Gynaecological cancer in pregnancy — structured oral station (12 minutes)

Opening prompt — "What governs how you manage this?"

Model response: [1]

• "Cancer in pregnancy is managed by a multidisciplinary team aiming for standard oncological treatment that preserves maternal prognosis while protecting the fetus. The decision is defined by three variables: the tumour type and stage, the gestational age, and the patient's values."[1]
• "She is at 19 weeks with what looks like a stage IB2 squamous cervical cancer and a strong wish to continue. I would immediately convene the MDT — gynaecological oncology, maternal-fetal medicine, medical and radiation oncology, neonatology, and psycho-oncology — and I would frame this around what standard treatment I can safely deliver now while the fetus matures."[1][2]

Probe 1 — "How did you stage her, and what imaging rules apply?"

• "I applied the ALARA principle: ultrasound first, MRI without gadolinium for local staging of the cervix and nodes, and limited CT chest for distant staging. Gadolinium is avoided in pregnancy."[2][6]
• "I know two pitfalls: CA-125 is unreliable in pregnancy, and NIPT can be inconclusive in a woman with cancer, so I would arrange alternative anomaly screening."[6]

Probe 2 — "She wants to continue. What is your plan for the cervical cancer?"

• "The goal is to control the tumour while the fetus matures to a safe gestational age, without compromising her prognosis. The established strategy is neoadjuvant chemotherapy to bridge to fetal maturity, then definitive surgery — radical hysterectomy at caesarean closer to term — as described by Karam and colleagues."[4]
• "Throughout, serial growth scans and cervical-length surveillance, because fetal growth restriction is the dominant fetal effect of chemotherapy in pregnancy."[6]
• "If at any point the disease or its pace makes definitive treatment non-deferrable, that balance shifts and we discuss whether continuing the pregnancy remains safe — a decision she owns, with full information."[1]

Probe 3 — "She will need chemotherapy. State the rules."

• "I avoid the first trimester. The data are explicit: in the INCIP study of 755 women, the major malformation rate was 3.6% overall; before 12 weeks it was 21.7% — odds ratio 9.24 — and after 12 weeks it was 3.0%, the same as the background population. She is 19 weeks, so the first-trimester risk is behind her."[3]
• "I never give the contraindicated agents at any gestation: methotrexate; hormonal therapies; HER2-targeted agents; VEGF and PARP inhibitors; antibody-drug conjugates; and all cellular therapies."[2]
• "I plan delivery at or after 37 weeks and time the final dose 2 to 4 weeks before birth so she does not deliver during her haematological nadir."[2]

Probe 4 — "What is the single most important thing to tell her about her baby's outcome?"

• "That the dominant, avoidable harm to her baby is being born too early — not the chemotherapy. In the Amant study, cognitive scores were lower in preterm children and IQ rose by about 11.6 points for each extra month of gestation. We are planning to avoid iatrogenic preterm delivery, and the long-term data — children assessed at 9 years — are reassuring: no difference in cognition, learning or behaviour versus unexposed children."[5]

Probe 5 — "She is terrified. Speak to her."

This is a scored communication domain — do it out loud: [1]

• "I would move to her eye level, use her name, and say plainly: 'This is a frightening diagnosis, and I am not going to ask you to choose between yourself and your baby. There is a way to treat your cancer that protects your pregnancy, and we have a whole team whose job is to get you both through this. The treatment does not appear to harm children in the long term when they are born at term — our biggest job together is to get your baby to a safe gestational age. I will explain every step, and you will never be rushed into a decision.'"[5]
• Acknowledge fear, commit to a follow-up, avoid jargon, and ensure a support person and psycho-oncology are involved.[1]