Counseling and surveillance of obstetrical risks for female childhood, adolescent, and young adult cancer survivors: recommendations from the International Late Effects of Childhood Cancer Guideline Harmonization Group

Kitty W.M. Bloemenkamp,William A. Grobman,Charlotte Demoor-Goldschmidt,Emily S. Miller,Louis S. Constine,Tom Walwyn,Yuriko Iwahata,Richard A. Anderson,Joop S.E. Laven,Rod Skinner,Saro H. Armenian,Hilary O. D. Critchley ,A. Mulders ,Matthew J. Ehrhardt,Angela Polanco,Anne-Lotte L F Van Der Kooi ,Daniel M. Green,Lillian R. Meacham,William H. Wallace ,Teresa K. Woodruff,Eline Van Dulmen–Den Broeder ,Jason Waugh,Cécile M. Ronckers,Marry M. Van Den Heuvel‐Eibrink ,Jeanette Falck-Winther,Leontien C. M. Kremer ,Melissa M. Hudson,Amber Samuel,Jennifer Levine ,Gill Levitt,Renée L. Mulder ,Iris Krishna,Wendy van Dorp

doi:10.1016/j.ajog.2020.05.058

Abstract

Female childhood, adolescent, and young adult cancer survivors have an increased risk of adverse pregnancy outcomes related to their cancer- or treatment-associated sequelae. Optimal care for childhood, adolescent, and young adult cancer survivors can be facilitated by clinical practice guidelines that identify specific adverse pregnancy outcomes and the clinical characteristics of at-risk subgroups. However, national guidelines are scarce and vary in content. Here, the International Late Effects of Childhood Cancer Guideline Harmonization Group offers recommendations for the counseling and surveillance of obstetrical risks of childhood, adolescent, and young adult survivors. A systematic literature search in MEDLINE database (through PubMed) to identify all available evidence published between January 1990 and December 2018. Published articles on pregnancy and perinatal or congenital risks in female cancer survivors were screened for eligibility. Study designs with a sample size larger than 40 pregnancies in childhood, adolescent, and young adult cancer survivors (diagnosed before the age of 25 years, not pregnant at that time) were eligible. This guideline from the International Late Effects of Childhood Cancer Guideline Harmonization Group systematically appraised the quality of available evidence for adverse obstetrical outcomes in childhood, adolescent, and young adult cancer survivors using Grading of Recommendations Assessment, Development, and Evaluation methodology and formulated recommendations to enhance evidence-based obstetrical care and preconception counseling of female childhood, adolescent, and young adult cancer survivors. Healthcare providers should discuss the risk of adverse obstetrical outcomes based on cancer treatment exposures with all female childhood, adolescent, and young adult cancer survivors of reproductive age, before conception. Healthcare providers should be aware that there is no evidence to support an increased risk of giving birth to a child with congenital anomalies (high-quality evidence). Survivors treated with radiotherapy to volumes exposing the uterus and their healthcare providers should be aware of the risk of adverse obstetrical outcomes such as miscarriage (moderate-quality evidence), premature birth (high-quality evidence), and low birthweight (high-quality evidence); therefore, high-risk obstetrical surveillance is recommended. Cardiomyopathy surveillance is reasonable before pregnancy or in the first trimester for all female survivors treated with anthracyclines and chest radiation. Female cancer survivors have increased risks of premature delivery and low birthweight associated with radiotherapy targeting the lower body and thereby exposing the uterus, which warrant high-risk pregnancy surveillance.

Highlights

Five-year survival rates for childhood, adolescent, and young adult (CAYA) cancer patients approach 80%.1 an increasing number of CAYA cancer survivors are at risk for adverse physical and psychosocial complications from their cancer or its treatment.[2]
Materials and Methods This guideline focuses on facilitating timely identification of CAYA cancer survivors at high risk of obstetrical complications diagnosed as having cancer before the age of 25 years who would benefit from preconception counseling and surveillance during pregnancy
There is moderate-level evidence that CAYA cancer survivors treated with radiotherapy to volumes exposing the uterus are at increased risk of miscarriage compared with the general population.9,14,23e29 this association was only borderline significant in a large cohort from the British Childhood Cancer Survivor Study (BCCSS)[26] and not significant in 2 smaller studies.[24,28]

Summary

Introduction

Five-year survival rates for childhood, adolescent, and young adult (CAYA) cancer patients approach 80%.1 an increasing number of CAYA cancer survivors are at risk for adverse physical and psychosocial complications from their cancer or its treatment.[2]. An increasing number of CAYA cancer survivors are at risk for adverse physical and psychosocial complications from their cancer or its treatment.[2] Reproductive health and pregnancy and delivery outcomes represent a critical area for longterm follow-up because having children is an important determinant of quality of life for CAYA cancer survivors.3e7. The risks of premature birth and postpartum hemorrhage are higher in CAYA cancer survivors than in women who did not have cancer,8e13 and these risks are further increased in survivors treated with abdominopelvic radiotherapy.9,11e14. Ajog.org type and prevalence of specific obstetrical and perinatal complications, characterize the clinical features of those at risk, help survivors make informed decisions, facilitate counseling and timely referral to high-risk obstetrical care, and enable opportunities for interventions to optimize pregnancy outcomes

Methods

Results

Conclusion