Fertility-sparing management in cervical cancer: balancing oncologic outcomes with reproductive success

Abstract

BackgroundCervical cancer is the fourth most common cancer among women worldwide, many of who are still within their reproductive lifespan. Advances in screening and treatment have increased the 5-year survival for early stage disease to over 90 % in developed countries. The focus is now shifting to reducing morbidity and improving fertility outcomes for cervical cancer patients. Radical trachelectomy with lymph node assessment became the standard of care for selected women with lesions <2 cm who desire fertility preservation. However, several questions still remain regarding the degree of surgical radicality required for tumors <2 cm, and fertility-sparing options for women with early-stage disesase ≥2 cm, and those with more advanced disease. Here, we compile a narrative review of the evidence for oncologic and pregnancy outcomes following radical trachelectomy, non-radical fertility-sparing surgery, and the use of neoadjuvant chemotherapy prior to surgery for larger lesions. We also review the literature for assisted reproductive technologies in women with more advanced disease.FindingsAvailable literature suggests that the crude recurrence and mortality rates after radical trachelectomy are <5 and <2 %, respectively (approx. 11 and 4 % for tumors ≥ 2 cm). Among 1238 patients who underwent fertility-sparing surgery for early cervical cancer there were 469 pregnancies with a 67 % live birth rate. Among 134 cases with lesions ≥ 2 cm, there were ten conceptions with a live birth rate of 70 %. Outcomes after non-radical surgery (simple trachelectomy or cervical conization) are similar, although only applicable among a highly selected patient population. For patients ineligible for fertility-preserving surgery or who require adjuvant radiation therapy, current options include ovarian transposition and cryopreservation of oocytes or embryos but other techniques are under investigation.ConclusionToday, many cervical cancer survivors have successful pregnancies. For those with early-stage disease, minimally invasive and fertility sparing techniques have resulted in improved obstetrical outcomes without compromising oncologic safety. Results from three ongoing trials on non-radical surgery for low-risk tumors <2 cm will further inform the need for radical surgery in such patients. For those in whom natural childbearing is unachievable, advances in assisted reproductive technologies provide reproductive options. Despite our advances, the effects of cervical cancer survivorship on quality of life are not fully elucidated.

Prevalence and Distribution of High-Risk Human Papillomavirus Genotypes in Invasive Carcinoma of the Uterine Cervix in Uruguay. An update on clinical outcome

“…In agreement with Bradbury et al we found significant correlation of OS with lymph node metastasis but not extrauterine invasion (Table III) (Bradbury, 2015), although other authors reported significant correlation of parametrial involvement with disease-free and overall survival (Jiamset, 2016 (Mao, 2016). Current literature suggests that patients with low-risk early-stage CC may be candidates for more conservative approaches, preserving reproductive function (Baiocchi, 2017;Willows, 2016). In contrast, CCRT is the standard of care in locally advanced stages of CC, which exceed the limit of the cervix towards parametria, annexes or pelvic organs (FIGO stages IB2, IIA2-IV) (Meng, 2016).…”

Human uterine transplantation: a review of outcomes from the first 45 cases

“…Moreover, the concept of draining the uterus through the ovarian vessels is not new. Following the development of the abdominal radical trachelectomy more than two decades previously, more than 400 infants have since been born in women who have undergone the procedure, proving that uteri remain viable when drained by the ovarian vessels alone …”

Obstetric Outcomes in Women With Early Bulky Cervical Cancer Downstaged by Neoadjuvant Chemotherapy to Allow for Fertility-Sparing Surgery

“…The current study provides the most accurate evidence to inform this subgroup of women with respect to their obstetric outcomes. As management standardization for these women fortunate enough to undergo fertility preservation is desirable, 46 our study can be informative toward treatment individualization. This strategy will need multicenter cooperation to confirm oncological safety.…”