cervical cancer in pregnant women

1. Ther Adv Med Oncol
(2013) 5(4) 211­–219
DOI: 10.1177/
1758834013494988
© The Author(s), 2013.
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Therapeutic Advances in Medical Oncology Review
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Introduction
Cervical cancer is the most commonly diagnosed
gynaecological malignancy during pregnancy.
Incidence rates vary from 0.1 to 12 per 10,000
pregnancies [Al-Halal et al. 2012; Takushi et al.
2002]. For cervical intraepithelial neoplasia (CIN),
reported incidence rates vary between 1.30 and
2.7 per 1000 pregnancies [Al-Halal et al. 2012].
Owing to the rarity of the disease, and the com-
plexity of all factors that have to be taken into con-
sideration, standardization of treatment is very
difficult. The treatment of cancer during preg-
nancy is most challenging in the case of cervical
cancer, since the pregnant uterus itself is affected.
The rarity of the situation makes large trials or ran-
domized studies impossible, and guidelines up to
now are based on small case series and expert
opinion.Several clinical practice guidelines [Amant
et al. 2010; Hunter et al. 2008; Morice et al. 2009]
as well as a Lancet series paper have been published
[Morice et al. 2012] in an attempt to reach a con-
sensus on treatment options during pregnancy.
When treating a pregnant patient with cervical
cancer, several issues are important: histological
subtype, disease stage, nodal status, gestational
age, obstetrical complications and also patients’
wishes concerning continuation versus termina-
tion of pregnancy.These factors have to be taken
into consideration and discussed in a multidisci-
plinary team as well as with the patient and her
partner, before deciding on the treatment plan.
Traditionally, treatment of cervical cancer during
pregnancy was avoided: the usual course of action
was termination of pregnancy during the first two
trimesters, or delay of treatment until foetal matu-
rity in the third trimester, followed by standard
treatment postpartum. In the last decade, preg-
nancy preservation and treatment during preg-
nancy has become more common. In this current
review, we aim to summarize available data and
treatment guidelines concerning cervical cancer
in pregnancy. Controversies and research priori-
ties are also identified.
Pre-invasive disease
The main treatment of pre-invasive disease dur-
ing pregnancy is observation. Pregnancy does not
influence cervical lesions, and progression to
invasive disease during pregnancy is very rare
(0–0.4%) [Paraskevaidis et al. 2002]. Colposcopy
and directed biopsies can be safely performed
during pregnancy, but endocervical curettage is
Cervical cancer in pregnant women:
treat, wait or interrupt? Assessment
of current clinical guidelines,
innovations and controversies
Sileny N. Han, Mina Mhallem Gziri, Kristel Van Calsteren and Frédéric Amant
Abstract: Cervical cancer during pregnancy is relatively uncommon. However, the incidence is
expected to increase as more women delay childbearing. When preservation of the pregnancy
is desired, optimal treatment is a major challenge to all. Whereas delay of treatment is an
option for pre-invasive disease, and also small invasive carcinomas without lymph node
involvement, management of tumours >2 cm remains experimental. Type of treatment needs
to be individualized and depends mainly on gestational age, disease stage, and histology.
Extensive counselling regarding the maternal and foetal risks is required. In this current
review, we aim to summarize available data and treatment guidelines concerning cervical
cancer in pregnancy. Controversies and research priorities are also identified.
Keywords: cervical cancer, chemotherapy, neonatal, pregnancy
Correspondence to:
Frédéric Amant, MD, PhD
Leuven Cancer Institute
(LKI), University Hospitals
Leuven, and Department
of Oncology, KU Leuven,
Herestraat 49, Leuven
3000, Belgium
frederic.amant@uzleuven.be
Sileny N. Han, MD
Mina Mhallem Gziri, MD
Leuven Cancer Institute
(LKI), Gynaecologic
Oncology, University
Hospitals Leuven, and
Department of Oncology,
KU Leuven, Belgium
Kristel Van Calsteren,
MD, PhD
Foeto-Maternal Unit,
University Hospitals
Leuven, KU Leuven,
Belgium
494988TAM541758834013494988Therapeutic Advances in Medical OncologySN Han, MM Gziri
2013
494988

2. Therapeutic Advances in Medical Oncology 5 (4)
212 http://tam.sagepub.com
contraindicated [Jain et al. 1997]. Physiological
cervical changes during pregnancy, such as
increased vascularity, hypertrophy and hyperpla-
sia of the endocervical glands could mimic CIN;
therefore, colposcopy needs to be performed by
experienced colposcopists. Also, several physio-
logical cellular changes, such as degenerated
decidual cells (Arias–Stella phenomena) and
trophoblastic cells with variably staining cyto-
plasm and enlarged nucleus could mimic high-
grade squamous intraepithelial lesions (HSILs),
and lead to false-positive results if the pathologist
is unaware of the pregnant state.
The American Society for Colposcopy and
Cervical Pathology (ASCCP) has provided con-
sensus guidelines for abnormal cervical screening
tests and cervical histology [Apgar et al. 2009;
Wright et al. 2007]. In the case of atypical squa-
mous cells of undetermined significance
(ASC-US) or low-grade squamous intraepithelial
lesions (LSILs) during pregnancy, the rate of
finding CIN 2–3 on postpartum follow up is only
3.7% [Dunn et al. 2001]. Initial colposcopic
examination can therefore be postponed until at
least 6 weeks postpartum.
In the case of HSILs during pregnancy, prenatal
colposcopy (with directed biopsy) is recom-
mended. When CIN 2–3 is biopsy proven, or
when the colposcopist is absolutely certain of the
absence of invasion based on colposcopy alone,
repeat cytology and colposcopy may be performed
every 12 weeks to monitor disease progression.
Treatment during pregnancy, such as ablation or
excision, is not indicated. A diagnostic excisional
procedure (such as conization), is only indicated
if uncertainty persists: in case the suspicion for
microinvasive disease is high, colposcopy is unsat-
isfactory, or cytology and colposcopy do not cor-
relate. The risks for obstetric complications such
as haemorrhage, cervical incompetence and foetal
loss need to be discussed with the patient.
Postpartum spontaneous regression of CIN 2–3
lesions is fairly common, 48–70% regress during
the course of pregnancy [Ahdoot et al. 1998;
Paraskevaidiset al.2002;Yostet al.1999].Caesarean
section is not required in the case of CIN lesions.
Invasive disease: symptomatology
In general, pregnancy-associated complaints can
mask cancer-related symptoms, resulting in
patient and physician’s delay, and in higher stages
when cancer is diagnosed during pregnancy. In
contrast, pregnancy is an opportunity to screen
for cervical cancer by performing a PAP smear, in
patients without routine gynaecologic checkups.
Sadugor and colleagues described as early as
1949 that in 8% of their cases, cervical cancer was
discovered during routine examination in the
asymptomatic patient [Sadugor et al. 1949].
Symptomatology of cervical cancer during preg-
nancy is similar to the nonpregnant patient.The
most common symptom is (postcoital) vaginal
bleeding, which is usually painless and can dif-
fer in quantity. Abnormal vaginal discharge
(bloody, watery, malodorous or purulent),
although less frequent, can also be found
[Nguyen et al. 2000]. Symptoms can be mis-
taken for complications of pregnancy, and diag-
nosis delay occurs if the level of suspicion is low.
Pelvic or lower back pain and bowel or urinary
symptoms, which may also mimic frequently
occurring pregnancy-related complaints, can be
found with advanced disease.
Staging
Zemlickis and colleagues analysed data of 40
patients with cervical cancer during pregnancy, and
found that pregnant women were more likely to
present with early disease because of regular, preg-
nancy-related obstetric examinations [Zemlickis
et al. 1991]. However, this was not found by
Stensheim and colleagues who reported no differ-
ences in extent of disease when comparing 80 preg-
nant patients with 111 lactating patients and 5865
nonpregnant patients diagnosed with cervical can-
cer [Stensheim et al. 2009]. Accurate staging is one
of the main issues in cancer management, in order
to tailor treatment with the aim of optimizing onco-
logic outcome. The International Federation of
Gynecology and Obstetrics (FIGO) schema for
staging, is primarily based on clinical examination,
also in the pregnant state [Pecorelli, 2009].
Physical examination
If pelvic examination and accurate clinical staging
is difficult in the ambulatory setting, examination
under anaesthesia is suggested.
Pelvic lymph node assessment
Histopathologic assessment of lymph nodes
remains the most accurate method for assessment
of nodal status. Lymph node status is one of the

3. SN Han, MM Gziri et al.
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most significant prognostic factors for patients
with cervical cancer [Delgado et al. 1990].
Especially in early-stage cervical cancer, lymph
node status can guide management. Information
on the lymph node involvement can be obtained
either by magnetic resonance imaging (MRI) or
surgical removal. Laparoscopic lymphadenec-
tomy as a staging procedure for pregnant
women with stage I disease is feasible during
pregnancy and allows for reliable risk stratifica-
tion. In 31 reported cases, maternal and neona-
tal morbidity was low [Morice et al. 2012].
However, it is wise to bear in mind that lym-
phadenectomy has no therapeutic effect by
itself [Petry, 2012]. The usefulness of this inva-
sive diagnostic procedure has to be evaluated
on an individual basis.
MRI
MRI is the reference diagnostic examination
which can help determine tumour size in three
dimensions, stromal invasion, amount of healthy
stroma, vaginal and parametrial invasion, and also
lymph node infiltration (Figure 1) [Nicolet et al.
2000]. As stated by the American College of
Radiology, present data have not documented any
deleterious effects of MRI exposure on the devel-
oping foetus in any trimester of the pregnancy
[Kanal et al. 2007]. Gadolinium (a category C
drug according to the US Food and Drug
Administration) should only be used if absolutely
essential. No adverse effects to the neonate have
been found after gadolinium exposure in all three
trimesters [Sundgren and Leander, 2011].
However, gadolinium crosses the placenta and is
excreted by the foetal kidney into amniotic fluid;
it remains unknown how long it stays in this space
with the potential for dissociation of gadolinium
ion from its chelate molecule (which then becomes
toxic) [Kanal et al. 2007]. MRI during pregnancy
for staging of locoregional spread has been
described by Zanetta and colleagues in 6 patients
[Zanetta et al. 1998] and also Balleyguier and col-
leagues in 12 patients [Balleyguier et al. 2013].
MRI features of cervical cancer in pregnant
patients were comparable to the nonpregnant
patient, and allowed for tailored treatment plan-
ning. A good correlation between MRI findings
and pathology specimens was also found [Zanetta
et al. 1998]. Possible difficulties of MRI interpre-
tation during pregnancy were: physiological
hyperintensity of the cervix, making the tumour
either isointense or hypointense; foetal move-
ment impairing image quality (especially for
small lesions); and also scanning without gado-
linium [Balleyguier et al. 2013]. A possible pitfall
may be mistaking dilated pelvic veins for pelvic
adenopathy when evaluating the axial plane; this
can be prevented by also examining the other
planes. Estimation of tumour size can be difficult
when a patient has already undergone diagnostic
conisation.
Ultrasound
In recent years, sonographic examination of local
disease extension has also been shown feasible for
preoperative staging. Some prospective studies
have shown that transrectal or transvaginal ultra-
sound is comparable to the diagnostic accuracy of
MRI [Epstein et al. 2013; Fischerova et al. 2008].
If an ultrasound expert is available, this can be a
good alternative to MRI during pregnancy.
Distant metastases
In general, nonionizing imaging modalities
including ultrasonography and MRI are used in
the diagnostic workup of distant metastases. The
general rule when performing radiologic and
nuclear medicine examinations during pregnancy
Figure 1. MRI of the cervix in the midsagittal plane.
Upper arrow: uterus containing the foetus (16 weeks
gestation).
Lower arrow: tumour of the cervix, 6 cm diameter.
Biopsy confirms a squamous cell carcinoma of the
cervix. FIGO stage IB2.

4. Therapeutic Advances in Medical Oncology 5 (4)
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is that the radiation doses should be kept as low as
reasonably achievable and avoided when possible.
Diagnostic pelvic computed tomography (CT)
and fluorodeoxyglucose positron emission tomog-
raphy (FDG-PET)/CT can often be avoided, but
are both possible without compromising foetal
heath, if they may provide significant diagnostic
information of the maternal state [McCollough
et al. 2007]. CT of the thorax with abdominal
shielding is indicated, in cases of high suspicion
for pleural and/or lung metastases. Special effort
can also be made to limit exposure by reducing
radiation dose and scanning field [Stabin et al.
2012]. The foetal dose from nuclear medicine
examinations is variable and depends on factors
related to maternal uptake and excretion of the
radiopharmaceutical, passage across the placenta
and also foetal uptake [McCollough et al. 2007].
Takalkar and colleagues have estimated foetal
radiation exposure in five pregnant women with a
diagnosis of malignancy who underwent FDG-
PET studies [Takalkar et al. 2011], they found
foetal exposure levels ranging between 1.1 and
2.43 mGy, which is significantly below the
threshold dose for deterministic effects (50–100
mGy).
The clinical value of serum tumour markers for
cervical cancer in nonpregnant patients is ques-
tionable. Also, during pregnancy, the value of
tumour markers is limited, and the physiological
circulating levels throughout gestation have not
been well studied [Caluwaerts et al. 2006; Han
et al. 2012b]. Maternal serum levels of squamous
cell carcinoma antigen have been reported in two
studies to date, with rising levels in the third tri-
mester, although mean levels remained below the
cutoffthroughouttheentirepregnancy[Schlageter
et al. 1998;Touitou et al. 1989].
Treatment
Type of treatment depends mainly on gestational
age, disease stage, histology and the patient’s per-
sonal preference. We strongly recommend cen-
tralisation of treatment and multidisciplinary
management due to the complexity of the issue at
hand; the team should consist of (at least) a
gynaecological oncologist, medical oncologist,
radiologist, radiotherapist, perinatologist and
neonatologist, experienced in treating cancer dur-
ing pregnancy [Han et al. 2012a]. With other
types of malignancy, e.g. breast cancer, we advo-
cate that the proposed management should
adhere to standard treatment as much as possible
[Amant et al. 2012a]. However, this is often not
possible in the case of cervical cancer, without
termination of pregnancy or delay of treatment.
Patients need to be aware that any type of treat-
ment during pregnancy is experimental. When
preservation of pregnancy is not needed, standard
treatment with radical hysterectomy (with foetus
in utero) and chemoradiation are both feasible
options.
When cervical cancer is diagnosed during the
first trimester of a wanted pregnancy, a conserva-
tive approach is proposed to reach the second
trimester. During the third trimester, foetal
maturity is awaited and a Caesarean section fol-
lowed by standard treatment is proposed. During
the second trimester, interventions including
lymphadenectomy, conisation, trachelectomy
and neoadjuvant chemotherapy can be consid-
ered [Amant et al. 2009].
Treatment during pregnancy
Stage IA. If there is a high suspicion for invasive
disease, the optimal time to perform a conization
during pregnancy is between 14 and 20 weeks
gestation. Stage IA1 disease is usually diagnosed
after conization, when maximum depth of inva-
sion and horizontal diameter of the lesion can be
evaluated microscopically. This is also acceptable
as final treatment if there are negative margins
present. Positive section margins have been
reported by Dunn and colleagues (46%; 6/13)
[Dunn et al. 2003] and alsoYahata and colleagues
(50%; 2/4) [Yahata et al. 2008], in the latter study,
both patients underwent a second conization with
no residual disease. In the case of adenocarci-
noma, Smith and colleagues [Smith et al. 2002]
reported an analysis of 560 nonpregnant women
with stage IA1 and IA2 disease; of the patients
who underwent lymphadenectomy, only 1.5%
had positive pelvic lymph nodes. The censored
survival rate was 99.1% and no recurrences were
reported in the 98 cases managed by conisation as
only surgery.
Delivery should be vaginal unless there are obstet-
ric indications for Caesarean section.
Stage IB1, tumour size ≤2 cm. In patients with sig-
nificant risk for lymph node metastases, staging
lymphadenectomy during pregnancy can provide
information on lymph node status. Positive lymph
nodes warrant prompt initiation of definitive
therapy.

5. SN Han, MM Gziri et al.
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In the case of negative lymph nodes, Morice and
colleagues [Morice et al. 2012] advocated that
foetal maturation can be awaited before receiving
appropriate therapy after delivery, and found an
average treatment delay of 16 weeks in published
case reports. However, there are no studies of
what constitutes a safe period of delay, and the
risk of tumour progression is always present
[Takushi et al. 2002]. Radical trachelectomy was
first described by Dargent, as a possibility for fer-
tility preservation in the nonpregnant woman.
The cervix together with the surrounding para-
metria is removed with preservation of the uterine
corpus and the ovaries, and a pelvic lymphad-
enectomy is also performed. It is considered safe
in the case of stage IB1 disease with a tumour size
≤2 cm, and no nodal involvement [Plante et al.
2004]. There are few published cases of antepar-
tum trachelectomy, with a foetal loss rate of 33%
(5/15) within 16 days after surgery [Karateke
et al. 2010; Morice et al. 2012; Ungar et al. 2006].
This procedure can be undertaken via the abdom-
inal or vaginal approach, and mainly depends on
the surgeon’s experience and personal preference.
The major concern is perioperative and postop-
erative bleeding, and also diminished blood sup-
ply of the uterus if the uterine arteries are
sacrificed [Karateke et al. 2010]. Postoperative
placenta hypoperfusion might be the explanation
for the high foetal loss rate. Although oncologic
outcome is good after this procedure, antepartum
trachelectomy is not the preferred type of treat-
ment during pregnancy due to the poor obstetric
outcome.
Alternatively, trachelectomy can be replaced by
conization or simple trachelectomy in selected
cases with tumour size ≤2 cm and negative nodal
status. Simple trachelectomy consists of amputa-
tion of the cervix, about 1 cm above the endocer-
vical tumour margin, then removal of the
endocervical canal with use of a loop electrosurgi-
cal excision procedure with a small loop electrode
[Rob et al. 2011]. The removal of parametrium
significantly adds to the morbidity and poor
obstetric outcome of radical trachelectomy. The
rationale for removal of the parametrium is to
obtain a clear margin of the cervical tumour and
to prevent local recurrence due to remaining can-
cerous parametrial lymph nodes [Benedetti-
Panici et al. 1996]. Several studies [Covens et al.
2002; Frumovitz et al. 2009; Kinney et al. 1995;
Stegeman et al. 2007; Wright et al. 2007] have
shown a parametrial involvement rate of <1% in
patients with tumour size ≤2 cm, negative pelvic
lymph nodes, and stromal invasion ≤10 mm; this
supports the option of less radical surgery without
parametrectomy in patients that fulfil these crite-
ria [Rob et al. 2011; Schmeler et al. 2011].
Stages IB1, tumour size >2 cm and higher
stages. When conservative surgical treatment
during pregnancy is not possible, neoadjuvant
chemotherapy (NACT) is an option to achieve
disease control until foetal maturation, followed
by radical hysterectomy postpartum [Karam et al.
2007].
For the nonpregnant patient, NACT is some-
times used for the treatment of bulky or locally
advanced disease, with the aim to reduce tumour
volume, and thus increase operability. In a recent
Cochrane review on the treatment of the non-
pregnant patient, NACT plus surgery versus sur-
gery alone in women with early or locally advanced
cervical cancer was evaluated (stages IB to IIIB)
[Rydzewska et al. 2012]. In 6 trials consisting of
1078 women, both progression-free survival and
overall survival were improved with NACT.There
was also a significant decrease in adverse patho-
logical findings with NACT (lymph node status:
odds ratio [OR] 0.54, 95% confidence interval
[CI] 0.40–0.73, p ≤ 0.0001; parametrial infiltra-
tion: OR 0.58, 95% CI 0.41–0.82, p = 0.002).
There were also no differences in the effect of
neoadjuvant chemotherapy on survival according
to total cisplatin dose, chemotherapy cycle length
or by cervical cancer stage. Cisplatin-based chem-
otherapy was used in all trials and administered in
2–4 cycles at 10- to 21-day intervals; cisplatin
dose varied from 17 to 50 mg/m2 per week. The
total cisplatin dose ranged from 140 to 300 mg/m2.
Cisplatin was used in combination with vincris-
tine (with or without bleomycin and/or mitomy-
cin) in four studies and with 5-fluorouracil (with
or without mitomycin) in two studies.
During pregnancy, NACT can be used to aim for
down staging or stabilization, while awaiting foe-
tal maturation. Cisplatin 50–100 mg/m2 every 3
weeks has been proposed as the standard treat-
ment during pregnancy because this has been
used most often during pregnancy [Morice et al.
2012]. However, meta-analyses have shown that
in studies in nonpregnant patients, using chemo-
therapy at shorter intervals (<14 days) was associ-
ated with improvement in survival, and also that
paclitaxel with platinum combination therapy was
superior to single-agent cisplatin [Moore et al.
2004]. Carboplatin has a more favourable toxicity

6. Therapeutic Advances in Medical Oncology 5 (4)
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profile with less nephrotoxicity and ototoxicity,
combined with similar efficacy [Moore et al.
2007]. Although paclitaxel during pregnancy has
not been described in many cases, preclinical
studies have shown that the transplacental passage
of paclitaxel is minimal [Van Calsteren et al. 2010].
Fruscio and colleagues summarized data of 36
patients who received NACT during pregnancy
for FIGO IB1 to IIIB disease with a tumour
diameter of at least 3 cm [Fruscio et al. 2012]. In
this series, all patients that received paclitaxel
with platinum combination therapy had partial
remission in contrast to single-agent treatments
[Fruscio et al. 2012]. Based on its toxicity profile
and also experience in ovarian cancer, paclitaxel
with cisplatin or carboplatin is recommended
during pregnancy [Amant et al. 2009; Zagouri
et al. 2013]. The use of ifosfamide during preg-
nancy is not recommended due to its reported
foetal toxicity, although Mir and colleagues have
treated five patients with sarcoma during preg-
nancy using doxorubicin and ifosfamide without
adverse events [Mir et al. 2012]. In order to ensure
foetal safety, all types of chemotherapy should be
avoided during the period of organogenesis in the
first trimester of pregnancy [Han et al. 2013].
Pregnancy-related physiologic changes influence
the pharmacokinetic processes of all drugs, includ-
ing chemotherapeutic agents. These changes are
mainly initiated by progesterone and oestrogen,
and cause an increase of plasma volume by 45%
and cardiac output by 50%, which leads to an
increase of hepatic and renal perfusion and also
enlargement of the distribution volume. Based on
these changes, a reduced drug concentration is
possible when the chemotherapeutic dosages are
based on body surface area. A small pharmacoki-
netics study in pregnant women who received
chemotherapy during pregnancy confirmed this
hypothesis [Van Calsteren et al. 2010]; a decreased
area under the curve and peak plasma concentra-
tion, and increased distribution volume and clear-
ance were observed for all chemotherapeutics in
this study (doxorubicin, epirubicin, carboplatin
and paclitaxel). The clinical significance of these
results is still undetermined; theoretically, stand-
ard dosing might be too low for the pregnant
patient, but up to now, no survival differences
were observed between women with cancer treat-
ment during pregnancy and stage-matched non-
pregnant women.
Many questions still remain on the subject of
NACT during pregnancy: optimal chemotherapy
regimen, interval, dose, number of cycles are still
unknown. Randomized trials are not possible, but
we advocate staying as close as possible to the
standard schemes. Also, longer follow up is
needed of maternal outcome after NACT during
pregnancy. Fruscio and colleagues reported a
death rate of 25% (9/36 patients) [Fruscio et al.
2012]; although the majority of these patients had
negative prognostic factors, and prognosis seems
similar to the nonpregnant patient when stage-
matched, oncologic efficacy needs to be studied
of a larger group before NACT can become
standard treatment during pregnancy.The patient
needs to be aware of the experimental character
of this treatment.
Neonatal outcome after chemotherapy in utero
In an interim analysis of 70 children exposed to
chemotherapy in utero, long-term follow up is
reassuring (median follow up of 22.3 months)
[Amant et al. 2012b]. General cognitive develop-
ment was within the normal range for most chil-
dren. Prematurity was an important factor that
was associated with impaired neurodevelopmen-
tal outcome.Three of these children had impaired
hearing, of which one child had been exposed to
cisplatin at 28, 31 and 34 weeks gestation.
However, CT showed a retracted tympanic mem-
brane, which was the result of chronic middle ear
infections, which confounds the explanation of
hearing loss. In 4 of the 70 cases, the tumour type
was cervical cancer. It is important to note that
none of these patients received chemotherapy
during the first trimester of pregnancy. Further
long-term follow up is still needed to address the
risk of infertility and malignancy for this group of
children.
Conclusion
Cervical cancer is the most challenging cancer type
during pregnancy since the pregnant uterus itself is
involved. Many questions and controversies still
remain on this subject. The facts and also the
uncertainties should be discussed with the preg-
nant patient, so she can make an informed deci-
sion.We encourage referral of patients to treatment
centres with experience with the treatment of can-
cer during pregnancy. Curing the disease is the
main objective. Treatment during pregnancy is
possible but more research is needed. NACT is
still in an experimental setting and participation
in ongoing studies is strongly recommended.
Maternal survival must not be compromised in

7. SN Han, MM Gziri et al.
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favour of treatment delay. When considering any
modifications in the standard treatment, this must
be thoroughly discussed with the patient.
Funding
This research received no specific grant from any
funding agency in the public, commercial, or not-
for-profit sectors.
Conflict of interest statement
FA is senior clinical investigator for the Research
Foundation-Flanders (F.W.O.).
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