Page 38 Complete Your CE Test Online - Click Here Pregnancy during cancer treatment Cancer during pregnancy is fairly rare, occurring more often in cancers that occur at younger ages. For example, breast cancer occurs in approximately one in 3,000 pregnant women. Overall survival may be worse in these cases, possibly due to delays in diagnosis [143]. Cervical cancer is also sometimes discovered during pregnancy. Although early stage disease can be treated during the second trimester, more advanced disease (i.e. stages 2-4) is problematic because treatment is needed right away and the usual treatment (i.e. radiation) is toxic for fetuses. Neoadjuvant chemo has sometimes been offered to pregnant women with locally advanced disease after the first trimester, with surgery or radiation after delivery, but data is lacking on long-term outcomes for the mothers so it is unknown if this may pose more risk to the woman [151]. Avoiding pregnancy Women of child-bearing potential are typically tested for pregnancy before radiation therapy or chemotherapy is started, and effective birth control must be used throughout and for some months after treatment in order to avoid fetal damage from teratogenic or mutagenic effects of the radiation/chemo or other harmful effects. Little is known about effects on the fetus when men conceive during or soon after radiation treatment or chemo, but men are also typically advised to avoid conception during and for some months after treatment [7]. Women who are found to be pregnant before they start cancer treatment may still be able to have their cancer treated, but it must be carefully timed based on: how far along the pregnancy is; the type, location, and stage of the cancer; and the woman’s wishes. The kinds of treatment with less fetal effect (such as surgery) may be done in early pregnancy, and some cancer treatment drugs can be given later in the pregnancy (after the first trimester), although they can restrict fetal growth and cause premature labor. It is best to work with an oncologist with some experience at treatment during pregnancy involved early in treatment planning [59]. Breastfeeding is generally not recommended during chemotherapy because drugs can be secreted in the breast milk that could affect the infant [143]. Fertility Women Women tend to have a more demarcated window in which they can bear children; however, it is still best to ask about future childbearing plans before treatment begins. Many types of cancer treatments carry the risk of infertility, but this varies by age, location of the cancer, and treatment regimen. Bone marrow and stem cell transplants usually cause infertility due to the pre-transplant regimen [25]. Especially in women older than 35, cancer treatment drugs can cause early ovarian failure with permanent infertility. In young women there may be amenorrhea that reverses after treatment with return of fertility, but they may still go on to have premature menopause. It is also important that women understand, that during treatment, menses do not always indicate fertility, as women can have menses while infertile; a woman can be fertile even when experiencing what appears to be amenorrhea. FSH levels are helpful in determining fertility after treatment. As noted above, pregnancy during most cancer treatments is not recommended and birth control is required, even during times the woman is not having menses [25]. Drug effects on fertility are often very hard to predict for any one woman, so women who know they want children despite chemotherapy may want to go ahead with cryopreservation of fertilized eggs unless they have religious or ethical objections to embryo preservation. Insurance does not always cover this procedure, which can be expensive [25]. Women who object to embryo preservation or who do not have a male partner or sperm donor can opt to have unfertilized eggs frozen, but “egg banking” is a newer procedure. Because the eggs of younger women are more likely to be healthier and more plentiful, some centers have an upper age limit in the mid-thirties for egg freezing. This procedure should be done in centers with a record of experience and success [213]. There are also investigational procedures, like partial removal of the ovary for freezing, but the evidence to support this procedure is sparse. Insurance companies rarely cover these kinds of procedures, and they can be costly. Maintaining frozen tissue (e.g. embryos, eggs, or ovarian tissue) involves annual fees [25]. Pelvic or abdominal radiation can cause ovarian failure if enough radiation reaches the ovaries. Sometimes the surgeon can relocate the ovaries so that they are out of the radiation field, which improves the chances they will continue to function. However, radiation can cause uterine fibrosis as well, so that the uterus cannot expand enough for a full term pregnancy. Radiation to the brain can affect the pituitary gland, which can in turn interfere with hormonal signals to release eggs [25]. Hormone therapy for hormone-receptor-positive breast cancer is available to premenopausal women (e.g. tamoxifen) and is usually continued for five or more years after treatment, but this is contraindicated in pregnancy. Premenopausal women must use careful birth control to avoid pregnancy during treatment with tamoxifen if sexually active. Women who want to have children sometimes postpone this treatment until after pregnancy, or suspend it for a time and then resume it after delivery. Women who are postmenopausal and have hormone-receptor-positive breast cancer can use aromatase inhibitors, which are specifically to be avoided before menopause and during pregnancy [25]. Gynecologic cancers can mean surgical removal of part of the reproductive tract. Sometimes it is possible to preserve fertility, but this depends on a number of factors, including the type and stage of cancer [25]. Women who want more children should involve a fertility specialist in the early stages of cancer treatment planning, well before treatment begins, as it can take a few weeks to harvest ova. Men It is always best talk about future plans for children before cancer treatment starts. Some chemotherapy drugs are more likely than others to cause infertility, and men older than 40 may be less likely to recover fertility. Sperm production usually recovers, if at all, within four years. As in women, bone marrow or stem cell transplants often cause permanent infertility [24]. Radiation to the testicles or lower abdomen can harm sperm production. It is important for men to know that they should avoid impregnating anyone during radiation or chemotherapy and for some time afterward because of possible damage to the sperm. Surgery that removes the prostate or urinary bladder causes men to be unable to conceive during sex, although a fertility specialist might be able to extract sperm from the testes or epididymus. Men who have not yet started cancer treatment can bank sperm at any time. This does involve some costs, including annual fees to maintain the frozen sperm, but it allows great flexibility with future parenthood for up to 20 years out. Insurance plans rarely cover sperm freezing and storage [24]. Nursing consideration: Men and women who want to have biological children after cancer treatment should consider banking sperm, embryos, or eggs before starting cancer treatment [24,25]. Cancer surgery Surgery for cancer, especially early stage tumors, is sometimes the mainstay of treatment. With solid tumors, surgery is almost always a part of the treatment plan. Cancer surgery can have different goals, just like all cancer treatment. Depending on the type of cancer and how advanced it is, surgery can be used to [197]: