Management of Invasive Carcinoma of the Uterine Cervix Associated with Pregnancy: Outcome in Intentional Delay in Treatment
Abstract & Commentary
Synopsis: Delay in treatment to allow for fetal maturity is safe in patients with early stage I cervical carcinoma associated with pregnancy.
Source: Takushi M, et al. Management of invasive carcinoma of the uterine cervix associated with pregnancy: outcome of intentional delay in treatment. Gynecol Oncol. 2002;87:185-189.
Takushi and colleagues retrospectively reviewed the medical records of 28 patients with invasive cervical cancer diagnosed during pregnancy or within 1 month after pregnancy to investigate maternal and neonatal outcomes after planned treatment delay to improve fetal maturity. Twenty-two patients (79%) had stage I disease, and 6 (21%) had stage II or III disease. All but 1 patient had squamous cell histology. Twenty cases were diagnosed before 22 weeks gestation, 4 between 22 and 36 weeks, 1 after 36 weeks, and 3 were diagnosed postpartum. In the immediate treatment group (n = 16), the stage was IA in 3 cases, IB in 7, and II or III in 6 patients. In 11 patients, hysterectomy was performed after therapeutic abortion or with fetus in situ. In 2 patients, cesarean section was followed by hysterectomy or radiotherapy. Three patients diagnosed postpartum were treated with either hysterectomy or radiotherapy. Fifteen patients were free of disease during the follow-up of 27-114 months. In the delayed treatment group (n = 12), the stage was IA1 in 8 cases, IA2 in 1, IB1 in 2, and IB2 in 1 case. In the 8 patients with stage IA1 tumor, the treatment was deferred until term with a delay of 6-25 weeks, and hysterectomy or therapeutic conization was performed after delivery. In the 4 patients with stage IA2, IB1, or IB2 tumor, the treatment was postponed until after 30 weeks’ gestation with a delay of 6-15 weeks. No disease progression was documented. Cesarean delivery was followed by hysterectomy in these patients. All patients were free of disease during the follow-up of 70-156 months, and their offspring were well with no sequelae. Takushi et al concluded that delay in treatment to allow for fetal maturity is safe in patients with early stage I cervical carcinoma associated with pregnancy.
Comment by David M. Gershenson, MD
The association of cervical cancer with pregnancy is fortunately quite rare, occurring in about 1 in 2000 to 10,000 pregnancies. When it does occur, obvious important considerations include the health of the mother and the viability and health of the fetus. No study has demonstrated an adverse effect of pregnancy on the biology or disease progression of the cervical cancer. Of course, there are no large prospective studies on this topic, and there never will be. Historically, cervical cancer in pregnancy was generally treated immediately, with the pregnancy being terminated. With advances in neonatal medicine and improved outcomes for increasingly premature infants, reports of planned delay of treatment began to emerge. This study from Japan certainly confirms the experience from several other studies, most of which originate from the United States. Takushi et al cite 10 other studies in which a small number of patients, 1-8, with cervical cancer in pregnancy (stages IA2 to IB2) are managed with delays in treatment of 1-32 weeks. And, with rare exception, the outcomes have been favorable. However, one wonders whether there has been lack of reporting in cases with poor outcomes. For patients with preinvasive cervical disease, the rule of thumb would be close monitoring during the pregnancy without intervention. The same has generally been true of stage IA1 disease (usually confirmed by conization). For those with stage IA2 or more advanced disease, however, firm guidelines become obscured. While the outcomes reported in all these studies are impressive and provide some reassurance that definitive treatment can be safely delayed in some pregnant patients with cervical cancer, this approach must be individualized, and the patient and her family must make the final determination after comprehensive informed consent. One must emphasize, as Takushi et al do, that there are no absolutes here. The precise risk of disease progression associated with treatment delay cannot be ascertained. Underestimation of the extent of disease remains a major concern. In general, for patients with stage II, III, or IV disease, immediate treatment, as practiced in this study, is recommended. The real dilemmas are in those patients with stage IA2, IB1, and IB2 disease.
Dr. Gershenson is Professor and Chairman Department of Gynecology M.D. Anderson Cancer Center, Houston.