Management of colorectal cancer in pregnancy: a multimodality approach

Colorectal cancer (CRC) is one of the 3 most common types of cancer in women, but CRC during pregnancy is rare, with a reported incidence of approximately 0.002%. Synchronous colon cancer during pregnancy presents a diagnostic and therapeutic challenge for clinicians because there are no generally accepted guidelines regarding diagnosis or treatment. The diagnosis is challenging because the presenting signs/symptoms of CRC are often attributed to the usual complications of pregnancy, which could delay the diagnosis and allow the cancer to progress to an advanced stage. Carcinogenesis of colon cancer in pregnancy is not clear, but a few studies suggest that the increased levels of estrogen and progesterone related to pregnancy stimulate the growth of CRC with their receptors. The aim of treatment is to start therapy for the mother as early as possible and to simultaneously deliver the baby at the earliest time allowable. The management mandates a multidisciplinary approach involving experts in obstetrics, neonatology, gastrointestinal surgery, and medical oncology. The medical community should be able to diagnose colon cancer earlier in pregnancy in order to improve prognosis. The primary care physician or obstetrician should refer the pregnant patient with significant gastrointestinal symptoms to the gastroenterologist for evaluation. Likewise, the gastroenterologist should be prepared to perform sigmoidoscopy (preferably without endoscopic medications) for significant lower gastrointestinal symptoms such as persistent rectal bleeding. Herein, the author reviews the literature concerning the diagnosis and treatment of CRC in pregnancy and discusses the role of newer agents approved for the treatment of CRC.     

First Case Report of Pregnancy on Alectinib in a Woman With Metastatic ALK-Rearranged Lung Cancer: A Case Report

This is the first case report of a patient with ALK-rearranged metastatic lung adenocarcinoma who became pregnant during treatment with alectinib. A multidisciplinary team of gynecologists, neonatologists, oncologists, psychologists, and pharmacologists was set up to handle the case. According to patient’s preference, the study drug was continued throughout pregnancy and the woman delivered a healthy baby girl at 35 weeks and 5 days of gestation. Fetal parameters remained normal during pregnancy. At birth, alectinib levels were 14 times higher in maternal plasma than in the fetus (259 versus 18 ng/mL). The average concentration of alectinib in the placenta was 562 ng/g. The baby was followed during her first 20 months, and no developmental anomalies were observed. After 32 months from diagnosis, the mother is well and in partial remission.     

Management of breast cancer during pregnancy using a standardized protocol.

PURPOSE: No standardized therapeutic interventions have been reported for patients diagnosed with breast cancer during pregnancy. Of the potential interventions, none have been prospectively evaluated for treatment efficacy in the mother or safety for the fetus. We present our experience with the use of combination chemotherapy for breast cancer during pregnancy. PATIENTS AND METHODS: During the past 8 years, 24 pregnant patients with primary or recurrent cancer of the breast were managed by outpatient chemotherapy, surgery, or surgery plus radiation therapy, as clinically indicated. The chemotherapy included fluorouracil (1,000 mg/m2), doxorubicin (50 mg/m2), and cyclophosphamide (500 mg/m2), administered every 3 to 4 weeks after the first trimester of pregnancy. Care was provided by medical oncologists, breast surgeons, and perinatal obstetricians. RESULTS: Modified radical mastectomy was performed in 18 of the 22 patients, and two patients were treated with segmental mastectomy with postpartum radiation therapy. This group included patients in all trimesters of pregnancy. The patients received a median of four cycles of combination chemotherapy during pregnancy. No antepartum complications temporally attributable to systemic therapy were noted. The mean gestational age at delivery was 38 weeks. Apgar scores, birthweights, and immediate postpartum health were reported to be normal for all of the children. CONCLUSION: Breast cancer can be treated with chemotherapy during the second and third trimesters of pregnancy with minimal complications of labor and delivery.     

Complementary and alternative therapies for cancer

Many cancer patients use therapies promoted as literal alternatives to conventional medical care. Such "alternative" modalities are unproven or were studied and found worthless. These can be harmful. An even greater proportion of cancer patients uses "complementary" therapies along with mainstream cancer treatment. Most are helpful adjunctive approaches that control symptoms and enhance quality of life. This review describes alternative as well as complementary therapies commonly used today by cancer patients. Herbal remedies also are discussed. Evidence regarding the efficacy and safety of complementary/alternative medicine (CAM) is reviewed, and implications for oncologists are discussed. To encourage open communication of CAM use by patients, oncologists should be knowledgeable about the most popular remedies and know where to find reliable information for themselves and for their patients.     

A favorable maternal and neonatal outcome following chemotherapy with etoposide, bleomycin, and cisplatin for management of grade 3 immature teratoma of the ovary

Ovarian cancer rarely complicates pregnancy. Usually these malignancies consist of germ cell tumors. Preserving maternal safety along with favorable neonatal outcome is a subject of debate in the management of ovarian cancer during pregnancy. In this report, the authors describe a 25-year-old primigravid woman who was diagnosed to with an ovarian immature teratoma which was diagnosed at 13th weeks of pregnancy during a routine sonography. She underwent oophorectomy at week 21 of her gestation. Then she received three cycles of BEP regimen (bleomycin, etoposide, and cisplatin) during her pregnancy until week 37 of gestation. At 36 weeks she delivered a male baby with mild glandular hypospadia who was otherwise normal. Management of immature teratoma after the first trimester of pregnancy is similar to non-pregnant patients and is safe for both the mother and the fetus.     

Weekly doxorubicin chemotherapy for breast cancer in pregnancy. A case report.

The simultaneous occurrence of breast cancer and pregnancy is rare. Little data are available about cytostatic treatment in patients with breast cancer during pregnancy. We report on a 31-year-old woman with a 28-week pregnancy and a T3 N+ Mx breast cancer treated with weekly doxorubicin chemotherapy. This was a well tolerated treatment without toxicity or complications for the mother. A partial response of the tumor was observed after 4 treatment courses. A normal baby was delivered. Doxorubicin and its metabolites were not detected in amniotic fluid collected through amniocentesis. Macroscopic and pathologic examinations of the placenta were normal. Although larger experiences are needed, weekly doxorubicin seems to yield satisfactory results without additional risks of fetal distress or malformations when given in women during the second and third trimester of pregnancy.     

Carcinoma of the breast during pregnancy: a review and update on treatment options.

Gestational breast cancer is occurring with increasing incidence because more women are delaying childbirth into their thirties and forties. Although breast cancer during pregnancy or within the first year postpartum is occurring more often, there is still some confusion regarding its treatment. Although breast conservation therapy has evolved as the major treatment in breast cancer, it has been thought that pregnancy was a contraindication for this type of breast cancer therapy due to risks imposed on the fetus by chemotherapy and radiation. However, recent studies have shown that the use of chemotherapeutics during the second and third trimesters is possible. Also, if chemotherapy is initiated after a lumpectomy, radiation can be withheld until after the birth of the baby when the cancer is detected in the second or third trimester.     

Breast cancer during pregnancy: A mini-review

Background

As modern women delay childbearing, pregnancy-associated breast cancer (PABC) becomes a more frequent problem faced by oncologists, gynecologists, and obstetricians alike. However, no evidence exists concerning the management of this condition.

Methods

We summarized the current literature regarding epidemiology, pathology, diagnosis, treatment and prognosis of PABC. Data were collected by searching PubMed and Medline for the period from 1950 to 2007.

Results

There are no randomized controlled trials regarding PABC management. Current evidence suggests that diagnosis may be carried out with limitations regarding staging; surgical treatment may be performed as for the non-pregnant women. Radiotherapy and endocrine therapy are contraindicated during pregnancy, while chemotherapy is allowed after the first trimester. Prognosis is considered poor. Subsequent pregnancy is allowed only 2 years after completing treatment.

Conclusions

Due to lack of prospective randomized controlled clinical studies, both ongoing studies and future evidence are expected to solve problems related to breast cancer management during pregnancy.     

Prise en charge psycho-oncologique de la jeune femme enceinte confrontée au cancer

Women who are diagnosed with cancer during pregnancy have to deal with two critical life events at the same time: pregnancy and cancer. More importantly, these two events lie at the opposite ends of the life continuum. With pregnancy a new life begins, while the word cancer is still associated for most people with the end of life and dying. From a medical standpoint there are several complicating factors in this situation: diagnosis is often delayed, because the focus of the physician (and the mother) is on pregnancy. Information giving is limited by the fact that there is still a paucity of statistical data on outcome and impact of treatment options. Also, several disciplines are forced to work together very closely and the collaboration of oncology, obstetric and psychological experts with family physicians is both very important yet sometimes challenging. The task of supporting a pregnant cancer patient can also mean a psychological burden for the caregivers and special attention needs to be paid to personal resources and as well as to each person’s individual limits. The important issues for a pregnant cancer patient are as follows: giving life and being in a life-threatening situation at the same time; experiencing overwhelming emotions while coping resources may be limited; feeling a responsibility to take care of the fetus/the child and at the same time needing to be cared for herself; choosing between treatment options that can only be second-best as there is no perfect solution (the loss incurred by terminating a pregnancy or the danger in risking its continuation); ambivalence towards chemotherapy (a poison); changes in body image caused by both the pregnancy and the effects of cancer treatment. In the post-partum period other issues arise: the joy of childbirth is hampered and breast-feeding may not be possible because of on-going chemotherapy; any other children will need minding during particularly heavy cancer treatment; both mother and child may need care, if the baby is premature; paternal ambivalence: joy about the child/sorrow about the mother, with the predominant issue being the constant fear of losing the mother. In this context, the patient and her partner need regular visits (obstetric and oncological) and psycho-oncological support from an experienced team. If the pregnancy is continued, the couple will need help in bonding with the child, both before and after the birth. If the pregnancy is terminated, the patient needs to be supported in her mourning process while at the same time helped in activating the resources needed to go through the treatment process. Integration of the partner is very important: cancer threatens the whole family with separation and loss. Such threats can seriously alter the course of family life, particularly in the case of cancer in a first pregnancy, when the family system is only just developing. Ideally, the partner will play an active part in the decision-making process, but this is a very difficult situation to be in: the woman is bearing a child that he may badly want to see born, but he also wants the best possible outcome for his partner and above all does not want her to die. This conflict is not easy to communicate. A role-change within the couple can be an additional burden. The woman, who until now was pregnant and healthy, is now pregnant and ill, while her partner is neither pregnant nor ill. He may well be feeling the pressure of such responsibility, but again, in the present situation this might not be something he feels he can talk about.     

First case of vaginal radical trachelectomy in a pregnant Japanese woman

A diagnosis of cervical cancer during pregnancy poses difficult management and ethical problems. Survival of the patient is the foremost concern, but fetal viability and well-being must also be addressed. Radical trachelectomy (RT) has recently begun to be performed as a possible treatment modality for early stage invasive uterine cervical cancer in pregnant patients who would like to continue their pregnancy. A 32-year-old Japanese woman visited a local hospital for prenatal care, and was diagnosed with a FIGO I B1 adenocarcinoma of the uterine cervix. She had a strong desire to avoid pregnancy termination, so she was admitted to our hospital for fertility-preserving surgery. After extensive counseling, vaginal radical trachelectomy with abdominal pelvic lymphadenectomy was performed in the 16th gestational week. The excised uterine cervix and lymph nodes were pathologically negative for cancer. To maintain her pregnancy, daily vaginal disinfection with povidone iodine, bed rest, and administration of ritodrine and an ulinastatin vaginal suppository were continued until the delivery. At 34 weeks' gestation, an emergency cesarean section was performed because of sudden premature rupture of the membranes. A baby girl was born weighing 2112 g, with Apgar score of 8/9. The mother remains without evidence of recurrence at the time of this report. This is the first case of successful pregnancy and delivery in Japan after vaginal RT.     

Exploring Oncologists' Beliefs About Psychosocial Groups

The authors investigated the beliefs of medical and radiation oncologists regarding psychosocial groups and their willingness to initiate referrals routinely to such groups. Sixteen of the 20 oncologists responsible for adult care in a geographically defined population of 1 million participated. The survey instrument queried the oncologists regarding the harm or benefit they expected from psychosocial groups and their views about appropriate intervention targets and timing. Although harm to patients was not a major concern, the respondents did not anticipate much benefit either. Benefits were expected during cancer treatment and after existing therapies failed. More than half the oncologists selected depression, anxiety, anger, and compliance with medical treatment as appropriate focuses for psychosocial groups. The authors found that the oncologists were only minimally concerned about the possibility that psychosocial programs would interfere with their treatments. They discuss implications for patient care such as responding to unmet needs and closing service gaps through increased communication as well as directions for research such as the merits of an oncologists' randomization design.     

Breast cancer and pregnancy

The diagnosis of breast cancer during pregnancy is a rare event, but the young age of the patient together with the emotional impact for both the family and the doctors make therapeutic choices usually very difficult. Until recently, the occurrence of pregnancy associated breast cancer was thought to hold a grave prognosis and therapeutic abortion was very often advised in common practice. The hormonal environment with the increase in estrogens and progesterone was the main factor for the fear of tumor stimulation. The course of breast cancer, however, does not appear to be adversely affected by continuation of pregnancy. In the last years it was realized that potentially curative therapies can be administered even when pregnancy is continued. Of course in the medical literature there is no randomized clinical trial helping in taking decision in this setting; however, a significant experience already exists in some institutions and can guide management in these difficult cases. The aim of our review is to give an answer to questions usually coming from various specialists who collaborate with the oncologists in treating these patients and furthermore to try and find some basic guidelines which can be used in the information of the patients regarding previous experience in this field. The problem of a pregnancy after treatment for breast cancer is also analyzed, as this aspect is an emerging issue in clinical oncology. The decision should be evaluated for each single patient, taking into account the prognosis of the patient and her desire of pregnancy.     

Successful Completion of Pregnancy in a Patient With Chronic Myeloid Leukemia Without Active Intervention: A Case Report and Review of the Literature

The management of patients with chronic myeloid leukemia (CML) during pregnancy is a matter of continued debate. We present a 21-year-old woman in whom CML was diagnosed during early pregnancy. Because the patient was asymptomatic and desired to carry the pregnancy to term while minimizing fetal exposure to medication, she was observed with no therapy for the duration of her pregnancy. The white blood cell count showed a slow downward trend throughout her pregnancy. She delivered a healthy baby and breast fed for a time before initiating therapy for CML. We reviewed the published case reports of women who had a pregnancy occur in the setting of treatment with imatinib. Given the adverse effects of fetal exposure to imatinib as treatment for the mother with CML, close observation might be an option for selected patients who are diagnosed with CML while pregnant and who have minimal clinical manifestations of CML.     

Breast cancer and pregnancy.

BACKGROUND: The management of women who have breast cancers diagnosed whilst they are pregnant is challenging. The aim is to give optimal treatment to the mother to maximise the chances of survival, whilst minimising the risks of harm to the fetus. However, few breast surgeons or oncologists develop expertise in this area owing to the rarity of the association. DESIGN: In this review we evaluate and summarise the current literature regarding the diagnosis, management and prognosis of pregnancy-associated breast cancer. Data were identified by searches of Medline, PubMed and references from relevant articles for the period from 1966 to 2004. Papers were selected based on their size and adequacy of design. RESULTS: There is a lack of controlled data concerning the management of pregnancy-associated breast cancer. The data available suggest that diagnosis and surgery may be carried out as for the non-pregnant patient, with some limitations on staging investigations. Radiotherapy is contraindicated during pregnancy although, in terms of immediate complications, chemotherapy can be used after the first trimester. CONCLUSIONS: Data from prospective databases that are currently recruiting will provide further important information concerning the management of this condition, and in particular the long-term sequelae for mother and fetus.     

Pregnancy after successful cancer treatment: what needs to be considered?

Over the last decade, advances in oncology led to improved treatment results and increasing numbers of long-term cancer survivors. Fulfilling the desire to have children is important for many patients after cancer treatment. Consequently, oncologists, gynecologists and obstetricians are seeing more patients who wish to conceive after treatment. The necessary prerequisites that should be considered when supporting a planned pregnancy after cancer treatment are discussed in this article. The possible consequences of chemotherapy and radiotherapy on the course of pregnancy and the health of the offspring, as well as the interactions between cancer and pregnancy, are reviewed with the focus on childhood cancer, malignant lymphomas, and breast cancer. Despite chemo- or radiotherapy, neither the teratogenic risk nor the risk of adventitious cancers appears to be increased for the offspring of cancer survivors. However, there is a slightly higher risk of miscarriage after chemotherapy. In case of radiation to the uterus, there is a higher risk of premature birth, intrauterine growth retardation, and increased perinatal mortality. The effect is more pronounced after prepubertal radiation than for postpubertal radiation. The former cancer patient's desire to conceive can nevertheless be supported, given that pregnancy and birth are closely monitored.     

Management of breast cancer diagnosed during pregnancy

Opinion statement Breast cancer during pregnancy is generally defined as cancer occurring during pregnancy or within 1 year of delivery, although treatment options are the most complicated when the disease is diagnosed during gestation. The challenges of treatment during gestation are discussed in this article. In general, a pregnant woman with breast cancer should be treated similarly to the nonpregnant patient, with specific recommendations tailored to gestational age at diagnosis, stage of the tumor, and the personal preferences of the patient. Despite the increasing literature focusing on treatment decisions, there are little prospective data regarding treatment or long-term outcome information to provide toxicity data that can be used to advise patients and guide decisions. Most of the retrospective and anecdotal data are based on the possibility of fetal loss or demise with specific treatment or treatment administered at specific times during pregnancy. Therefore, it is impossible to accurately quantify risks to the fetus or the mother, and decisions should be made after careful discussion between the patient, her family, and the medical team. The physician must have a clear understanding of the pharmacology and teratogenic potential of individual agents, thus limiting risks.     

Gynecological cancers and pregnancy: the point of view of the oncology gynecologist

Cervical cancer and nonepithelial ovarian cancer are the most frequent gynecological tumors diagnosed during the pregnancy. The management of patients with a malignant tumor discovered during her pregnancy depends on the type of the tumor, the tumor stage and the term of the pregnancy. In most of cases, a conservative management of the pregnancy could be offered without affect the optimal approach for the treatment of the tumor nor the survival of the patient. But such management needs to be determined in a multidisciplinary staff with oncologists, neonatologists, obstetricians but also the point of view of the patient.     

The pregnant mother with breast cancer: diagnostic and therapeutic management

This review describes the epidemiology, pathology, clinical picture and therapeutic management of pregnant women with breast cancer. In addition, it covers other important issues like the safety of both diagnostic and treatment procedures, the indications for pregnancy termination, the mother and fetal outcome as well as the metastatic potential to the placenta and/or fetus. Several recommendations are also provided.     

Chemotherapy for a patient with advanced non-small-cell lung cancer during pregnancy: a case report and a review of chemotherapy treatment during pregnancy

BACKGROUND: Lung cancer is the most common cause of cancer death in women in the USA. Lung cancer arising during pregnancy is rare and has been reported only 15 times since the 1950s. However, the use of chemotherapy for lung cancer during pregnancy has not previously been reported. METHODS: The history, treatment and outcome of a patient with stage IV non-small-cell lung carcinoma (NSCLC) diagnosed during pregnancy is presented. Previous published reports on lung cancer were retrieved by a literature search of Medline and Cancerlit. RESULTS: A 31-year-old woman was diagnosed as having stage IV NSCLC with bilateral pulmonary involvement when 26 weeks pregnant. Her shortness of breath progressed to dyspnea at rest on 100% inspired oxygen. Therefore, she was treated with systemic chemotherapy using cisplatin and vinorelbine. Despite this treatment, her oxygenation declined further over the next 4 days and thus the baby was delivered via cesarean section after 27 weeks of gestation. Four cycles of vinorelbine and cisplatin have now been administered. Following this treatment, the patient has experienced a significant clinical improvement and no longer requires supplemental oxygen. No chemotherapy-related adverse effects have been noted in the baby. In the 15 previously reported patients with concurrent lung cancer and pregnancy, chemotherapy administration during pregnancy has not been described. CONCLUSIONS: Treatment of lung cancer with chemotherapy during pregnancy should be considered on an individual basis with regard to the stage of the cancer and the maturity of the fetus. To our knowledge, the case presented here is the first report of a woman receiving chemotherapy for lung cancer while pregnant.