Cancer in pregnancy- seeing beyond the bump!

Cancer diagnosis during pregnancy or in the post-partum period is thankfully a rare occurrence, with an estimated incidence of 1 in 1000 pregnancies in England. A key challenge is distinguishing symptoms of concern from the raft of ‘normal’ pregnancy related changes. A recent paper published in the BJGP explores how pregnancy can influence the way both pregnant women and health care professionals interpret symptoms, with important implications for diagnostic delay, prognosis and treatment options. 

The most commonly diagnosed cancers in pregnancy are breast, melanoma, cervical, haematological, ovarian and colorectal. There is significant overlap between pregnancy related symptoms such as nausea, fatigue and abdominal discomfort, and non-specific symptoms of cancer. Given such symptoms are common and cancer is rare, it’s not surprising that diagnostic overshadowing may occur. However, are we too quick to dismiss symptoms that we would investigate in non-pregnant individuals? Research suggests that even for breast cancer, with more focal and distinct symptoms, pregnancy is associated with delays both in women presenting to healthcare, and in diagnosis after presentation.

A recent qualitative study published in the BJGP used semi-structured interviews to explore the experiences of 20 women diagnosed with any cancer either during pregnancy or up to 3 months following pregnancy, assessing symptom appraisal and help-seeking prior to a cancer diagnosis. Participants were recruited in 2022 via an advert on Mummy’s Star, a UK charity supporting those with cancer during and around pregnancy.

A key theme identified was the tendency for all parties to interpret symptoms ‘through the lens of pregnancy’. Examples included patients assuming abdominal pain was pregnancy related (when in fact it was bowel cancer) or those assuming breast lumps to be part of the expected hormonal changes. Online searches including the term ‘pregnancy’ often confirmed this view and beliefs were also sometimes ‘reinforced by HCPs initial assessments or their lack of evidence concern’, reassuring patients that symptoms were ‘normal’ or ‘hormonal’. Concerningly, such reassurance was reported even in the presence of red flag symptoms, such as bleeding from a nipple or breast lump.

Those with cancers other than breast were more likely to have presented to primary care multiple times prior to diagnosis. Some with frequent consultations reported HCPs made them feel ‘silly’, ‘overly anxious’ or ‘hysterical’ first time mothers. In some cases patients weren’t examined, but simply reassured over the phone, missing opportunities to detect clinical signs. It is worth noting the study window included the pandemic, potentially affecting decision making on mode of assessment. 

This sits alongside the MBRRACE-UK report 2024, which identified ‘inadequate investigation of symptoms’ as a common theme in women who died. 

‘Remember the essentials’

Key recommendations from both sources include the importance of a thorough history, cancer/familial cancer history and clinical examination. Act on abnormal findings- refer for cancer investigations on the equivalent timescale to non-pregnancy individuals. If cancer is not suspected, clear safety netting is key, detailing specific timeframes for review if not improving, and actions to take if deteriorating.

The MBRRACE-UK report 2024  urges us to properly investigate ‘new, persistent or unusual symptoms’, including:

• Pain not responding to analgesia
• Anaemia not responding to iron supplementation (note British Society for Haematology guidelines recommend checking FBC 2-3 after commencing supplements to assess) 
• Severe headaches
• Vomiting and weight loss- note it is not common for women to experience N+V in subsequent pregnancies if they did not in previous pregnancies, onset of pregnancy related nausea and vomiting should be prior to 16/40 and other causes excluded.
• Rectal bleeding or changes in bowel movements 
• Breast lumps, abnormal nipple appearance or discharge
• Repeated presentation with the same symptom 

In conclusion, the key message when caring for pregnant women presenting with new, persistent or unusual symptoms is to keep an open mind,  remain alert to the risk of diagnostic overshadowing and remember to see ‘beyond the bump’  as serious pathologies such as cancer may present for the first time during pregnancy.