The incidence of cancer during gestation has risen due to multiple factors such as advanced maternal age and improvement in cancer treatment, which has resulted in longer life span and a rising number of survivors who will then become pregnant. Whether a woman is diagnosed with cancer during pregnancy or becomes pregnant after surviving the disease, navigating treatment for both the mother and the fetus can seem daunting for patients as well as their care providers, as there is a higher risk of morbidity for these patients. This chapter aims to describe safe diagnostic and therapeutic options during pregnancy and includes special considerations regarding survivors’ treatment. Breast cancer, lymphoma, leukemia and cervical cancer are the focus of the chapter and obstetric management of patients with these malignancies is addressed, including antenatal care, delivery considerations and breastfeeding.

The present chapter outlines the sexual aftermath of cancer treatment and strategies for improvement. Sexual dysfunction is underdiagnosed and undertreated after surgery, chemotherapy, radiation, and hormone-modulating therapies. The treatment of genitourinary syndrome of menopause (GSM) is multimodal and includes behavioral modifications, local therapy, and physical therapy. Vaginal estrogen should be first-line treatment for GSM in women with hormone non-responsive cancer. For those with ovarian, endometrial, and breast cancer, vaginal estrogen may be considered with persistent symptoms after regular use of non-hormonal moisturizers. As an alternative, vaginal androgens may be of utility in improving libido and vaginal health. The authors do not endorse the use of compounded formulas due to a lack of formula standardization and a dearth of safety and efficacy data. Vaginal lasers, including CO2 lasers, are discouraged after two sham-controlled randomized trials found they were not effective, and adverse events have been reported in women with cancer. Dyspareunia is common, especially if encountered in the setting of radiation-induced vaginal stenosis. Treatment may involve addressing GSM, serial vaginal dilation, pelvic floor therapy, and/or psychological therapy. In those with low sexual desire, filbanserin and bremelanotide are novel FDA-approved therapies with central mechanisms that may change the landscape for treating female sexual desire disorders.

Endometrial cancer is the most common gynecologic malignancy in the United States, and is rising in both incidence and associated mortality. In 2023 an estimated 66,000 new cases of uterine cancer will be diagnosed in the United States and over 400,000 women will be affected globally. Risk factors for the development of endometrial cancer include advancing age, obesity and and conditions associated with metabolic syndrome, such as diabetes. Obesity is the most important risk factor for endometrial cancer, and as rates of obesity rise, so does the incidence of endometrial cancer. Surgery is the mainstay of initial management of endometrial cancer, and staging now includes sentinel lymph-node mapping, along with a minimally invasive surgical approach for removal of the uterus, fallopian tubes, and ovaries. Fortunately, 75% of patients with endometrial cancer have International Federation of Gynecologic and Obstetrics (FIGO) stage I disease, and 5-year overall survival rates exceed 90%. High-risk stage I patients are often recommended to receive adjuvant therapy and women with locally advanced disease and/or distant disease typically require multimodality treatment that can include some combination of surgery, chemotherapy, and radiotherapy. Endometrial cancer is more often being detected in young obese women. In women of childbearing age in whom endometrial cancer is diagnosed and wish to retain their ability to have children, a conservative alternative to hysterectomy for these women is the use of oral progestin or a levonorgestrel intrauterine system (LNG-IUS).

Improvements in multimodality treatment of anal and colorectal cancer has led to increased numbers of women survivors who experience gynecologic problems in long-term survivorship. The etiology of gynecologic problems after anal and colorectal cancer treatment is complex and multifactorial. Pelvic radiation, surgery and chemotherapy can all cause anatomic, hormonal and psychological changes. Consideration of preventative measures can ideally reduce the risk of vaginal stenosis, dyspareunia, sexual dysfunction, infertility, premature menopause and pelvic pain after therapy. Proactive screening and appropriate treatment of cancer therapy late effects can improve patients’ quality of life during survivorship.

Premature ovarian insufficiency (POI) is a heterogeneous diagnosis caused by a multitude of factors including genetic, autoimmune, iatrogenic, social, and environmental. It is defined as loss of ovarian function prior to 40 years of age with subsequent secondary amenorrhea for at least 4−6 months in conjunction with elevated follicle stimulating hormone levels on two different measurements. Prompt recognition of symptoms should encourage thorough history-taking and work-up, as some causes of POI are associated with conditions requiring additional screening or medical management. Early initiation of hormone replacement therapy is necessary to prevent long-term sequelae from chronic hypoestrogenism such as cardiovascular events, poor bone health, and cognitive dysfunction. Extensive counseling with regards to future fertility and family building options is necessary as the diagnosis of POI can be psychologically devastating to many women.

Thyroid cancer is one of the most prevalent endocrine malignancies worldwide, with increasing incidence rates over the past few decades. Thyroid cancer has a higher prevalence in women, and therefore, careful consideration of gynecologic factors is crucial aspect of its management and care. We discuss the epidemiology, risk factors, and management strategies for common types of thyroid cancer generally and particularly in women. Comprehensive care that integrates oncological and gynecologic management is crucial to optimize outcomes for women with thyroid cancer. Further research is needed to better understand the interplay between thyroid cancer and gynecologic health, and to develop tailored approaches to address the specific needs of this patient population.

Leukemias represent a range of bone marrow disorders that are broadly differentiated into acute and chronic. Acute leukemias, characterized by the proliferation of immature blood cells (blasts) and defined by peripheral blood or bone marrow blast percentage of 20 percent or more, are aggressive hematologic malignancies that are universally fatal without treatment. Chronic leukemias are mature leukemias with differentiated cells. Obstetric and gynecologic complications pose significant risk to the patient. Knowledge regarding uterine bleeding, fertility planning, and the management of the pregnant patient with leukemia are necessary in order to appropriately address these patients. In this chapter, we briefly review both acute and chronic leukemias, epidemiology, diagnosis and management, obstetric and gynecologic complications, teratogenicity of chemotherapies utilized in the treatment of each leukemia and finally detail our approach to the management of these patients.

Cervical cancer is the most common gynecologic malignancy worldwide and the third most common in the United States. While incidence and mortality rates have decreased significantly with improved access to screening and prevention methods in the United States, cervical cancer remains a significant cause of cancer morbidity and mortality in resource-limited countries. Human papillomavirus (HPV) infection is the cause of almost all cervical cancer and is associated with 99.7% of cervical cancer. Additional risk factors associated with HPV include early onset of sexual activity, multiple sexual partners, history of sexually transmitted infections, increased parity, and immunosuppression. Non-HPV-related risk factors include cigarette smoking, oral contraceptive use, and low socioeconomic status. Squamous cell carcinoma is the most common histologic subtype of cervical cancer, comprising around 70% of cases, and adenocarcinoma is the second most common histologic subtype, comprising approximately 25% of cases. Cervical cancer is staged clinically, and stage is the most important prognostic factor. Early-stage disease can generally be treated surgically with a hysterectomy. Fertility-sparing surgical options include cold knife conization and radical trachelectomy in select cases. Adjuvant therapy with chemotherapy, radiation, or chemoradiation may be required for early-stage disease with specific risk factors. Advanced-stage disease is primarily treated with chemoradiation. Using FIGO 2018 staging, five-year survival rates were 92−97% for stage IA tumors and 76−92% for stage IB tumors. Lymph node involvement is associated with worse prognosis with five-year survival rates near 40−60%. Routine screening with cervical cytology is recommended starting in young adulthood to identify and treat females with high-grade dysplasia. Routine HPV vaccination is recommended to protect against development of cervical cancer from persistent high-risk HPV infection.

Cancer patients often have a variety of skin eruptions ranging from infections to irritant contact dermatitis. Reviewing gentle skin care and educating patients on potential side effects of various treatments, such as post-radiation dermatitis or vulvovaginal graft-versus-host disease, is beneficial. This chapter will focus on common vulvar conditions that may arise during cancer treatment such as infections (folliculitis, abscesses and furuncles, angioinvasive infections, herpesvirus and candidal infections), primary dermatoses (lichen sclerosus and lichen planus), and therapy side effects (genitourinary syndrome of menopause, lymphedema, acquired lymphatic anomaly, radiation dermatitis and recall, toxic erythema of chemotherapy, and immune-checkpoint inhibitor cutaneous toxicities). Additionally, considerations for vulvar biopsies are discussed.

Sometimes patients and clinicians don’t agree and there is conflict. Many people prefer to avoid conflict, however working through it allows us to discuss our differences of opinion, explore the options, and come up with an agreement that we all can live with. Good communication skills can help shift the focus from “Who’s right?” to “What’s our shared interest?” This roadmap is different as it is about how you find your path amidst conflict. Start by noticing there is a disagreement. Prepare yourself by pausing, being curious, and assuming positive intent. Invite the other person’s perspective and listen to their story, emotion, and what it means to their sense of self. Identify what is at the root of the conflict and if possible, articulate it as a shared interest. Brainstorm to address the shared interest, and look for options that address everyone’s goals. Remember that conflicts occur because people care deeply, which means that resolving the conflict will take time and effort. Even in instances where it is not possible to agree, skillful communication can allow for graceful disagreement.

Conflict with our colleagues is stressful and evokes strong emotion, yet handled well can improve outcomes and relationships and enhance collaboration. There are issues of hierarchy, power, and respect. Similar to dealing with conflict with patients is the need to establish a safe space, practice deep listening, and earn trust. Being open to exploring the breadth of the problem, both parties perspectives, your role in the conflict, how you feel about events, and what it means to you will help you approach the situation with a more open mind. Keeping a focus on improving the situation and relationship rather than solely on being right will help maintain calm. The roadmap for conflict with colleagues includes noticing when conflict is bubbling up, preparing your approach instead of jumping in reactively, starting softly to avoid provoking defensiveness, inviting the other person’s perspective before you share yours, using neutral language to reframe emotionally charged issues, acknowledging the emotion of the situation (rather than handling your colleague’s emotions directly), and finding a path forward that addresses both parties’ concerns, creating new options where needed.

To hone your skills, one needs to observe what “good” looks like, practice, and receive feedback. We recommend setting a communication skills goal before the encounter, and then debriefing how it went, celebrating what you did well, and considering what to do differently next time, as well as what you learned in the process. Practicing skills in conversation roadmaps is incomplete without building of our internal capacities, like curiosity and emotional awareness, which help us foster more authentic connection. Learning new skills is not linear. Be kind to yourself when you’re having a bad day or feeling burnt out. Better communication skills can help they leads to more engaged clinical encounters which provide positive feedback making patient care more rewarding. Also, the roadmaps in this book are a kind of scaffold for learning, intended to provide support until you get your foundation settled. After a while, you may no longer need them. True expertise requires building both skills and capacities, practicing regularly, and caring for oneself in the process.

Multiple family members means multiple perspectives, agendas, emotions, and values. And, families are more than a collection of individuals. They have with their own way of functioning as a whole. When meeting with family about their loved one’s care, there are important steps similar to the maps we used with patients themselves. First, pre-meet to decide who’s going to be invited. The team should also agree upon a big picture headline. During the conference, introduce all participants and the purpose of meeting. Assess what the family knows and their different perspectives. Update the family using a headline, and address questions and concerns. Empathize and respond to the various emotions in the room. Prioritize the patient’s values. Align with the patient’s values and support the family. Finally, summarize and provide a concrete follow-up plan. An effective family conference can get everyone on the same page, ensure that the patient and family understand the medical situation, and help the family and care team come together to make treatment decisions that align with the patient’s values.

Some situations are particularly challenging. These include high-stakes, high-emotion conversations, like when patients talk about miracles or when they request hastened death. In the case of miracles, it is because they understand how bad things are that miracles are invoked. In the case of requests for hastened death, the request is brought on by suffering or fear of suffering. In both cases, the first thing is to do is take a breath and then explore, rather than react from a place of emotion. Another challenge is when responding to emotion isn’t enough. This can occur when a patient really does want information, when patients are coping through intellectualizing, when the emotion is too overwhelming, or when the level of emotion (and sometimes physical agitation) is elevated to the point of feeling or being unsafe. Each of these requires a tailored response like giving information, nonconfrontation, or containment before being able to move forward. Finally, in situations when our own emotions become elevated, it is important to allow ourselves to feel while being mindful we remain of service to the patient, and that we get support from trusted team members and colleagues.

Discussing treatment options is more complex than giving information and making a recommendation. Today, shared decision making includes patient access to the electronic medical record and internet searches, however patients still turn to their clinicians as the most important and trusted source. In addition to balancing information and emotion, clinicians need to take into account how involved patients wish to be in decision making. A roadmap for discussing treatment decisions is: 1. Prepare for the visit, 2. Frame the decision to be made, 3. Ask about decision-making preferences explicitly, 4. Adapt the discussion and recommendations based on patient decision-making preferences (shared decision making, clinician-led decision making, pros/cons), 5. Check for patient understanding, 6. Establish how the patient wants to proceed with the decision-making process. Take care with how statistics are presented and consider providing decision aides. Asking patients how they want to make decisions will help ground decisions in their values.

When prolonging life with acceptable quality of life becomes difficult, goals of care discussion are necessary. For clinicians and patients, the discontinuation of disease-modifying therapy can feel like a failure. This can lead clinicians to offer treatments we don’t believe are good options or offering treatment on the condition that our patients make an improbable recovery. The roadmap for late stage goals of care discussions is REMAP. Reframe why the status quo isn’t working, expect emotion and respond with empathy, map big picture values, align with the patient’s values, and finally plan medical treatments based on what’s important to your patient. Some things to note: Mapping thoroughly will help you make sure you don’t miss something important. A useful shift in thinking for many clinicians is first talking about what you will do before talking about what should be stopped or you won’t offer. And, clearly linking your recommendations to the patient’s values will help your proposed plan be more acceptable. By grounding ourselves in what is medically possible and using the patient’s values to guide our next steps, we can cocreate a plan that is both possible and meaningful.

Most clinicians prefer that patients plan for their future illness care before things become urgent or they lose the ability to make decisions. Completing an advance directive form by itself does not always impact future care decisions. Rather than focusing on hypothetical specific treatment decisions in the future or the completion of forms, conversations early in serious illness focusing on what matters most to patients may help guide care decisions over time and prepare patients and families for future conversations about specifics in real time when things do progress. The key is to plan on multiple small conversations over time. A roadmap for having these early goals of care discussion is PAUSE (Pause to make time for the conversation, Ask permission to discuss the topic and explain why, Uncover values first (don’t lead with code status), Suggest selecting a surrogate, Expect emotion/End). Some patients shy away from considering a future state when their disease has worsened, and are not interested in talking about what matters to them. Exploring why using a motivational approach and focusing on your relationship may help plant the seed and make future conversations easier.

Clinicians and patients have varying degrees of comfort in discussing prognosis. Patients can swing between worry or understanding that death is near and hope or optimism that lets them live life. This prognostication awareness pendulum may require a clinician negotiate the discussion over time. The cognitive roadmap for prognosis discussion is ADAPT (Ask what they know about their medical condition, Discover what they want to know about prognosis, Anticipate ambivalence, Provide information about what to expect, and Track emotion and respond with empathy). Some patients want prognostic information, some don’t, and some are ambivalent. While respecting their wishes, exploring why in each of these scenarios may be helpful to understand their concerns and how best to address them. Be aware that patients and their family members may have different prognostic information needs. Having separate conversations (with permission) may be in order. When they are concerned about destroying hope or prognosis is uncertain, using the frame of “hope and worry” can be helpful. Finally, when patients or family members don’t believe our prognosis, be curious as to why and focus on the relationship.