The notion that pregnancy hurts women diagnosed with melanoma has been debated for decades. It has been suggested, even assumed, that women who present with melanoma during pregnancy will have a worse prognosis. The hype about this evolved from dramatic reports and notable case studies of either pregnant women with a history of melanoma or those diagnosed with melanoma during pregnancy who then developed widespread disease.
Another disturbing aspect of this is the fact that melanoma is unique in that it is the most common cancer to metastasize to the placenta (Baergen, Johnson, Moore, et al., 1997). If there were evidence of placental metastasis, the risk for development of fetal metastases is 22 percent, thereby necessitating a thorough pathologic evaluation of the placenta with histologic evaluation (Leachman, Jackson, Eliason, Larson, & Bologna, 2007) and for the infant to be thoroughly examined and monitored closely.
Concern about the impact of melanoma on pregnancy came from older studies suggesting that pregnant women diagnosed with localized melanoma during pregnancy had poorer survival rates (Pack & Scharnagel, 1951), and that pregnancy subsequent to a melanoma diagnosis may contribute to metastasis.
There was also controversy regarding the influence of hormones on melanoma, specifically estrogen. This was based on a theoretical risk that estrogens may hinder survival, because estrogen receptors have been seen on melanoma cells. Essentially, the question was, if you provided exogenous forms of estrogen, as in estrogen-based contraceptives or hormone replacement therapy (HRT) for menopausal symptoms, or became pregnant (when estrogen levels fluctuate), were you, in essence, feeding melanoma cells? Due to this potential risk, women had been counseled not to get pregnant, HRT was discontinued, and non-estrogen birth control forms were recommended to women for at least two years from the time of diagnosis (which represents the greatest risk period for relapse).
Why am I even blogging about this?
Melanoma primarily affects individuals in the prime years of life, and a significant proportion of patients treated for melanoma are women between the ages of 15 and 45, the years of childbearing (Brady & Noce, 2010). One more interesting stat is that melanoma is the most commonly diagnosed cancer in pregnant women (Stensheim, Moller, van Dijk, & Fossa, 2009). Based on this, I felt this topic was blog-worthy.
To add my two cents, this is an age group that is generally healthy, and routine health exams are not always so regular, given their overall good health, but when a woman becomes pregnant, regular exams become part of the routine, and the normal skin changes seen in pregnancy may prompt a more detailed skin assessment, leading to a potential melanoma diagnosis.
To make sense of the controversy and to offer a bit more than just my opinion, I will refer you to a nice review of the literature by Brady and Noce (2010) reviewing 12 previously published reports on the impact of pregnancy on survival in patients with melanoma. They concluded that there was no evidence supporting the hypothesis that pregnancy hurts the outcomes in melanoma patients with clinically localized disease. They concluded that there was not enough evidence in the literature to support counseling women to delay childbearing.
They did, however, state that, for patients with more advanced melanoma, recommendations must be individualized. They stated that, in patients with advanced disease, there are immunological mechanisms that favor fetal allograft survival that may hurt pregnant melanoma patientsí survival.
Regarding the issue of hormonal impact on melanoma, Driscoll and Grant-Kels (2008) concluded that there was enough strong evidence suggesting that neither oral contraceptives nor HRT increased the risk of melanoma or metastases. Another study by Jhaveri et al. (2011) reported that risk for placental and/or fetal metastases was extremely low, and that they seemed to occur in women with widely metastatic disease.
Certainly, the decision to become pregnant after a diagnosis of melanoma must be given serious thought, and women must be counseled extensively. However, the most recent data supports optimism for women hoping one day to begin or add to their family.
Baergen R.N., Johnson, D., Moore, T., & Benirschke, K. (1997). "Maternal melanoma metastatic to the placenta: a case report and review of the literature," Archives of Pathology Medicine, 121(5), 508-11.
Brady, M.S., & Noce, N.S. (2010). "Pregnancy is not detrimental to the melanoma patients with clinically localized disease," The Journal of Clinical Aesthetic Dermatology, 3(3), 22-28.
Driscoll, M.S., & Grant-Kels, J.M. (2008). "Melanoma and pregnancy," G Ital Dermatol Venereol, 143(4), 251-7.
Jhaveri, M.B., Driscoll, M.S., & Grant-Kiels, J.M. (2011). "Melanoma in pregnancy," Clinical Obstetrics and Gynecology, 54(4), 537-545.
Leachman, S.A., Jackson, R., Eliason, M., Larson, A.A., Bolognia, J.L. (2007). "Management of melanoma during pregnancy, Dermatology Nursing, 19(2), 145-152, 161.
Pack, G.T., & Scharnagel, I.M. (1951). "The prognosis for malignant melanoma in pregnant women," Cancer, 4, 324-334.
Stensheim, H., Moller, B., van Dijk, T., Fossa, & S.D. (2009). "Cause-specific survival for women diagnosed with cancer during pregnancy or lactation: a registry-based cohort study," Journal of Clinical Oncology, 27, 45-51.