As survivorship from both childhood and adult cancers increases, combined with more women having their first child later in life, the complex issues of pregnancy after a diagnosis and treatment of cancer have become increasingly relevant. Adults of child bearing age account for approximately a tenth of all new cancer cases in the UK, with twice as many cases in females as males in this age group1; thus potentially large numbers of women are being affected by these issues. Studies have shown that up to 75% of people with a childhood or adolescent cancer diagnosis are interested in the opportunity to have children2 and that subsequent loss of reproductive potential after cancer treatment negatively impacts quality of life in young survivors. In one study, 27% of patients admitted that concerns about fertility had impacted on their treatment decisions.3 As recently as 2009, only 34–72% of reproductive-age women treated for cancer recall having a discussion about the effects of cancer treatment on future fertility2; this is despite studies showing that receiving specialized counselling about reproductive loss, and pursuing fertility preservation is associated with less regret and improved quality of life for survivors.4
The lifetime risk of breast cancer (BC) in the UK is one in nine, making it the commonest cancer in women. BC is the leading cause of death in women between the ages of 35 and 54, and 15% of women are diagnosed before the age of 45 years; this extrapolates to almost 5000 women of reproductive age with a new diagnosis of BC annually in the UK. Other cancers which often occur in women of childbearing age include leukaemia, lymphoma and melanoma. Those who survive childhood and adolescent cancers prior to reaching childbearing age are obviously also affected. Whilst this chapter covers pregnancy after diagnosis and treatment of all cancers, there will be a particular focus on BC.
In cancer survivors the chance of conceiving compared to the normal population is reduced, however there are large variations depending on the tumour type. Those with thyroid cancer and melanoma have pregnancy rates almost equivalent to the general population. Whilst the lowest rates are seen in those with previous BC, with rates nearly 70% lower than the general population.5 The lower rates in BC are likely due to a combination of factors including patient and physician misconceptions with regard to higher rates of hormonally-driven recurrence during pregnancy, use of gonadotoxic chemotherapy regimens and use of endocrine therapies over extended periods of time.6 If patients are diagnosed in the later reproductive years, postponement of pregnancy whilst undergoing treatment may itself lead to infertility, outside of any effects of treatments received.
In the European Society of Medical Oncology (ESMO) guidelines on Cancer, Pregnancy and Fertility, pregnancy is not discouraged in any cancer survivors, including following BC diagnosis and ...