Ovarian cancer during pregnancy

Nine months of pregnancy can be an exciting part of a mother's life, but can become very difficult when faced with a cancer diagnosis. If you have any symptoms that worry you and you're wondering if you might have ovarian cancer while pregnant, talk to your doctor right away about diagnostic tests.

It is important to note that most ovarian tumors found during pregnancy are not cancerous, and those that are cancerous are often at an early stage. For most women, this means that the life of the child should not be endangered. In addition, many women can preserve their fertility (if desired) with conservative surgery by removing only the affected ovary and fallopian tube. Although standardized treatments for ovarian cancer have been proposed and studied, research is still lacking due to its rarity. Thus, treatment and care for ovarian cancer during pregnancy is often highly individualized.

Facts about ovarian tumors during pregnancy

During pregnancy, it is rare to find a tumor or mass of the ovary. One study estimates that only 2.4-5.7% of pregnancies will have an ovarian mass.

If an ovarian tumor is found, the tumor is rarely malignant (cancerous). The above study mentions that of these masses, only about 5% should be malignant.

If the lump resolves before the second trimester, surgery may not be offered. The lumps or cysts can come and go, and if the lump disappears in the second trimester, it may simply be due to early pregnancy.

Surgery is often done to remove a specimen of the lump for biopsy (for diagnosis and staging). Before prescribing surgery or more serious treatment, your doctor will want to confirm whether the tumor is cancerous. Thus laparoscopy and laparotomy will be used to remove part of the mass for biopsy including histology and if there is fluid (ascites or mass contains fluid) it can be removed and sent for cytology report. These tests can determine if a growth is cancerous and the grade and stage of the cancer if it is cancerous.

If additional imaging tests are needed, there are safer options. X-rays and magnetic resonance imaging are generally considered safe during pregnancy. Abdominal CT is not recommended during pregnancy.

Facts about ovarian cancer treatment during pregnancy

Fertility can often be preserved if the cancer is diagnosed early. If ovarian cancer is detected and diagnosed at an early stage (before large metastases), a unilateral salpingo-oophorectomy may be performed, in which the ovary and fallopian tube are left on the other side to preserve fertility.

Chemotherapy is prescribed only in the second or third trimester and, if possible, postponed until delivery. Numerous studies show that chemotherapy can lead to severe deformities (83.3%) and/or miscarriage when given in the first trimester. There are few concerns about chemotherapy in the second and third trimesters, although there is always the possibility of long-term effects and/or teratogenic effects. That is why it is postponed after childbirth, if it is considered safe enough for the health of the mother.

A conservative operation is performed, but usually not earlier than the 16-20th week of pregnancy. Doctors prefer to wait a few weeks in the second trimester before having surgery. This is because surgery in the first trimester is more likely to cause a miscarriage (spontaneous abortion). Such a result is rarely observed with conservative operations after the first trimester.

Total reduction surgery is usually planned after pregnancy. Unless the cancer is very advanced and life-threatening to the mother (or fetus), total reduction surgery (removal of all visible tumors and problem areas) is usually delayed until after birth. This is mainly done to protect the fetus and the less stable condition of the mother during pregnancy. Conservative surgery plus chemotherapy as needed is usually the course during pregnancy.

If the cancer is in an advanced stage, treatment often must be continued as if there was no pregnancy. If cancer is so life-threatening to the mother (and fetus), the risks of complex cancer treatment may outweigh the risks to the fetus. Total reduction surgery is still possible without damaging the fetus, but there are risks associated with more invasive surgery.

Radiation therapy is considered dangerous at any stage of pregnancy. Studies show that the high-energy x-rays used can harm the fetus in any trimester, so this treatment is not used during pregnancy. Doctors prefer to wait after birth to start radiation therapy. The risk to the developing child depends on the dosage and the area being treated.

FAQ

Does pregnancy increase the chance of getting ovarian cancer?

First of all, ovarian cancer is rare, and scientific studies have not shown that pregnancy alone increases the chances of getting ovarian cancer. In fact, women who carry a child before age 30 may have a reduced lifetime risk of developing ovarian cancer.

This question is often asked because ovarian tumors or cancerous tumors are more easily detected during pregnancy due to routine ultrasound procedures. Often these ultrasounds can detect suspicious growth in early pregnancy. If an ovarian tumor is found early, you and your doctor can plan diagnosis first and then treatment.

Can I still have debulking surgery and undergo chemotherapy during pregnancy?

Short answer: yes. However, most treatment plans include only conservative surgery during pregnancy after 16–20 weeks, with reduction surgery after delivery if necessary. Because chemotherapy is contraindicated (not recommended) during the first trimester, it will only be given after that time. However, doctors usually try to delay chemotherapy until after delivery.

Delaying volume reduction surgery and chemotherapy can be problematic because ovarian cancer may have more time to grow, spread, and differentiate (go through cancer-promoting cellular/DNA changes). However, the harm of delay will depend on the stage and extent of the cancer. The more aggressive the cancer, the faster it can spread.

Does cancer pose any risk to my developing child?

In most cases, ovarian cancer does not affect your growing baby. Concerns arise if the cancer is life-threatening for the mother, is too large and blocks normal growth or blood flow to the fetus, or if the cancer causes abnormal levels of hormones in the body. There is little documented evidence of spread of ovarian cancer to the fetus, amniotic sac, or placenta during pregnancy, so there is probably no cause for concern. Your doctor can help you understand your specific situation and how it may or may not affect your child.

Ovarian cancer treatment and its side effects usually pose a risk to the fetus. This is why only conservative surgery is suggested during pregnancy, and why gynecologist-oncologists prefer to postpone surgery until the 16th to 20th week of pregnancy. This is due to the higher incidence of miscarriages (spontaneous abortions) during surgery in the first trimester and early in the second. This is also the reason why chemotherapy is not prescribed in the first trimester and why doctors try to delay chemotherapy treatment until delivery. In the first trimester, the frequency of teratogenic effects/deformities (83.3%) and miscarriage is extremely high. Chemotherapy treatment in the second half of pregnancy may result in poor appetite, nausea/vomiting and/or low blood counts, indicating poor diet or increased risk of infection (especially during childbirth).

Will this mean a change in how I can have a baby?

Much of your pregnancy care will depend on the stage and extent of your specific cancer. Many women can continue with a normal vaginal delivery. Others may be scheduled for a caesarean section, but this may be due to other factors unrelated to the cancer. If the cancer is in an advanced stage, your medical team may suggest a caesarean section so they can perform reduction surgery at that time.

How can I tell the difference between a symptom of pregnancy and a symptom of ovarian cancer?

Hopefully, by the time you start experiencing symptoms, your doctors will have already seen the abnormal mass in your ovaries on a regular ultrasound and begin a treatment plan. However, it's always important to talk to your doctor about the evolution of symptoms, especially if you have a family history of ovarian, breast, or colorectal cancer or know of a cancer susceptibility gene mutation in your family or personal genetics.

Typical symptoms of ovarian cancer are bloating, frequent urination or an urgent need to urinate, lower abdominal pain, fullness, fast/hard overeating, fatigue, constipation, back headache, and pain during sex. Because most, if not all, of these symptoms can also be pregnancy-related, it may be difficult for you to figure out what might be causing them on your own. One of the reasons it's so important to let your doctor know about your symptoms is that they can be a sign of complications, such as cancer of the reproductive system. In most cases, ovarian cancer detected during pregnancy is asymptomatic.