Cancers in pregnancy, possible therapies and when to do them

It is not a frequent event, that of a tumor diagnosed during pregnancy: it happens to one pregnant woman every thousand although, as the Italian association of medical oncology (Aiom) reminds us, the incidence is increasing as a consequence of increasing age average at which women have a child. In 40% of all cases it is breast cancer. Next in frequency are cervical cancers, lymphomas, melanomas and thyroid cancers. But, experts point out, it is possible to be treated even during pregnancy. With what therapies and from what month of gestation did we ask Lucia Del Mastro, Full Professor and Director of the Medical Oncology Clinic of the IRCCS Policlinico San Martino Hospital, University of Genoa, among the leading experts in Italy on pregnancy risks and fertility preservation in cancer patients. “The first message to pass on is this: when a tumor is discovered during pregnancy, management must be multidisciplinary and we must therefore turn to expert centers where proven teams operate in the management of these complex cases”, he tells Oncoline Del Mastro . It is in fact a very delicate situation and the options are evaluated together by oncologists, surgeons, neonatologists, anesthetists and other specialists to establish the most suitable strategy together with the patient. Case by case.

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Surgery always, and chemotherapy from the second trimester

“From the point of view of treatments – continues the expert – if the tumor is in an initial stage (not metastatic, ed.) surgery is always possible, at any moment of gestation: whether the pregnancy is at the beginning or advanced does not it makes a difference, because the operation does not compromise the progress of the pregnancy and does not increase the risks for the fetus or complications for the mother”. Radiotherapy, on the other hand, can never be performed. As regards pharmacological therapies, once the first trimester of gestation has passed, it is possible to resort to different types of very effective chemotherapies, without increasing the risk of malformations or cognitive deficits for the fetus: “The data in scientific literature reassure us – continues Del Mastro – They show, in fact, that in pregnant cancer patients undergoing chemotherapy in the second and third trimester of gestation, the risk of malformations for children is the same as that of children born to non-ill women: approximately 3%. Therefore, chemotherapy cannot be given in the first three months, while we are confident in administering it from the fourth month onwards, because we know that in utero exposure to many chemotherapy drugs has no effect on development after this time window, nor does it increase complications for women. Chemotherapy can also be done before surgery, to reduce the size of the tumor. However, it is not possible to use other drugs, such as anti-hormonal drugs, which can have consequences on the development of the genital organs, anti-HER2 drugs which have consequences on amniotic fluid, and immunotherapies, according to the data we currently have.”

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Early induced birth

This is, of course, a general discussion. There are different types of breast cancer and each case – as mentioned – must be evaluated individually. If, for example, the tumor is diagnosed at the beginning of pregnancy and requires immediate treatment – as may be the case with aggressive triple negative breast cancer – the possibility of abortion is also taken into consideration, because between the surgery removal of the tumor and the start of drug therapy would take too long and this delay can have consequences on the prognosis, explains the expert. All these decisions are always made together with the patient, who can take this risk if she wants. But in any case she-she reiterates she-she it is not necessary to wait until you have given birth to start chemotherapy. Patients with mutations in the BRCA genes are treated no differently than those without mutations. When a metastatic tumor is diagnosed, however, any other treatments are postponed until after the birth.

Delivery that can be anticipated. “In our center – concludes del Mastro – we wait until the 35th week of pregnancy, because before the 34th the risks for the development of the brain and, therefore, cognitive deficits increase. Pharmacological therapies can then be resumed, or started, after a few days.”