Should Pregnancy Testing be Standardized During Chemotherapy?

Administering chemotherapy to pregnant women with breast cancer can harm the fetus and cause birth defects down the line. However, guidelines are vague when it comes to pregnancy testing throughout treatment for premenopausal women.

Recently, a group of researchers from the Dubin Breast Center at the Tisch Cancer Institute at Mount Sinai in New York City investigated whether or not pregnancy testing for this patient population should be standardized. Their results are will be presented at the 2019 ASCO Annual Meeting.

The research team started by surveying 5 breast medical oncologists and 6 infusion nurses, and found that 40% of physicians and 33% of nurses diagnosed a pregnancy during chemotherapy.

“It was a little bit of a scary thought thinking that we don’t have guidelines for this,” said study author Katherine FitzPatrick, RN, BSN, OCN, assistant nurse manager at the Dubin Breast Center, in an interview with Oncology Nursing News.

Educating Patients on the Risks

When it comes to educating patients of childbearing age, the conversation should be twofold. Nurses must address the potential for infertility, but they also must talk to their patients about the risks that a pregnancy can pose.

“One of the main concerns when someone hears that they have a breast cancer diagnosis and they’re going to be undergoing chemotherapy is that they would lose fertility function, which makes it difficult to have the conversation about the risk of pregnancy,” FitzPatrick said. “You may lose your periods or might not be able to have a baby again, but there is still a chance that you could get pregnant.”

FitzPatrick discussed previous literature that showed that chemotherapy, especially when given in the first 19 weeks, could potentially cause the following health effects to the baby after it is born:

• Asymptomatic pulmonary arterial fistula
• Hydro encephalopathy
• Pyloric stenosis
• Polycystic kidney disease

“We do know that you can safely give certain types of chemotherapy in the third trimester and we have administered that for patients who found out that they had breast cancer when they were pregnant,” FitzPatrick said. “A lot of times, we will do everything we can in terms of treatment before they have to get chemotherapy, so it is pushed out to the third trimester.”

Starting and Continuing the Conversation

FitzPatrick admitted that it is not always easy for nurses to talk about the potential downfalls of pregnancy to women who are already concerned about their ability to have a child. However, that conversation is vital.

“If a patient is interested in fertility preservation, or the patient is extremely upset that they cannot preserve their eggs or can never have a child again, it could be a sore subject. We have to keep that in mind when we’re discussing the risk of pregnancy,” she said.

Current standards, according to ASCO and NCCN Guidelines, recommend pregnancy screening at the start of chemotherapy treatment, but monitoring for pregnancy after that lacks standardization.

While the research team did not recommend additional testing at the start of each treatment, they do acknowledge the importance of continually talking with patients about pregnancy risks and the importance of using non-hormonal birth control.

“We need to make sure that the patient is using a barrier-method contraception,” FitzPatrick said. “It’s something that we can’t really overlook at this point. We need to make sure that this conversation is happening every time they get treated.”

Looking Ahead

FitzPatrick said that this issue is currently being studied in breast cancer because of the large number of premenopausal patients. Moving forward, she hopes that standardized pregnancy conversations move to all realms of the cancer space.

“My hope is that we can standardize this across all premenopausal patients, regardless of the type of cancer they have,” she said. “One thing that we have found coming out of this study is that we do need to make a bigger emphasis on the risk of pregnancy during chemotherapy while still emphasizing the risk of infertility.”

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