Originally published as JCO Early Release 10.1200/JCO.2008.21.6192 on March 23 2009

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Cancer During Pregnancy: The Time Has Come for a Prospective Program

Institut Gustave Roussy and University Paris-Sud, Villejuif, France

To the Editor:

We read with a great interest the paper published recently by Stensheim et al¹ about the epidemiology and prognosis of cancers diagnosed during pregnancy in the Cancer Registry and the National Birth registry of Norway. This article includes a large cohort of 42,500 women, treated between 1967 and 2002, for a cancer diagnosed at the ages of 16 to 49 years.¹ The aim of this study was to evaluate the prognosis of cancers diagnosed during pregnancy or lactation. There are many interesting data in this excellent article.

During the study period, 2,311 patients had postcancer pregnancies. Surprisingly, 184 patients treated for invasive cervical cancer and 68 for ovarian cancer became pregnant after treatment of the disease. This means that these patients underwent a conservative treatment at the time of surgical management of their gynecologic cancer. Nevertheless, these figures appear to be relatively high for these conservative treatments because this type of surgery was introduced relatively recently.

Conservative management of cervical cancer is based on radical trachelectomy whose standardization, propelled by Dargent et al,² began 15 to 20 years ago. However, this procedure was not used extensively during the period of this study. Another procedure proposed for conservative management of cervical cancer, proposed by some teams, is the use of chemotherapy conization, but this is even more recent.³ Did the 184 patients reported in the present series as having a postcancer pregnancy undergo such conservative management or, in reality, were some of these patients treated conservatively using a simple conization for microinvasive or in situ disease?

Similarly, 68 patients became pregnant after treatment of an ovarian cancer. This figure is also a little surprising. Perhaps some of them had conservative treatment of nonepithelial cancer, but it is also possible that some of them had borderline malignancies for which conservative management was already routinely used during the study period. Such results are potentially important because they can modify the study of the prognostic impact on patients who were considered as having cancer—that is to say, invasive disease.

Similarly, studying the prognosis of patients who had a postcancer pregnancy compared with others, Stensheim et al¹ concluded that such patients had a lower risk of recurrence in cases of cervical and hematological cancer. However, we are not sure that it is possible to reach such a conclusion. Patients who succeed in becoming pregnant after treatment of their tumor probably had their disease diagnosed at an early stage, at least in cases of cervical cancer, compared with others. Furthermore, how many patients died of disease before they were able to become pregnant in the population studied?

Nevertheless, even with such limitations (some of which were pointed out by the authors in the Discussion section),¹ this series is one of the largest devoted to the prognostic impact of pregnancy and lactation on the cancer. In this series, 516 patients had a cancer diagnosed during pregnancy and 531 during the lactating period. Such events are therefore not so rare. The two most frequent tumors were cervical cancer and melanoma.

One of the most important points in this context is to try to harmonize the management of such patients by offering them the same chances of being cured as nonpregnant patients and to propose maintaining their pregnancy (if such a proposal is safe from an oncologic point of view).⁴ This is why we decided to draw up national recommendations for the management of cancer during pregnancy in France. Nearly 30 experts were involved in writing and validating such recommendations. Recommendations about the management of invasive cervical cancer during pregnancy were finalized recently and approved by three different scientific societies.⁵ These recommendations were published in national and international journals.⁵ Recommendations about the management of ovarian malignancies and breast cancer will be finalized shortly. Grants were obtained from the French National Cancer Institute to undertake joint programs about this topic bringing together different institutions defined as referent centers. The time has probably come, to validate international recommendations about the management of cancer during pregnancy and also to conduct prospective studies or programs in this context.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

REFERENCES

1. Stensheim H, Møller B, van Dijk T, et al: Cause-specific survival for women diagnosed with cancer during pregnancy or lactation: A registry-based cohort study. J Clin Oncol 27:45–51, 2009.[Abstract/Free Full Text]

2. Dargent D, Martin X, Sacchetoni A, et al: Laparoscopic vaginal radical trachelectomy: A treatment to preserve the fertility of cervical carcinoma patients. Cancer 88:1877–1882, 2000.[CrossRef][Medline]

3. Maneo A, Chiari S, Bonazzi C, et al: Neoadjuvant chemotherapy and conservative surgery for stage IB1 cervical cancer. Gynecol Oncol 111:438–443, 2008.[CrossRef][Medline]

4. Germann N, Haie-Meder C, Morice P, et al: Management and clinical outcomes of pregnant patients with invasive cervical cancer. Ann Oncol 16:397–402, 2005.[Abstract/Free Full Text]

5. Morice P, Narducci F, Mathevet P, et al: French recommendations on the management of invasive cervical cancer during pregnancy. Int J Gynecol Cancer in press.

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