Thank you Tineke Vandenbroucke, MSc and Dr Amant for your thoughtful questions. We share your passion to treat pregnant women who are diagnosed with cancer so that they are able to make informed decisions, deliver healthy infants, and maintain their health and their treatment during the pregnancy and after delivery.

The child in question was twin B of a dichorionic diamniotic twin pregnancy that was complicated by the diagnosis of ovarian cancer at 14 weeks’ gestation. Chemotherapy included 4 cycles of cisplatin/paclitaxel. Because of malpresentation of twin A, a primary cesarean delivery was performed at 38 weeks gestation. Twins A and B had Apgar scores of 9,9 and 8,9 and birthweights of 2608 and 2633 g. respectively. Twin B required phototherapy for jaundice but had no other medical issues that were recognized during the neonatal admission. There were no delays in language or motor skills in early childhood for either twin.

At age 5 years, the mother noted tic-like movements, difficulties in the first grade, auditory processing issues, and preoccupation with rituals in twin B. The mother believed that she herself has Asperger’s syndrome and noted similar features in this child. At age 10 years, twin B demonstrated deficits in receptive and expressive language and decreased eye contact. A computed tomography scan was reportedly normal during his evaluation according to the mother, but we did not view directly a copy of this report. Current diagnoses for twin B are Tourette’s syndrome, obsessive compulsive disorder, and Asperger’s syndrome. Twin A is without disabilities.

The cognitive mean scores (Full Scale Intelligent Quotient and Bayley Scale of Infant Development–III [BSIDIII) for this sample do appear to be slightly above what would be found in the general population. By the current “deviation IQ” definition of IQ test standard scores, approximately two-thirds of all test-takers obtain scores from 85 to 115 and approximately 5% of the population scores above 125. Our sample scores appear to fall in line with 66% of the general population with the following distribution: BSID III cognitive scores: range = 95–145; median = 110; mode = 110; mean = 113; Full Scale Intelligent Quotient scores: range = 74–141; median = 114; mode = 96; mean = 112.

Our sample of mothers who were diagnosed with cancer (and their children) may also be representative of an “above average” socioeconomic environment based on maternal education and financial stability, thus resulting in the slightly higher mean scores. The children came from enriched and highly verbal homes. It is not an unusual profile for some very young children to score quite high because of verbal enrichment that at times evens out once school age because there is a more level playing field after formal educational exposure.

We agree with previously reported findings that issues with future developmental performance often are related to premature gestational age at birth. We also agree that iatrogenic preterm deliveries at <35-36 weeks’ gestation should be discouraged when cancer is diagnosed during pregnancy and when treatment can be offered to extend gestation. In our sample, 24 infants (18 exposed, 6 control infants) of 57 infants (42%) were delivered at <37 weeks’ gestation. The children in the chemotherapy-exposed group delivered at a statistically significant earlier gestational age, compared to the control group. However, we did not find a significant difference in mean gestational ages between the children who scored within the normal range compared with those with abnormal results in either the cognitive or behavioral areas. Only 3 children who were delivered at 32, 38.6, and 40 weeks’ gestation showed poor scores on developmental testing. Gestational ages of the 12 children with clinical behavior scores ranged in the exposure group from 32.4–39.3 weeks’ gestation and in the control group from 35.1–40.1 weeks’ gestation. Per your suggestion, an applied predictive model confirmed our initial findings that gestational age was not predictive of developmental scores for the 29 children who underwent assessment on the BSIDIII, the 28 children on the Wechsler Preschool and Primary Scale of Intelligence-R/Wechsler Intelligence Scale for Children-III, or the 14 children who completed the math and reading tests. How ever and interestingly, when scores were plotted separately for the exposed and control groups, we noted a significant relation between gestational age and cognitive scores on the BSIDIII, with a 2.3-point increase in the BSIDIII cognitive score for each gestational week gained. This was found to be true only for the exposed group ( P = .026). This predictive correlation of prematurity and developmental outcome will be further studied as we continue to grow our sample size with increased subjects in both the control and chemotherapy-exposed groups.