The identification of incidental adnexal masses in pregnancy has increased with the utilization of routine prenatal ultrasound. It has been estimated that 1% to 4% of pregnant women will be found to have an adnexal mass.[74,75] The majority of these masses will resolve on their own, but for the persistent adnexal masses, approximately 1% to 8% will be malignant.[76-79] Although a diagnosis of cancer during pregnancy is uncommon, it is a situation that requires extensive counseling concerning the risks and benefits of possible treatment options, ideally with a multidisciplinary team approach.[80]
Many institutions do not have mental health professionals on staff as part of their routine care for oncology patients. Nevertheless, a psychological consultation and/or mental health support should be offered to a pregnant woman found to have cancer.[81] The opportunity for a woman to process the meaning and significance of her medical condition during the initial adjustment and treatment-planning phase can be an essential component of the informed decision-making process. Ultimately, this emotional challenge is a conflictual crisis, with the joy of creating a life intertwined with the fear of a life-threatening condition. Treatment choices influence not only the future of the cancer patient but also the health and welfare of her unborn child.
Many institutions do not have mental health professionals on staff as part of their routine care for oncology patients. Nevertheless, a psychological consultation and/or mental health support should be offered to a pregnant woman found to have cancer.[81] The opportunity for a woman to process the meaning and significance of her medical condition during the initial adjustment and treatment-planning phase can be an essential component of the informed decision-making process. Ultimately, this emotional challenge is a conflictual crisis, with the joy of creating a life intertwined with the fear of a life-threatening condition. Treatment choices influence not only the future of the cancer patient but also the health and welfare of her unborn child.
The management of asymptomatic adnexal masses persisting in pregnancy is a controversial issue. Surgery during pregnancy has many risks associated with complications of miscarriage, rupture of the membranes, preterm labor, and preterm birth.[82] Conservative treatment is usually recommended for the management of early-stage malignant ovarian cancers.[51,79,83-85] An adnexectomy with staging is most commonly performed, followed by hysterectomy, and in some cases chemotherapy.[79]
For the diagnosis of cervical cancer in pregnancy, conservative management is the rule, with careful surveillance of dysplasia and small lesions during gestation to ensure the optimal outcome for mother and baby.[86] Cervical conization during pregnancy is usually reserved for the patient with suspected invasive cancer since complications, including significant hemorrhage, miscarriage, fetal loss, and increased perinatal deaths, can be disastrous.[87,88] Additionally, conization should not be preformed within 4 weeks of expected delivery, to reduce childbirth and postpartum complications. There is significant evidence favoring the delay of treatment until fetal maturity as a reasonable course of action without deleterious effects on the mother.[89,90] Cesarean radical hysterectomy with pelvic lymphadenectomy is an option, but with attention to potential blood loss.
Cancer Arising From Pregnancy
Gestational trophoblastic disease (GTD) is a unique type of women's cancer arising from pregnancy, specifically the abnormal development of placental tissue. GTD ranges from the benign form (complete or partial hydatidiform mole) to malignancies of various pathologic types. Clinically, women believe they are pregnant but experience unexpected vaginal bleeding and demonstrate an elevated blood pregnancy level (ie, human chorionic gonadotropin, or beta-hCG) with an abnormal ultrasound. The worldwide incidence of GTD is approximately 1 to 2 per 1,000 pregnancies.[91] These tumors respond extremely well to chemotherapy, and cure is possible in the presence of widely metastatic disease.
The abrupt psychological shift experienced by a woman facing a diagnosis of GTD can be traumatic.[92] The swing from excitement and anticipation of a future child to the sadness associated with the loss of a viable pregnancy to the anxiety and fear connected with a potentially malignant and life-threatening condition is profound and certainly unique to this disease entity.
The majority of women diagnosed with GTD are at the height of their reproductive potential, so issues concerning future fertility and pregnancy outcomes as well as overall sexual health are of paramount importance. Women are counseled to abstain from pregnancy for at least 1 year during the extended surveillance period. During this time, blood beta-hCG levels are followed, much like CA-125 or prostate-specific antigen levels in ovarian or prostate cancer. A concurrent pregnancy, which normally causes beta-hCG levels to rise, can mimic a cancer recurrence. A survivor's reproductive capacity is therefore delayed. Moreover, when a new pregnancy does occur, the woman will likely have significant anxiety over the rising beta-hCG levels and subsequent pregnancy. As survival from this disease is generally expected, psychosocial, fertility, and sexual health issues have a key role in the quality of life of survivors.[93]
Although treatment outcomes from chemotherapy and surgery in this setting have been described in some detail, the psychosocial aspects and long-term health consequences have rarely been explored. A few studies have described the psychosocial impact of GTD. Researchers from the New England Trophoblastic Disease Center—one of the specialized treatment centers in the United States—retrospectively surveyed 111 patients who had been diagnosed with GTD 5 to 10 years earlier.[94] More than half of the survivors were fearful of a secondary malignancy and of future testing despite being 5 to 10 years from their initial diagnosis.[94] Moreover, 40% of the respondents had significant concerns over their reproductive future; nearly 20% felt angry that their fertility had been compromised; and more than 30% mourned their pregnancy loss.[94] Patients reporting the highest quality-of-life scores had less disease-specific distress, greater social support, and were more likely to have had children following their treatment.[94] Interestingly, 75% of the survivors indicated that if a counseling program or support group were available following their diagnosis, they would have participated, and more than 50% would have enrolled in such a program 5 to 10 years after their diagnosis and cure.[94] These data provide powerful evidence that cancer-specific distress continues to affect women years after the completion of treatment.
A large Australian study by Petersen et al analyzed responses from 74 patients with molar pregnancies. Sixty percent of the survivors expressed severe anxiety and depression, in addition to significant levels of sexual dysfunction independent of time from diagnosis, age, children, or chemotherapy requirement.[93] Psychosocial issues were studied among patients over time, and more pronounced psychosocial distress was noted during the initial months following diagnosis.[93] The authors recommended a "multidisciplinary approach to care" addressing the medical, emotional, and social issues surrounding this unique disease entity, to improve survivors' well-being.[93]
While these studies highlight some significant psychosocial effects experienced by GTD survivors, many unanswered questions remain about the immediate and long-term health consequences of GTD treatment—in particular, issues of secondary malignancies and premature menopause. No research has assessed anxiety related to beta-hCG levels and its impact on family-building methods or whether treating physicians address fertility and quality-of-life concerns with survivors. Furthermore, no studies have compared levels of cancer-related distress and sexual health status in GTD survivors to those of other gynecologic cancer survivors or women without cancer but with reproductive concerns. Unique survivorship issues ensue when young women are faced with a cancer arising from a pregnancy.
