Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-cd9895bd7-jn8rn Total loading time: 0 Render date: 2024-12-26T09:41:48.394Z Has data issue: false hasContentIssue false

Chapter 10 - Cancer and Pregnancy

Published online by Cambridge University Press:  23 October 2024

By
Jenifer Dinis Ballestas
Edited by
Laurie J. Mckenzie  and
Denise R. Nebgen
Laurie J. Mckenzie
Affiliation:
University of Texas MD Anderson Cancer Center, Houston
Denise R. Nebgen
Affiliation:
University of Texas MD Anderson Cancer Center, Houston
Get access

Summary

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.

Keywords

PregnancyCancerBreastLymphomaLeukemiaCervicalHodgkinChemotherapyRadiation
Type
Chapter
Information
Caring for the Female Cancer Patient
Gynecologic Considerations
 , pp. 147 - 178
Publisher: Cambridge University Press
Print publication year: 2024

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Smith, L. H., Danielsen, B., Allen, M. E., Cress, R. Cancer associated with obstetric delivery: results of linkage with the California cancer registry. American journal of obstetrics and gynecology. 2003;189(4):1128–35.CrossRefGoogle ScholarPubMed
Stensheim, H., Møller, B., Van Dijk, T., Fosså, S. D. Cause-specific survival for women diagnosed with cancer during pregnancy or lactation: a registry-based cohort study. Journal of Clinical Oncology. 2009;27(1):45–51.CrossRefGoogle ScholarPubMed
Eibye, S., Kjær, S. K., Mellemkjær, L. Incidence of pregnancy-associated cancer in Denmark, 1977–2006. Obstetrics & Gynecology. 2013;122(3):608–17.CrossRefGoogle ScholarPubMed
Boere, I., Lok, C., Poortmans, P., et al. Breast cancer during pregnancy: epidemiology, phenotypes, presentation during pregnancy and therapeutic modalities. Best Pract Res Clin Obstet Gynaecol. 2022:82:46–59.CrossRefGoogle ScholarPubMed
Navrozoglou, I., Vrekoussis, T., Kontostolis, E., et al. Breast cancer during pregnancy: A mini-review. European Journal of Surgical Oncology (EJSO). 2008;34(8):837–43.Google ScholarPubMed
Amant, F., Nekljudova, V., Maggen, C., et al. Outcome of breast cancer patients treated with chemotherapy during pregnancy compared with non-pregnant controls. European Journal of Cancer. 2022;170:54–63.CrossRefGoogle ScholarPubMed
Alex, A., Bhandary, E., McGuire, K. P. Anatomy and Physiology of the Breast during Pregnancy and Lactation. Diseases of the Breast during Pregnancy and Lactation. 2020;1252:3–7.Google ScholarPubMed
Vashi, R., Hooley, R., Butler, R., Geisel, J., Philpotts, L. Breast imaging of the pregnant and lactating patient: Physiologic changes and common benign entities. American Journal of Roentgenology. 2013;200(2):329–36.CrossRefGoogle ScholarPubMed
Mitchell, K. B., Johnson, H. M., Eglash, A. Academy of Breastfeeding Medicine. ABM Clinical Protocol# 30: breast masses, breast complaints, and diagnostic breast imaging in the lactating woman. Breastfeeding Medicine. 2019;14(4):208–14.Google Scholar
American College of Obstetricians and Gynecologists Practice Bulletin No. 164 Summary. Diagnosis and management of benign breast disorders. Obstet Gynecol. 2016 Jun;127(6):1181–3.Google Scholar
ACOG Committee Opinion No. 273. Guidelines for diagnostic imaging during pregnancy and lactation. Obstet Gynecol. 2017;130(4):e210–e216.CrossRefGoogle Scholar
Slanetz, P. J., Moy, L., Baron, P., et al. ACR Appropriateness Criteria® breast imaging of pregnant and lactating women. Journal of the American College of Radiology. 2018;15(11):S263–75.Google Scholar
American Society of Breast Surgeons. Position Statement on Screening Mammography. 2018. www.breastsurgeons.org/docs/statements/Position-Statement-on-Screening-Mammography.pdfGoogle Scholar
Collins, J. C., Liao, S., Wile, A. G. Surgical management of breast masses in pregnant women. The Journal of Reproductive Medicine. 1995;40(11):785–8.Google ScholarPubMed
Johnson, H. M., Mitchell, K. B. Low incidence of milk fistula with continued breastfeeding following radiologic and surgical interventions on the lactating breast. Breast Disease. 2021;40(3):183–9.CrossRefGoogle ScholarPubMed
Keleher, A., Wendt III, R., Delpassand, E., Stachowiak, A. M., Kuerer, H. M. The safety of lymphatic mapping in pregnant breast cancer patients using Tc‐99 m sulfur colloid. The Breast Journal. 2004;10(6):492–5.CrossRefGoogle Scholar
Han, S. N., Amant, F., Cardonick, E. H., et al. Axillary staging for breast cancer during pregnancy: Feasibility and safety of sentinel lymph node biopsy. Breast Cancer Research and Treatment. 2018;168(2):551–7.CrossRefGoogle ScholarPubMed
Wolters, V., Heimovaara, J., Maggen, C., et al. Management of pregnancy in women with cancer. International Journal of Gynecologic Cancer. 2021;31(3):314–22.CrossRefGoogle ScholarPubMed
Loibl, S., Han, S. N., von Minckwitz, G., et al. Treatment of breast cancer during pregnancy: an observational study. The Lancet Oncology. 2012;13(9):887–96.CrossRefGoogle ScholarPubMed
Shah, N. M., Scott, D. M., Kandagatla, P., et al. Young women with breast cancer: Fertility preservation options and management of pregnancy-associated breast cancer. Annals of Surgical Oncology. 2019;26(5):1214–24.CrossRefGoogle ScholarPubMed
Reprotox. Herceptin. 2022. www.reprotox.org/member/agents/25182/printSummaryGoogle Scholar
Reprotox. Tamoxifen. 2022. www.reprotox.org/member/agents/17850Google Scholar
Schuurman, T. N., Witteveen, P. O., Van Der Wall, E., et al. Tamoxifen and pregnancy: An absolute contraindication?. Breast Cancer Research and Treatment. 2019;175(1):17–25.CrossRefGoogle ScholarPubMed
Keyser, C. E., Staat, M. B., Fausett, C. M., Shields, L. C. Pregnancy-associated breast cancer. Reviews in Obstetrics and Gynecology. 2012;5(2):94–9.Google ScholarPubMed
Matsuo, K., Klar, M., Youssefzadeh, A. C., et al. Assessment of severe maternal morbidity and mortality in pregnancies complicated by cancer in the US. JAMA Oncology. 2022;8(8):1213–16.CrossRefGoogle ScholarPubMed
Nowik, C. M., Gerrie, A. S., Wong, J. Conservative management of presumed fetal anemia secondary to maternal chemotherapy for acute myeloid leukemia. American Journal of Perinatology Reports. 2021;11(04):e137–41.Google ScholarPubMed
La Nasa, M., Gaughan, J., Cardonick, E. Incidence of neonatal neutropenia and leukopenia after in utero exposure to chemotherapy for maternal cancer. American Journal of Clinical Oncology. 2019;42(4):351–4.CrossRefGoogle ScholarPubMed
Cardonick, E. H., Gringlas, M. B., Hunter, K., Greenspan, J. Development of children born to mothers with cancer during pregnancy: Comparing in utero chemotherapy-exposed children with nonexposed controls. American Journal of Obstetrics and Gynecology. 2015;212(5):658–e1.CrossRefGoogle ScholarPubMed
Lambertini, M., Ameye, L., Hamy, A. S., et al. Pregnancy after breast cancer in patients with germline BRCA mutations. Journal of Clinical Oncology. 2020;38(26):3012–23.CrossRefGoogle ScholarPubMed
Iqbal, J., Amir, E., Rochon, P. A., et al. Association of the timing of pregnancy with survival in women with breast cancer. JAMA Oncology. 2017;3(5):659–65.CrossRefGoogle ScholarPubMed
Alipour, S., Omranipour, R., editors. Diseases of the Breast during Pregnancy and Lactation. Springer; 2020.CrossRefGoogle ScholarPubMed
Azim, Jr, H. A., Bellettini, G., Liptrott, S. J., et al. Breastfeeding in breast cancer survivors: Pattern, behaviour and effect on breast cancer outcome. The Breast. 2010;19(6):527–31.CrossRefGoogle ScholarPubMed
Bhurosy, T., Niu, Z., Heckman, C. J. Breastfeeding is possible: A systematic review on the feasibility and challenges of breastfeeding among breast cancer survivors of reproductive age. Annals of Surgical Oncology. 2021;28(7):3723–35.CrossRefGoogle ScholarPubMed
Halaska, M. J., Uzan, C., Han, S. N., et al. Characteristics of patients with cervical cancer during pregnancy: A multicenter matched cohort study. An initiative from the International Network on Cancer, Infertility and Pregnancy. International Journal of Gynecologic Cancer. 2019;29(4).CrossRefGoogle Scholar
Bhatla, N., Aoki, D., Sharma, D. N., Sankaranarayanan, R. Cancer of the cervix uteri: 2021 update. International Journal of Gynecology & Obstetrics. 2021;155:28–44.CrossRefGoogle ScholarPubMed
Beharee, N., Shi, Z., Wu, D., Wang, J. Diagnosis and treatment of cervical cancer in pregnant women. Cancer Medicine. 2019;8(12):5425–30.CrossRefGoogle ScholarPubMed
Perkins, R. B., Guido, R. S., Castle, P. E., et al. Erratum: 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. Journal of Lower Genital Tract Disease. 2021;25(4):330–1.CrossRefGoogle ScholarPubMed
Mailath-Pokorny, M., Schwameis, R., Grimm, C., Reinthaller, A., Polterauer, S. Natural history of cervical intraepithelial neoplasia in pregnancy: Postpartum histo-pathologic outcome and review of the literature. BMC Pregnancy and Childbirth. 2016;16(1):1–6.CrossRefGoogle ScholarPubMed
Robinson, W. R., Webb, S., Tirpack, J., Degefu, S., O’Quinn, A. G. Management of cervical intraepithelial neoplasia during pregnancy with LOOP excision. Gynecologic Oncology. 1997;64(1):153–5.CrossRefGoogle ScholarPubMed
Han, S. N., Mhallem Gziri, M., Van Calsteren, K., Amant, F. Cervical cancer in pregnant women: treat, wait or interrupt? Assessment of current clinical guidelines, innovations and controversies. Therapeutic Advances in Medical Oncology. 2013;5(4):211–19.CrossRefGoogle ScholarPubMed
European Society of Gynaecological Oncology. Cervical cancer chapter. https://eacademy.esgo.org/pdfviewer/web/viewer.html?file=https%3A//eacademy.esgo.org/util/document_library%3Fdc_id%3D3351%26g_id%3D41%26vxc%3D/esgo/document_library%3Fdc_id%3D3351Google Scholar
Ilancheran, A. Neoadjuvant chemotherapy in cervical cancer in pregnancy. Best Practice & Research Clinical Obstetrics & Gynaecology. 2016;33:102–7.CrossRefGoogle ScholarPubMed
Bigelow, C. A., Horowitz, N. S., Goodman, A., et al. Management and outcome of cervical cancer diagnosed in pregnancy. American Journal of Obstetrics and Gynecology. 2017;216(3):276–e1.CrossRefGoogle ScholarPubMed
American College of Obstetricians and Gynecologists. Prediction and prevention of spontaneous preterm birth: ACOG Practice Bulletin, Number 234. Obstetrics and Gynecology. 2021;138(2):e65–90.CrossRefGoogle Scholar
McIntosh, J., Feltovich, H., Berghella, V., Manuck, T. The role of routine cervical length screening in selected high-and low-risk women for preterm birth prevention. American Journal of Obstetrics and Gynecology. 2016;215(3):B2–7.CrossRefGoogle ScholarPubMed
Cliby, W. A., Dodson, M. K., Podratz, K. C. Cervical cancer complicated by pregnancy: episiotomy site recurrences following vaginal delivery. Obstetrics and Gynecology. 1994;84(2):179–82.Google ScholarPubMed
Arakawa, A., Ichikawa, H., Kubo, T., et al. Vaginal transmission of cancer from mothers with cervical cancer to infants. New England Journal of Medicine. 2021;384(1):42–50.CrossRefGoogle ScholarPubMed
Paraskevaidis, E., Bilirakis, E., Koliopoulos, G., et al. Cervical regeneration after diathermy excision of cervical intraepithelial neoplasia as assessed by transvaginal sonography. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2002;102(1):88–91.CrossRefGoogle ScholarPubMed
Himes, K. P., Simhan, H. N. Time from cervical conization to pregnancy and preterm birth. Obstetrics & Gynecology. 2007;109(2):314–19.CrossRefGoogle ScholarPubMed
Baucom, A., Herzog, T., Jackson, A., Wahab, S. A., Billingsley, C. A case of placenta previa with increta with a history of pelvic radiation. Gynecologic Oncology Reports. 2021;37:100800.CrossRefGoogle ScholarPubMed
Bentivegna, E., Maulard, A., Pautier, P., et al. Fertility results and pregnancy outcomes after conservative treatment of cervical cancer: A systematic review of the literature. Fertility and Sterility. 2016;106(5):1195–211.CrossRefGoogle ScholarPubMed
Pinnix, C. C., Osborne, E. M., Chihara, D., et al. Maternal and fetal outcomes after therapy for Hodgkin or non-Hodgkin lymphoma diagnosed during pregnancy. JAMA oncology. 2016;2(8):1065–9.CrossRefGoogle ScholarPubMed
Maggen, C., Dierickx, D., Cardonick, E., et al. Maternal and neonatal outcomes in 80 patients diagnosed with non‐Hodgkin lymphoma during pregnancy: Results from the International Network of Cancer, Infertility and Pregnancy. British Journal of Haematology. 2021;193(1):52–62.CrossRefGoogle ScholarPubMed
Shah, M. R., Brandt, J. S., David, K. A., Evens, A. M. Lymphoma occurring during pregnancy: Current diagnostic and therapeutic approaches. Current Oncology Reports. 2020;22(11):1–3.CrossRefGoogle ScholarPubMed
Kritharis, A., Walsh, E. P., Evens, A. M. Managing lymphoma during pregnancy. In Azim H. A. (ed.), Managing Cancer During Pregnancy (pp. 159–73). Springer; 2016.Google Scholar
Pinnix, C. C., Andraos, T. Y., Milgrom, S., Fanale, M. A. The management of lymphoma in the setting of pregnancy. Current Hematologic Malignancy Reports. 2017;12(3):251–6.CrossRefGoogle ScholarPubMed
Maggen, C., Dierickx, D., Lugtenburg, P., et al. Obstetric and maternal outcomes in patients diagnosed with Hodgkin lymphoma during pregnancy: A multicentre, retrospective, cohort study. The Lancet Haematology. 2019;6(11):e551–61.CrossRefGoogle ScholarPubMed
Kal, H. B., Struikmans, H. Radiotherapy during pregnancy: Fact and fiction. The Lancet Oncology. 2005;6(5):328–33.CrossRefGoogle Scholar
Woo, S. Y., Fuller, L. M., Cundiff, J. H., et al. Radiotherapy during pregnancy for clinical stages IA–IIA Hodgkin’s disease. International Journal of Radiation Oncology* Biology* Physics. 1992;23(2):407–12.Google ScholarPubMed
Das, G., Damotte, V., Gelfand, J. M., et al. Rituximab before and during pregnancy: a systematic review, and a case series in MS and NMOSD. Neurology-Neuroimmunology Neuroinflammation. 2018;5(3):e453.CrossRefGoogle Scholar
Reprotox. Rituximab 2022. www.reprotox.org/member/agents/28797Google Scholar
Anand, S. T., Ryckman, K. K., Baer, R. J., et al. Hypertensive disorders of pregnancy among women with a history of leukemia or lymphoma. Pregnancy Hypertension. 2022;29:101–7.CrossRefGoogle ScholarPubMed
Evens, A. M., Advani, R., Press, O. W., et al. Lymphoma occurring during pregnancy: antenatal therapy, complications, and maternal survival in a multicenter analysis. Journal of Clinical Oncology. 2013;31(32):4132–9.CrossRefGoogle Scholar
Gaudio, F., Nardelli, C., Masciandaro, P., et al. Pregnancy rate and outcome of pregnancies in long-term survivors of Hodgkin’s lymphoma. Annals of Hematology. 2019;98(8):1947–52.CrossRefGoogle ScholarPubMed
Weibull, C. E., Eloranta, S., Smedby, K. E., et al. Pregnancy and the risk of relapse in patients diagnosed with Hodgkin lymphoma. J Clin Oncol. 2016;34:337–44.CrossRefGoogle ScholarPubMed
Shliakhtsitsava, K., Romero, S. A., Dewald, S. R., Su, H. I. Pregnancy and child health outcomes in pediatric and young adult leukemia and lymphoma survivors: A systematic review. Leukemia & Lymphoma. 2018;59(2):381–97.CrossRefGoogle Scholar
McCullough, L., Ng, A., Najita, J., et al. Breastfeeding in survivors of Hodgkin lymphoma treated with chest radiotherapy. Cancer. 2010;116(20):4866–71.CrossRefGoogle ScholarPubMed
Fracchiolla, N. S., Sciumè, M., Dambrosi, F., et al. Acute myeloid leukemia and pregnancy: Clinical experience from a single center and a review of the literature. BMC Cancer. 2017;17(1):1–8.CrossRefGoogle Scholar
Milojkovic, D., Apperley, J. F. How I treat leukemia during pregnancy. Blood, The Journal of the American Society of Hematology. 2014;123(7):974–84.Google Scholar
Vandenbriele, C., Dierickx, D., Amant, F., Delforge, M. The treatment of hematologic malignancies in pregnancy. Facts, Views & Vision in ObGyn. 2010;2(2):74–87.Google ScholarPubMed
Chelghoum, Y., Vey, N., Raffoux, E., et al. Acute leukemia during pregnancy: A report on 37 patients and a review of the literature. Cancer. 2005;104(1):110–17.CrossRefGoogle Scholar
Brenner, B., Avivi, I., Lishner, M. Haematological cancer in pregnancy. The Lancet. 2012;379(9815):580–7.CrossRefGoogle Scholar
Cortes, J., O’Brien, S., Ault, P., et al. Pregnancy outcomes among patients with chronic myeloid leukemia treated with dasatinib. Blood. 2008;112(11):3230.CrossRefGoogle Scholar
Reprotox. Imatinib. 2022. www.reprotox.org/member/agents/25202Google Scholar
Beyer-Westendorf, J., Tittl, L., Bistervels, I., et al. Safety of direct oral anticoagulant exposure during pregnancy: A retrospective cohort study. The Lancet Haematology. 2020;7(12):e884–91.CrossRefGoogle ScholarPubMed
Aldoss, I., Pillai, R., Yang, D., et al. Late and very late relapsed acute lymphoblastic leukemia: Clinical and molecular features, and treatment outcomes. Blood Cancer Journal. 2021;11(7):1–4.CrossRefGoogle ScholarPubMed
Zgardau, A., Ray, J. G., Baxter, N. N., et al. Obstetrical and perinatal outcomes in female survivors of childhood and adolescent cancer: A population-based cohort study. JNCI: Journal of the National Cancer Institute. 2022;114(4):553–64.CrossRefGoogle Scholar
Siu, B. L., Alonzo, M. R., Vargo, T. A., Fenrich, A. L. Transient dilated cardiomyopathy in a newborn exposed to idarubicin and all-trans-retinoic acid (ATRA) early in the second trimester of pregnancy. International Journal of Gynecologic Cancer. 2002;12(4):399–402.CrossRefGoogle Scholar
Anand, S. T., Chrischilles, E. A., Baer, R. J., et al. The risk of preterm birth among women with a history of leukemia or lymphoma. The Journal of Maternal-Fetal & Neonatal Medicine. 2021;8:1–9.Google Scholar
Teh, W. T., Stern, C., Chander, S., Hickey, M. The Impact of Uterine Radiation on Subsequent Fertility and Pregnancy Outcomes. BioMed research international. 2014;2014:482968.CrossRefGoogle ScholarPubMed
Loren, A. W., Chow, E., Jacobsohn, D. A., et al. Pregnancy after hematopoietic cell transplantation: A report from the late effects working committee of the Center for International Blood and Marrow Transplant Research (CIBMTR). Biology of Blood and Marrow Transplantation. 2011;17(2):157–66.CrossRefGoogle Scholar
Balas, N., Hageman, L., Wu, J., et al. Conditioning intensity and probability of live birth after blood or marrow transplantation, a BMTSS report. Blood Advances. 2022;6(8):2471–9.CrossRefGoogle ScholarPubMed
Chiodi, S., Spinelli, S., Bruzzi, P., et al. Menstrual patterns, fertility and main pregnancy outcomes after allogeneic haematopoietic stem cell transplantation. Journal of Obstetrics and Gynaecology. 2016;36(6):783–8.CrossRefGoogle ScholarPubMed
Gerstl, B., Sullivan, E., Koch, J., et al. Reproductive outcomes following a stem cell transplant for a haematological malignancy in female cancer survivors: A systematic review and meta-analysis. Supportive Care in Cancer. 2019;27:4451–60.CrossRefGoogle ScholarPubMed
Sasagasako, N., Tani, H., Chigusa, Y., et al. Placenta Accreta in a woman with childhood uterine irradiation: A case report and literature review. Case Reports in Obstetrics and Gynecology. 2019;2019:2452975.CrossRefGoogle Scholar
Bowman, Z. S., Simons, M., Sok, C., Draper, M. L. Cervical insufficiency and placenta accreta after prior pelvic radiation. Journal of Obstetrics and Gynaecology. 2014;34(8):735.CrossRefGoogle ScholarPubMed
Baucom, A., Herzog, T., Jackson, A., Wahab, S. A., Billingsley, C. A case of placenta previa with increta with a history of pelvic radiation. Gynecologic Oncology Reports. 2021;37:100800.CrossRefGoogle ScholarPubMed
Ogg, S. W., Hudson, M. M., Randolph, M. E., Klosky, J. L. Protective effects of breastfeeding for mothers surviving childhood cancer. Journal of Cancer Survivorship. 2011;5(2):175–81.CrossRefGoogle ScholarPubMed
Bansal, N., Hazim, C. F., Badillo, S., et al. Maternal cardiovascular outcomes of pregnancy in childhood, adolescent, and young adult cancer survivors. Journal of Cardiovascular Development and Disease. 2022;9(11):373.CrossRefGoogle ScholarPubMed
Thompson, K. A. Pregnancy and cardiomyopathy after anthracyclines in childhood. Frontiers in Cardiovascular Medicine. 2018;5:14.CrossRefGoogle ScholarPubMed
Nolan, M., Oikonomou, E. K., Silversides, C. K., et al. Impact of cancer therapy-related cardiac dysfunction on risk of heart failure in pregnancy. Cardio Oncology. 2020;2(2):153–62.Google ScholarPubMed
American College of Obstetricians and Gynecologists Practice Bulletin No. 212. Pregnancy and heart disease. Obstet Gynecol. 2019 May;133(5):e320–56.Google Scholar
Drugs and Lactation Database (LactMed®) [Internet]. Bethesda (MD): National Institute of Child Health and Human Development; 2006. www.ncbi.nlm.nih.gov/books/NBK500576/Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×