 1.06, 95% CI 1.01 to 1.11), high birth weight (RRR: 1.04, 95% CI 1.01 to 1.06) and caesarean section (OR: 0.95, 95% CI 0.91 to 0.98).

CONCLUSIONS

Results suggest an association between pregnancy-associated cancers and adverse birth outcomes in the offspring. While this is strongest for prenatally diagnosed cancers, some smaller associations exist for postnatally diagnosed cancers, indicating that cancer itself could affect fetal development, or that cancer and adverse birth outcomes share risk factors. Future studies on maternal cancer during pregnancy should consider including some postnatal years in their exposure window.

Pregnancy-related venous thromboembolism and risk of occult cancer

The cancer risk during the first year after a pregnancy-related venous thromboembolism episode is higher than expected.An aggressive search for cancer in women with pregnancy-related venous thromboembolism is probably not warranted, due to low absolute risk.

Maternal cancer and congenital anomalies in children - a Danish nationwide cohort study

Several studies on pregnancy-associated cancers have suggested an association with congenital anomalies in offspring. Previous studies have included maternal cancers diagnosed up to 2 years after pregnancy; however, long latency periods of some cancers mean that cancers diagnosed many years postpartum might have been present during pregnancy in a preclinical state. This paper considers the association between maternal cancers diagnosed from 2 years prior to pregnancy until the mother reaches 50 years of age, and congenital anomalies, as diagnosed at birth or within the first year of life. The current population-based study looks at associations of cancers in mothers with congenital anomalies in their children. Children were followed up from birth to diagnosis of a congenital anomaly, death, emigration or end of follow-up (whichever occurred first). A total of 56,016 children (2.6%) were considered exposed to a maternal cancer of any type; and they had a hazard ratio (HR) of 1.04 (95% confidence interval [CI]: 1.00, 1.09) compared with unexposed children. The greatest HR was seen among children whose mothers had been diagnosed with cancers before or during pregnancy (HR: 1.37, 95% CI: 1.07, 1.75). Similar results were seen when paternal cancers were used as a ‘negative control’. Statistically significant associations were seen for some specific congenital anomalies of organ systems (congenital anomalies of the musculoskeletal system [HR: 1.13, 95% CI: 1.02, 1.25]) and for some specific types of maternal cancer (leukaemia [HR: 1.31, 95% CI: 1.01, 1.61], The results of the main analyses suggest a small increase in risk of congenital anomalies in offspring of mothers diagnosed with cancer from 2 years before pregnancy, until the mother reaches 50 years of age; with the greatest increase seen for exposure in the pre-pregnancy and pregnancy period. These results may reflect shared causes for some cancers and some congenital anomalies. The similar results seen for paternal cancers indicate that the cause may be genetic or related to the families’ social and environmental conditions.

Perinatal Considerations in Women With Previous Diagnosis of Cancer

As the average age that women have their first child increases and cancer therapies improve survival, obstetricians are more likely to care for pregnant women who have survived cancer. Managing these pregnancies can be challenging, as they may be associated with higher risks of maternal and neonatal morbidity and mortality. Different types of cancer require different types of intervention, including surgery, chemotherapy, radiation, or combinations of these. Prior cancer treatments therefore present different potential complications during pregnancy. Although for most women who survive cancer carrying a pregnancy does not seem to increase mortality rates, there are some associated neonatal morbidities. The most common perinatal complication associated with pregnancy after cancer is prematurity. Women who desire pregnancy after cancer survival should not be discouraged, but appropriate counseling and follow-up should be provided.

Malignant melanoma arising in an in vitro fertilisation pregnancy: A case report

Malignant melanoma diagnosed during pregnancy results in confusion about staging and management. In this case report, a 39-year-old pregnant woman, who had undergone conception via in vitro fertilisation, was diagnosed with malignant melanoma of a growing lesion on her back in the 20th week of gestation. She delivered her baby by caesarean section in the 38th week. Metastasis was not found by chest X-ray, ultrasonography and positron emission tomography after delivery. She has been disease free for 6 months postpartum. Surgical resection of malignant melanoma and postponing of the sentinel lymph node biopsy has been proposed. Risk of adverse perinatal outcomes has not been increased; but the prognosis of malignant melanoma is known to be poorer when diagnosed during pregnancy. As a conclusion, any pigmentary change in the nevi should be assessed carefully during pregnancy.

Breast cancer and fertility

OPINION STATEMENT

The increased availability of assisted reproductive technologies (ART) allows women with fertility issues to increase their chances of a successful pregnancy with the use of medications that, in some cases, increase circulating estrogens. There has been significant concern that the use of these medications will increase the risk of hormone-sensitive cancers such as breast, ovarian and uterine malignancies. Additionally, for those women who are diagnosed with a breast cancer during their reproductive years, this diagnosis can be particularly difficult as future fertility is a major concern for many young breast cancer survivors. With the current available data, there does not appear to be a statistically significant increase in the risk of developing breast cancer with ART, although several series suggest a potential possible related increase in borderline ovarian and uterine cancers. For breast cancer survivors, there does not appear to be an increased risk of death associated with subsequent pregnancies when compared with breast cancer patients who did not have subsequent pregnancies, although waiting at least 2 years after the diagnosis of breast cancer potentially may convey a protective effect. Therefore, when systemic therapy for breast cancer is recommended, early counseling and referral to a reproductive endocrinologist is warranted to provide optimal fertility preservation options. Further safety and outcomes studies are warranted for children.