Patient-Centered Care in the Management of Cancer During Pregnancy

Biology, care, and outcomes of gestational breast cancers: a review

PURPOSE

The incidence of gestational breast cancers, breast cancers diagnosed during pregnancy, is increasing. There is a critical need to understand the pathophysiology, treatment recommendations, and remaining questions regarding care and therapeutics for this complex condition.

METHODS

Here, we review existing data regarding evaluation and management of gestational breast cancer, including safe imaging modalities, timing and choice of chemotherapy, evidence regarding targeted therapies during pregnancy. We highlight the importance of multidisciplinary care including oncologic, obstetric, and psychosocial care.

RESULTS

Gestational breast cancers are associated with unique biologic and clinicopathologic features that are impacted by physiologic changes of pregnancy such as upregulation of target genes associated with cell proliferation and immune regulation. Patients with gestational breast cancers more often present at advanced stages, are more likely to have aggressive tumor subtypes (i.e., triple negative or HER2 positive), and overall have worse prognoses than patients with non-gestational breast cancers. In this review, we synthesize recommendations for treatment strategies based on pregnancy trimester, optimal timing and choice of surgery, chemotherapy, targeted therapies, and psychosocial support.

CONCLUSION

Developing a framework for clinical care and treatment of patients with gestational breast cancers is integral to improving outcomes for patients with gestational breast cancers. Optimal treatment includes collaborative management with a multidisciplinary team dedicated to both maternal and fetal care.

Impact of pregnancy on the treatment and outcomes of glioma: a cohort study

BACKGROUND

Pregnancy's impact on cancer has been understudied throughout the literature. The current authoritative cancer database in the US, NCI's SEER database, tracks nearly all aspects of cancer care however has no provision to track pregnancy. Consequently, there are no systematic evidence based clinical guidelines available for this vulnerable population.

OBJECTIVE

This retrospective cohort study outlines reported clinical presentation, obstetric outcomes, and treatment regimens for pregnant patients diagnosed with glioma to better understand current practice pattern for glioma during pregnancy.

EVIDENCE REVIEW

An exhaustive PubMed and Cochrane based literature search was performed for pregnancy and glioma. Individual patient data was extracted primarily from case reports and case series, since pregnancy is an exclusion criterion for most clinical trials.

FINDINGS

We identified a cohort of 94 patients, 54% of whom (n = 51/94) were diagnosed prior to their pregnancy. Of the patients who were diagnosed during their pregnancy, diagnosis was most common in the second trimester (27%, n = 25/94). Seizure was the most common presenting symptom and maternal survival varied significantly by glioma grade. Treatment delays were common and were most detrimental to maternal survival in glioblastoma (GBM) (22 months (no delay) vs 8 months (delay) p < 0.10). Most patients regardless of tumor grade delivered healthy babies (80%, n = 75/94) while GBM carried the highest rate of birth complications or defects (15% n = 3/20). Fetal exposure to chemotherapy and/or radiotherapy increased the rate of birth defects or complications from 5% (n = 2/47) to 16% (n = 6/37).

CONCLUSIONS AND RELEVANCE

In summary, we found wide practice variation in management of glioma during pregnancy. Systematic reporting on this vulnerable population is needed to better serve mothers and fetuses during this incredibly challenging life event.

Oncologic Surgery for Lower Gastrointestinal Tumors during Pregnancy: A Literature Review

Background

Colorectal cancer (CRC) during pregnancy can be a challenging situation due to the spatial confinement of the tumor with the growing uterus carrying the fetus. It is one of the more common tumor entities occurring in pregnant women, and therefore, it has to be taken into account if "patients describe suspicious" symptoms.

Summary

Diagnosis and treatment are complex and require a specialized multidisciplinary team of visceral oncologists with expertise in colorectal surgery, gastrointestinal oncologists, gynecologists, obstetricians, and neonatologists to coordinate the optimal treatment plan with the patient. Multimodal treatment options depend on gestational age and tumor stage. Radical surgical oncologic therapy at the latest possible stage of pregnancy is often the only feasible, potentially curative treatment option. Chemotherapy and radiotherapy should be postponed to the postpartum period, if possible. Neonatological aspects, including the high risk of serious complications for the infant during and after anesthesia for oncologic surgery, such as cerebral hemorrhage, pulmonary hypoplasia, and necrotizing enterocolitis, must always be in the focus when considering the optimal timing of surgery, as well as the prognosis of the mother concerning her tumor.

Key Message

Treatment of CRC during pregnancy is based on highly individualized therapeutic decisions rather than on standardized guideline recommendations. Surgical resection via partial colectomy, anterior rectal resections, and abdominoperineal extirpations are feasible. However, it has always to be considered if surgery has to be performed in elective situations or damage control procedures due to emergencies, such as mechanical ileus or perforations with intra-abdominal sepsis.

Anaesthetic management of oncological disease in pregnancy: a narrative review

INTRODUCTION

Cancer complicates approximately 1 in 2000 pregnancies, with increasing incidence due to factors such as increased maternal age, obesity and advancements in antenatal testing. Anaesthetists play a crucial role in managing pregnant patients with cancer, both during delivery and in providing anaesthesia for oncological treatments. This review explores the challenges in anaesthetic management and specific considerations for common cancers encountered in pregnant patients.

METHODS

An electronic literature search was carried out using PubMed and Google Scholar to identify peer-reviewed articles published in English from 1 January 1990 to 30 July 2024.

RESULTS

Two main areas were identified: anaesthetic management related to pregnancy and the peripartum period in patients with cancer; and oncological management during pregnancy. Current data suggest that pregnancy does not worsen cancer prognosis, but diagnosis and treatment are complicated by the overlap of cancer symptoms with physiological changes of pregnancy and concerns about the safety of diagnostic procedures and treatments. Ultrasound and magnetic resonance imaging are preferred imaging modalities, while careful use of ionising radiation is advised. Treatment during pregnancy, including surgery, chemotherapy and radiotherapy is possible, with specific timing and modality considerations to ensure maternal and fetal safety. Anaemia, poor nutrition and preterm birth are significant concerns in managing pregnant patients with cancer. For operative births, neuraxial techniques are preferred, though general anaesthesia may be required in complex cases. Comprehensive multidisciplinary support, including psychosocial care, is essential for optimal outcomes. Oncological surgery during pregnancy should preferably be scheduled for the second trimester, with consideration for fetal monitoring and steroids. Regional anaesthesia should be utilised if possible and uteroplacental perfusion maintained. Increased risks of thromboembolism should be addressed postoperatively, along with psychological support.

DISCUSSION

Effective and safe anaesthetic management of cancer in pregnancy requires a multidisciplinary approach to balance maternal and fetal safety, with a focus on careful planning and individualised care.

"I didn't really fit into any boxes": understanding the experiences of women affected by cancer in pregnancy and up to one-year postpartum-a mixed-method systematic review

PURPOSE

Little is known about women's experiences of cancer during pregnancy and up to one-year postpartum. As the incidence of gestational cancer rises parallel to increasing rates of early onset cancers there is an imperative need to understand their experiences. The aim of this research is to understand women's experiences of gestational cancer during pregnancy and up to one-year postpartum.

METHODS

This systematic integrative review followed the JBI methodology for mixed method systematic reviews (MMSR) which integrates empirical data from qualitative and quantitative primary studies. The search strategy included electronic databases, APA PsycINFO, CINHAL, Medline, Scopus, and the Web of Science Core Collection. The review has been reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive methodological quality assessment was undertaken using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

Thirteen studies were included, reporting on the experiences of 266 women. The findings represented the women's insight on the psychological impact of their gestational cancer, the impact on women's identity as a mother and a patient, and women's experiences of complex care.

CONCLUSIONS

Gestational cancer reflects an emerging focus of clinical practice and an opportunity for much needed new research to explore woman-centered care exploring supportive care needs and models of maternity care.

IMPLICATIONS FOR CANCER SURVIVORS

Women's experiences indicate that services are under-resourced to address the holistic and integrated supportive care needs of women affected by cancer across both maternity and cancer care teams.

Management of multiple myeloma presenting as malignant spinal cord compression during pregnancy: a case report

not included as this is letter to the editor.

Experiences of cohabiting partners of women diagnosed with cancer during pregnancy: a qualitative study

PURPOSE

When a pregnant woman is diagnosed with cancer, she faces complex and unique challenges while navigating both obstetric and oncological care. Despite often being the primary support for women diagnosed with cancer during pregnancy (CDP), little is known about the experiences of their partners. We undertook an in-depth exploration of the experiences of partners of women diagnosed with CDP in Australia.

METHODS

Semi-structured interviews were conducted with partners of women diagnosed with CDP treated in Australia. Interviews explored partners' inclusion in decision making and communication with health professionals and their own coping experiences. Data were analysed thematically.

RESULTS

Data from interviews with 12 male partners (N = 12) of women diagnosed with CDP were analysed. Two unique themes relevant to partners were identified: 'Partners require support to adjust to changing roles and additional burdens' and 'Treating the couple as a team facilitates agency and coping, but partners' needs are placed second by all'.

CONCLUSION

Partners of women diagnosed with CDP commonly experience unique stressors and a substantial shift in previously established roles across multiple domains including medical advocacy, household coordination and parenting. Partners' coping is interlinked with how the woman diagnosed with CDP is coping. Inclusion of partners in treatment decisions and communications, and considering partners' wellbeing alongside that of the woman with CDP, is likely to be supportive for partners. In turn, this is likely to enhance the quality of support that women diagnosed with CDP receive from their partners.

Diagnostic, Management, and Neonatal Outcomes of Colorectal Cancer during Pregnancy: Two Case Reports, Systematic Review of Literature and Metanalysis

OBJECTIVE

Colorectal cancer (CRC) during pregnancy is a rare occurrence, with a reported incidence of 0.8 cases per 100,000 pregnancies. Managing CRC during pregnancy poses substantial challenges for clinicians: the diagnosis is often complicated and delayed due to symptom overlap with pregnancy-related manifestations, and medical imaging is constrained by safety concerns for the foetus.

METHODS

This article presents two cases of advanced CRC diagnosed and managed during pregnancy. Additionally, we conducted a systematic review of the literature to assess diagnostic and prognostic factors involved in CRC in pregnant individuals. The systematic review, with pre-registration and approval through Prospero, involved an extensive search of medical databases (Pubmed, Web of Science, Scopus and Scholar) and statistical analysis using t-test for continuous variables and chi square for dichotomous variables.

RESULTS

A total of 1058 studies were identified. After applying exclusion criteria, sixty-six studies were included. Women whose initial symptoms were severe abdominal pain not responsive to common medical treatments and constipation (acute abdomen) had a mean gestational age at delivery lower than those who presented with paucisymptomatic onset. In our study groups, women who underwent chemotherapy during pregnancy had a higher mean gestational age at delivery and did not experience worse neonatal outcomes compared to those who did not undergo chemotherapy.

CONCLUSIONS

CRC during pregnancy poses unique diagnostic and therapeutic challenges. Collaborative efforts among various medical disciplines are essential to manage CRC during pregnancy.

Caring for Pregnant Patients with Cancer: A Framework for Ethical and Patient-Centred Care

(1) Background: Caring for pregnant cancer patients is clinically and ethically complex. There is no structured ethical guidance for healthcare professionals caring for these patients. (2) Objective: This concept paper proposes a theoretically grounded framework to support ethical and patient-centred care of pregnant cancer patients. (3) Methodological approach: The framework development was based on ethical models applicable to cancer care during pregnancy-namely principle-based approaches (biomedical ethics principles developed by Beauchamp and Childress and the European principles in bioethics and biolaw) and relational, patient-focused approaches (relational ethics, ethics of care and medical maternalism)-and informed by a systematic review of clinical practice guidelines. (4) Results: Five foundational discussion themes, summarising the key ethical considerations that should be taken into account by healthcare professionals while discussing treatment and care options with these patients, were identified. This was further developed into a comprehensive ethics checklist that can be used during clinical appointments and highlights the need for a holistic view to patient treatment, care and counselling while providing ethical, patient-centric care. (5) Conclusion: The proposed framework was further operationalised into an ethics checklist for healthcare professionals that aims to help them anticipate and address ethical concerns that may arise when attending to pregnant cancer patients. Further studies exploring clinicians' attitudes towards cancer treatment in the course of pregnancy and patient experiences when diagnosed with cancer while pregnant and wider stakeholder engagement are needed to inform the development of further ethical, patient-centred guidance.

A Systematic Patent Review (2008-2023) for Treatment in Pregnancy

INTRODUCTION

During pregnancy, the woman's body undergoes anatomical and physiological changes, making this period susceptible to maternal-fetal diseases and complications. The consequences of not treating pregnant women include premature birth, low birth weight fetuses, and postnatal behavior disorders. Developing new therapies can accelerate the discovery of safe and effective drugs, contributing to designing novel natural and synthetic products to treat complications the pregnancy.

OBJECTIVE

This study aimed to carry out a patent review to identify and explore trends in innovation and therapeutic strategies for treating pregnant women.

METHODS

The Espacenet and WIPO databases were used, with the inclusion criteria being the keywords "pregnancy and drug" and code A61k, from 2008 to 2023, and as exclusion were the access to the patent and focus on human pregnant women.

RESULTS

After the final screening, 32 patents were selected, with strategies for the treatment of diseases in pregnant women. Of these, 20 patents are on preclinical studies on animals and 12 on pregnant women. It was observed that universities lead the ranking of applications (17/32), and China has the highest number of patents (18/32). Most findings contain herbal medicines and/or the association of natural extracts with synthetic drugs.

CONCLUSION

From this perspective, new drug administration systems were also developed, which can be a promising source for obtaining new medicines for the treatment of pregnant women; however, research is still limited and shows a gap in stimulating the rapid development of safe drugs that improve the health of pregnant women.

Choosing the appropriate pharmacotherapy for breast cancer during pregnancy: what needs to be considered?

INTRODUCTION

Breast cancer is the most commonly diagnosed malignancy during pregnancy. Breast cancer during pregnancy is a challenging clinical condition requiring proper and timely multidisciplinary management.

AREAS COVERED

This review focuses on the management of breast cancer during pregnancy with a focus about the current state-of-the-art on the feasibility and safety of pharmacotherapy approaches in this setting.

EXPERT OPINION

Multidisciplinary care is key for a proper diagnostic-therapeutic management of breast cancer during pregnancy. Engaging patients and their caregivers in the decision-making process is essential and psychological support should be provided. The treatment of patients with breast cancer during pregnancy should follow the same recommendations as those for breast cancer in young women outside pregnancy but taking into account the gestational age at the time of treatment.Anthracycline-, cyclophosphamide-, and taxane-based regimens can be safely administered during the second and third trimesters with standard protocols, preferring weekly regimens whenever possible. Endocrine therapy, immune checkpoint inhibitors, and targeted agents are contraindicated throughout pregnancy, also due to the very limited data available to guide their administration in this setting. During treatment, careful fetal growth monitoring is mandatory, and even after delivery proper health monitoring for the children exposed in utero to chemotherapy should be continued.