Maternal survival of patients with pregnancy-associated cancers in Taiwan - A national population-based study

Cancer and Pregnancy in the Post-Roe v. Wade Era: A Comprehensive Review

Cancer during pregnancy, affecting 1 in 1000 pregnancies, is rising in incidence due to delayed childbearing and improved detection. Common types include breast cancer, melanoma and cervical cancer and Hodgkin's Lymphoma. There are several physiological changes that occur during pregnancy that make its management a challenge to clinicians. Managing it requires multidisciplinary approaches and cautious test interpretation due to overlapping symptoms. To minimize fetal radiation exposure, non-ionizing imaging is preferred, and the interpretation of tumor markers is challenging due to inflammation and pregnancy effects. In terms of treatment, chemotherapy is avoided in the first trimester but may be considered later. Immunotherapy's safety is under investigation, and surgery depends on gestational age and cancer type. Ethical and legal concerns are growing, especially with changes in U.S. abortion laws. Access to abortion for medical reasons is vital for pregnant cancer patients needing urgent treatment. Maternal outcomes may depend on the type of cancer as well as chemotherapy received but, in general, they are similar to the non-pregnant population. Fetal outcomes are usually the same as the general population with treatment exposure from the second trimester onwards. Fertility preservation may be an important component of the treatment discussion depending on the patient's wishes, age and type of treatment. This article addresses the complicated nature of a diagnosis of cancer in pregnancy, touching upon the known medical literature as well as the ethical-legal implications of such a diagnosis, whose importance has increased in the light of recent judicial developments.

Pregnancy-associated Cancer and Chemotherapy during Pregnancy

The diagnosis of pregnancy-associated cancer, although rare, is a condition of great human and social significance and difficult clinical management. A pregnancy-associated neoplasm is defined as a cancer diagnosis made during pregnancy or within 12 months after delivery/abortion. The most common cancers in pregnancy occur most frequently in women of reproductive age with an incidence overall like that observed in non-pregnant women of the same age. This incidence is likely to increase in view of both the expected increase in certain malignancies among young women (particularly breast cancer and melanoma) and the increasing frequency of pregnancies undertaken later in life (fourth and fifth decades of life) that is characterizing modern society. Chemotherapy is generally contraindicated before 12 weeks of pregnancy due to the increased risk of congenital anomalies while exposure in the second and third trimester of pregnancy to chemotherapy has been associated with more growth restriction and preterm delivery. Clinical decisions about the optimal management should consider maternal and fetal characteristics with the involvement of a multidisciplinary team.

Ileal adenocarcinoma in a young pregnant woman: A rare case report

Primary intestinal malignancies account for only 1%-3% of all malignant gastrointestinal tumors. Adenocarcinomas are uncommonly located in the ileum. Ileal adenocarcinoma (IA) is rare and difficult to diagnose because of its location. IA is common in older men and rare in young pregnant women. A 23-year-old pregnant woman was hospitalized several times for repeated vomiting and abdominal pain. Her symptoms were relieved after symptomatic treatment. She exhibited no typical manifestations of intestinal obstruction, such as abdominal distension, difficulty passing gas and defecation. Unfortunately, she was misdiagnosed with acute gastroenteritis. On the second day after delivery, the patient stopped passing gas and computed tomography (CT) revealed an intestinal obstruction. She was treated as paralytic ileus. However, in view of failed conservative management, she was decided for an exploratory laparotomy. A malignant ileal tumor 5cm from the ileocecal valve was found incidentally and was surgically excised accompanied with End-to-side anastomosis of ileal and transverse colon. The operation lasted 195 minutes. Pathological examination revealed an IA. Pregnant woman who experience symptoms of intestinal obstruction should be alert to the possibility of malignancy in the small intestine. IA is an insidious tumor in pregnant women. An "IA triad" can be defined as refractory vomiting, vague abdominal pain, and weight loss (or inadequate weight gain in pregnant women). Pregnant women with an IA triad should undergo investigation with endoscopy or, if necessary, magnetic resonance imaging (MRI).

A rapid reduction in tumor size by cyclin-dependent kinase inhibition in hormone receptor-positive postpartum breast cancer: a case report of two patients and a review of the literature

Background

Postpartum breast cancer (PPBC) as an independent entity different from PABC. PPBC is defined as breast cancer (BC) diagnosed within 5 years after delivery in many relevant literatures and is associated with a poor prognosis and a decrease in overall survival. PPBC patients commonly present with inflammatory breast cancer (IBC) phenotype, multifocal lesions, and lymph node metastasis. Hormone receptor-positive (HR+) PPBC is an under-investigated subtype. In PPBC, the risk of death of HR+ subtype significantly increased two-fold, while that was only modestly increased for triple-negative breast cancer (TNBC) subtype, and was not significant in human epidermal growth factor receptor 2-positive (HER2+) subtype. HR+ PPBC is a subtype associating with enhanced signatures of cell cycle control, T-cell activation and exhaustion, decreased HR signaling, and altered P53 signaling. The recommended treatment for HR+ PPBC patients is still lacking. Cyclin-dependent kinase (CDK) 4/6 inhibitors are used as a novel treatment standard not only in pretreated patients but also in the first-line setting of HR+ metastatic breast cancer (MBC). However, there is no clinical case report on the application and efficacy of CDK4/6 inhibitors in HR+ PPBC patients.

Case Description

This article describes the clinical cases of two patients with advanced HR+ PPBC who were rapidly relieved after receiving leuprorelin combined with letrozole combined with dalpiciclib. We reviewed the related literature of PPBC, and found that HR+ PPBC has not been clinically classified as a BC subtype, and only some basic studies suggested that HR+ PPBC may be sensitive to CDK4/6 inhibitors. The purpose of this study is to provide the basis for the related research on the therapeutic effect of CDK4/6 inhibitors in HR+ PPBC through the report of clinical cases.

Conclusions

This article reports for the first time the good therapeutic effects of CDK4/6 inhibitors on HR+ PPBC patients. Based on our findings, we suggest that dalpiciclib combined with endocrine therapy can be considered as the first-line treatment for patients with advanced HR+ PPBC. Our case report provides new clinical evidence for the related research on the role of CDK4/6 inhibitors in HR+ PPBC therapy.

[Cancer during pregnancy: Proposal of a clinical care pathway based on a regional cohort]

OBJECTIVES

Cancer during pregnancy affects 1 in 1000 pregnancies. This situation requires multidisciplinary team, however there is no care pathway dedicated to these patients. The main objective was to describe oncological, obstetrical, and neonatal care through a regional inventory. Our secondary objective was to define a regional "cancer and pregnancy" care pathway.

MATERIAL AND METHOD

We carried out an observational, retrospective study from 2013 to 2019 including 48 women (all cancer types) from 2013 to 2019 in Occitania. Then, we defined an "optimal care pathway" and we assessed whether it was respected in the breast cancer subgroup of our cohort.

RESULTS

Live births occurred in 79% of the women included. Maternal treatment was initiated during pregnancy for 67% of our population (44% chemotherapy). The most frequent pregnancy complication was preterm delivery (39%), mainly iatrogenic (86.6%). No patient in the group of breast cancer benefited from all of the ten criteria of the "optimal care pathway" that we proposed.

CONCLUSIONS

A coordinated regional care pathway seems necessary to optimize communication between the healthcare providers (oncologists, gynecologists and multidisciplinary prenatal diagnosis centers, pharmacologists, pediatricians, psychologists, and general practitioners). This study identifies weaknesses in the management of women with cancer during pregnancy and suggests regional improvement opportunities.

Survival in Women Diagnosed With Breast Cancer During Pregnancy

INTRODUCTION

Pregnancy rarely coincides with breast cancer, but when it does, uncertainties remain about how survival is affected. In a nation-wide study, we investigated survival in women diagnosed with breast cancer during pregnancy.

MATERIALS AND METHODS

Through health registries, we identified women with breast cancer at ages 15-44 years from 1973-2016 in Denmark and included 156 who were pregnant at diagnosis and 11,110 who were not. We compared overall mortality in pregnant and non-pregnant women using multivariate Cox regression stratified by time since cancer: <2 and ≥2 years.

RESULTS

During the first 2 years after diagnosis, the hazard ratio of overall death was 2.28 (95% CI: 1.48-3.52) for pregnant versus non-pregnant breast cancer patients after adjustment for age and calendar period and 1.62 (95% CI: 1.05-2.50) after further adjustment for extent of disease. Adjusting for additional tumor characteristics, the hazard ratio was still significantly increased. Beyond the first 2 years, there was no excess mortality.

CONCLUSION

Our study identifies the early period after breast cancer as a period of particular interest in future studies on survival after breast cancer in pregnancy. We found no evidence that survival is affected by pregnancy when 2 or more years have passed since diagnosis.

Cancer survival in women diagnosed with pregnancy-associated cancer: An overview using nationwide registry data in Sweden 1970-2018

BACKGROUND

Pregnancy-associated cancer (PAC) is increasing over time in many countries. We provide a comprehensive, population-based overview of cancer survival in women with PAC across five decades.

METHODS

We performed a nationwide cohort study of 121,382 women diagnosed with cancer at age 15-49 between 1970 and 2018 using birth and cancer registers in Sweden. Pregnancy-associated cancer was defined as diagnosed during pregnancy and within one year of delivery, while non-PAC was outside this window. Cox regression estimated adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) comparing cancer mortality for PAC versus non-PAC.

RESULTS

In total, 5079 women had a diagnosis of PAC. Cutaneous malignant melanoma, breast, cervical, thyroid and central nervous system (CNS) were the most common sites of PAC. A higher cancer mortality was observed in PAC versus non-PAC for breast (HR = 1.72, 95% CI 1.54-1.93) and uterine cancer (myometrium/unspecified) (8.62, 2.80-26.53), in which all PAC deaths were uterine sarcomas. Increased mortality was also observed in upper digestive tract cancer diagnosed during pregnancy and colon cancer diagnosed during first year after delivery. Contrary, the HR for CNS tumours was significantly decreased (0.71, 0.55-0.91). Survival after PAC improved for most sites over time, with survival after breast cancer during pregnancy in recent years being similar to that of non-pregnancy associated breast cancer.

CONCLUSION

For the majority of sites, PAC was not associated with poorer prognosis compared to non-PAC, a finding which was stable over time. The main exceptions were breast cancer and rarer cancers, such as uterine sarcoma.