PREGNANCY AFTER CANCER TREATMENT BY FIGO

 Introduction

There has been a rise in the incidence of cancer in reproductive-age men and women. This could be attributed to a rise in obesity and more exposure to various carcinogens. Approximately two million reproductive-age women between the ages of 15 to 49 years are diagnosed with cancer annually.  In 2022, the most common cancer types encountered were breast (32.8%), thyroid (15.1%), uterine cervical (12.5%), ovarian (4.4%), colorectal (4.3%), and lung (3.1%). The most common cancer types reported in pediatric populations include leukemia (53%), central nervous system tumors (22%), and neuroblastoma (9%). Cancer treatments include surgery, chemotherapy, and radiotherapy;  there are emerging therapies such as immunotherapy as well.  Cancer and its treatment profoundly affect fertility, resulting in significantly reduced pregnancy rates among survivors. Garg et al. reported that only 17.4% of cancer survivors had at least one subsequent live birth compared with 21.7% of age- matched controls, with an incidence rate ratio (IRR) of 0.69 across all cancer types. 

preconception

It is the natural desire of many women who have completed their cancer treatment to experience motherhood. Many factors need to be discussed to make this journey as safe as possible for the mother and the fetus. It is important to ensure that the women are in remission for 1 to 2 years. They should be provided with a reliable and safe contraceptive during this time. Women should be aware of the increased risk of cancer recurrence when stopping treatments such as tamoxifen in estrogen receptor-positive cancers before pregnancy. 

Women should be screened for mental health problems after going through the trauma and anxiety in the process of cancer treatment, and living with the pressure of possible cancer recurrence in the future. Women who have undergone adjuvant chemotherapy should be aware of the toxicity of these agents on their vital organs such as the liver, kidney, or heart. And the relevant checks need to be done in the preconception period. 

pregnancy and post-partum

Pregnant women with a history of cancer treatment should be managed in a consultant-led unit with maternal and fetal specialists. Screening for pre-eclampsia, aneuploidy, and gestational diabetes should be carried out on women. It is recommended to prescribe aspirin to reduce the risk. Serial fetal surveillance should be offered in the third trimester. Studies show that women with a history of cancer or previous pelvic surgery are at increased risk of caesarean delivery, but no increased risk of assisted delivery. In women with BRCA 1 or BRCA 2 mutations who have completed their families and are undergoing a caesarean section, a bilateral salpingo-oophorectomy can be offered to reduce their lifetime cancer risk. 

The history of cancer treatment in the post-partum period does not require the addition of LMWH, unless there is active malignancy or other factors that increase the thrombo-embolic risk. The oncology follow-up of women in the postpartum period is similar to that of non-pregnant patients. Adjuvant hormone therapy such as tamoxifen may be resumed 2 weeks after delivery, and breastfeeding will be contraindicated in this setting. 

Conclusion 

Obtain a detailed history of a past cancer diagnosis, associated treatments, and complications of treatment. Where possible, obtain appropriate screening for common complications such as cardiac, pulmonary, renal, hepatic, and endocrine toxicities. Screening may include cardiac auscultation, electrocardiogram, and lung function testing such as spirometry. If there are concerns for potential cancer- related cardiac dysfunction, such as cardiomyopathy, it is advisable to obtain assessment by an obstetric physician or obstetrical provider with appropriate expertise.  If possible, advise patients to wait 1–2 years after completing their cancer treatment before becoming pregnant.  Provide advice on nutrition, folic acid supplementation, and a healthy lifestyle for pregnancy and for the long term after pregnancy. Support breastfeeding in women without contraindications. Begin low- dose aspirin prophylaxis for patients at risk for gestational hypertension. 

THE GRAPES OF WRATH

 I am visiting South Africa with my daughter and staying with the in-laws. It's alright, but there is no unlimited wifi in Granny’s house. Johannesburg is a big cosmopolitan city, every suburb is kilometers from another one, and having a car makes getting around pretty easy. I went to visit my friend who teaches in a high school nearby. I visited her and asked if she had any books for me to read to kill time. I picked two books, one of which was a book by an author named John Steinbeck. It looked quite worn out and old, and I assumed it was perhaps written by one of the local South African authors. 

It had been over a decade since I read a big fiction novel. The story takes place in the United States in the 1930s. I found the book extremely descriptive. The first hundred pages describe the situation of the Joad family on their farm and home. Tom Joad, who had served in prison, is released, and he comes to his hometown and finds that his family is forced to leave their home and their land, due to poor weather conditions. It showed the feeling of loss, uncertainty, sorrow, and hope for the future. Tom Joad later becomes a favourite character in the story.

I loved how the story described their situation and the road trip to California. They had hopes and dreams to find a better home and better jobs. They meet several different people on their road trip. And it all describes the situation in the States with other people struggling to make a living. They finally reach California, and their expectations are shattered. It was shocking to see how the family struggled to find work, and how difficult it was for Ma Joad to buy bread, coffee, or sugar and put food on the table every day. Ma Joad's role became more prominent once the family settled in California, and struggled day to day. 

Throughout the book, the Joad family and thousands of other Dust Bowl refugees face systemic cruelty in California. They are starved, underpaid, and treated with hostility by powerful landowners who want to keep wages low.

Steinbeck uses the metaphor of grapes growing heavy and fermenting to describe how individual misery transforms into a powerful, collective rage. In Chapter 25, he explicitly lays out this imagery:

"...and in the eyes of the people there is the failure; and in the eyes of the hungry there is a growing wrath. In the souls of the people the grapes of wrath are filling and growing heavy, growing heavy for the vintage."

At its core, the book is powered by its characters—particularly the resilient Ma Joad and the volatile, evolving Tom Joad. Through their eyes, Steinbeck transforms a massive historical crisis into an intimate family tragedy. The Joad's lose their home, their dignity, and family members along the way, yet they refuse to lose their humanity. It is significant how in the most difficult times the migrant families help each other. 

Steinbeck brilliantly alternates between descriptive chapters of the Joad's' specific journey and broader, journalistic chapters that describe the forces at play: corporate greed, the banking system, and the collective plight of thousands of displaced. 

What makes the book truly unforgettable is its transition from despair to defiance. The "wrath" of the title isn't just destructive anger; it is a righteous, unifying force. Steinbeck argues that when individuals look past their own survival and realize they are part of a larger human collective, they become impossible to defeat. This book really touched me, in one of the vulnerable stages of my life, and I am glad I came across this beautiful piece of literature. 

THE BUCKET LIST

 When I was a little girl, I used to look at my mother’s miserable life and think to myself that I would do better when I grew up. She had a hard time raising us with my dad being constantly overseas. Money was always scarce, and everything was a mission, from school pick-ups to homework. Every now and then, her in-laws would visit from another province and add to her misery and exhaustion. She was not loved or cared for; she did not have much autonomy. I don't remember her being able to spoil herself. She became more and more overweight, antisocial, and depressed. I am hoping I will be able to keep my sanity at this point in my life, keep going, and be a hot and confident mama for my little daughter.  I have been reading a lot of books and watching a lot of movies. I came across a movie called The Bucket List starring Morgan Freeman and Jack Nicholson. Just watching these great actors having a conversation on screen is the most amazing thing ever. They are diagnosed with advanced cancer and are exploring their end-of-life options. Jack Nicholson is the rich guy with the terrible attitude and the money, organizing a lot of travelling and great experiences. Morgan helps him get in touch with his inner soul and become a better human. 

I have summarised their adventures below:

• Witness something truly majestic: They try to accomplish this by visiting the Himalayas, but the view is completely blocked by a heavy storm. Later, Edward realizes a different kind of majesty at the end of the film.

• Help a complete stranger for a common good: This was one of Carter’s deeply personal goals.

• Laugh until I cry: They achieve this in a hilarious, light-hearted hospital scene later in the movie when Carter explains the incredibly bizarre (and disgusting) truth about Edward’s beloved, ultra-expensive "Kopi Luwak" coffee beans.

• Drive a Shelby Mustang: They rent out a racetrack and aggressively drag-race vintage sports cars.

• Skydive: This is the very first thing they do after leaving the hospital, featuring a terrified Carter and a thrilled Edward jumping out of an airplane.

• Kiss the most beautiful girl in the world: Edward originally scoffs at this, assuming it means a supermodel. At the end of the film, after reconciling with his estranged daughter, he hugs his young granddaughter and kisses her on the cheek, finally crossing it off.

• Go to the Pyramids/See the Great Sphinx: They sit on top of the Pyramids of Giza, discussing life, faith, and Egyptian myths about the afterlife.

Additional Global Milestones (Seen in the Travel Montage)

While they don't read every item aloud, their journey across the globe checks off several massive travel goals:

• Go on an African Safari (Shot in Tanzania)

• Ride a motorcycle on the Great Wall of China

• Visit the Taj Mahal in India

• Dine at Chevre d'Or in France

This movie really got me thinking about my life and my priorities. What are the things I genuinely want to do? It would have been easier if I could have made friends with someone like Jack Nicholson, who would have funded my dreams and ambitions. Perhaps it would be easier to think about your bucket list when you have stage four cancer, and you do not need to save for retirement or leave money for your kids.  We are focusing on the smaller check goals and then to bigger long term goals in this bucket list. 

1. Blasting on eating out with family in a sit-down restaurant!

2. Buy my little girl a bicycle, I hope she plays with it, and does not disappoint me

3. Send my review article for publication to that stupid and expensive journal

4.  Book and travel to whatever conference I want to 

5. Have a spa day and a whole-body massage

6. Go and visit my home country if the political situation allows. I cannot think about any other travel destination until I make it home, eat at a fancy local restaurant…go to grandma’s house where I was born and raised…and go through all my sentimental items. 

7. Have a Mamma Mia, ABBA theme birthday party, with a live band playing! full of dancing, singing, laughter, and fun.