Gestational cancer refers to a malignant diagnosis that is made during pregnancy, and has an estimated occurrence of 1 in 1000 pregnancies . Common cancers in pregnancy include breast, cervical, ovarian, hematologic cancer and melanoma . Diagnosing malignancy in pregnancy is often challenging, considering that constitutional symptoms are often misattributed to physiologic symptoms of pregnancy . The management of cancer in pregnancy is complex and takes into account both maternal and fetal impact. Risks and benefits regarding chemotherapy, radiation therapy, surgery and early delivery must all be considered . A multidisciplinary approach is recommended to help patients navigate through difficult decision making in gestational cancer.
Chemotherapy is the mainstay treatment for many malignant conditions. The fetal implications of chemotherapeutic agents vary with trimester [3-5]. Exposure to chemotherapy in the first trimester significantly increases the risk for spontaneous abortion and for developing malformation in surviving pregnancies. Given the high teratogenic potential during organogenesis, most recommend avoidance of chemotherapy during the first 13 weeks of gestation [3-5]. Administration of chemotherapy during the second and third trimester is considered an acceptable approach, with the most common fetal risks including fetal growth restriction, preterm prelabor rupture of membranes, preterm contractions and preterm delivery . Long term implications of antenatal chemotherapy in the second and third trimester are not well elucidated, though existing data has reassuringly not demonstrated significant neurodevelopmental impact . Pelvic radiation therapy unavoidably results in intrauterine fetal demise and decreases the likelihood of future fertility, whereas non-pelvic radiation therapy has promising pregnancy outcomes . When treatment for gestational cancer requires surgery, the optimal timing of surgical intervention is early in the second trimester, when the risk for pregnancy loss is low and the uterine size does not yet compromise intraabdominal access [6,8-11]. A minimally invasive approach is preferred over an open laparotomy, though is not without risk. While laparoscopy allows for shorter operating times and fewer adverse fetal effects, risks of laparoscopy during pregnancy include uterine perforation, hypercapnia and uterine hypoperfusion [6,12].
Given the complexity of pregnancy complicated by an oncologic diagnosis, multidisciplinary models have been proposed to help facilitate care amongst different subspecialists. While national guidelines have proposed termination of pregnancy as an option in the individualized care of gestational cancer patients, the involvement of family planning specialists has not been standardized . In fact, there is a paucity of published data regarding termination of pregnancy in the setting of gestational cancer.
We recently published a manuscript detailing the diagnosis and management of a high risk Gastrointestinal Stromal Tumor (GIST) in a pregnant patient at our institution, who presented with an abdominal mass in the first trimester . Surgical excision confirmed stage IIIb small intestinal GIST, and genetic testing of the tumor indicated benefit from adjuvant chemotherapy with Imatinib. Forgoing treatment placed the patient’s probability of two year recurrence free survival at 1%. “The timing of our patient's diagnosis contributed to the complexity of its management: the benefit of Imatinib in a patient with a high risk for tumor recurrence had to be weighed against the risk of Imatinib initiation in the first trimester of a desired pregnancy” . The comprehensive care team included providers from maternal fetal medicine, gynecologic oncology, surgical oncology, and complex family planning. The collaborating subspecialists were able to offer truly comprehensive options counseling, and the patient ultimately elected to undergo a dilation and evacuation at 19 weeks gestation. Our experience with a pregnancy complicated by high grade disease highlighted the importance of providing gestational cancer patients with abortion access.
The recent overturn of federal protections on abortion access has impacted reproductive rights in the United States [14-16]. Many states have adopted restrictions on termination of pregnancy care, increasing the access to abortion gap across the country . The political climate change has affected the autonomy of millions, including those afflicted by gestational cancer . The hindrance of necessary medical care to this patient cohort is discongruent with national medical guidelines. Many Americans now have to decide between optimizing their prognosis at the expense of teratogenic effects of chemoradiation therapy and delaying their necessary treatment so as to avoid fetal complications. Traveling to states with more liberal abortion policies is a marginalizing option, as it disproportionately excludes those without the financial means to afford travel expenses. With fewer locations offering termination of pregnancy, providers are overwhelmed by increasing patient load, resulting in longer wait times for procedure completion; this in turn poses undo risk related to terminations performed at later gestational ages.
While inequitable access to health care precludes optimal standardization of care in gestational cancer, efforts should be channeled towards integrating complex family planning into multidisciplinary care teams. Offering termination of pregnancy as a part of the plan of care discussion empowers gestational cancer patients to make a truly informed decision.