Ovarian tumors can be surgically staged and – if it is of low malignant potential – can be laparoscopically removed, usually without endangering the pregnancy. Large tumors or those with aggressive pathology, like epithelial tumors, are much more difficult. Advanced or large tumors often have uterine and pelvic involvement, and treatment usually means a hysterectomy.
The literature contains reports of a very few women who have undergone chemotherapy to control peritoneal spread while keeping a pregnancy. However, despite giving birth to normally developed children, a number of these women died from recurrent disease, Dr. Morice noted.
Hematologic Cancers: True Emergency
Cancers of the blood are rare in pregnancy, occurring in only 1 of every 6,000. But when they do occur, they can be devastating, Dr. Benjamin Brenner wrote in the special series (Lancet 2012;379:580-7).
Pregnant patients with Hodgkin’s lymphoma generally do as well as their nonpregnant counterparts and can receive the same chemotherapy regimens, observing the first-trimester delay to favor the fetus.
Those who present with non-Hodgkin’s lymphoma are likely to have a very poor outlook. This disease is very rare in pregnant women, and symptoms can overlap with Hodgkin’s. Those factors, combined with a desire to avoid imaging, can delay diagnosis until the cancer is more advanced, said Dr. Brenner of the Rambam Health Care Campus, Haifa, Israel.
Acute leukemia is also rare, but demands urgent attention regardless of gestational stage, Dr. Brenner warned. "Patients diagnosed with acute leukemia during the first trimester are recommended to terminate the pregnancy, in view of the high risk of toxic effects on the fetus and mother, along with the expected need for further intensive treatment including stem-cell transplantation, which is absolutely contraindicated during gestation."
Talking It Out
Despite the emerging positive evidence, treating cancer during pregnancy can be a tough sell, Dr. Amant said. "Women have been told over and over to avoid taking so much as an aspirin. It’s very difficult to convince them that a fetus can not only survive a mother’s cancer treatment, but have a good chance of developing normally."
The stress of a cancer diagnosis during a desired pregnancy is very hard on patients, Dr. Temkin added. "Pregnancy is a time when many women come to grips with their own mortality as well as that of giving new life. Adding a diagnosis of cancer of top of that – especially in the face of a much-desired pregnancy – can be devastating."
These women are faced with two options: terminate the pregnancy and concentrate on their own treatment, or continue the pregnancy knowing that their unborn child will be exposed to the possible risks of radiation, chemotherapy, and surgery. Either option can "inflict terrible guilt on a pregnant woman. We can try to minimize that to some degree, but it’s important to know from the outset that what is the right solution for one patient is not right for the next."
Connecting with other women who have experienced the same situation can be of immense value, Dr. Cardonick said. She participates in an online support group called "Hope for Two."
The organization’s main goal is to link new patients with survivors who can help educate them as well as lend emotional support. Patients call in or fill out a secure online request for a personal match-up with a survivor, who is often a woman who has had the same type of cancer.
The website also contains links to news and medical articles, books, and financial assistance sources, and allows new patients to securely contact Dr. Cardonick’s pregnancy registry. "We keep in touch with the baby’s pediatrician and the mom every year, to see how things are going and [to] collect information," she said. "The best way to treat these women in the future depends on the information we continue to gather in the present."
None of the researchers interviewed for this article had any relevant financial disclosures. Dr. Litton noted that she had no financial disclosures for her 2011 ASCO poster.