Guideline 72: Cutaneous melanoma

Cutaneous melanoma
Section 9: Melanoma in women

9.1 Pregnancy

Pregnancy is frequently associated with increased activity of benign melanocytes leading to pigmentary changes. This has led to concern that pregnancy is deleterious for women with melanoma.

The prognoses of women with thickness-matched melanomas who embarked on a pregnancy after apparently successful surgical treatment of AJCC stage I or II melanoma have been compared.^{240,
241, 242,
243} No difference in disease-free or overall survival is found between women who have, and women who have not, become pregnant after melanoma treatment. Prognosis is mainly dependent on tumour thickness.^{240,
241,
242,
243} Evidence level 2++

There is no substantial evidence of an effect of pregnancy in women with stage III and IV melanoma, but as the prognosis for these groups is already poor, the possibility of a maternal death during pregnancy or when the child is an infant is high. Obstetricians and others managing pregnant women with advancing stage IV melanoma should be aware that terminating the pregnancy will have no effect on the outcome for the mother. Evidence level 3

The placenta of an infant born to a mother with stage III or IV melanoma should be examined for the presence of melanoma metastases. If they are present there is a 20% risk of death of the baby from transplacental melanoma.^{244,
245, 246} Evidence level 3

Women who develop melanoma during a pregnancy show a greater mean thickness of the primary lesion at the time of excision than age-matched non-pregnant women.^{242,
243} This suggests either delayed diagnosis or accelerated growth due to the hormonal and immunological environment of pregnancy. There is no evidence to support the suggestion that it is physiological for melanocytic naevi to change during pregnancy.²⁴⁷ Evidence level 2++

There are no good data on prognosis for women who embark on a pregnancy having had a melanoma diagnosed and treated during a previous pregnancy. One paper reports that patients with stage I or II disease have no greater recurrence rate than non-pregnant age-matched controls but that those with nodal disease have significantly higher recurrence rates.²⁴⁸ Evidence level 4

Women with a significant risk of recurrence (localised disease of >1mm thickness) who wish to become pregnant after surgery for stage I or II melanoma should be advised to delay pregnancy for two years postsurgery, as the likelihood of recurrence is highest during this period.

Pregnant women who present with growing or changing pigmented lesions should be treated as non-pregnant women.

9.2 Oral contraception after melanoma treatment

Meta-analysis provides no evidence that use of the oral contraceptive is a risk factor for melanoma.²⁴⁹ Five large studies indicate that oral contraceptive use by women after surgery for stage I or II melanoma does not adversely affect their prognosis.^{248,
250, 251,
252, 253,
254} Evidence level 2++

Women who have had a melanoma treated should select contraception in the same way as women who have not had a melanoma.

9.3 Hormone replacement therapy (HRT) after melanoma treatment

Five case controlled studies show no effect of HRT as a risk factor for melanoma.^{251,
252,
255, 256,
257} Evidence level 2+

Women who have had stage I and II melanoma and who wish to take HRT should be treated as women who have not had melanoma.