Lung Cancer During Pregnancy

pregnant woman talking to a doctor about lung cancer during pregnancy
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Lung cancer can and does occur during pregnancy at times, and since lung cancer is increasing in never smokers, especially young women, it may become an increasing problem in the future. There are a number of special challenges when lung cancer occurs during pregnancy, ranging from difficulties in making the diagnosis or choosing the best treatment options for both the mother and baby.

Lung Cancer in Pregnant Women

Many people are surprised to hear that pregnant women can develop lung cancer. Most people associate lung cancer with those who are older and have smoked. Yet that's not always the case.

Lung cancer can occur in young adults and unlike the recent decreases in lung cancer in older people, lung cancer in younger people is increasing. In fact, for one group of people, the incidence of lung cancer has increased the most: young, never-smoking women.

Characteristics of Lung Cancer in Pregnant Women

While lung cancer may occur during pregnancy, it is not very common. The first case of lung cancer in a pregnant woman was reported in 1953, and as of 2016 there has only been an additional 70 cases reported in the literature.

A review of the literature helped reveal some characteristics of lung cancer diagnosed during pregnancy. Overall, the average age at diagnosis was 36, and the cancer was diagnosed at an average gestation of 27.3 weeks (with a range from 8 weeks to 38 weeks). Non-small cell lung cancer was the cause in 82%, but unfortunately, many of the diagnoses were made when the tumor was already very advanced. The fact that 97% of tumors were diagnosed at stage 3 or stage 4 suggests that lung cancer that occurs during pregnancy follows an aggressive course. On a more optimistic note, 82% of the women gave birth to normal newborns.

Is Lung Cancer Different in Pregnant Women?

There haven't been enough pregnant women with lung cancer to do in-depth studies of these cancers, but we know that lung cancer in young adults is often different from lung cancer in older adults, that lung cancer in women may be different from lung cancer in men, and that lung cancer in non-smokers often differs from that in non-smokers.

In a 2016 European study, only 50% of women who developed lung cancer while pregnant had a history of smoking (and since the women were young, they had not smoked that long if they did).

As noted earlier, the fact that lung cancer is usually diagnosed in the advanced stages in pregnant women suggests an aggressive course of the disease. A 2019 study looking at PD-L1 levels in pregnant women supports the theory that the relative suppression of the immune system during pregnancy may reduce the body's immune response to cancer.

Types

It's thought that lung adenocarcinoma, a type of non-small cell lung cancer, is responsible for the majority of lung cancers found in pregnant women. This is the type of lung cancer which is found most often in young people and never smokers with the disease. 

Why It May Be Hard to Diagnose

An obvious reason why diagnosing lung cancer in pregnant women can be difficult is that we usually try to avoid radiation exposure, such as lung CT scans or chest x-rays, during pregnancy. Another reason, however, has to do with the most common type of lung cancer found in pregnant women noted above.

There are two major categories of lung cancer: non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). with 80% of lung cancers being NSCLC's. Non-small cell lung cancers are again broken down into lung adenocarcinomas (around 50% of NSCLCs) squamous cell carcinomas of the lung (30% of NSCLCs) and large cell lung cancer.

Small cell lung cancers and squamous cell lung cancers tend to occur near the large airways. Due to their location, these cancers tend to cause symptoms early on such as a cough, recurrent infections due to airway obstruction, or coughing up blood.

In contrast, lung adenocarcinomas tend to grow in the periphery of the lungs, and may grow quite large before they cause symptoms. Because of their location, they often cause slowly progressive shortness of breath, often first occurring only with exertion. They may also cause fatigue. Since some degree of shortness of breath and fatigue are so common with pregnancy, many women might first dismiss their lung cancer symptoms as being related to pregnancy; especially if they have never smoked.

Diagnostic Options

There are options for testing for lung cancer in pregnant women that minimize exposure of the baby to radiation. Tests such as MRI do not use radiation and are considered relatively safe in pregnancy. X-ray studies such as CT scans may be done when necessary if the baby is shielded from exposure.

Gene Mutations

Among young adults, non-smokers, and women with lung cancer, there is a much greater incidence of "actionable gene mutations." In other words, tumors in young people are more likely to have genetic changes for which the newer targeted therapies may be effective. For this reason, it is extremely important for women who are diagnosed during pregnancy (as well as all young adults who are diagnosed with the disease) to have molecular profiling (gene testing) done on their tumors.

Some of these changes may include EGFR mutations, ALK rearrangements, ROS1 rearrangements, BRAF mutations, and more.

Why Lung Cancer in Pregnant Women Is Increasing

It's thought that the main reason why lung cancer in pregnant women is increasing is that lung cancer is increasing in young people worldwide. At the same time, the age at first pregnancy is increasing in developed countries.
The mutational signature of these tumors suggest that secondhand smoke is not a major culprit, but the precise reasons have eluded us at this time. There is some concern that radon exposure in the home is increasing due to changes in home construction, but issues such as these have only recently begun to be studied.

We do know that there is a relationship between estrogen and lung cancer but aren't certain whether this may play a role in lung cancer in pregnant women. Lung cancer cells often have estrogen receptors, and the risk of lung cancer has been linked to hormone replacement therapy, oral contraceptive use, etc.

Facing Lung Cancer as a Pregnant Woman

A diagnosis of lung cancer during pregnancy may seem to come out of left field. You are waiting to hear the words "it's a boy" or "it's a girl," not "you have lung cancer."

If you've been diagnosed with lung cancer during pregnancy, there are a few things you should know. People have received treatment during pregnancy and gone on to deliver healthy babies. It may be surprising, but treatments such as some types of chemotherapy are relatively safe for the baby during the latter part of pregnancy (not during the first trimester). The use of targeted therapies during pregnancy, though package inserts would certainly caution against their use, has also been associated with healthy babies when they have been used.

Managing Both

Being diagnosed with lung cancer during pregnancy is a little like walking a tightrope, but that tightrope walk can go much better if you have specialists helping you on both sides.

It's important to find an oncologist who is comfortable treating pregnant women with lung cancer. You may need to get a second opinion (or a third or a fourth). If you have a tumor with a targetable mutation (such as ALK), finding a lung oncologist who specializes in your particular molecular subtype of cancer can be very helpful. It can be challenging finding these providers, but connecting with other young lung cancer survivors on social media can be priceless. One lung cancer organization, the Bonnie Addario Lung Cancer Foundation (now merged with the Lung Cancer Alliance to become the GO2 Foundation), has taken a particular interest in young people with lung cancer.

At the same time, having an obstetrician who specializes in high-risk pregnancies is important. This physician can help you weigh the risks of prematurity with an early delivery against the risks of continuing the pregnancy and exposing the baby to the treatments you need.

Treatment Options

Surgery for lung cancer offers the best option for a cure for women with early-stage disease (stage 1, Stage 2, and stage 3A). Thoracic surgery can be performed on pregnant women, though special care is required for monitoring both patients. The growing abdomen can also create challenges. As with any treatment the care team including the surgeon, oncologist, and obstetrics specialist will need to work together to determine the optimal care for both mother and baby.

Chemotherapy

During second and third trimester, chemotherapy is not associated with a teratogenic effect, meaning that chemotherapy is unlikely to cause birth defects. There is a risk of babies having a low birth weight as well as a small risk of intrauterine growth retardation.

A 2010 study found that metastases to the baby from the tumor occurred 26% of the time. Due to this risk, your obstetrician may consider delivering your baby well before your official due date. In another study, it was found that for women treated with chemotherapy while pregnant, there were no metastases to the placenta or fetus.

Unfortunately, the prognosis for women treated with chemotherapy alone is poor, so other options may be considered.

Targeted Therapies

In the past, targeted therapies (such as Tarceva (erlotinib) for EGFR mutations) were avoided during pregnancy, but several recent case reports have discussed cases in which drugs such as Tarceva, Iressa (gefitinib), or Xalkori (crizotinib) were used, with no evidence of any effect on the baby after delivery.

In a 2015 report published in JAMA Oncology, a woman was treated successfully throughout her pregnancy. She was diagnosed (twin pregnancy) with stage 4 lung cancer with brain metastases at 10 weeks gestation, and Tarceva was started at the beginning of her second trimester (after an ethics consultation). When evaluated 13 months postpartum, the babies were both healthy and the mother was able to work as well as care for her babies (without treatment her expected life expectancy would have been less than one year).

Testing did show that Tarceva crossed into the placenta, but levels were much lower than the mother's blood concentration of the drug.

Fertility After Lung Cancer Treatment

If you develop lung cancer during pregnancy you may wonder about future pregnancies. It's true that some chemotherapy drugs can cause infertility, and thus these are questions you want to ask right away if you are hoping to have another child. There are options, such as freezing embryos before starting treatment, that can leave the door open if you would wish to become pregnant in the future. At that time you will face the decision about whether you are healthy enough to carry a baby or if you should consider a surrogate.

A Word From Verywell

Lung cancer during pregnancy is becoming more common. Though there are certainly many risks, many people have gone on to receive treatment and deliver healthy babies. Treatment of lung cancer during pregnancy depends on how far along you are (the gestational age of the baby). and many other factors such as the type and stage of your cancer, molecular profiling, and social support.

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Article Sources

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  2. Okuyama M, Mezawa H, Kawai T, Urashima M. Elevated Soluble PD-L1 in Pregnant Women's Serum Suppresses the Immune Reaction. Frontiers in Immunology. 2019. 10:86. doi:10.3389/fimmu.2019.00086

  3. Ji Y, Schwartz J, Hartford A, et al. Successful Treatment of Non–Small Cell Lung Cancer With Erlotinib Throughout Pregnancy. JAMA Oncology. 2015. 1(6):838-840. doi:10.1001/jamaoncol.2015.1300

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