With Fedro A. Peccatori, MD, PhD, Director of the Fertility & Procreation Unit in the Division of Gynecologic Oncology at the European Institute of Oncology
By Sarah DiGiulio
Treating pregnant women with cancer is a balancing act. Aggressive treatment may be the best course for the mother with highest chance of survival—yet too much treatment poses severe risks to developing fetuses.
New data collected from Sweden's nationwide health registries showed that maternal cancer during pregnancy is associated with increased risks of fatal outcomes (though rare), including stillbirth and neonatal mortality. The data included 984 women who were diagnosed with cancer during pregnancy and 2,723 women who were diagnosed with cancer the year after pregnancy. (The data was collected from more 3,947,215 singleton births included in the registries between 1973 and 2012.)
Another significant finding from the research: preterm birth explained 89 percent of the association of maternal cancer during pregnancy with neonatal mortality. The data was recently published in the Journal of Clinical Oncology (2017;35:1522-1529).
"The correlation of preterm birth with impaired neonatal outcome, confirmed also by the current study, underlines the need for true multidisciplinary management of any pregnant woman with cancer," wrote Fedro A. Peccatori, MD, PhD, of the European Institute of Oncology, Milan, Italy, and Monica Fumagalli, MD, of the University of Milan, in an editorial accompanying the new research (J Clin Oncol 2017;35:1499-1500).
The safety and outcomes for expectant mothers with cancer and their fetus depends on the cancer type, the stage of the disease, the health of the mother and the fetus, and other factors, Peccatori and Fumagalli explained. But the new data suggest there's a need to increase collaborative research initiatives that address the still unknown questions about treating expectant mothers with cancer—and there needs to be better awareness on the part of providers and their patients about current guidelines.
Peccatori, who is Director of the Fertility & Procreation Unit in the Division of Gynecologic Oncology at the European Institute of Oncology, explained further why more work on this topic is needed.
1. Why would you say these new findings from the Swedish cohort by Lu, et al., are significant?
"[The paper] underlines, for the first time, that patients who suffer from cancer during pregnancy may have higher stillbirth and infant mortality rates compared to the reference population. The study comes from Sweden, where stillbirth and infant mortality rates are very low, but it was quite clear that the main determinant of morbidity and mortality was prematurity, which is avoidable in most of the instances in this group of patients.
"Cancer during pregnancy is increasing, as the age at first and subsequent births are increasing. Thus, speaking of cancer during pregnancy is not trivial. It is estimated that one [in] 3,000 pregnancies may be complicated by cancer. Most of these are curable and can be treated during pregnancy with surgery and chemotherapy, the latter from the second trimester. Baby health for most of these mothers is of utmost importance and all the variants that may influence it are surely worth reporting."
2. What would you say are some of the biggest unknowns when it comes to how to treat cancer in pregnant women—and the challenges in delivering high-quality care to these patients?
"As said, cancer can be treated also during pregnancy. Nonetheless, you need a really multidisciplinary and multi-professional team to take care of the pregnant mother with cancer. In my institute, we have set up a collaboration with the Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Milan University where we found the best possible obstetricians, perinatologists, and neonatologists to take care of these women.
"Still, many questions remain. The effect of the disease on the pregnancy evolution, the placental toxicity of drugs, and the different models of baby attachment after a diagnosis of cancer during pregnancy are still unanswered questions that our group is investigating. Chemotherapy can be safely administered starting from the second trimester, but we are still missing comprehensive and detailed information about long-term outcome on the offspring."
3. What is most important to know about this recent research and how to care for pregnant women with cancer?
"Too often, cancer during pregnancy is considered an oxymoron and many physician advise for pregnancy interruption. Unfortunately, the data that support an active management of cancer during pregnancy are not well-known. The issue is also underserved in medical education.
"When we say 'need for action,' we mean more humbleness, more knowledge, more collaboration, and more research. All this can be done if we share data within collaborative initiatives, as the multinational International Network on Cancer Infertility and Pregnancy, which was launched in Europe, but includes also U.S. centers.
"Treating cancer during pregnancy is possible, but not trivial. To achieve the best results for the mothers and their babies, you need to understand this unique situation and act accordingly."