European Journal of Obstetrics & Gynecology and Reproductive Biology 167 (2013) 1823

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European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Cancer in pregnancy: a survey of current clinical practice

Sileny N. Han a, Vesna I. Kesic b, Kristel Van Calsteren c, Sladjana Petkovic d, Frederic Amant a,1,*,
On behalf of the ESGO Cancer in Pregnancy Task Force
a
Leuven Cancer Institute (LKI), Gynecological Oncology, University Hospitals Leuven, KU Leuven, Belgium, Herestraat 49, 3000 Leuven, Belgium
b
Faculty of Medicine, University of Belgrade, Department of Obstetrics and Gynecology, Clinical Center of Serbia, Visegradska 26, Belgrade, Serbia
c
Department of Obstetrics and Gynecology, University Hospitals Leuven, KU Leuven, Belgium, Herestraat 49, 3000 Leuven, Belgium
d
Faculty of Medicine, University of Kragujevac, Serbia

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To evaluate physicians attitudes and knowledge regarding the treatment possibilities for
Received 25 July 2012 patients with cancer in pregnancy.
Received in revised form 5 October 2012 Study design: A 30-item questionnaire was mailed electronically to physicians across Europe, who were
Accepted 24 October 2012
potentially involved in care of pregnant patients and/or cancer, using the membership directories of
different professional societies.
Keywords: Results: 142 surveys were eligible for analysis. A median of 2 (range 0100) patients with cancer in
Cancer
pregnancy were treated per center in 2010. The vast majority of respondents (94%) agreed that
Pregnancy
Surgery
management of pregnant patients with cancer should be decided by a multidisciplinary team. When
Chemotherapy cancer is diagnosed in the rst or early second trimester of pregnancy, 44% of respondents prefer
Radiotherapy termination of pregnancy: if the patient wishes to preserve the pregnancy, 77% consider deliberate delay
Management and treatment later in pregnancy. When cancer is diagnosed in the late second or third trimester of
European Society of Gynecological pregnancy, 58% prefer preterm delivery in order to start cancer treatment in the postpartum period: 37%
Oncology would not give chemotherapy or radiotherapy during pregnancy. Treatment during pregnancy with the
aim of a term delivery is preferred by 41% of respondents. Univariate logistic regression analysis found a
trend that non-academic hospitals prefer termination of pregnancy (odds ratio [OR] = 0.68; 95% CI, 0.28
1.63; P = 0.39), and also no treatment during pregnancy (OR = 0.70; 95% CI, 0.331.50; P = 0.36).
Conclusion: Termination of pregnancy, delay of maternal treatment and iatrogenic preterm delivery are
frequently applied strategies in the management of pregnant cancer patients. These results suggest that
current treatment is not in line with recent evidence, and there is room for improvement on the
oncologic treatment of pregnant women. Centralization of treatment is needed.
2012 Elsevier Ireland Ltd. All rights reserved.

1. Introduction with cancer is 1: 10002000 pregnancies [4,5]. In Europe, with a

Nowadays, a greater proportion of women decide to postpone
childbearing. During the last decade, the age of rst birth in Europe
has increased by an average of two years [1], reaching 30 years in
some countries [2]. The risk of developing cancer increases with
age [3]. This is why an association between cancer and pregnancy
may be expected to occur more frequently. The incidence of cancer
during pregnancy is difcult to calculate due to the lack of central
registries, but the approximate risk of association of pregnancy
* Corresponding author at: Gynecological Oncology, University Hospitals Leuven,
KU Leuven, Belgium. Tel.: +32 16 34 42 52; fax: +32 16 34 46 29.
E-mail addresses: Frederic.amant@uzleuven.be,
frederic.amant@uz.kuleuven.ac.be (F. Amant).
1
Frederic Amant is senior clinical investigator for the Research Fund-Flanders
(F.W.O.).
population of 382 million women and a birth rate of 11:1000, the
expected number of deliveries is about 4.2 million annually [6].
The estimated number of pregnant patients diagnosed with cancer
would therefore be approximately 20004000 annually.
Management of cancer during pregnancy is a challenge.
Diagnostic, staging, and therapeutic interventions must be
performed carefully, bearing in mind risk factors associated with
both the pregnant mother and the unborn child.
In order to concentrate research efforts on the topic of cancer in
pregnancy, a European Society of Gynecological Oncology (ESGO)
Cancer in Pregnancy Task Force was initiated in 2009 (http://
www.esgo.org/Networks/Pages/TaskForces.aspx). Important differ-
ences in the approach of pregnant cancer patients among members
within this task force were observed. We therefore decided to
conduct a survey with the aim of exploring the current practice in
management of cancer in pregnancy. The survey was conducted

0301-2115/$ see front matter 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ejogrb.2012.10.026
 S.N. Han et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 167 (2013) 1823 19

before the publication of the interim analysis on the long term
outcome of children exposed to chemotherapy in utero [7].
2. Materials and methods
We designed a two-page questionnaire with 30 questions on
physicians practice in the treatment of cancer in pregnancy
(Addendum 1). The two main subjects were, rstly, who should
treat patients with cancer in pregnancy and where? Secondly,
should treatment be initiated during pregnancy or is it
preferable to avoid treatment during pregnancy (by termination
of pregnancy or iatrogenic preterm labor)? Demographics,
practice type and self-reported rate of treating pregnant cancer
patients were also questioned; these data were collected
retrospectively for the year 2010. The survey was pilot-tested
among the members of the ESGO Fertility Preservation Task
Force, and after feedback, changes were made to avoid
ambiguity in phrasing. We used SurveyMonkey (http://
www.surveymonkey.com) for survey distribution and data
collection. From March to July 2011, the membership directories
of different professional societies across 14 European countries
were used to reach physicians involved in care of pregnant
patients and/or cancer (Addendum 2). Participants were not
required to answer all questions; therefore, some answers may
have missing values.
Supplementary data associated with this article can be found,
in the online version, at http://dx.doi.org/10.1016/j.ejogrb.2012.
10.026.
We used standard descriptive analysis: categorical variables by
number of respondents in the categories and their percentages,
and continuous variables by median, minimum and maximum.
Univariate logistic regression analysis was also undertaken to
examine factors independently associated with the preferred
treatment strategies during pregnancy.
3. Results
From March to July 2011, 246 questionnaires were returned:
104 (42%) of them were excluded because the questions on cancer
in pregnancy were not answered, leaving a nal sample size of 142
(58%) for the analysis. There were 19 (13%) non-European
respondents (Fig. 1), included because they were members of
one of the professional societies mentioned. Table 1 depicts the
demographic data of the respondents: most were either gyneco-
logic oncologists (48%) or general obstetricians/gynecologists
(37%). Sixty-one percent of the participants had the necessary
specialties in their center for the management of cancer in
pregnancy (obstetrics and gynecology, neonatology, medical and
radiation oncology). A median of 2 patients (range 0100; SD 12.2)
were diagnosed with cancer in pregnancy annually per center. The

Unknown
United States
Ukraine
United Kingdom
Turkey
The Netherlands
Thailand
Switzerland
Sweden
Spain
Slovakia
Serbia
Russia
Romania
Portugal
Poland
Philippines
Norway
Nigeria
Mexico
Country

Malaysia
Latvia
Jordan
Italy
Israel
Ireland
Indonesia
India
Iceland
Hungary
Greece
Germany
France
Finland
Estonia
Denmark
Czech Republic
Croaa
Bulgaria
Brazil
Belgium
Austria

0 2 4 6 8 10 12 14 16 18
No of respondents
Fig. 1. Number of respondents per country.
20 S.N. Han et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 167 (2013) 1823

Table 1 Table 2
Demographics of respondents. Summary of answers on the following question According to your opinion, at which
level of care should these patients be treated?.
N %
At least At least
Subspecialization
secondary tertiary
Gynecological oncologist 68 47.9
General obstetrician/gynecologist 53 37.3 Oncological care 47 (33%) 84 (59%)
Medical oncologist 8 5.6 Obstetric/neonatal care 57 (40%) 74 (52%)
Perinatologist 6 4.2 Subgroup of patients treated 44 (31%) 87 (61%)
Radiation oncologist 2 1.4 with chemo- and/or radiotherapy
Other/unknown 5 3.5 during pregnancy
Practice
Academic 90 63.4
Non-academic 51 35.9 Table 3
# Deliveries per year Summary of answers on the following question Which specialities are involved if
<100 21 14.8 you have a multidisciplinary team? (multiple answers possible).
1002000 35 24.6
20015000 57 40.1 Answer options Response rate %
>5000 18 12.7
Oncologist (gynecological/ 128 90
Unknown 11 7.7
surgical/medical)
# Cancer patients per year (all types)
Obstetrician 120 85
<100 26 18.3
Radiotherapeutic specialist 99 70
100500 61 43.0
Neonatologist 96 68
5015000 25 17.6
Pathologist 84 59
>5000 5 3.5
Radiologist 83 58
Unknown 25 17.6
Psychologist 58 41
# Cancer in pregnancy patients per year
Nuclear medicine specialist 55 39
<5 76 53.5
Skipped question 13 9
510 25 17.6
1130 11 7.7
>30 2 1.4
Unknown 28 19.7
3.2. Treatment: timing?/during pregnancy or not?

Eighty-nine percent of respondents discuss the possibility of

majority did not receive treatment during pregnancy (surgery:
median 1, range 050; chemotherapy: median 0, range 014;
radiotherapy: median 0, range 012).
3.1. Treatment: who and where?
Three survey items asked who should treat patients with cancer
in pregnancy and which level of care is required (Table 2). The vast
majority of respondents (94%) agreed that management of
pregnant patients with cancer should be decided by a multidisci-
plinary team (Table 3), of which 88% take the opinion of the patient
and/or her partner into consideration. Decisions were based solely
on the opinion of the patient or oncologist in 3% of respondents.
Psychological support is also offered in 73% of centers.
treating cancer during pregnancy (with surgery, chemotherapy,
radiotherapy). However, 44% prefer termination of pregnancy
when cancer is diagnosed in the rst or early second trimester, and
58% prefer iatrogenic preterm delivery in order to start cancer
treatment in the postpartum period when cancer is diagnosed in
the late second or third trimester (Table 4). Thirty-seven percent of
respondents believe that no chemotherapy or radiotherapy during
pregnancy should be given. A median gestational age of 34 weeks
(range 2840; SD 2.3) is considered safe for preterm delivery. If
chemotherapy and/or radiotherapy are utilized during pregnancy,
48% provide long-term follow up of the children. Only one third of
centers have a registry of pregnant patients with cancer, but 75%
are interested in registering patients anonymously in a centralized
web-based database.

Table 4
Physicians attitude toward management of cancer during pregnancy.

Question Yes No Not answered

When cancer is diagnosed in the rst or early

second trimester of pregnancy:
Termination of pregnancy is preferred 62 (44%) 44 (31%) 36 (25%)
If the patient wishes to preserve the pregnancy, 109 (77%) 11 (8%) 22 (15%)
deliberate delay and treatment later in pregnancy
should
be considered
When cancer is diagnosed in the late second or
third trimester of pregnancy:
Preterm delivery in order to start cancer treatment 83 (58%) 34 (24%) 25 (18%)
in the postpartum period is preferred
Treatment during pregnancy with the aim of a 59 (41%) 55 (39%) 28 (20%)
term delivery is preferred
In decision making on management of cancer
during pregnancy:
Maternal prognosis is of primordial importance 116 (82%) 1 (0.7%) 25 (18%)
If the patient wishes to preserve the pregnancy, 52 (37%) 63 (44%) 27 (19%)
all potential harm for the fetus should be avoided
(so no chemotherapy or radiotherapy during pregnancy)
 S.N. Han et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 167 (2013) 1823
Table 5
Univariate analysis of treatment during pregnancy.
Question Type of hospital
Odds Ratio
When cancer is diagnosed in the rst or early
second trimester of pregnancy:
Termination of pregnancy is preferred .68
If the patient wishes to preserve the 1.83
pregnancy, deliberate delay and treatment
later in pregnancy should be considered
When cancer is diagnosed in the late second
or third trimester of pregnancy:
Preterm delivery in order to start cancer 1.07
treatment in the postpartum period is preferred
Treatment during pregnancy with the aim 1.34
of a term delivery is preferred
In decision making on management of
cancer during pregnancy:
If the patient wishes to preserve the pregnancy, .70
all potential harm for the fetus should be
avoided (so no chemotherapy or radiotherapy
during pregnancy)7
Type of hospital: non-academic hospital (n = 37; reference group) versus academic hospital (n = 69); number of patients: less than ve (n = 75; reference group) versus ve or
more patients (n = 31).
Univariate logistic regression analysis was undertaken to
examine factors independently associated with the preferred
treatment strategies during pregnancy (Table 5). The following
two covariates were explored: number of patients treated
annually (categorized as none or less than ve and ve or more);
and type of center (categorized as non-academic hospital or
academic hospital). Although no statistical signicant relation-
ship was seen, we found a trend that non-academic hospitals
prefer termination of pregnancy (odds ratio [OR] = 0.68; 95% CI,
0.281.63; P = 0.39), and also no treatment during pregnancy
(OR = 0.70; 95% CI, 0.331.50; P = 0.36). In concordance with this
observation, an increased likelihood was found for academic
hospitals to consider treatment during pregnancy after the rst
trimester (OR = 1.83; 95% CI, 0.784.28; P = 0.17). Similar trends
were found for centers treating ve or more patients annually,
although the wide condence intervals make the ndings less
strong (Table 5). A subanalysis of only the European respondents
(n = 123) led to similar results.
4. Comment
Treatment of cancer in pregnancy has become more acceptable
in the last decade, and an increasing number of reviews on this
topic are being published. Meanwhile, original studies remain
scarce, mostly due to the low incidence per center. To the best of
our knowledge, this is the rst study to assess healthcare providers
practice in the management of cancer in pregnancy. Findings from
this survey may guide future research and education.
Several notable ndings are revealed by this study. The most
important observation is that there is no consensus about
management of cancer during pregnancy among respondents. A
signicant number are very reluctant to start oncologic treatment
during pregnancy and would prefer iatrogenic preterm delivery.
Almost half of specialists (44%) would recommend termination of
pregnancy as their rst choice when cancer is diagnosed during the
rst or early second trimester of pregnancy. Preterm delivery in
order to start cancer treatment in the postpartum period is
preferred by 58%. Consistent with these ndings is the opinion that
37% of respondents would not consider chemo- and/or radio-
therapy during pregnancy.
Although certain circumstances warrant this cautious ap-
proach to avoid oncologic treatment during pregnancy (e.g.
21
Number of patients
95% CI P Odds Ratio 95% CI P
.281.63 .39 .93 .382.27 .87
.784.28 .17 1.15 .423.15 .79
.512.25 .86 .94 .422.12 .89
.632.85 .45 1.66 .743.70 .22
.331.50 .36 .67 .603.13 .46
termination of pregnancy during the rst trimester when
advanced stage disease is diagnosed and treatment needs to
start as soon as possible), several studies have shown that
different types of oncologic treatment can be utilized during
pregnancy without compromising fetal health [711]. The
placental barrier protects the fetus from a considerable amount
of chemotherapy, although passage rates vary considerably per
drug: animal models show 110.8% transplacental transfer of
anthracyclines [12,13], and even less transfer of taxanes (0.8
2.4%) [14]. Carboplatin transplacental transfer is highest (43
156%) [14,15]. Radiotherapy during pregnancy is even more
controversial than chemotherapy and is often avoided during
pregnancy. Studies have shown, however, that radiotherapy is
possible in certain cases, if the radiation eld is sufciently far
from the fetus, and proper lead shielding is in place to protect
against radiation leakage and collimator scatter of the tele-
therapy machine. Phantom models can help estimate the
anticipated radiation dose to the fetus during simulated
treatment [18]; if the threshold dose of approximately 0.1 Gy
is not reached, radiation effects (such as fetal death, mental
retardation and organ malformation) are kept to a minimum. In
each case, a careful balance needs to be made between maternal
benet and fetal risk [16,17].
Sixty-six percent of respondents think that delivery between
32 and 34 gestational weeks is safe for the newborn. Such an
approach may be explained by the specialist prole of
participants, who were mostly gynecologists coming from
tertiary health centers where high-level obstetric and neonatal
service can be provided. Although this is a gestational age
associated with more favorable outcome when compared to
<32 weeks, the mortality and neonatal morbidity of preterm
births between 32 and 36 weeks can still be substantial
(considered safe in 78% of respondents) [19,20]. Until recently,
the outcomes of infants born at moderate preterm (3233 weeks)
and late preterm (3436 weeks) gestations were thought to be
similar to those of infants born at 37 weeks and above. Several
recent studies, however, have shown that although their
problems may be less obvious than those of extremely preterm
neonates, adverse outcome such as long-term health, neurode-
velopmental and educational problems are signicantly greater
in this group than previously believed [21,22]. When possible, a
term delivery should be aimed for.
22 S.N. Han et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 167 (2013) 1823
Choosing the appropriate treatment for a specic patient
requires a multidisciplinary approach which involves non-
oncological specialties such as perinatology and neonatology.
Most participants in our survey (94%) aim for a multidisciplinary
approach. However, the small number of pregnant patients with
cancer per center (none or less than three in 48% of centers) and
even smaller number of those who actually receive treatment
during pregnancy raise the question of quality of care for these
patients. This is supported by the trend found in logistic
regression results: although analyses were not statistically
signicant, a probable explanation is the small sample size.
Meanwhile, the self-reported rates from the current survey in the
two centers in the United States (n = 70 and n = 100 in 2010)
suggest that centralization is possible.
Our results also show ambivalence in treatment strategy. Most
physicians believe that the mothers prognosis is of the utmost
importance. To aim for the best standard of care without
compromising maternal prognosis, treatment needs to be started
promptly. However, most physicians also regard oncological
treatment to be unsafe for the unborn fetus (chemotherapy in
particular), but avoiding treatment during pregnancy risks
jeopardizing the health of both mother and child. The mothers
health can be impaired by delay of treatment, and the childs health
can be impaired by iatrogenic prematurity or even termination of
pregnancy. Additionally, termination of pregnancy does not
benet maternal prognosis [23,24]. The lack of consensus might
be compounded by the fact that gynecologists/perinatologists and
oncologists have little knowledge of each others eld of expertise,
and over- or under-estimate the issues concerned.
Some limitations of the study have to be noted. First, most of the
participants were either obstetricians/gynecologists (37%) or gyne-
cological oncologists (48%). The attitudes among physicians from
different medical specialties and different clinical settings might
vary signicantly, and our surveyed sample did not include many
neonatologists, medical oncologists or radiation oncologists. Under-
standably, obstetricians would be hesitant to discuss oncology risks
with pregnant patients, while oncologists would not be competent
to decide upon obstetric issues. This underscores the importance of a
multidisciplinary approach [25]. Second, these results may be
subject to response bias. It is possible that those who chose to
respond to our survey were more sensitive to and knowledgeable
about pregnancy and cancer issues due to their practice environ-
ment. Also, 42% of physicians who started to ll in the survey did
not answer any questions on cancer in pregnancy: this might imply
an interest but simultaneous lack of knowledge in the subject. As we
utilized membership directories of different professional societies
across Europe, and also individual mailings via contact persons of
European Board and College of Obstetrics and Gynecology (EBCOG)
accredited centers, it was not possible to reconstruct the exact
distributed number of questionnaires or response rate.
Despite these limitations, our ndings suggest that inconsis-
tency exists in practice behavior of pregnancy and cancer care. This
may be because of a lack of good quality evidence on the fetal
safety after in utero exposure to cytotoxic therapy. Another
important issue is related to the workload in this specic eld of
clinical practice. The low numbers of cases seen by one physician
or even in one center supports the concept of centralization for
cancer and pregnancy management in order to improve the quality
of care. A strict referral system in order to centralize specic
expertise should be proposed.
Several guidelines have been presented in the past few years.
The most comprehensive are international guidelines for treat-
ment of gynecological cancers [26] and for treatment of breast
cancer during pregnancy [25]. The European Society of Medical
Oncology (ESMO) has also published clinical practice guidelines on
cancer, fertility and pregnancy [27]. Long term follow-up of 70
children who were exposed to chemotherapy in utero did not
reveal increased morbidity and mortality, especially when
examining cardiac and neurological function [7]. More studies
are needed, however, of both oncological and obstetrical aspects,
so that all pregnant cancer patients receive standard care as much
as possible. Currently, several prospective registration studies are
ongoing, and active participation is encouraged. Ongoing studies
are http://www.cancerinpregnancy.org (all cancer types, Europe);
http://www.germanbreastgroup.de (breast cancer only, Europe);
http://www.cancerandpregnancy.com (all cancer types, US) and
http://www.motherisk.org/women/cancer.jsp (all cancer types,
Canada). Cancer during pregnancy should be treated the same
way globally, but based on differences in legislation, and also in
personal, cultural, and religious beliefs, differences between the
European countries and also between Europe and other parts of the
world are to be expected. This warrants ongoing international
investigation and collaboration.
5. Conclusion
In summary, our study suggests that physicians remain
uncertain as to how and when to treat cancer during pregnancy.
Current knowledge relies mainly on experiences from small case
series on cancer in pregnancy and several case reports. The
ndings of this study should provide a foundation for additional
research and possible targeted interventions that aim to improve
physician knowledge. The ESGO Cancer in Pregnancy Task Force
welcomes active members who want to improve current
knowledge through collaboration.
Conict of interest
We declare that we have no conicts of interest.
Funding
This research is supported by Research Foundation-Flanders
(F.W.O.) and Belgian Cancer Plan, Ministry of Health, Belgium.
The funding sources had no involvement in study design;
collection, analysis, and interpretation of data; in the writing of
the manuscript; nor in the decision to submit the paper for
publication.
Condensation
This survey shows that termination of pregnancy, delay of
maternal treatment and iatrogenic preterm delivery are frequent
strategies in the management of pregnant cancer patients.
Acknowledgements
We thank Marieke Taal and the ESGO Administrative Ofce
for distributing the questionnaire. We thank Ben Van Calster for
statistical advice. We thank the members of the ESGO Cancer in
Pregnancy Task Force for their collaboration: Anna Skrzypczyk
(Maria Sklodowska-Curie Memorial Cancer Center and Institute
of Oncology, Warsaw, Poland), Annette Hasenburg (Universi-
tatsklinikum Freiburg, Freiburg, Germany), Catherine Uzan
(Institute de Cancerologie Gustave Roussy, Villejuif, France),
Christianne Lok (Center for Gynecological Oncology Amsterdam,
Amsterdam, The Netherlands), Christoph Benedicic (Universi-
tatsklinik fur Frauenheilkunde und Geburtshilfe, Graz, Austria),
Daiva Vaitkiene (Kaunas University of Medicine, Kaunas,
Lithuania), Fedro Peccatori (European Institute of Oncology,
Milan, Italy), Janina Markowska (Poznan University of
Medical Sciences, Poznan, Poland), Karina Dahl-Steffensen
 S.N. Han et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 167 (2013) 1823
(Vejle Hospital, Vejle, Denmark), Maysoon Iraki (Luzerner
Kantonsspital, Sursee, Switzerland), Michael Halaska (2nd
Medical Faculty for the Charles University, Prague, Czech
Republic), Monica Fumagalli (IRCCS Ca Granda Ospedale
Maggiore Policlinico Milano, Milan, Italy), Nelleke Ottevanger
(Radboud University Medical Center Nijmegen, Nijmegen, The
Netherlands), Nicholas Pavlidis, (Ioannina University Hospital,
Ioannina, Greece), Nicholas Reed (Beatson Oncology Center,
Gartnavel General Hospital, Glasgow, United Kingdom), Olivier
Cottier (Center Hospitalier Universitaire Vaudois, Lausanne,
Switzerland), Paolo Zola (University of Turin, Turin, Italy),
Pierluigi Benedetti Panici (La Sapienza University, Umberto I
Hospital, Rome, Italy), Rainer Kimmig (University Clinic Essen,
Essen, Germany), Robert Fruscio (Ospedale San Gerardo, Monza,
Italy), Roman Rouzier (Universite Paris 6 Pierre et Hopital Tenon,
Paris, France), Sibylle Loibl (Ambulantes Krebszentrum Frank-
furt, and German Breast Group, Neu-Isenburg, Germany), Uwe
Lang (Medical University of Graz,Graz, Austria), Wojciech
Kolawa (University Hospital of Krakow (Jagiellonian University),
Krakow, Poland).
References
[1] Frejka S, Sardon JP. First birth trends in developed countries: persisting parent-
hood postponement. Demographic Research 2006;15:14780.
[2] OECD Family Database. SF2.3: mean age of mothers at rst childbirth. OECD
social policy division directorate of employment, labour and social affairs.
http://www.oecd.org/els/social/family/database; 2012. Ref type: online source.
[3] American Cancer Society, Cancer Facts and Figures. http://www.cancer.org/
acs/groups/content/@epidemiologysurveilance/documents/document/acspc-
031941.pdf; 2012. Ref type: online source.
[4] Nieminen U, Remes N. Malignancy during pregnancy. Acta Obstetricia et
Gynecologica Scandinavica 1970;49:3159.
[5] Stensheim H, Moller B, van DT, Fossa SD. Cause-specic survival for women
diagnosed with cancer during pregnancy or lactation: a registry-based cohort
study. Journal of Clinical Oncology 2009;27:4551.
[6] United Nations data retrieval system. http://data.un.org/; 2012. Ref type:
online source.
[7] Amant F, Van Calsteren K, Halaska MJ, et al. Long-term cognitive and cardiac
outcomes after prenatal exposure to chemotherapy in children aged
18 months or older: an observational study. Lancet Oncology 2012;13:25664.
[8] Aviles A, Neri N. Hematological malignancies and pregnancy: a nal report of
84 children who received chemotherapy in utero. Clinical Lymphoma
2001;2:1737.
23
[9] Van Calsteren K, Heyns L, De Smet F, et al. Cancer during pregnancy: an
analysis of 215 patients emphasizing the obstetrical and the neonatal out-
comes. Journal of Clinical Oncology 2010;28:6839.
[10] Cardonick E, Usmani A, Ghaffar S. Perinatal outcomes of a pregnancy compli-
cated by cancer, including neonatal follow-up after in utero exposure to
chemotherapy: results of an international registry. American Journal of Clini-
cal Oncology 2010;33:2218.
[11] Lataifeh IM, Al Masri M, Arahmeh S, et al. Management of cancer during
pregnancy: obstetric and neonatal outcomes. International Journal of Gyne-
cological Cancer 2011;21:115964.
[12] Van Calsteren K, Verbesselt R, Beijnen J, et al. Transplacental transfer of
anthracyclines, vinblastine, and 4-hydroxy-cyclophosphamide in a baboon
model. Gynecologic Oncology 2010;119:594600.
[13] Van Calsteren K, Verbesselt R, Van Bree R, et al. Substantial variation in
transplacental transfer of chemotherapeutic agents in a mouse model. Repro-
duction Science 2011;18:5763.
[14] Van Calsteren K, Verbesselt R, Devlieger R, et al. Transplacental transfer of
paclitaxel, docetaxel, carboplatin, and trastuzumab in a baboon model. Inter-
national Journal of Gynecological Cancer 2010;20:145664.
[15] Van Calsteren K, Verbesselt R, Ottevanger N, et al. Pharmacokinetics of
chemotherapeutic agents in pregnancy: a preclinical and clinical study. Acta
Obstetricia et Gynecologica Scandinavica 2010;89:133845.
[16] Kal HB, Struikmans H. Radiotherapy during pregnancy: fact and ction. Lancet
Oncology 2005;6:32833.
[17] Mazonakis M, Varveris H, Damilakis J, Theoharopoulos N, Gourtsoyiannis N.
Radiation dose to conceptus resulting from tangential breast irradiation.
International Journal of Radiation Oncology Biology Physics 2003;55:38691.
[18] Mhallem Gziri M, Han SN. Tongue cancers during pregnancy: case reports and
review of literature. Head and Neck 2011 [Epub October 19].
[19] Saigal S, Doyle LW. An overview of mortality and sequelae of preterm birth
from infancy to adulthood. Lancet 2008;371:2619.
[20] Boyle JD, Boyle EM. Born just a few weeks early: does it matter? Archives of
Disease in Children Fetal and Neonatal Edition 2011 [Epub August 24].
[21] Engle WA, Tomashek KM, Wallman C. Late-preterm infants: a population at
risk. Pediatrics 2007;120:1390401.
[22] Khashu M, Narayanan M, Bhargava S, Osiovich H. Perinatal outcomes associ-
ated with preterm birth at 3336 weeks gestation: a population-based cohort
study. Pediatrics 2009;123:10913.
[23] Cardonick E, Dougherty R, Grana G, Gilmandyar D, Ghaffar S, Usmani A. Breast
cancer during pregnancy: maternal and fetal outcomes. Cancer Journal
2010;16:7682.
[24] Brenner B, Avivi I, Lishner M. Haematological cancers in pregnancy. Lancet
2012;379:5807.
[25] Amant F, Loibl S, Neven P, Van Calsteren K. Breast cancer in pregnancy. Lancet
2012;379:5709.
[26] Amant F, Van Calsteren K, Halaska MJ, et al. Gynecologic cancers in pregnancy:
guidelines of an international consensus meeting. International Journal of
Gynecological Cancer 2009;19(Suppl. 1):S12.
[27] Pentheroudakis G, Orecchia R, Hoekstra HJ, Pavlidis N. Cancer, fertility and
pregnancy: ESMO Clinical Practice Guidelines for diagnosis, treatment and
follow-up. Annals of Oncology 2010;21(Suppl. 5):v26673.