Malignant melanoma in pregnancy. A population-based evaluation

BACKGROUND

For many years, there has been controversy in the medical community regarding the correlation of female hormonal factors with the outcome of women with malignant melanoma. There have been multiple reports that women with high hormone states, such as pregnancy, had thicker tumors and/or a worse prognosis compared with a group of control women.

METHODS

The authors used a database that contained maternal and neonatal discharge records from the entire state of California from 1991 to 1999 and linked those records to the California Cancer Registry, which maintains legally mandated records of all cancers reported in California during the same time period. Four hundred twelve women with malignant melanoma diagnosed during or within 1 year after pregnancy were identified (145 antepartum, 4 at delivery, and 263 postpartum) and were compared with a group of age-matched, nonpregnant women with melanoma (controls). The database captured only pregnancies at > or = 20 weeks of gestation.

RESULTS

When comparing women who had pregnancy-associated melanoma with the control group, the authors found no difference in the distribution of disease stage (82.0% of pregnant and postpartum women had localized melanoma vs. 81.9% of control women) or the tumor thickness (mean: 0.77 mm for pregnant women, 0.90 mm for postpartum women, and 0.81 mm for the control group). In a multiple regression model that controlled for age, race, stage, and tumor thickness, pregnancy had no impact on survival in women with melanoma. Lymph node assessment and positivity of lymph nodes also were equivalent between the two groups. Maternal and neonatal outcomes did not differ between pregnant women with melanoma and control women who were pregnant and had no history of malignancy. Small numbers of women with advanced melanoma and the inability to capture melanoma that occurred in pregnancies that were lost or were terminated prior to 20 weeks limited the conclusions primarily to women with localized melanoma.

CONCLUSIONS

In this large, population-based study of pregnant women in California from 1991 to 1999 with malignant melanoma, there were no data found to support a more advanced stage, thicker tumors, increased metastases to lymph nodes, or a worsened survival. The outcome for women with localized melanoma associated with pregnancy was excellent. Maternal and neonatal outcomes also were equivalent to those of pregnant women without melanoma.

Effect of pregnancy on survival in women with cutaneous malignant melanoma

PURPOSE

An adverse influence of pregnancy on the risk of death in women with cutaneous melanoma was suggested historically by anecdotal reports. Previous studies included small numbers of women observed for short periods.

METHODS

Using data from the Swedish National and Regional Registries, we performed a retrospective cohort study of all Swedish women who were diagnosed with cutaneous melanoma during their reproductive period, from January 1, 1958, to December 31, 1999. The relationship between pregnancy status at the diagnosis of melanoma and overall survival was examined in multivariable proportional-hazards models.

RESULTS

The cohort comprised 185 women (3.3%) diagnosed with melanoma during pregnancy and 5,348 (96.7%) women of the same childbearing age diagnosed with melanoma while not pregnant. There was no statistically significant difference in overall survival between pregnant and nonpregnant groups (log-rank chi(2)1[r] = 0.84, P = .361). Pregnancy status at the time of diagnosis of melanoma was not related to survival in a multivariable Cox model in the 2,101 women (hazard ratio for death in the pregnant group was 1.08; 95% CI, 0.60 to 1.93). In the multivariable analysis, pregnancy status after diagnosis of melanoma was not a significant predictor of survival (hazard ratio for death in women who had pregnancy subsequent to the diagnosis of melanoma was 0.58; 95% CI, 0.32 to 1.05).

CONCLUSION

The survival of pregnant women with melanoma is not worse than the survival of nonpregnant women with melanoma. Pregnancy subsequent to the diagnosis of primary melanoma was not associated with an increased risk of death.

Pregnancy outcome in non-gynecologic cancer

OBJECTIVE

The objective was to determine the prevalence of non-gynecologic cancer in pregnancy and its maternal and fetal outcome in a single tertiary center in the Eastern Province of Saudi Arabia.

METHOD

Retrospective chart review was done of 54 patients with a diagnosis of non-gynecologic cancer in pregnancy at Dhahran Health Center from January 1990 to December 2001 using the Dhahran Health Information database. Maternal and fetal outcome were determined for 17 women with active cancer during pregnancy (Group I, 18 pregnancies) and for 44 women in cancer remission (Group II, 96 pregnancies). Seven women were pregnant during active cancer and during cancer remission.

RESULTS

There were 114 pregnancies in 54 women with cancer. The prevalence in pregnancy was 1.5:1,000 (54 cancer in 70,987 pregnancies). Thyroid (33) and breast (11) cancer accounted for 75% of all cancer. Induced abortion, spontaneous abortion, stillbirth and low birth weights in Group I were: 5 (28%), 0 (0%), 1 (6%) and 2 (11%), respectively, and in Group II were: 1 (1%), 11 (11%), 0 (0%) and 3 (3%), respectively. Live births for Group I, II and all patients with cancer were 12 (66.7%), 84 (87.5%) and 96 (84.2%), respectively, with p =0.025 There were three maternity deaths among 17 women in Group I. None of 44 women in Group II died.

CONCLUSION

The diagnosis of active cancer in pregnancy carries a significant increase in perinatal and maternal mortality. However, pregnancy during cancer in remission has favorable outcome, pregnancy in this group should not be discouraged.

Prognostic influence of pregnancy before, around, and after diagnosis of breast cancer

A woman's risk of developing breast cancer is closely related to reproductive factors. Whereas the etiological importance of reproductive factors is well described, less is known about the prognostic influence of these factors. The prognostic effect of childbearing before, around, and after diagnosis is reviewed based on the literature and on studies from Danish Breast Cancer Cooperative Group, DBCG. In women with breast cancer overall number of childbirths is found to be without prognostic importance. Women with early primary childbirth seem to have an inferior prognosis compared to women who postpone childbearing. It is generally accepted that early first childbirth is associated with reduced risk of developing breast cancer. Thus, it is proposed that women who develop breast cancer despite an early first delivery represent a selected group of patients with particularly aggressive disease. Women diagnosed with breast cancer during pregnancy often present with advanced disease, but pregnancy at time of diagnosis does not seem to be an independent prognostic factor. However, women diagnosed with breast cancer in the first years after childbirth have a significantly reduced survival. It is assumed that these women, due to the physiological changes during pregnancy, experience growth induction of the tumours during the preclinical stage. In contrast, there is no evidence that pregnancy after breast cancer treatment has a negative influence on prognosis.

Worse survival in breast cancer among women with recent childbirth: results from a Swedish population-based register study

This study was designed to investigate how time since childbirth affects breast cancer survival using unselected population-based data linking data from the Swedish Cancer Registry, fertility register, and population census registers. A total of 14,693 parous women < or =45 years of age with breast cancer were identified. Information on deaths was collected, and 5- and 10-year survival rates were calculated according to time since most recent childbirth. Mortality during the first 10 years of follow-up was further investigated in a Cox analysis, with adjustments for age at diagnosis, time period during which the diagnosis was made, number of children, and age at the time of the first child's birth. Women with diagnosis during pregnancy had a 5-year survival rate of 52.1% (95% CI, 41.2%-61.9%) and a 10-year survival rate of 43.9% (95% CI, 33.1%-54.2%), compared with survival rates of 80.0% (95% CI, 79.6%-81.4%) and 68.6% (95% CI, 67.5%-69.7%), respectively, in women diagnosed >10 years since childbirth. In the multivariate model, we found that time since childbirth was associated with inferior survival rates in cases of diagnosis <8 years after childbirth, in which the lowest survival rates were seen in women with diagnosis during pregnancy in the first 5 years of follow-up (adjusted relative risk compared with women with >10 years since last childbirth, 2.6; 95% CI, 1.8-3.4). The adjusted hazard ratios could be described by a decreasing function of a logarithmic transformation of years since childbirth. We found that the time of follow-up was of importance, in that women with a recent pregnancy had particularly lower survival rates during the first 5 years after diagnosis. The mechanisms behind the poor survival in breast cancer for women with recent childbirth are not known, but we suggest that one explanation might be a lower proportion of hormone receptor-positive tumors.

Pregnancy-associated mortality after birth, spontaneous abortion, or induced abortion in Finland, 1987-2000

OBJECTIVE

To test the hypothesis that pregnant and recently pregnant women enjoy a "healthy pregnant women effect," we compared the all natural cause mortality rates for women who were pregnant or within 1 year of pregnancy termination with all other women of reproductive age.

STUDY DESIGN

This is a population-based, retrospective cohort study from Finland for a 14-year period, 1987 to 2000. Information on all deaths of women aged 15 to 49 years in Finland (n=15,823) was received from the Cause-of-Death Register and linked to the Medical Birth Register (n=865,988 live births and stillbirths), the Register on Induced Abortions (n=156,789 induced abortions), and the Hospital Discharge Register (n=118,490 spontaneous abortions) to identify pregnancy-associated deaths (n=419).

RESULTS

The age-adjusted mortality rate for women during pregnancy and within 1 year of pregnancy termination was 36.7 deaths per 100,000 pregnancies, which was significantly lower than the mortality rate among nonpregnant women, 57.0 per 100,000 person-years (relative risk [RR] 0.64, 95% CI 0.58-0.71). The mortality was lower after a birth (28.2/100,000) than after a spontaneous (51.9/100,000) or induced abortion (83.1/100,000). We observed a significant increase in the risk of death from cerebrovascular diseases after delivery among women aged 15 to 24 years (RR 4.08, 95% CI 1.58-10.55).

CONCLUSION

Our study supports the healthy pregnant woman effect for all pregnancies, including those not ending in births.

Case control study of novel prognostic markers and disease outcome in pregnancy/lactation-associated breast carcinoma

A case control study of pregnancy/lactation associated breast carcinoma (PAC) was conducted on 24 test cases with two controls per case, matching age, tumor grade, tumor size and axillary lymph nodes status. During seven years of this study, 6% of all patients with breast cancer had PAC. In this study, 67% of the test cases showed positive axillary lymph nodes compared to 49% in our series of 315 cases of non-pregnancy/non-lactating women with breast carcinoma (p < 0.05). The expression of nine prognostic markers, i.e. ER, PR, p53, C-erbB-2, EGFR, Cathepsin-D, PCNA, DNA ploidy and S-phase fraction, were studied by immunohistochemistry and flow cytometry. Hormone receptor status showed a statistically significant difference between the two groups, i.e. 29% immunoreactivity in test cases compared to 58% in controls with a p value of 0.007. Among p53, C-erbB-2, EGFR and Cathepsin-D in the test group, only EGFR showed a significant correlation, i.e. 33% immunoreactivity in test cases and 19% immunoreactivity in controls (p < 0.05). Higher PCNA positivity was seen in the test group compared to controls, i.e. 35% in test patients and 28% in controls (p < 0.05). Metastasis to bone and liver was a common feature of test patients as compared to controls (p < 0.05). After a median follow-up of 72 months, there was no significant difference in the overall survival (OS) of test cases and controls as 54% deaths were recorded in test patients and 44% in controls at the end of this study (p > 0.05). In summary, in spite of some significant differences in the expression of few prognostic markers, i.e. ER/PR, EGFR, PCNA and metastatic potential, there was no significant difference in the OS of PAC vs. control group if compared stage for stage.

Childbearing and survival after breast carcinoma in young women

BACKGROUND

Many young patients with breast carcinoma have not started, or completed, their desired families. How childbearing after a diagnosis of breast carcinoma affects survival is of importance to these women and their families. The authors measured relative mortality among young patients with breast carcinoma with and without births occurring after diagnosis.

METHODS

The authors conducted a cohort study using data from three population-based cancer registries in the U.S. (Seattle, Detroit, and Los Angeles), linked to birth certificate data in each state. Four hundred thirty-eight women younger than 45 years of age with primary invasive breast carcinoma were identified as having births after diagnosis. In addition, 2775 comparison women, matched on the basis of age at the time of diagnosis, race/ethnicity, diagnosis year, disease stage, and presence of previous nonbreast primary tumors, were identified among those with breast carcinoma without births after diagnosis. Relative mortality was assessed using multivariable statistical methods.

RESULTS

After adjustment for stage of disease, age at diagnosis, study region, diagnosis year, and race/ethnicity, women with births occurring 10 months or more after diagnosis had a significantly decreased risk of dying (relative Risk [RR] = 0.54, 95% confidence interval [CI], 0.41-0.71) compared to women without subsequent births. Women pregnant at the time of diagnosis had a mortality rate similar to those who did not give birth (RR = 1.10, 95% CI, 0.80-1.60).

CONCLUSIONS

The results of the current study, in light of growing evidence from other studies using various methods, may provide some reassurance to young women with breast carcinoma that subsequent childbearing is unlikely to increase their risk of mortality.

[Breast cancer and pregnancy. Analysis of our casuistry and literature review]

The results of 14 cases of breast cancer and pregnancy observed in 1261 breast carcinoma, diagnosed and in treatment between January 1980 and March 2001 were analysed. The results were compared with 122 cases of not pregnant patients with similar ages (< or = 40). The pregnant patients had a medium following of 58.6 months and controls of 73.9 months. Otherwise the results are not significant; it shows a higher incidence of disseminate carcinomas diagnose in the pregnant patients (14.3% vs. 4.9%), a higher recidives (50% vs. 37.4%) and a higher mortality (50% vs. 30.3).

Pregnancy and early-stage melanoma

BACKGROUND

Cutaneous melanomas are aggressive tumors with an unpredictable biologic behavior. It has been suggested that women who present with melanoma during pregnancy have a worse prognosis due to more aggressive behavior of the melanoma. The objective of the current study was to evaluate the long-term effect of pregnancy on disease progression in women with Stage I-II melanoma.

METHODS

From 1965 to 2001, 46 pregnant women were treated for a Stage I-II melanoma at the University Medical Center Groningen. These patients were compared with an age-matched and gender-matched control group (nonpregnant) of 368 women with Stage I-II melanoma. The patients were staged according to the 2002 American Joint Committee on Cancer TNM classification system for melanoma. The 10-year disease-free survival (DFS) and 10-year overall survival (OS) rates were calculated using logistic regression analysis.

RESULTS

The median age of patients in the pregnant group was 30 years (range, 18-46 years), and the median age of patients in the nonpregnant group was 36 years (range, 17-45 years). The median follow-up was 109 months (range, 1-356 months). Pregnant patients presented more often with thicker melanomas (median, 2.0 mm vs. 1.7 mm; not statistically significant). No differences with regard to tumor location, histologic subtype, tumor ulceration, or vascular invasion were detected between the pregnant group and the nonpregnant group. There was no statistical difference in the 10-year DFS and 10-year OS rates between the two groups. The 10-year DFS rates for patients in the pregnant and nonpregnant groups, respectively, were 88% versus 86% for patients with Stage I melanoma and 67% versus 73% for patients with Stage II melanoma. The 10-year OS rates for patients in the pregnant and nonpregnant groups, respectively, were 94% versus 90% for patients with Stage I melanoma and 82% versus 81% for patients with Stage II melanoma.

CONCLUSIONS

Pregnancy does not appear to have an adverse, long-term effect on survival in patients with clinically localized melanoma. Further studies should address whether pregnant patients present with thicker lesions and/or whether they have decreased DFS compared with nonpregnant women. The prognosis for women with melanoma during pregnancy, as it relates to survival, still is dependent on tumor thickness and ulceration.

The prognostic impact of hormone receptors and c-erbB-2 in pregnancy-associated breast cancer and their correlation with BRCA1 and cell cycle modulators

A population-based series of 122 patients with pregnancy-associated breast carcinomas was histologically revised and the relationship between hormone receptors, c-erbB-2, BRCA1, p27, cyclin E, and cyclin D1 was studied. The 5-year overall survival was 41%; 70% had tumor size >20 mm; 72% had metastasized to regional lymph nodes; 95% were histologic grade II or III; 66% and 75% were negative for estrogen and progesterone receptor, respectively; and c-erbB-2 expression was high (44%). BRCA1 expression was reduced in 33% of the cases. The expression of p27, cyclin D1, and cyclin E was low, 11%, 9%, and 16%, respectively. Cyclin D1 was positively associated with the hormone receptors (p< or =0.01). In multivariate analysis, lymph node status, progesterone receptor, and c-erbB-2 were significant prognostic factors. In subdividing the group according to lymph node status, c-erbB-2 and progesterone receptor retained a prognostic significance in the node positive group only. In conclusion, pregnancy-associated breast carcinomas are aggressive tumors, with low expression of hormone receptors, BRCA1, p27, and cyclin E and D1, and high expression of c-erbB-2.

Pregnancy-associated breast cancer: a case control and long-term follow-up study in China

Pregnancy associated (PA) breast cancer is defined when diagnosed during pregnancy or within one year afterwards. To analyze the prognostic factors related to this disease and assess the impact of pregnancy on breast cancer patients, 88 PA breast cancer patients initially treated in the Shanghai Cancer Hospital from 1957 to 1990 were reviewed. A non-PA group including 176 patients individually well matched to the PA group was also analyzed. Univariate analysis suggested prognostic value for clinical tumor size, TNM stage, and breast feeding time among the classic prognostic factors, pregnancy associated factors and treatment modalities were evaluated. Multivariate analysis demonstrated clinical tumor size, TNM stage and axillary lymph node metastasis as independent prognostic factors. Compared with the non-PA group, the PA group was significantly correlated with delay at diagnosis, large size of the tumor, late TNM stage, extension to the skin or chest wall and administration with oophorectomy. The overall survival rates of 5-year, 10-year and 20-year were 40.39%, 36.29% and 30.70%, respectively, which were worse than those in the non-PA group, but did not reach a significant difference (p=0.0536). We are conducting further basic research to analyze the biologic characteristics of PA breast cancer.

Primary mediastinal large B-cell lymphoma

Primary mediastinal large B-cell lymphoma (PMLBCL) is a distinct disease entity that has a relatively short history. The prognosis and therapy of patients with PMLBCL is still controversial. We summarize our experience with PMLBCL at the Medical University of South Carolina between 1997 and 2000.

Nonbilharzial bladder carcinoma complicating pregnancy: review of the literature

The purpose of this review is to evaluate tumor presentation and characteristics, and maternal-fetal outcomes of pregnancies complicated by nonbilharzial bladder carcinoma. The mean age of the patients was 29.5 years (range = 18-40). Symptoms and diagnosis occurred after the first trimester in 20 (83%) and 22 (92%) cases, respectively. Presenting complaints included painless gross hematuria [N = 12 (50%)], vaginal bleeding [N = 7 (29%)], dysuria [N = 2 (8.4%)], abdominal pain [N = 2 (8.4%)], and 1 instance each of urgency, frequency, recurrent cystitis, and no symptoms. Tumors were initially identified by ultrasound [N = 12 (50%)], cystoscopy [N = 11 (46%)], and intravenous urography [N = 1 (4.5%)]. Transitional cell carcinoma was found in 17 (74%), adenocarcinoma in 5 (22%), and squamous cell carcinoma in 1 (4.5%) patient. Tumors did not favor a specific bladder location, tended to be low grade [8 (40%) = grade 1, 7 (35%) = grade 2; 5 (21%) = grade 3], and noninvasive [N = 19 (79%)]. Treatment was typically by transurethral resection (N = 18), but 3 women required radical cystectomy, 2 received radiation, 1 received chemotherapy, and 1 underwent partial cystectomy. Three (14%) women died of their disease and 3 (14%) fetuses were lost because of complications of cancer or its treatment. Bladder carcinoma in pregnancy can mimic cystitis or obstetric hemorrhage and should be considered when evaluations for these conditions are negative. Routine ultrasound evaluation of the bladder in these patients may improve the diagnostic yield. Pregnancy is not a contraindication to treating most forms of bladder cancer.

TARGET AUDIENCE

Obstetricians and Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to list the various types of bladder cancers, to describe the presenting symptoms in a patient with a bladder cancer, and to outline the work up and treatment strategies for bladder cancer.

Ovarian carcinoma associated with pregnancy. A review of 9 cases

BACKGROUND

The purpose of this study was to review patients with ovarian cancer in pregnancy, the effectiveness of the available methods of treatment and their prognosis.

METHODS

A retrospective review of all women diagnosed to have cancer of the ovary associated with pregnancy who delivered at the authors' hospitals between January 1976 and December 2000. The demography, clinical presentation, time and mode of diagnosis, treatment, pregnancy outcome and maternal survival were noted.

RESULTS

The incidence of ovarian carcinoma in pregnancy in the series was 0.08/1000 deliveries. Of the 9 patients, 7 had epithelial cancers; 4 serous cystadenocarcinoma, 2 mucinous cystadenocarcinomas and one undifferentiated cancer. One patient each had dysgerminoma and granulosa cell tumor. Six patients were in FIGO stage Ia, one Ic, one IIa. One patient was in stage III. Five patients were treated by unilateral salpingo-oophorectomy during pregnancy. Three patients had total abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy followed by chemotherapy. Debulking of the tumor was done in a patient in stage III with subsequent chemotherapy. This patient died 13 months from the time of diagnosis of the tumor. The overall 5-year survival rate in the series was 78% and 100% for stage Ia.

CONCLUSIONS

Association of ovarian cancer with pregnancy is a rare occurrence. Early diagnosis and appropriate treatment offers the best prognosis for the patient. The higher survival rates in the series was attributed to a larger number of patients in stage I of the disease and 2 patients with a germ cell tumor and dysgerminoma which have the best prognosis. Aggressive postoperative chemotherapy also contributed to the better outcome.

Pregnancy-associated breast cancer

Twelve premenopausal women diagnosed with pregnancy-associated breast cancer between May 1985 and October 1999 were reviewed. Three patients were diagnosed in the first trimester of pregnancy, five in the second trimester, and three during the third trimester. There was one patient who was five weeks postpartum. At the time of diagnosis nine patients had lymph node involvement and two of these had metastatic disease. Four patients received primary chemotherapy. The remainder had surgery. Five patients died, two had metastatic disease at time of diagnosis, median survival was 31 months. There were three fetal deaths, one termination and two during primary chemotherapy. The diagnosis of breast cancer during pregnancy is difficult. Presentation is usually at an advanced stage. Surgery can be safely performed during pregnancy and adjuvant chemotherapy should not be postponed until after delivery.

[Clinical behavior of thyroid papillary cancer in pregnancy: optimal time for its treatment]

OBJECTIVE

To analyze the clinical characteristic and evolution of papillary thyroid cancer with pregnancy and know the optimal time to treatment.

MATERIAL AND METHODS

Cohort analytic study with two groups: One with 6 papillary cancer and pregnancy and group 2 with 24 papillary cancer and the same age, prognostic score AMES and MACIS, treatment, time of follow up and mortality. The variables analyzed was clinical presentation, local, regional, distant recurrence, and mortality. The statistical analyzed by Chi Square and t test.

RESULTS

There were no statistical differentiation between the two groups in age, prognostic score, rates of recurrence and mortality with a time of follow up for G1 83 (33 to 240) months and 88 (12 to 288) months for G2. There were differences only in clinical presentation with positive cervical nodes in 100% of patients in G1 vs. 12.5% in G2. This condition does not alter the final evolution.

CONCLUSION

A pregnant patient with papillary thyroid cancer can wait the end of the pregnancy and then receive the appropriated cancer treatment.

Acute leukemia during pregnancy: a single institutional experience with 17 cases

We reviewed the medical records of 17 consecutive patients with concomitant acute leukemia and pregnancy seen at our institution over a 37-year period. Fifteen cases each were either newly diagnosed or classified as acute myeloid leukemia (AML). Seven diagnoses (41%) occurred in the first, 7 (41%) in the second, and 3 (18%) in the third trimester. In general, nine patients received chemotherapy while pregnant-eight in the second trimester and one in the third. The overall complete remission rate among the 13 patients with newly diagnosed AML was 69%, compared with 86% in those who were pregnant during chemotherapy. Long-term survival was documented in five of the nine complete responders. Three of four patients who elected to delay treatment until after delivery died within days of starting chemotherapy. Unintentional fetal loss occurred in four patients (29%), including two without exposure to chemotherapy. There were no instances of congenital malformation. The results from the current study confirm that pregnancy per se may not affect the outcome of chemotherapy in AML. In addition, it is suggested that treatment delays may compromise maternal outcome without improving pregnancy outcome.

Breast cancer during pregnancy: diagnostic and therapeutic dilemmas

The management of breast cancer associated with pregnancy encompasses many diagnostic and therapeutic dilemmas. The various modalities used for screening, diagnosis, and staging of breast cancer are not always applicable during pregnancy. The risk to the unborn child plays a major role in the decision process. Overall, the prognosis of patients with pregnancy-associated breast cancer is worse because a large proportion of patients are first seen with more advanced disease. However, stage for stage, the prognosis is similar.

Pregnancy and breast cancer

Pregnancy-associated breast cancer (PABC) and pregnancy subsequent to breast cancer are two areas of concern facing women of childbearing age. The current approach to the management of PABC is to treat the cancer with some modification because of the pregnancy. The clinical management of both PABC and pregnancy occurring after breast cancer in young survivors, with emphasis on issues in clinical decision making, clinical management, and client education and support, are addressed.

[Cervical cancer in pregnancy--practical recommendations]

Five-year survival did not differ between 20 pregnant women and 541 patients with invasive cervical cancer treated with radical surgery at the Department of Obstetrics and Gynecology of the University of Graz. Therapeutic recommendations are given. In stage Ib to IIb disease, surgery is recommended postpartum following the induction of fetal lung maturity if fertility should be preserved and if the cancer is diagnosed after the 20th week of pregnancy. The same is recommended in stage Ia independent of the duration of gestation. In advanced disease (stage IIIb to IVb) definite therapy should be applied immediately after diagnosis. If cervical intraepithelial neoplasia grade III is suspected, colposcopy, cytology and biopsy are mandatory. Definite therapy should be performed 6 weeks postpartum.

Breast cancer in pregnancy--our experience with six patients in the University Hospital, Kuala Lumpur

Presentation of breast cancer during pregnancy is a rare situation and one that requires a multidisciplinary approach involving an obstetrician, surgeon and oncologist. Management should be along the same principles as in non-pregnant patients and delay is not justifiable. Mastectomy and axillary clearance is the best option, followed by chemotherapy, which is safe after the first trimester. Radiation if required should be delayed until after delivery of the baby. We present here our experience with 6 patients who presented with breast cancer during pregnancy. Five patients refused any treatment until after delivery, while one underwent only a mastectomy and axillary clearance. The outcome was poor; all of them died between 14 months and 52 months. The poor outcome probably reflects the late stage at presentation in four of the patients (State 3 and 4) rather than the delay in treatment, while delay in treatment in the two who presented with early cancer (Stage 1 and 2) led to a more advanced stage after delivery.

[Gestational trophoblastic disease: the epidemiological analysis of 342 cases]

Between 1987-1996 dates were collected to assess frequency and risk factors for gestational trophoblastic disease in a case-control study of 342 women with trophoblastic tumors and 342 pregnant women admitted for deliveries or spontaneous abortion to University Hospitals in Poznan, Poland. Were analyzed the age of women obstetric history, place of live and repeat appearance of hydatidiform mole. The risk of trophoblastic disease increased with increase in maternal age and above third pregnancy. The risk independent of living in town or in the country. The second and more incident of hydatidiform mole was associated with greater risk of malignant sequele. The study of the pregnancy of gestational trophoblastic disease was led in Great Poland in the support on the date from all pathologic centres in this region and public demographic office. The frequently of hydatidiform mole was between 1987-1996 2.32 per 100,000 women, and 0.76 for 1000 live birth (1 HM for 1315 live birth). The frequently of choriocarcinoma was 0.08 per 100,000 women (and 0.38 per 10,000 live birth (1 CHA per 26,315 live birth).

[Management of lymphoblastic lymphomas during pregnancy]

Lymphoblastic lymphoma (non-Hodgkin lymphoma) is a highly uncommon but serious condition during pregnancy. With multidisciplinary management (obstetrics, pediatrics, hematology and anesthesia), outcome is generally good for both mother and child. Chemotherapy must be initiated rapidly, during pregnancy. Consequences depend on the stage of the disease, its progressive nature and the of pregnancy. During the first trimester, medical termination should be proposed in order to initiate chemotherapy cannot be started until the second trimester using alkaloids. Chemotherapy has little effect on the fetus during the second trimester. During the trimester, extraction should be discussed as soon as the fetal maturity is sufficient.

Primary cardiac sarcoma in pregnancy: a case report and review of the literature

Primary cardiac sarcoma (PCS) is a rare disease with a poor prognosis, because of diagnostic delay, therapeutic difficulties, and high metastatic potential. Surgery is the standard treatment. A case of PCS in pregnancy is reported, with a review of published surgical series of PCSs, focusing on the role of surgery and adjuvant therapy. Prompt surgery improved cardiac function and patients' outcome in comparison with untreated cases. The role of adjuvant treatment was analyzed only in a few series, mainly without distinction between postoperative chemotherapy and radiotherapy; adjuvant therapy improved survival in the larger series of resected PCSs. Only three other cases of PCS in pregnancy were reported. In the present case, resection was performed with no major complication for the mother and the infant. Even if the patient's survival was short, cardiac surgery allowed prolonging of pregnancy until an acceptable possibility of fetal survival was reached. Although resection is not curative in most cases, surgery remains the treatment of choice for PCS and has a definite palliative significance. The role of postoperative chemotherapy and radiotherapy is difficult to ascertain; however, adjuvant chemotherapy seems advisable in high-grade tumors.

Pregnancy after breast carcinoma: outcomes and influence on mortality

BACKGROUND

To the authors' knowledge, no previous studies have identified an adverse effect of pregnancy on patient survival after breast carcinoma. However, results are difficult to interpret because of failure to control for stage of disease at the time the pregnancy occurred.

METHODS

Study participants were women diagnosed with invasive breast carcinoma between 1983-1992 who previously had participated in a population-based case-control study or, if deceased, proxy respondents. Information regarding subsequent pregnancies was obtained by self-administered questionnaire or telephone interview. Information regarding breast carcinoma recurrences was obtained by questionnaire and from cancer registry abstracts. Women who became pregnant after a diagnosis of breast carcinoma (n = 53) were matched with women without subsequent pregnancies based on stage of disease at diagnosis and a recurrence free survival time in the comparison women greater than or equal to the interval between breast carcinoma diagnosis and onset of pregnancy in the women with a subsequent pregnancy.

RESULTS

Sixty-eight percent of women who became pregnant after being diagnosed with breast carcinoma delivered one or more live-born infants. Miscarriages occurred in 24% of the patients who became pregnant compared with 18% of the controls (women without breast carcinoma) of similar ages from the case-control study. Five of the 53 women who had been pregnant after breast carcinoma died of the disease. The age-adjusted relative risk (RR) of death associated with any subsequent pregnancy was 0.8 (95% confidence interval [95% CI], 0.3-2.3). All five deaths occurred among the 36 women who had a live birth (age-adjusted RR = 1.1; 95% CI, 0.4-3.7).

CONCLUSIONS

The findings of the current study are based on a small number of deaths but do not suggest that pregnancy after a diagnosis of breast carcinoma has an adverse effect on survival.

Parity, age at first childbirth and the prognosis of primary breast cancer

Reproductive factors are known to be aetiologically important in breast cancer, but less is known regarding their effect on breast cancer prognosis. We have investigated the prognostic effect of age at first birth and total parity using data from the Danish Breast Cancer Cooperative Group that, since 1977, has collected population-based information on tumour characteristics, treatment regimes and follow-up status on Danish women with breast cancer. Details of pregnancy history were added from the Danish Civil Registration System and the National Birth Registry. Included in the study were 10,703 women with primary breast cancer. After adjusting for age and stage of disease (tumour size, axillary nodal status and histological grading), the number of full-term pregnancies was found without prognostic value. However, women with primary childbirth between 20 and 29 years experienced a significantly reduced risk of death compared with women with primary childbirth below the age of 20 years [20-24 years: relative risk (RR) = 0.88, 95% confidence interval (CI) 0.78-0.99; 25-29 years: RR = 0.80, 95% CI 0.70-0.91]. Further adjustment for oestrogen receptor status did not influence these results. The effect was not modified by age at diagnosis, tumour size or nodal status. In conclusion, low age at first childbirth, but not parity, was associated with a poor prognosis of breast cancer. We speculate whether women who develop breast cancer despite an early first full-term pregnancy might represent a selected group with a more malignant disease.

The incidence of colorectal cancer during pregnancy in Japan: report of two cases and review of Japanese cases

Colorectal cancer during pregnancy is very rare. We report two additional cases of rectal carcinoma. A 34-year-old woman with an obstructive adenocarcinoma of the rectal region was diagnosed at labor. A 35-year-old woman with an adenocarcinoma of the rectal region was diagnosed at 32 weeks of gestation and underwent a cesarean section and rectal resection at 35 weeks of gestation. A retrospective review of the Japanese literature was performed to identify patients who appeared to have primary colorectal cancer during pregnancy. Thirty-six patients with colon cancer (75.0%), 10 (20.8%) with rectal cancer, and two (4.2%) of unknown sites have been reported in Japanese series. The average age of the mother was 32.2 years. The calculated incidence of colorectal cancer among Japanese pregnant women was one case per 502,316 live births during the years between 1986 through 1995. Although the majority of colorectal cancers diagnosed during pregnancy are rectal carcinomas, the patients in Japan were predominantly complicated by colon cancer. The fetal risk seems small, because there were no cases of colorectal cancer metastatic to the products of conception.

Pregnancy and the prognosis of malignant melanoma

The influence of pregnancy on the prognosis of malignant melanoma (MM) is unclear. Since 1951, a number of case reports have suggested that pregnancy may have an adverse effect on the clinical course of MM. We reviewed the literature on pregnancy and MM and focused on the well-controlled studies. Based on a limited number of controlled trials, pregnancy before, after, or during the time of diagnosis of stage 1 MM does not appear to affect survival. However, these data should be interpreted with caution because the duration of follow-up and number of patients may not be sufficient to observe a true effect.

[Treatment of breast cancer during pregnancy]

Breast cancer occurring during pregnancy is a rare clinical situation. A multidisciplinary approach is needed involving an obstetrician a medical oncologist and a surgeon. It should be treated according to the same principles applied in non pregnant patients. Abortion or termination of pregnancy don't improve survival. Decisions regarding abortion should be based on the desires of the patient and on therapeutic necessities. Surgery if necessary is always possible, radiation therapy should be avoided by reason of fetal toxicity, chemotherapy if absolutely necessary is possible after the first trimester.

Overall survival from breast cancer in women pregnant or lactating at or after diagnosis. Auckland Breast Cancer Study Group

The effect of concurrent or subsequent pregnancy or lactation has been studied in women with breast cancer to determine if these variables influence prognosis. Information was collected from 382 women potentially capable of bearing children, aged less than 45 years, in the Auckland Breast Cancer Study Group data file, a consecutive series of women diagnosed with breast cancer from 1976 to 1985, with a median follow-up of 10.2 years. The prevalence of both pregnancy at diagnosis and lactation at diagnosis was 2.6%. The incidence of pregnancy subsequent to diagnosis was 3.9%. Women pregnant at the time of breast cancer diagnosis had significantly more advanced disease than non-pregnant patients, and there was a similar trend for women lactating at diagnosis. Overall survival in these women was poor compared with the non-pregnant and non-lactating groups; only 2 of 10 pregnant patients and 0 of 10 lactating patients survived more than 12 years. The adverse outcome for women lactating at diagnosis of their breast cancer persisted despite allowance for nodal status, tumour size and age. However, survival was similar between pregnant and non-pregnant patients when these variables were taken into account. No significant differences in survival were found between those women who had pregnancies subsequent to diagnosis of breast cancer and breast cancer patients who did not become pregnant.

Pregnancy influences breast cancer stage at diagnosis in women 30 years of age and younger

BACKGROUND

To evaluate the purported decreased survival of pregnancy-associated (PA) breast cancer, a previously described homogeneous cohort of women of childbearing age with primary operable cancer was studied. The current analysis was designed to (a) identify those patients among the cohort known to have PA cancer and (b) compare clinical factors, pathologic characteristics, stage at diagnosis, and survival statistics for PA and non-PA cancer subgroups.

METHODS

All patients < or =30 years of age who underwent definitive operation between 1950 and 1989 at the Memorial Sloan-Kettering Cancer Center (MSKCC) for primary operable (stages 0-IIIA) breast adenocarcinoma were analyzed.

RESULTS

Twenty-two of the 227 young women with primary operable breast cancer had PA cancer. Disease-related survival was decreased (p = 0.004) in these 22 women compared with the remaining 205 patients with non-PA cancer. PA cancer patients were found to have larger tumors (p < 0.005), and a greater proportion had advanced staged (IIB or IIIA) cancers (p < 0.02). Among patients diagnosed with early invasive cancers (stages I or IIA), no difference (p = NS) in survival was observed comparing PA and non-PA subgroups (73% vs. 74% 10-year survival). Patients with stage IIIA cancer had shorter disease-free and overall survival when associated with pregnancy (0% vs. 35% 10-year survival).

CONCLUSIONS

Women 30 years of age or younger with PA breast cancer have decreased survival compared with patients with non-PA cancer from the same cohort. Women with PA cancer have larger, more advanced cancers at the time of definitive surgery. Women with early staged PA cancers appear to have survival similar to that for women with early staged non-PA cancer.

Breast cancer during pregnancy: quantifying the risk of treatment delay

OBJECTIVE

To quantify the risk of axillary nodal metastases due to delayed treatment of breast cancer during pregnancy.

METHODS

A mathematical model using recently published data was developed to correlate primary breast tumor size with the percentage of pathologically positive axillary lymph nodes. Using this relationship obtained from pathologic data and the accepted relationship of tumor growth and time, Y2 = Y1e(In2)n/DT, an equation estimating the increased risk of axillary metastases due to each day of treatment delay was derived: delta X = 3.7 n/DT, where X = percent positive axillary lymph nodes, n = number of days delay in treatment, and DT = tumor doubling time.

RESULTS

A 1-month delay in treatment for an early-stage primary breast cancer with a 130-day doubling time increases the risk of axillary lymph node involvement by 0.9%. A 3-month delay increases the risk by 2.6%, and a 6-month delay by 5.1%. For breast cancer with a 65-day doubling time, a 1-month delay increases the risk by 1.8%, a 3-month delay by 5.2%, and a 6-month delay by 10.2%.

CONCLUSION

Axillary lymph nodes are the most important prognostic indicator for survival in breast cancer. Our mathematical model suggests the daily increased risk of axillary metastases due to treatment delay is 0.028% for tumors with moderate doubling times of 130 days and 0.057% for tumors with rapid doubling times of 65 days. This minimal maternal risk may be acceptable to some third-trimester pregnant women with early breast cancer, who prefer organ-sparing treatment with radiation after delivery to a mastectomy during pregnancy. This model further quantitates the increased risk of mortality borne by pregnant women whose breast cancer diagnosis is delayed.

Impact of pregnancy on non-metastatic breast cancer: a case control study

The diagnosis of breast cancer during pregnancy remains uncommon and therefore leads to non-standardized management. We reviewed retrospectively 28 such women treated at this centre and compared them with age and stage matched controls. Differences in management and outcome were analysed for statistical significance. There was no significant difference in overall survival (P = 0.86) and relapse-free survival (P = 0.48) between the two groups. Chemotherapy after the first trimester of pregnancy carried no significant morbidity. Pregnancy does not appear to be an adverse prognostic factor for breast cancer.

[Breast cancer during pregnancy]

Approximately 2-3% of all breast cancers coincide with pregnancy or lactation and this tumour affects one to four out of 10000 pregnant women. Breast cancer associated with pregnancy (BCAP) has generally been believed to have a particularly grim prognosis. Several recent studies suggest however, that survival in BCAP does not substantially differ from that of non-pregnant, age and stage matched patients. BCAP may managed with standard methods. Surgery should be considered in all patients deemed to be operable. Therapeutic abortion does not need to be routinely performed, unless adjuvant chemotherapy or radiotherapy is to be applied or the patient necessitates systemic therapy for advanced disease. Prophylactic ovarian ablation does not influence significantly the course of BCAP and should be undertaken only in case of progressive or recurrent disease.

Hepatocellular carcinoma during pregnancy and its comparison with other pregnancy-associated malignancies

BACKGROUND

Cancer in pregnancy is rare and hepatocellular carcinoma (HCC) in pregnancy even rarer. The impact of pregnancy on the prognosis of patients with different types of cancer remains controversial. Reported cases of HCC in pregnancy are largely isolated and highly scattered. Thus, the effect of pregnancy on the prognosis of patients with HCC and the risk factors of developing HCC in pregnancy are not well documented.

METHODS

A series of five patients with HCC in pregnancy seen at two different centers is reported. A Medlar search for articles between 1957 and 1993 with the key words "Hepatocellular Carcinoma" and "Pregnancy" was conducted. All reported cases were combined and analyzed in terms of race, age, parity, hepatitis B surface antigen status, cirrhosis, serum alpha-fetoprotein (AFP) levels at presentation, history of taking oral contraceptive pills and fetal and maternal outcome. The impact of pregnancy on 12 other malignancies as reported in the medical literature also was reviewed.

RESULTS

To the authors' knowledge, The five cases reported here constitute the largest series of HCC in pregnancy. A literature search revealed 23 additional cases. Analysis of the 28 cases suggests that the rarity of HCC in pregnancy results from a combination of three factors: the male predominance of HCC, the late age at which the tumor usually presents in women, and decreased fertility in women with advanced cirrhosis (hepatitis is a predisposing factor for HCC development). Long term use of oral contraceptives and high parity enhance the risk. Elevated AFP level is useful for diagnosis. The median survival is shorter than for patients who are not pregnant. There is no significant difference in survival between pregnant and not pregnant women matched by tumor stage, age, and other clinical parameters in most malignancies except in some tumors like lymphoma, thyroid cancer, and nasopharyngeal carcinoma.

CONCLUSION

Pregnancy has an adverse effect on the prognosis of patients with HCC, lymphoma, thyroid cancer, and nasopharyngeal carcinoma but not of most other malignancies. Measurement of AFP level is recommended for screening HCC in pregnant women at high risk.

The prognosis of cervical cancer associated with pregnancy: a matched cohort study

OBJECTIVE

To assess the effect of pregnancy on the prognosis of cervical cancer and the morbidity of standard treatment.

METHODS

We analyzed 44 women with cervical carcinoma associated with pregnancy, who were matched with 44 controls. Matching criteria were age, stage of disease (according to the International Federation of Gynecology and Obstetrics classification), tumor type, treatment modality, and period of treatment.

RESULTS

In 23 cases, cervical cancer was diagnosed during pregnancy and in the other 21 cases, within 6 months after delivery. Thirty-nine women had early-stage disease (eight IA, 25 IB, and six IIA), and five had advanced stages (four IIB and one IIIB). The overall 5-year survival rate was 80% among subjects and 82% among controls, whereas the relative risk (RR) of dying within 5 years was 1.12 (95% confidence interval [CI] 0.48-2.65). With regard to the 5-year survival rate (85% for both subjects and controls, the RR of dying was 1.00 [95% CI 0.35-2.83]); no differences were found between subjects and controls for early-stage cervical carcinoma. The size of the group with advanced-stage cervical carcinoma was too small to allow any statistical analysis. No statistically significant differences in survival were observed between cases diagnosed during pregnancy and cases diagnosed after delivery. In addition, the mode of delivery had no effect on survival. Early complications within 6 weeks after treatment were seen 33 times in 25 subjects and 29 times in 23 controls. No differences were observed in the prevalence and type of early complications in subjects versus controls. Late complications after 6 weeks of treatment were seen nine times in nine subjects and 11 times in ten controls. No significant differences were observed in the prevalence and type of late complications in subjects versus controls.

CONCLUSION

The prognosis of early-stage cervical cancer is similar in pregnant and nonpregnant patients when standard treatment is given. Because of the limited number of patients, no conclusions can be drawn about advanced-stage cervical cancer. The goal should be standard oncologic treatment, which does not lead to increased morbidity in pregnant patients.

Gastric cancer in the young, with special reference to 14 pregnancy-associated cases: analysis based on 2,325 consecutive cases of gastric cancer

Clinicopathologic features of gastric cancer in young women were analyzed with special reference to pregnancy (P). Among 2,325 consecutive patients, there were 152 young patients under 40 years of age (57 males and 95 females), and 14 P-associated cases were identified. The male-to-female ratio was 1.7:1.0 on the whole, but 1.0:1.7 in the young group with more females predominating as the age of patients decreased. Among characteristics of gastric cancer in the young females, we noted a significantly higher frequency of both Borrmann type 4 cancer and poorly differentiated adenocarcinoma with the scirrhus type of growth and peritoneal metastasis. These characteristics were more pronounced in the P-associated cases. Although we were unable to determine the mechanism for these tendencies, our findings suggest that the development and growth of gastric cancer in young women may be influenced by their natural, biological and hormonal circumstances. The prognosis of the young women with or without associated pregnancy was good after curative surgery. Both early detection of gastric cancer and subsequent potentially curative surgery are the best ways to obtain good survival for young women, as is the case for members of other age and sex groups.

Special problems. Breast cancer and pregnancy

Pregnancy-complicated carcinoma of the breast occurs in 3% of patients with breast cancer. Breast cancer associated with pregnancy occurs in 3 of every 10,000 pregnancies. This article provides the background information to allow the treating physician to consider the patient's wishes and arrive at a reasonable, appropriate, and effective treatment and follow-up plan.

Breast cancer and pregnancy

BACKGROUND

Breast cancer developing during pregnancy or lactation is such an infrequent problem that, when it occurs, physicians are confronted with ethical and therapeutic challenges. Moreover, there are very few references to compare or discuss breast cancer in pregnant women in Taiwan. We hope that data from this review will add to our understanding of such difficult problem as well as help improve the treatment of our patients.

METHODS

Between 1979 and 1988 the charts of 21 women, who were pregnant or postpartum within one year of the breast cancer diagnosis, were analyzed retrospectively. All of the patients were followed until Dec. 1990. Patients with pregnancy-associated breast cancer were compared with nonpregnant women (199 cases) of similar age who were treated at the same hospital and during the same period.

RESULTS

We found no statistical differences in the overall 5-year survival rate between pregnant (57.1%) and nonpregnant (69.6%) groups. It is noteworthy that the time lag was significantly longer in the pregnant group than in the nonpregnant group. A stage-by-stage comparison showed equivalent survival rates between pregnant and nonpregnant patients. The pregnant patients at stage II had a somewhat lower survival rate; however, there was no statistical significance.

CONCLUSIONS

The rule of cancer treatment, "early diagnosis followed by aggressive management," is still a key principle to improve the treatment in pregnant women with breast cancer.

Effect of pregnancy on prognosis for young women with breast cancer

Breast cancer in women under 30 years old carries a poor prognosis, for reasons that have not been identified. This study aimed to identify prognostic factors in this age group. Special attention was paid to the history of pregnancy. The clinical presentation and course of breast cancer was documented for 407 women, aged 20-29 years, who registered between 1978 and 1988 at one of nine cancer centres. Eligible patients had histologically confirmed local or regional invasive breast carcinoma, and received part or all of their initial therapy at the participating hospital. For patients whose breast cancers were diagnosed during pregnancy, the risk of dying from breast cancer was significantly greater than that of women who had never been pregnant (relative risk 3.26 [95% CI 1.81-5.87], p = 0.0004). Adjustment for number of axillary nodes affected and tumour diameter reduced the relative risk only slightly (2.83 [1.24-6.45], p = 0.023). For each 1-year increment in the time between the latest previous pregnancy and breast cancer diagnosis, the risk of dying decreased by 15% (relative risk 0.85, p = 0.011). Thus concurrent or recent previous pregnancy adversely affects survival of breast cancer in young women. The size of the effect is such that it probably contributes substantially to the poor prognosis of breast cancer in this age group as a whole.

[Special problems of primary hyperparathyroidism in pregnancy]

In cases of premature, persistent nausea and vomiting, or if these conditions continue past the 14th week of pregnancy, the possibility of primary hyperparathyroidism should be considered and the condition eradicated in order to avoid serious complications for mother and child. Judging from our experience and according to current literature, starting in the 12th week of pregnancy the effects of primary hyperparathyroidism on both mother and child can be prevented through surgery.

[Pregnancy and hematologic malignancies: a therapeutic approach]

Pregnancy coexisting with evolutive malignant blood disease (Hodgkin's disease, acute leukemia, non-Hodgkin's lymphoma, chronic myeloproliferative disorder) is a therapeutic dilemma because of possible adverse reactions associated with the use of cytostatic agents. Therapeutic abortion, when needed, must be proposed only after a careful evaluation of the following parameters: the emergency of treatment, the prognosis of the disease, the term of pregnancy, the risks of therapy for the foetus and the mother, and the psychosocial context. From the clinical data published so far, the teratogenicity of cytostatic drugs seems to be minimal after the second trimester, and the outcome of pregnancy is often favorable, whatever the hemopathy. Radiation therapy must be used very cautiously and only in supradiaphragmatic areas. An overview of specific problems is done for each category of malignant blood disease.

Survival of breast cancer patients after subsequent term pregnancy: "healthy mother effect"

OBJECTIVE

A population-based matched survival study was conducted to assess the risk of death for breast cancer patients in relation to whether they were delivered of a live born child subsequent to the cancer diagnosis.

STUDY DESIGN

Among the 2548 women < 40 years old diagnosed with carcinoma of the breast in 1967 to 1989 in Finland there were 91 eligible patients with subsequent deliveries (> or = 10 months after the diagnosis) for whom 471 controls were matched for stage, age, and year of breast cancer diagnosis. The controls had to have survived at least the interval between the diagnosis and the delivery of their matched counterparts. The follow-up started from the date of the first delivery after the diagnosis or after the corresponding interval for the matched controls. A stratified Cox proportional hazards survival analysis was performed.

RESULTS

The controls had a 4.8-fold (95% confidence interval 2.2 to 10.3) risk of death compared with those who were delivered after the diagnosis of breast cancer.

CONCLUSION

Our interpretation of this result is a "healthy mother effect" (i.e., that only women who feel healthy give birth and those who are affected by the disease do not). Nevertheless, six of eight deaths among the 91 patients who did give birth were related to breast cancer.

Does pregnancy influence the prognosis of malignant melanoma?

The effect of pregnancy on the clinical course of malignant melanoma (MM) is unclear. Early clinical and laboratory evidence suggested a relation between hormones and MM and subsequently between pregnancy and MM. We reviewed the literature on MM and pregnancy to address three questions: What is the effect on prognosis if an MM is diagnosed during pregnancy? What is the effect of previous pregnancies on the prognosis of MM? What effect does a subsequent pregnancy have on the prognosis of MM? On the basis of a limited number of controlled studies, it does not appear that being pregnant before, after, or at the time of diagnosis of stage I MM influences the 5-year survival rate. However, caution in interpreting these data must be taken because it is possible that the duration of follow-up and size of the study populations are not sufficient to observe a true effect.

Cancer in pregnancy

OBJECTIVE

To estimate the incidence of cancer arising in pregnancy and to report its recurrence in those women with a past history of the disease.

DESIGN

Retrospective study over 11 years.

SETTING

John Radcliffe Maternity Hospital.

PATIENTS

25,568 Oxford District Health Authority residents who delivered at the John Radcliffe Maternity Hospital, and 6775 residents who had a termination of pregnancy, between 1 January 1981 and 31 December 1985.

INTERVENTIONS

Retrospective analysis of case records to identify pregnancies complicated by cancer and follow-up through patients' general practitioners.

MAIN OUTCOME MEASURES

Maternal mortality and disease recurrence.

RESULTS

The study identified 32 pregnancies complicated by cancer in 28 women and four terminations of pregnancy performed for cancer as the main or secondary indication. By the end of 1991, three women had died, one woman had been treated for disease recurrence, 17 women were in good health and seven women had been lost to follow-up. There were six cases of cancer arising de novo in pregnancy, i.e. an incidence of 2.35 per 10,000 deliveries (95% confidence interval 0.47 to 4.22). Only one pregnancy was complicated by disease recurrence.

CONCLUSION

The incidence of cancer arising de novo in pregnancy is lower than the most quoted figure of 9.92 per 10,000 pregnancies.

[Effect of pregnancy on the incidence and course of malignant diseases]

Fortunately, coincidence of pregnancy associated with malignant neoplasm is rare. As reported in the literature, incidence is 1.5-10: 10,000 pregnancies. The study presented reports data on the incidence and outcome of 16-35 years old female patients suffering from malignant neoplasms. Patients, who were treated in Freiburg 1980-1989, were considered for evaluation. We analysed the impact of pregnancy on the outcome of these patients by stratifying patients for the time of diagnosis (before, during, or after a pregnancy). 247 patients were included. 118 patients developed a neoplasia after a successful pregnancy. In 24 patients, neoplasia was diagnosed during pregnancy, and 28 patients became pregnant after diagnosis and therapy for a malignancy. Further 77 patients without pregnancy, but in whom neoplasia diagnosed at the age of 16-35 years were included. Cancer of the cervix uteri, breast cancer, ovarian cancer, and malignant lymphomas were the most frequent neoplasias diagnosed in young women. In an analysis stratified for stage of disease, we found no significant difference between 3- and 5-years survival of patients with pregnancies before, during, or after diagnosis and treatment of neoplasia. Due to the inhomogeneity of the subgroups analysed, the question, whether pregnancy has any impact on the outcome of neoplasm could not be conclusively answered. The necessity for the establishment of national and international registries collecting sufficient data about incidence and outcome of patients with pregnancies associated with malignant neoplasms is emphasised.