Coping with Advanced Melanoma During Pregnancy

Kelly was 26 weeks pregnant when she started to experience seizures along the left side of her body. After meeting with several doctors, she learned her symptoms started from a skin cancer. “I was diagnosed with stage IV melanoma in my armpit that had spread to my brain and was a serious threat to me and my unborn child,” says Kelly.

In the past few years, researchers have been studying cases like Kelly’s to address the controversies and likely outcomes for expectant mothers. “Pregnant women with melanoma were believed to have a much worse prognosis in the past. Now we have controlled studies to support that a pregnant woman with early stage melanoma has the same prognosis as a nonpregnant woman (with the same melanoma stage),” says Marcia Driscoll, MD, PharmD, associate professor of dermatology at the University of Maryland School of Medicine. Dr. Driscoll has been writing about melanoma and pregnancy for more than 15 years and is glad this subject is finally getting the thorough attention it deserves.

While the American Academy of Dermatology has established new guidelines for treating melanoma in pregnant women, each patient’s case is unique, and you should consult a doctor about any concerns. We asked Kelly and JB (women who both prefer that their full names not be used) to share their stories with us.

Early Detection Is Still Crucial

Melanoma is one of the most common cancers in young women, most notably during their reproductive years. A 2009 Norwegian study found that the most common malignancy during pregnancy was melanoma, representing 31 percent of all malignancies that arise during this time. Each patient’s prognosis, however, is dependent on several factors.

When basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), sometimes called nonmelanoma skin cancers (NMSCs), are caught early, they’re generally not cause for concern. The same holds true for melanomas that are thin and in the earliest stages. Dr. Driscoll explains, “Treatment involving excisions (including a specific type of skin cancer surgery known as Mohs micrographic surgery), using a local anesthetic known as lidocaine, is safe during pregnancy and poses no harm to your baby.” You should have no different outcome or way of treatment than if you were not pregnant.

If a tumor is bigger, a larger excision may be necessary, which also means an increased amount of local anesthesia will be used. When further along in your pregnancy, this may cause a bit more concern. If this is the case, your OB-GYN should connect with your dermatologist and oncologist to determine proper next steps. Advanced stage melanoma (when the cancer has spread to the lymph nodes or to distant organs) is more difficult to treat, pregnant or not. But the complications are greater in pregnant patients.

Complications with Diagnosis

While pregnancy doesn’t increase your risk of developing skin cancer, it does change how the body fights the disease. “When the body is pregnant, its normal defenses for detecting cancer are lowered because the immune system is working to protect the fetus rather than the mother,” explains Kelly’s oncologist, Sapna Patel, MD, associate professor of melanoma medical oncology at The University of Texas MD Anderson Cancer Center.

Women who are pregnant should continue to get regular skin exams performed by a dermatologist. If the doctor sees a suspicious lesion, a biopsy is safe. If melanoma is diagnosed, further detection methods may be needed, depending on how far along the pregnancy is. For melanomas that have reached .8 mm in thickness, or have spread beyond the primary tumor site, a sentinel lymph node biopsy (SLNB) may be necessary to determine whether metastatic cells have reached the lymph nodes. While doctors may advise against delaying treatment if the cancer has spread, it’s best to avoid the use of general anesthesia (as with an SLNB) in the first trimester. Thereafter, a modified SLNB may be performed, with precautions taken to avoid potential allergic reactions.

What Your Cancer Stage Means for Your Baby

Melanoma is a very aggressive form of cancer and when it metastasizes it can go anywhere, including the placenta. Those with advanced melanoma, meaning the cancer has spread beyond the original site, are at a high risk of transferring cancer to the placenta. However, even if you have melanoma in the placental tissue, only in one-fourth of the cases is the fetus affected. “It’s a very small group of women who have had fetal involvement, and treatment has been on a case-by-case basis,” says Dr. Driscoll.

If a mother received treatment for melanoma while pregnant, doctors will check the placenta carefully after delivery for signs of melanoma. As Dr. Patel further explains, “This would not manifest in the baby being born with active melanoma, but they could develop the disease in a few years after birth.” You may want to consider getting a pediatric dermatologist involved right away to perform skin exams as a precautionary measure.

This was a huge concern of Kelly’s doctors who sent her placenta out to be tested after labor. Luckily, the cancer had not spread to the placenta.

Treatment Options Differ for Advanced Melanoma Cases

When cancer has become more advanced, treatment options may be limited during pregnancy. Radiation therapy is not permitted, as it harms the body and therefore the baby. Immunotherapy, which has become a frontline treatment for melanoma, should be avoided as well. “A baby’s immune system matures a great deal while it’s in the mother’s womb,” says Dr. Patel. “If immunotherapy is administered while carrying a baby whose immune system is still developing, you create an autoimmune condition and the baby cannot survive because its own T cells will start attacking its body.”

Given how advanced Kelly’s cancer was, her OB-GYN immediately called for a consultation with MD Anderson to discuss the complexities of her case. Her baby needed to be delivered right away, as the only treatment options for her were contraindicated during pregnancy. “There’s no way to treat a pregnant woman with melanoma in her brain while she’s pregnant,” says Dr. Patel.

“I was admitted to the hospital the next day and was told, ‘You’re probably going to deliver this baby before you leave,’” recalls Kelly. She had a cesarean section at her local hospital in California, before her journey led her to Houston where she began her care guided by Dr. Patel. Her baby girl remained in the NICU for four months due to the early delivery but was otherwise deemed healthy.

Ten days after Kelly gave birth, surgeons removed the lesion from her brain and 28 lymph nodes in her left underarm. After some recovery time, she began immunotherapy. “About a month later, I started Keytruda, which I still receive every three weeks,” says Kelly. She also had two gamma knife surgeries, a non-invasive procedure that involves gamma radiation beamed onto tumor sites in the brain.

Kelly’s treatment plan was carefully laid out by a medical team who determined the appropriate plan that would have the best outcome for her and the growing fetus. Thankfully for her, her pregnancy was far enough along that she could safely deliver the baby, but unfortunately for some women, they may be faced with more difficult choices.

Tough Decisions

A young woman, JB, was 31 years old when she was faced with the unimaginable. “I was diagnosed with stage II mucosal melanoma during my first trimester of pregnancy,” she says. Mucosal melanoma is a rare, aggressive form found on surfaces such as nasal passages and female genitalia. Her prognosis was dim — a 5 percent five-year survival rate if she didn’t undergo treatment.

JB, who had a 1-year-old son at the time, had surgery while pregnant to remove the primary tumor, which had grown to 6 centimeters and showed spread to her lymph nodes. After her medical team looked at the biopsy results, she was given two options. She could carry the baby until it was in a viable place and deliver early, but there would be a good chance the cancer would spread to the baby. “Metastatic melanoma is so aggressive that we can’t guarantee the baby will be able to fully mature in the womb,” says Dr. Patel. Her other option was to receive immunotherapy or bio-chemotherapy, both of which would most likely reject the pregnancy.

“With a patient like JB, the doctor has to have a serious conversation with her and her family about options,” says Dr. Patel. Due to the severity of her case, JB, under the guidance of her doctors, terminated her pregnancy so she could receive lifesaving treatment. “If the family decides the baby’s life is most important, and the mother’s body is used as an incubator as the baby continues to develop, there is a possibility the mom won’t make it that long and therefore the baby may be lost as well,” says Dr. Driscoll.

Kelly, who was already a mother to twins, says, “You have to think — two babies at home with a mom is better than three babies with no mom.”

Two weeks after that procedure, JB received intensive treatment over the course of three months. Four different types of biochemotherapy were administered through a constant fusion along with daily injections of Interferon. This was all done as an inpatient, where she would stay in the hospital for a week at a time. At the end of her initial treatment, JB already had a recurrence, which prompted her oncologist to switch to immunotherapy. Another surgery and round of radiation later, the cancer had finally cleared.

JB is now in remission, although the grueling treatment took a toll on her body. “This put me into early menopause and, unfortunately, I cannot carry another baby myself,” says JB. She has been exploring her options for having more children in the future.

Only one in 1,000 pregnancies is complicated by cancer — and even fewer by melanoma. If you find yourself in this situation, be sure to consult with your primary care doctor right away and, together, come up with an appropriate medical team that will determine your best course of action. Aside from your OB-GYN or dermatologist, a surgical oncologist, maternal fetal specialist or radiologist may be involved in these rare but serious cases. All should be in constant communication with one another to ensure you’re getting the best care. It’s important to note that these scenarios aren’t exclusive to skin cancer and are a possibility with most types of cancer during pregnancy.

Today, Kelly has had a complete response to treatment, and her little girl is a healthy, bouncing 2-year-old. She continues to go for full body scans every four months. JB has been cancer free for the past two years and enjoys spending time with her son who is now 4 years old. She gets scanned every three months and is grateful for the treatment she received.

“Be vigilant with yourself. If something looks new or has changed, don’t be embarrassed,” says Kelly. “Get it checked out right away — the earlier detection you have, the better.”