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.