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Cancer and Pregnancy

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Cancer and pregnancy are not usually conditions that most people associate with each other, but they are occurring more often than many nurses realize.

In fact, approximately one of every 1,000 pregnancies will be affected by cancer, according to a new study.

Treating a pregnant woman with cancer is a complex and delicate balancing act.

As more women are affected, nurses need to understand how challenging detection and treatment can be in these cases.

The most common cancer during pregnancy is breast cancer, which occurs in about one in 3,000 pregnancies, according to the National Cancer Institute, and is followed by cervical cancer, lymphoma, and thyroid cancer.

Since more women are delaying childbirth until later in life, nurses can expect to see more cases of cancer during pregnancy. As women age, the risks of developing cancer are generally greater.

Improved diagnostic testing for cancer is resulting in an increase in detection of cancers in pregnancy.

How Pregnancy Affects Cancer
Current evidence suggests the changes in a woman’s body during pregnancy could impact cancer’s development.

“Pregnancy can exacerbate cancer,” says Eileen Ludden, RNC, BSN, director of labor and delivery at Holy Cross Hospital in Silver Spring, Md.

For example, the estrogen-rich environment of pregnancy can encourage pre-existing abnormal breast cells or growths to develop quickly and aggressively. Changes in the immune system during pregnancy also can create an atmosphere in which cancer cells thrive.

But prompt diagnosis and a good treatment plan can help women achieve better outcomes. For most pregnant women with cancer, the prognosis is the same as for other women of the same age with the same type and stage of cancer, according to the American Society of Clinical Oncology.

A new study by The University of Texas M.D. Anderson Cancer Center found women under age 35 diagnosed with pregnancy-associated breast cancer had the same long-term outcomes as women who weren’t pregnant when diagnosed. The study was published online Feb. 29 in the journal Cancer.

“People tend to think pessimistically about cancer in pregnancy, but a lot of women in the U.S. are successfully managed for cancer during pregnancy,” says Debra Keith, RN, MS, CNM, director of the Center for Life at Providence Hospital in Washington, D.C.

The University of Texas study also found pregnancy-associated breast cancer is more likely to be advanced at diagnosis, suggesting pregnancy might hinder and delay diagnosis.

“Sometimes pregnancy can mask symptoms of cancer,” Ludden says.

Possible symptoms of cancer, such as excessive gas and abdominal bloating, easily can be overlooked and result in a delay in diagnosing cancer. Ludden cites the case of one woman who had back pain during pregnancy and was diagnosed after delivery with metastatic lung cancer. Because cancer symptoms often can masquerade as typical pregnancy issues, nurses should be aware of the possibility of cancer in pregnancy and ensure all symptoms are accurately documented and reported.

On the flip side, pregnancy could be the key for some women to an early cancer diagnosis.

The Center for Life at Providence Hospital cares for a large population of underserved and uninsured pregnant women who often don’t have access to routine pap smears, breast exams, and mammograms.

“For many of the women we serve, coming in for a prenatal visit is the first time they may have seen a healthcare provider,” Keith says. “We can pick up breast lumps or abnormal pap smears that might not have been detected otherwise until they are at a very advanced stage.”

A Delicate Balancing Act

With today’s advancements in high-risk obstetrical, neonatal, and oncology care, treatments can be safer and more effective than many believe.

Eileen Ludden, RN

A multifaceted approach that includes a specialized, multidisciplinary team means pregnancies can often have a successful outcome.

It is possible to have chemotherapy during pregnancy, although individual treatment plans are based on a wide variety of factors, including a woman’s particular cancer diagnosis; the size, type, and location of a cancer tumor; the types and potential side effects of specific chemotherapy and other treatment regimens; the stage of the cancer; and how far along a woman is in pregnancy.

In some cases, surgery to remove a cancerous tumor can be performed successfully on a pregnant woman, says Keith, who cites a case in which a pregnant woman had a thyroid tumor successfully removed during pregnancy.

Treatment decisions are made to give mothers the best chance for a successful cancer outcome while minimizing the risks to the baby and maximizing gestational development.

“Sometimes, the oncologist will recommend treatment immediately, and other times treatment may be able to wait until farther along in the pregnancy or after delivery,” Keith says.

Some breast cancer cases, for example, might be serious enough threats to the mothers’ health and life that treatment should not wait until after delivery. Chemotherapy might be started during pregnancy, although it could be delayed until a woman is in her second trimester to minimize the risk of serious complications to the developing fetus in the first trimester.

In other cases, patients may be advised that it is better for mother and baby to delay treatment until after the baby is sufficiently developed and can be delivered safely. This can include performing a cesarean section, with delivery earlier than full gestation, but waiting long enough to ensure the baby’s lungs have developed sufficiently. This can be as early as 32 to 34 weeks gestation.

”Accurately weighing the chances of having a healthy baby and a healthy mother at the same time are critical,” Keith says. “We want to make sure we have a healthy baby but not wait so long to deliver that it may jeopardize the mother’s treatment and health.”

Visit Hope for Two, the Pregnant With Cancer Network, online at www.PregnantWithCancer.org.

Catherine Spader, RN, is a contributing writer for Nursing Spectrum.

To comment, e-mail editorDC@nursingspectrum.com.

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