Navigating the Complexities of Cancer Treatment During Pregnancy
When it comes to addressing cancer in pregnant patients, a new guideline from the American Society of Clinical Oncology (ASCO) emphasizes the intricate balance between the mother's health and the welfare of her unborn child. This guidance, recently published in the Journal of Clinical Oncology, dives into several critical issues surrounding this sensitive topic.
Dr. Mikkael A. Sekeres, a co-author of the guidelines and the head of the Division of Hematology at the Sylvester Comprehensive Cancer Center in Miami, shared with Oncology News Central (ONC) that “a cancer diagnosis occurs in approximately one in every 1,000 to 2,000 pregnancies.” While such cases are relatively rare, the implications—both medically and psychologically—are profound, necessitating a thorough consideration of both the mother’s and fetus’s needs. He stressed the importance of engaging in shared decision-making with pregnant patients facing cancer, taking into account factors like the cancer's aggressiveness, the potential risks associated with diagnosis and imaging, effective treatment options, and most importantly, aligning with the patient's personal goals.
The evidence-based guidelines focus on vital clinical inquiries concerning the recommended diagnostic procedures, management strategies for both new and recurring cancers, and special considerations for obstetrical care that go beyond typical pregnancy protocols.
It's noteworthy that much of the evidence that informs these recommendations is considered low quality. It largely stems from retrospective observational studies, case series, and individual case reports. However, the authors argue that the resulting recommendations are still highly valuable—they provide essential real-world insights that can steer clinical practice.
According to Dr. Ann H. Partridge, another co-author and the director of the Adult Survivorship Program at Dana-Farber Cancer Institute in Boston, three key factors must be weighed when balancing patient care and fetal safety: 1) understanding the patient's preferences regarding the continuation of the pregnancy, along with the medical and social options available; 2) evaluating the risks posed by the disease and its treatment; and 3) assessing the potential impacts on the fetus if the patient does not receive optimal therapy and exploring possible adjustments to treatment to protect the fetus without compromising the mother's care.
Dr. Partridge also emphasized the importance of transparency. "It is crucial to be candid about what we know and what remains uncertain regarding both data and individual cases," she added.
A significant recommendation from the guideline is that pregnant patients diagnosed with cancer should receive care from a multidisciplinary team. This includes pharmacists who frequently collaborate to tailor treatment plans based on the patient's current health status and response to therapies. Clinicians from various specialties should ensure that patients and their families are well-informed and involved in the consent process before commencing or continuing any treatment regimen.
Moreover, the panelists highlighted that patient autonomy and personal preferences must be prioritized, acknowledging that cancer may create situations requiring immediate therapeutic intervention. In emergencies, the termination of pregnancy might be necessary to safeguard the life of the pregnant patient or to reduce the risk of fatality.
The guideline also provides comprehensive insights on diagnostic evaluations, including imaging techniques, biopsy options, minimally invasive procedures, survivability outcomes, and systemic therapies.
One of the more contentious aspects of managing pregnant cancer patients involves the use of drugs whose teratogenic effects are unknown. Dr. Sekeres pointed out that the recommendations for diagnosis and oncologic as well as obstetric management primarily rely on retrospective observational data, which, while offering important insights into this unique and complex patient population, come with limitations such as potential biases, small sample sizes, and variations in study groups and treatment methods.
He noted that newer treatments often exclude pregnant individuals from trials leading to drug approval, which complicates treatment decisions. "As a result, we frequently find ourselves postponing the use of these therapies until after delivery or opting for alternatives where some data is available," Dr. Sekeres explained.
When discussing whether the teratogenic risks associated with newer therapies, such as bispecific agents or antibody-drug conjugates, are clearly understood, Dr. Partridge candidly responded, "No, these risks remain poorly defined, though biologically plausible concerns exist, making this a challenging area to study."
In his role as an associate editor for the Journal of Clinical Oncology, Dr. Sekkeres was recused from any involvement in the peer review of this particular manuscript. He disclosed consulting or advisory roles with various pharmaceutical companies and noted institutional research funding from others. Dr. Partridge also mentioned receiving royalties related to her authorship with UpToDate.
