1. CANCER AND PREGNANCY: CONCERNS, CARE, AND CAVEATS Bradley J. Monk, MD, FACS, FACOG Professor and Director Division of Gynecologic Oncology Department of Obstetrics and Gynecology Creighton University School of Medicine at St. Joseph’s Hospital and Medical Center, a Member of Catholic Healthcare West Phoenix, Arizona USA bradley.monk@chw.edu

2. Cancer in Pregnancy No American Society of Clinical Oncology (ASCO) cancer treatment guidelines in pregnancy ASCO Recommendations on Fertility Preservation in People Treated for Cancer. J Clin Oncol, Vol 24, No 18 (June 20), 2006: pp. 2917-2931 Cancer, fertility and pregnancy: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Pentheroudakis G, Orecchia R, Hoekstra HJ, Pavlidis N; ESMO Guidelines Working Group. Ann Oncol. 2010 May;21 Suppl 5:v266-73. National Comprehensive Cancer Network (NCCN) only has guidelines for breast cancer

3. Importance of Multidisciplinary Team Obstetrician / Perinatologist Neonatologist Surgeon Radiation Oncologist Medical Oncologist Social work Genetic Counselor Clergy Ethicist Other

4. Incidence by Age of the More Common Malignancies Seen in Pregnancy American Cancer Society, Facts and Figures, 1995

5. Incidence of Tumor Types in Pregnant Women Cancer, fertility and pregnancy: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Pentheroudakis G, Orecchia R, Hoekstra HJ, Pavlidis N; ESMO Guidelines Working Group. Ann Oncol. 2010 May;21 Suppl 5:v266-73.

6. Oncologic Issues Timing of therapy Type of therapy Maternal effects of therapy Maternal outcomes Berman, DiSaia & Tewari. Ch 58, Maternal-Fetal Medicine, 5th Ed, Creasy & Resnik (eds), 2004

7. Obstetrical Issues Fetal effects of therapy Antepartum fetal surveillance Corticosteroid use Amniocentesis Timing of delivery Route of delivery Berman, DiSaia & Tewari. Ch 58, Maternal-Fetal Medicine, 5th Ed, Creasy & Resnik (eds), 2004

8. Ethical, Religious, Legal Scioeconomic & Issues Pregnancy termination Fetal advocate Fetal viability Maternal risk / future fertility Health-care costs & expenditure Right to autonomy Mother ’ s overall prognosis Berman, DiSaia & Tewari. Ch 58, Maternal-Fetal Medicine, 5th Ed, Creasy & Resnik (eds), 2004

9. Crucial Periods in Prenatal Development Moore P (ed). The Developing Human, 6 th Ed, 1998

10. Gestational Age and Effects of Antineoplastic Therapy Cancer, fertility and pregnancy: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Pentheroudakis G, Orecchia R, Hoekstra HJ, Pavlidis N; ESMO Guidelines Working Group. Ann Oncol. 2010 May;21 Suppl 5:v266-73.

11. Incidence of Abnormalities and of Prenatal & Neonatal Death in Mice given 200 cGy Radiation Tewari Ch 16, Clinical Gynecologic Oncology, 7th Ed, DiSaia & Creasman (eds) 2007

12. Surgical Considerations in Pregnancy 18-22 wks’ EGA Check amniotic fluid volume & document FHTs pre-operatively Indocin per rectum pre and postoperative Midline incisionTilt table left side down to move gravid uterus off the IVC “Hands off uterus” Document FHTs in PACU Tocodynometer x 2-3 days DVT prophylaxis Berman, DiSaia & Tewari. Ch 58, Maternal-Fetal Medicine, 5th Ed, Creasy & Resnik (eds), 2004

13. Drug Safety Categories in Pregnancy ASafety established using human studies BPresumed safety based on animal studies CUncertain safety; no human studies; animal studies show adverse effect DUnsafe; evidence of risk that may in certain clinical circumstances be justifiable XHighly unsafe

14. Cytotoxic Chemotherapy and Hormonal Therapy in Pregnancy Cancer, fertility and pregnancy: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Pentheroudakis G, Orecchia R, Hoekstra HJ, Pavlidis N; ESMO Guidelines Working Group. Ann Oncol. 2010 May;21 Suppl 5:v266-73.

15. Effects & Risks after Exposure to Ionizing Radiation in Utero Tewari Ch 16, Clinical Gynecologic Oncology, 7th Ed, DiSaia & Creasman (eds) 2007

16. SERUM TUMOR MARKERS Pregnant & Non-Pregnant Patients Tewari Ch 16, Clinical Gynecologic Oncology, 7th Ed, DiSaia & Creasman (eds) 2007

17. Background: Pregnancy Associated Breast Cancer (PABC) = Diagnosis during pregnancy or the first postpartum year The most common cancer in pregnant/ postpartum women Occurs in about 1/3000 pregnancies Average age at the time of diagnosis: 32- 38 years NCI: www.cancer.gov 2011www.cancer.gov

18. Background: PABC Delay in Diagnosis Delay of diagnosis up to 5-15 mo after the onset of symptoms. Patients present more often at an advanced stage than in non-pregnant, age-matched population. Why? Physiologic changes of the pregnant/lactating breast may hinder diagnosis Physician reluctance to perform biopsy antepartum NCI: www.cancer.gov 2011www.cancer.gov Clark et al. Clin Oncol. 1989

19. Background: PABC PABC has been associated with a poor prognosis Most recent data show women with PABC have same survival stage for stage as non- pregnant women with breast cancer Kelcher et al 2001

20. Rodriguez et al 2008 Patients identified through the California Cancer Registry (1991-1999) 797 pregnant women compared with 4,177 age- matched non-pregnant controls PABC with higher death rate (39.2% compared with 33.4% P=.002) When controlled for stage, size of tumor, hormone receptor status, age, race, type of surgery, survival is moderately worse in PABC (P=.046) Obstet Gynecol. 2008 Jul;112(1):71-8.

21. Cardonick et al 2010 Voluntary National Registry 130 patients diagnosed with breast cancer and followed prospectively. Women diagnosed with PABC can receive treatment comparable to non-pregnant women Leads to similar survival when matched for stage at diagnosis Cancer J. 2010 Jan-Feb;16(1):76-82.

23. Thank You Bradley.monk@chw.edu