Cancer in pregnancy: maternal-fetal conflict

Abstract

The occurrence of malignancies during pregnancy has increased over the last decades. They complicate approximately 1 per 1000 pregnancies. The most common malignancies associated with pregnancy include malignant melanoma, malignant lymphomas and leukemia, and cancer of the cervix, breast, ovary, colon and thyroid. Since it is impossible for prospective randomized clinical trials to be conducted in this field, relevant data have been generated from case reports and matched historical cohort studies in order to evaluate the treatment outcomes and the issues complicating the management of malignancy in the pregnant patient. There is almost always a conflict between optimal maternal therapy and fetal well-being. The maternal interest is for an immediate treatment of the recently diagnosed tumor. However, the optimal therapy, be it chemotherapy, radiotherapy or surgery, may impose great risks on the fetus. Consequently, either maternal or fetal health, or both, will be compromised. Therefore, both the pregnant patient and her physician are often in a dilemma as to the optimal course. On the basis of the medical facts, we discuss the issues raising potential ethical conflicts and present a practical ethical approach which may help to increase clarity in maternal-fetal conflicts. We review the available data informing the incidence and impact of the most common malignancies during pregnancy and their treatment on both the pregnant woman and her fetus. The optimal therapy for the tragic diagnosis of cancer in pregnancy requires a collaborative and interdisciplinary approach between gynecologists, oncologists, obstetricians, surgeons, neonatologists, psychologists, nursing staff and other disciplines. The purpose of this article is not to answer specific questions or to construct management schemes for specific tumors but to provide a framework for approaching some of these complex issues.

Fig. 1.

The time-dependent development of maternal and fetal prognoses during tumor therapy in pregnancy. Pregnant women must confront the diametrically opposed facts of a life-giving and a life-threatening process. In this maternal-fetal conflict maternal and fetal prognoses are reciprocal according to a model of diametrical relations. On the other hand, omission of tumor therapy for the fetus' sake will increase maternal morbidity and mortality. Chemo- and/or radiotherapy administered during the first trimester will raise the risk of fetal malformations or spontaneous abortions. In the case of relative treatment indications the fetus may be allowed to mature until week 24 of gestation and longer so that it can be delivered via cesarean section

Fig. 2.

Ethical conflicts. For the decision-finding process the physician/health-care team has to consider the interests and well-being of the pregnant patient but also the well-being of the unborn. This goal can be achieved by adopting the two specific principles of autonomy (voluntas aegroti) and beneficence (salus aegroti). The pregnant patient has her own perspective on her best interests and personal well-being that are based on her very individual values and beliefs. Therefore, she must be given the freedom to choose alternative courses of therapeutic action based on her values and beliefs. The fetus does not yet possess the capacity to express personal beliefs or perspectives on his/her own interests. Therefore, there is no autonomy-based obligation of the physician to the fetus. The principle of beneficence (which also includes the principle of non-maleficence) requires the physician to assess objectively the various therapeutic options and to implement those which will most probably offer the patient the greatest balance of benefit over risks. However, at the same time, the physician has to consider the well-being of the fetus and also try to offer the fetus the greatest balance of benefits over risks (principle of beneficence and principle of justice). Therefore, there is a beneficence-based obligation of the physician to the mother but also to the fetus. Hence, the application of the two principles of autonomy and beneficence to two individuals, the mother and the fetus, may result in conflict

Fig. 3.

Potential treatment options during the different stages of pregnancy. Tumor therapy in the pregnant woman depends among other features on the tumor entity, on the staging and on the time of pregnancy. On the one hand, the medical indications must take into account the patient's physical state, disease process, and treatment options. On the other hand, an ethical evaluation of the medical facts must include the patient's autonomy and her well-being as well as the well-being of the unborn (for comments see text). According to the individual and case-specific decision-finding process within the interdisciplinary treatment set-up, different courses of action may result