EXPECTING a child and treating cancer is one of the situations that no woman would like to have to experience. Yet it happens. It happens once in a thousand pregnancies, more or less. And when it happens, always and inevitably, women come to terms with anxiety and the fear of having to choose between the possibility of healing and that of putting the child they are expecting at risk of malformations.
A fear whose foundation lies in the fact that chemotherapy attacks rapidly proliferating cells, such as those of cancer. But also of the fetus in the phase of organ formation, that is, in the first 12 weeks of intrauterine life. For this reason there is a broad consensus in the oncology field that chemotherapy should not be administered until the completion of the first trimester of pregnancy, that is, that of the organogenesis of the future baby.
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But given that the exact time of conception may be uncertain and that some systems or organs continue to develop even after 10 weeks of pregnancy, in clinical practice, the question remains: at what exact gestational age can chemotherapy be safely started, avoiding to cause congenital malformations in the future baby? The answer has now been confirmed in large numbers by the study “Association of Chemotherapy Timing in Pregnancy With Congenital Malformation“published on JAMA Network Open, the largest and most detailed investigation into the relationship between chemo, pregnancy and fetal malformations.
The risk of malformations
The authors conducted a multicenter cohort study of 755 women registered in the INCIP database, theInternational Network on Cancer, Infertility and Pregnancy, with an average age of 33 years undergoing chemotherapy in different gestational phases between 1977 and 2019. About 50% of the tumors were in the breast, followed by the cervix, lymphomas, gastrointestinal carcinomas and then others. From the analysis of the data it emerged that in cancer patients who begin chemo during the first trimester of pregnancy, the risk of fetal malformations is actually significantly higher, as expected: it was 21.7% compared to 3. , 6% detected in the general population. But in women treated during the second and third trimester, the probability of malformations was 3%
Safe after 13 weeks
“Based on our results – said the authors – we suggest that chemotherapy can be started starting at 12 weeks […]. Introducing a one-week safety period could be considered to further reduce the risk – they add – However, there is no rationale for delaying chemotherapy beyond 14 weeks of gestation, as previously recommended. “. In short, it is good news, confirmed today on a high number of women. “Yes, the study confirms what we already knew and what we already do, but it certainly has the merit of having been conducted on a wide range of patients”, he says Lucia Del Mastro, oncologist and head of the Breast Unit of the San Martino Polyclinic Hospital in Genoa, one of the national reference centers for the treatment of cancers in gestation.
400 women in Italy, mainly with breast cancer
But how many women have to face a tumor and a pregnancy at the same time in our country? “About one in a thousand pregnancy is complicated with a tumor – the expert continues – In Italy we count about 400 cases a year. These are mainly patients with breast cancer, as also shown by the study on Jama. But all of them must know that , with the right protocols, pregnancy and anti-cancer treatment can coexist without risk to the baby. Most of our patients, once aware of this possibility, are even more motivated than the others: a child is one more big reason to face cancer. with confidence”.
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What can be done right away instead? “If it is an early and operable tumor – replies the oncologist – for example breast, it can be surgically removed even in the first trimester, the situation changes if the cancer is located in sites directly involved in gestation, such as the uterus or ovaries. On the other hand, when medical therapy is required, that is chemo, we wait for the thirteenth week, as confirmed by the study just published, because in the organogenesis phase even the safest drugs raise the risk of fetal malformations, which is between 10 and 25%, as well as that of having an abortion, which is between 20 and 30% “.
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Pregnant women, and we are always talking about the second and third trimester of gestation, can be given many chemotherapy drugs, while hormone therapy and molecular target drugs (the so-called targeted therapy) are not indicated. “By applying the right protocols, you go on without risks for the mother and the baby – continues Del Mastro – In any case, when there are risks, it is above all a question of low birth weight and premature birth”. However, it must be clear that we are talking about complex patients, who should be followed in expert centers, that is, structures with good caseloads, with high numbers of women treated for cancer and at the same time expecting a child. These women, unlike both other pregnant women and other cancer patients, have special needs: for example, frequent ultrasound examinations, continuous updating and modulation of chemotherapy doses, given the rapid change in weight. Supportive therapies, such as antiemetics or steroids, are also different for them. And they need a multidisciplinary approach: the oncologist, the gynecologist and the neonatologist must interact and share any information, always. “In our centers – concludes Del Mastro – we have seen many women with breast cancer and expecting a child pass by, and all the pregnancies went well”.
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