ASCO's New Guideline on Cancer Care During Pregnancy: Balancing Mother and Fetus
The American Society of Clinical Oncology (ASCO) has released a groundbreaking guideline that navigates the intricate path of cancer care for pregnant patients, emphasizing the delicate balance between maternal health and fetal well-being. This comprehensive guide, published in the Journal of Clinical Oncology, addresses critical questions in this rare but complex scenario.
According to Mikkael A. Sekeres, MD, chief of the Division of Hematology at Sylvester Comprehensive Cancer Center in Miami, cancer diagnoses during pregnancy are infrequent, occurring in only about one in 1000-2000 pregnancies. However, the implications are profound, impacting both mother and fetus. Sekeres emphasizes the importance of shared decision-making, considering the cancer's aggressiveness, the toxicity of diagnostic procedures, and patient goals.
The guideline, grounded in evidence, tackles key clinical questions. It outlines recommended diagnostic and evaluation criteria, optimal management strategies for new and recurrent cancers, and obstetrical considerations beyond standard pregnancy care. While the evidence supporting these recommendations is primarily derived from low-quality sources like retrospective observational studies, case series, and individual case reports, the authors believe the recommendations are robust, offering valuable real-world data for clinical practice.
Ann H. Partridge, MD, MPH, director of the Adult Survivorship Program and co-founder of the Program for Young Adults with Breast Cancer at Dana-Farber Cancer Institute in Boston, highlights the importance of balancing care and fetal risks. She outlines three crucial considerations: understanding patient preferences regarding pregnancy, weighing disease and treatment risks, and assessing fetal risks with optimal therapy. Partridge stresses the need for transparency about known and unknown data, both for individual patients and the broader context.
The guideline emphasizes multidisciplinary care, including pharmacists, who collaborate to tailor treatment plans. It advocates for informed consent discussions between patients and caregivers before therapy initiation or continuation. Patient autonomy and personal preferences are paramount, with the understanding that cancer emergencies may necessitate immediate cancer-directed therapy, potentially requiring pregnancy termination to prevent maternal death or mitigate severe risks.
Diagnostic evaluation recommendations cover imaging modalities, biopsy techniques, minimally invasive procedures, survival outcomes, and systemic therapies. One of the most challenging aspects is managing drugs with unknown teratogenic potential. Sekeres acknowledges the limitations of existing evidence, which is often based on retrospective studies and small case series, leading to uncertainty in newer therapies like bispecific agents and antibody-drug conjugates.
Partridge confirms the lack of comprehensive understanding regarding the teratogenic risks of these therapies, citing biological plausibility concerns and the challenges in studying them. The guideline's authors, Sekeres and Partridge, have declared their financial interests, ensuring transparency and adherence to ethical standards in their contributions to this critical area of oncology.
