- Can I have a cervical screening test during pregnancy?
- If you’re planning a pregnancy
- If you’re already pregnant and due for a cervical screening test
- Getting abnormal results while you’re pregnant
- Further information
- ‘I was pregnant when I was told I had cervical cancer’ – mum-of-one (39)
- Cervical cancer
- Pregnancy after a cone biopsy
- Pregnancy after other treatment
- What to remember
- Pregnant With Cervical Cancer
- 1. What every clinician should know
- 2. Diagnosis and differential diagnosis
- What is the first step in screening for cervical cancer in pregnancy?
- What features of the presentation will guide me toward possible causes and next treatment steps?
- How are abnormal pap smear results interpreted and managed?
- What initial studies should you perform to help make the diagnosis?
- When do you need more aggressive tests?
- How are the colposcopy results interpreted?
- What signs and symptoms should make you concerned for invasive disease?
- 3. Management
- If a diagnosis of cervical cancer is made, how is a pregnant patient treated?
- What imaging studies (if any) will be helpful?
- How is treatment of cervical cancer made specific to pregnant women?
- What are the various treatments available based on stage?
- Are alternative treatments available?
- What novel therapeutics are emerging?
- What mode of delivery is recommended for pregnant patients with cervical cancer?
- How do you counsel the patient and family on prognosis of cervical cancer in pregnancy?
- 4. What’s the evidence?
- RELATED: WHAT WOMEN AGES 35-44 NEED TO KNOW ABOUT CERVICAL CANCER
- RELATED: WHAT IT’S LIKE TO HAVE A HYSTERECTOMY AT AGE 25
- RELATED: WHAT TO EXPECT A DAY, WEEK, AND MONTH AFTER HAVING A C-SECTION
- Related posts:
Treatment of Cervical Cancer Based on Different Stages of Pregnancy
The treatment of cervical cancer is based on the location of the tumour, the stage of cervical cancer, your overall health, and the particular trimester of pregnancy you’re currently in. Here are following treatment modes for the different stages of pregnancy for mothers affected by cervical cancer.
- Treatment of Cervical Cancer in Early Stages of Pregnancy
Routine Pap tests followed by a biopsy are used for the treatment of cervical cancer in the early stages of pregnancy. Surgery may be done during this stage which involves removing the tumour and surrounding healthy tissue in the cervix. This is non-invasive and poses little risk to the mother and the baby.
If your cervical cancer is in its earliest stages during pregnancy, your doctor may postpone treatment after a healthy delivery due to no threat to the pregnancy. After pregnancy, you may be subject to a hysterectomy (removal of the uterus) based on how far cancer has progressed after your pregnancy.
- Treatment of Cervical Cancer in Second and Third Trimester
Chemotherapy may be combined with radiation therapy to provide the necessary treatment during this stage. These treatment methods are usually safe and do not harm the foetus during the second and third trimesters.
- Pregnant Women Who Have a Small Tumour
For small tumours, there are two treatment options available for mothers-to-be: a cone biopsy, and a trachelectomy. Since a trachelectomy poses a risk to the unborn baby and may cause foetal demise during the operation, it is avoided during pregnancy. A cone biopsy is the preferred method. In this method, a conical section of tissue is removed from the cervix for examination and diagnosis.
- Pregnant Women Having Large Tumour
Your doctor will recommend chemotherapy for treating large tumours. You will either be advised to opt for early delivery or wait until the second or third trimester to start with this treatment.
There are no treatment methods known for completely treating cervical cancer in pregnant mothers. Treatment methods will vary based on the stage and extent of cancer along with the overall health of the patient. Findings from studies and data from clinical trials performed on previous non-pregnant cervical cancer victims are used to assist with treatment or delay cervical cancer therapies during pregnancy.
Your doctor may advise you to abort the pregnancy if your cervical cancer has progressed to the most advanced stages of your pregnancy.
There are many ways to prevent cervical cancer from developing. The primary method is treating it as soon as it is detected, if possible, before the pre-cancerous stage and not letting it mature any further. The most common methods of prevention are:
- Using condoms during sexual intercourse
- Avoiding early sexual contact or not having sex with multiple partners
- Eliminating smoking/drug abuse
- Avoiding skin-to-skin contact with someone who already has an HPV infection
- Routine HPV vaccination starting between ages 9 to 12
It is recommended that every woman should undergo routine Pap testing (Pap smear) or HPV DNA Testing to diagnose signs/symptoms of cervical cancer. Routine vaccination is even recommended for those who have sex with multiple partners even beyond the age of 21 and above to prevent pre-cancerous stages from developing.
Make an appointment with your doctor and attend regular Pap screening tests to prevent the chances of cervical cancer from developing. By adopting a healthy lifestyle, not smoking, and ensuring you’re not sexually active before 21, you will greatly diminish the probability of Cervical Dysplasia from occurring. Routine vaccinations are also important for the prevention of HPV infections and cervical dysplasia.
During treatment, you may ask your doctor for palliative care which is known to provide relief from pain and other symptoms of serious illnesses.
We recommend you ask for a second healthcare provider’s opinion when considering attending an examination for the diagnosis of cervical cancer. Sit with your doctor and ask about the treatment options available to you if you are diagnosed with cervical cancer during pregnancy since treatment methods differ according to individual medical profiles.
Also Read: Uterine Fibroids During Pregnancy
Can I have a cervical screening test during pregnancy?
You will not usually need to have cervical screening if you’re pregnant, or could be pregnant, until at least 12 weeks after you’ve given birth. This is because pregnancy can make it harder to get clear results.
If you’re planning a pregnancy
It’s a good idea to ask your GP if you’re up to date with your cervical screening. This is so any tests or treatment can be arranged around your pregnancy.
If you’re already pregnant and due for a cervical screening test
Tell your GP or clinic you’re pregnant when you’re invited for cervical screening. You will usually be advised to reschedule the test for a date around 12 weeks after your baby is born.
But, if you’ve previously had an abnormal result from a cervical screening test, you may need to be screened while you’re pregnant. Your GP or midwife may ask you to have a cervical screening test at your first antenatal appointment. This test will not affect your pregnancy.
Getting abnormal results while you’re pregnant
An abnormal result does not mean you have cancer. Cervical screening is a test to help prevent cancer.
There are different kinds of abnormal result depending on if your sample was tested for:
- abnormal cell changes in your cervix – left untreated, this could turn into cancer
- HPV – some types of HPV can lead to cell changes in your cervix and cancer
Depending on the results, you may need:
- no treatment
- another cervical screening test 1 year after your abnormal test
- a colposcopy
Having a colposcopy during pregnancy
A colposcopy is a simple procedure to look at your cervix. It’s safe to have during pregnancy.
It’s similar to having cervical screening but it’s carried out in hospital.
If a colposcopy shows changes to the cells on your cervix, you may need another colposcopy around 3 to 6 months after you give birth, to check on the abnormal cells.
Sometimes you’ll need treatment to remove the abnormal cells if they have not returned to normal after giving birth.
You can talk to your GP or midwife about any concerns you have.
It’s important to go to all of your follow-up appointments after you’ve had your baby.
- Pregnancy and baby guide
- Cervical screening
‘I was pregnant when I was told I had cervical cancer’ – mum-of-one (39)
An estimated 300 women in Ireland are diagnosed with cervical cancer every year. For many, the life-saving vaccine which protects against seven out of 10 cervical cancers is the difference between life or death. Despite the compelling scientific evidence that concludes that the vaccine is both safe and groundbreakingly effective for both girls and boys, a campaign, spread on the internet and social media, has meant that there has been an alarming drop off in the uptake of the vaccine.
Pleading with parents to ignore the conspiracy theories, Dr Jennifer Grant of the Beacon Hospital explains why children should be vaccinated against HPV.
“Mass scaremongering about potential vaccine side effects has resulted in a decline in vaccine uptake in the past year to less than half of all eligible school girls taking up the offer for free vaccination. Recent evidence from Scotland and Australia has shown a reduced rate of pre-cancer changes and cancer cases in young girls following vaccination. In my eyes, there is no debate.
“The vaccine protects against the main types of HPV virus and reduces the risk of developing cervical cancer and genital warts, but does not remove the need for cervical smear tests.
HPV is linked to a lot of mouth, throat, anal and penile cancers. Therefore, boys should also get vaccinated. It is offered free of charge to all girls but not boys as yet. In November 2015, the European Medicines Agency reported no link between chronic fatigue-like syndromes and the HPV vaccine.”
Two women who were diagnosed with cervical cancer explain how the vaccine can save lives.
After struggling to conceive Katrzyna was overjoyed when she discovered she was pregnant only to be shocked by bad news soon after…
The 39-year-old – who lives with her partner Peter and baby girl Melanie, now one-year-old, in Whitehall, Dublin – explains why she will vaccinate her daughter when the time comes and is encouraging other parents to do the same.
“I was experiencing bleeding so I went to my GP and I had a smear test. I was referred for an ultrasound and that’s when the doctor told me I was pregnant. I was thrilled because I thought I was unable to have children as we had been trying for some time.
“I was eight weeks pregnant when the results from the smear came back and I was told I had severe dysplasia. I was referred to the colposcopy clinic. At that time, I still thought it was related to the pregnancy, so I wasn’t worried.
“By the time the baby’s 12 week scan came around, I had completely forgotten about the smear test. Myself and my partner Peter were told that there was a 50pc chance that the baby could have a genetic condition or heart disease, so we were dealing with that.”
Reeling from the news that her baby could be born with major health concerns, the business woman, who is originally from Poland, was dealt another devastating blow when it was confirmed that she had cancer.
“When I went to the colposcopy clinic, the first question the doctor asked when he checked my cervix was ‘How many children do you have already?’ I said, ‘It’s my first baby’. I knew from his reaction it wasn’t good news.
“I had a biopsy and three days later, I had the results. I was told that I had cancer and that it was locally advanced.
“I was sent for an MRI so they could see what stage cancer I had. That was the most difficult part, that really was the deciding factor in how the team would proceed.”
Unsure whether she could continue the pregnancy and advance with treatment, the doting mum explains,
“From the beginning, I said that if there was any chance for both of us, I would take the chance and that’s what I did.
“When the results came back, I had stage 2B cervical cancer which meant that I needed radiotherapy, but that was impossible because I was pregnant so my team decided chemotherapy would be the best option, but it would only contain the cancer.
“In the midst of all this we found out that the baby didn’t have any genetic problems, but her heart was not developing properly. She had Hypoplastic Right Heart Syndrome, so the right ventricle was smaller than it should be. It was just another complication on top of the cancer.
“My doctors contacted hospitals around the world to see if they had any similar cases – the goal was to start on a chemo that would cause the least amount of damage to the baby.”
Delaying radiotherapy treatment until after her pregnancy, Katrzyna received chemotherapy treatment from the 20th week of her pregnancy until baby Melanie was born on September 28 last year.
“I underwent a C-section and a hysterectomy at the same time. The doctors wanted to put me under anaesthetic but I wanted to hold Melanie.
“They understood, so they did the epidural first. I got to see her and hold her and kiss her and then she was transported to the Rotunda Hospital.
“When Melanie was two-months-old, I started radiotherapy and began more chemotherapy.
“It was hard because she was so small and I hated leaving her, but Peter and his mum were amazing. I could not have done it without them. Peter was my rock throughout it all.
“I finished the whole treatment in January it was an amazing moment. It was the hardest thing to go through, but Melanie is really beautiful. She really is amazing and I am so grateful she is healthy and happy.
“The only problem she has is a hearing loss, she is not deaf but she does not hear 100pc so she has small hearing aids. We thought she would need open heart surgery when she was born, but her heart repaired itself while I was pregnant and she was born with a hole in her heart, but that healed when she was six-months-old.”
Speaking about the importance of the vaccine, the first-time mum says: “I was very good with the smear test. I did everything right, I had them every year or two years and they were all clear. I am convinced smear tests are not enough. I had a really healthy lifestyle too.
“Seventy percent of the population has the virus, while it’s unclear why it develops into cancer in some people’s bodies and not others. What we do know is that the vaccine is safe and it can really prevent cancer.
“I trust the science. I know I will vaccinate Melanie and keep her safe. I hope nobody else has to go through what we did.”
Of the 420 cancer cases attributable to HPV each year, 335 are in women and 85 are in men.
Donal Buggy, head of services and advocacy at the Irish Cancer Society is calling on the government to “invest in the extension of the national HPV school vaccination programme to boys.
“HIQA is currently completing a health technology assessment looking at feasibility of introducing a gender-neutral HPV vaccination programme.
“They’re looking at the clinical and economic benefits of providing the vaccine on a gender-neutral basis as HPV can be transmitted during sexual intercourse or skin-to-skin contact with an infected person.”
Donal explains: “In relation to vaccines in general, they are most effective when they are delivered at a population level so giving boys accessibility to the vaccine will help with immunity and protects girls.
“If boys are not carrying the HPV virus they are not transferring it to girls.”
It’s important to make sure that you go to all of your follow up appointments after you’ve had your baby.
Pregnancy after a cone biopsy
A cone biopsy removes a cone shaped wedge of tissue from your cervix. It can cause particular problems with future pregnancies. But these are not common.
Narrowing of the cervix
After a cone biopsy there is a very small chance that the cervix can narrow. This is called cervical stenosis. The cervix might become so tightly closed that sperm can’t get in. If this happened, you wouldn’t be able to get pregnant naturally.
If you’re having periods after a cone biopsy you have not got complete cervical stenosis. If the lining of the womb can get out, when it is shed as a period, then sperm can get in.
Some women may need surgery to stretch (dilate) the cervical opening.
Some treatments for CIN or very early stage cancer (stage 1A) can lead to a small risk of complications in future pregnancies. Women who have had a cone biopsy have:
- a higher chance of their babies being born before 37 weeks (preterm delivery)
- a higher risk of a baby that weighs less than 2.5kg (low birthweight)
- an increase in birth by caesarean section
You may have an increased risk of early birth because the cone biopsy has weakened your cervix. The cervix is really a muscle that keeps the entrance to the womb closed unless you are in labour.
In some women who have had a cone biopsy, there is a risk that the cervix may start to open too soon because of the weight of the growing baby. Serious problems can usually be prevented.
If your doctor thinks your cervix may start to open too soon, you can have a sort of running stitch put around it to hold it shut. Your doctor may call this a purse string suture. The stitch is cut before you go into labour, usually at about week 37 of your pregnancy. The cervix can then open normally for the baby to come out.
Pregnancy after other treatment
It’s very unlikely that any other treatment for abnormal cells, such as laser therapy, cold coagulation or cryotherapy will affect your ability to get pregnant in the future.
The most likely way that these treatments can affect your ability to get pregnant, is if you get an infection after treatment which spreads into your fallopian tubes.
Infection in the fallopian tubes can cause them to become blocked. If both your tubes are blocked, then your eggs can’t travel down the tubes into your womb. This would mean that you couldn’t get pregnant naturally.
Such a severe infection is unlikely after treatment for abnormal cells. See your GP straight away if you have any symptoms of infection. These can include:
- heavy bleeding, especially if it’s more than during a period
- a vaginal discharge that smells or is green or yellow in colour
- period like pains that last more than a day or two
- a high temperature (fever)
As with cone biopsy, studies looking at pregnancy after LLETZ show that there is a small rise in risk of birth before 37 weeks and having a low birth weight baby. This risk can depend on the amount of cervical tissue that has been removed.
There is also a slight increase in the risk of your waters breaking early (premature rupture of membranes) if you’ve had treatment with LLETZ.
If you are pregnant, you should let your midwife or doctor know if you have had treatment for abnormal cervical cells.
What to remember
You may feel worried about these risks, but remember:
- the risk of developing serious side effects during pregnancy is small
- if you have cervical abnormalities, having treatment is very important
- your doctor will talk through the treatment options, and discuss any potential risks to future pregnancies
Pregnant With Cervical Cancer
Being diagnosed with cervical cancer is scary enough on its own — but what if you are diagnosed while you are pregnant? Experts estimate that about 3 percent of cervical cancer cases are diagnosed during pregnancy. Although the odds of this happening to you are small, it’s important to be aware of the possibility.
Cervical cancer can be detected by a Pap smear, which is often performed during pregnancy, or from a doctor’s exam prompted by symptoms you might be experiencing (such as bleeding). Your pregnancy may affect how your doctor decides to treat the cancer, depending on the stage of the cervical cancer and how far along you are in your pregnancy.
Pregnancy and Early-Stage Cervical Cancer
If your doctor finds cervical cancer in its early stages (e.g., stage IA), you will most likely be able to continue safely with your pregnancy. Treatment will be postponed until several weeks after the baby is delivered; only then will you be treated with a hysterectomy (removal of the uterus and cervix) or cone biopsy (removal of part of the cervix), depending on how much the cancer has progressed.
Some pregnant women do not have cervical cancer, but are diagnosed with having “dysplasia” — mild cervical abnormalities or precancerous cells that could progress to cervical cancer. “We do a colposcopy and get biopsy confirmation,” says Daniel McNeive, MD, an obstetrician-gynecologist in St. Louis. “And if it is indeed dysplasia and not cancer, we just watch it and repeat the Pap smear later in the pregnancy.”
Another treatment option at this stage is a loop electrosurgical excision procedure, or LEEP, which can remove the abnormal cells from the cervix before cancer develops. LEEP uses an electrically charged wire loop to cut away abnormal cells from the cervix.
However, a recent study in the medical journal The Lancet found that pregnant women who undergo LEEP are at increased risk of delivering preterm babies or having a low-birth-weight infant. For this reason, researchers suggest that women carefully discuss the risks and benefits of LEEP before deciding to undergo the procedure while they are pregnant. “Women should seek detailed information on , but also on long-term pregnancy-related before they consent,” lead study author Maria Kyrgiou, MD, of Central Lancashire Teaching Hospitals in Preston, England, told HealthDay News Service.
Another problem with LEEP, according to Dr. McNeive, is that the procedure may make it difficult to tell later if all the cancer has been removed. “And we need to be sure,” he says.
Pregnancy and Advanced Cervical Cancer
For women whose cervical cancer is more advanced, treatment decisions become more complex. Your doctor will discuss options with you, which may include termination of the pregnancy if an aggressive cervical cancer is diagnosed, or if cancer is diagnosed very early in the pregnancy. “You always have the option of waiting” until after delivery to be treated says McNeive. “But women need to know that a stage IA at 10 weeks of pregnancy could become a stage III by the time she delivers.” This can affect the treatment chosen as well as the rates of survival, he cautions.
For women who have reached their second or third trimester, it may be possible to delay treatment for cervical cancer until the baby is delivered. In this case, delivery will take place as early as is safe for the baby. “If you are far enough along, we may be able to deliver early and treat the cancer after that,” McNeive says.
Making the Treatment Decision
If you are diagnosed with cervical cancer while pregnant, you and your doctor will work together to devise a treatment. Your doctor will explain all options, as well as the benefits and risks of each treatment. Since the decision to treat cervical cancer is especially complex in the case of a pregnant woman, you may want to seek a second opinion before deciding.
1. What every clinician should know
Clinical features and incidence
Cervical cancer is the second most common malignancy in women worldwide. As cervical cancer frequently occurs in young women, it is not surprising that the disease is one of the most common cancers diagnosed during pregnancy.
It is now recognized that human papillomavirus (HPV) is a prerequisite for the development of cervical cancer. As HPV is extremely common in young women, preinvasive cytologic abnormalities are frequently diagnosed in pregnant women. The majority of these changes represent low-grade abnormalities that often are transient and resolve without intervention. A smaller subset of women have high-grade abnormalities that carry a significant risk for persistence and ultimately progression to invasive cervical cancer.
HPV infects the basal keratinocytes of the cervix and can lead to a series of progressive precancerous changes known as cervical intraepithelial neoplasia (CIN). While HPV is extremely common, particularly among young sexually active women, the development of cervical cancer is rare. The long preinvasive phase from HPV infection to the development of cervical cancer allows for the detection and eradication of preinvasive changes.
2. Diagnosis and differential diagnosis
What is the first step in screening for cervical cancer in pregnancy?
Papanicoalou (Pap) testing can be safely performed during pregnancy and it is recommended that all pregnant women undergo cytologic screening with the Pap test at their initial prenatal visit (unless a recent Pap smear has been performed prior to pregnancy). As in non-pregnant women, cervical sampling can be performed safely with sampling of the ectocervix as well as endocervical sampling with a cytobrush or comparable device.
What features of the presentation will guide me toward possible causes and next treatment steps?
The normal pregnant cervix is typically characterized by ectropion which may be accompanied by inflammation and may be mistaken as an abnormality. Women with a normal Papanicoalou test do not require further evaluation during pregnancy. Abnormal pap results require further assessment.
How are abnormal pap smear results interpreted and managed?
Atypical squamous cells of undetermined significance (ASC-US) is an abnormality that is frequently seen in young women. While the lesion is poorly reproducible, the overall risk of cancer is low (between approximately 0.1-0.2%). Pregnant women over the age of 20 years may either elect to undergo colposcopy or may safely defer colposcopy until 6 weeks or more postpartum.
Low-grade squamous intraepithelial lesions (LSIL) are also common in reproductive age women. CIN 2 or greater will be detected in approximately 12-16% of women with LSIL. For pregnant women over the age of 20 colposcopy is preferred for evaluation although it is acceptable to defer colposcopy until 6 weeks or more postpartum. Pregnant women 20 years of age or younger do not require evaluation and should undergo cytologic follow-up in 1 year.
Women with high-grade squamous intraepithelial lesions (HSIL) on cytology have a high prevalence of underlying CIN 2 or greater. Pregnant women with HSIL should undergo colposcopy with directed biopsy of any lesions suspicious for CIN 2 or 3, or cancer. Women with HSIL should not undergo ECC or an excisional procedure as part of their evaluation.
Although atypical glandular cells (AGC) is a relatively uncommon cytologic diagnosis, these women are at substantial risk for underlying high-grade abnormalities. Studies have suggested that 9-38% of women have high-grade cervical intraepithelial neoplasia or adenocarcinoma in situ and a further 3-17% of women have invasive cancer. Pregnant women with AGC should undergo colposcopy with biopsy of any suspicious lesions.
What initial studies should you perform to help make the diagnosis?
Like non-pregnant women, pregnant women with cytologic abnormalities are typically evaluated with colposcopy. During the procedure acetic acid is applied to the cervix and the cervix and vagina are visualized under low power magnification. An adequate colposcopy should allow visualization of the entire transformation zone. While the ectropion that accompanies pregnancies facilitates visualization of the transformation zone, it may be mistaken for a cervical abnormality. A number of studies have suggested that colposcopy during pregnancy is safe and not associated with adverse fetal outcomes.
When do you need more aggressive tests?
Although cervical biopsy is safe during pregnancy, the procedure may be associated with more bleeding than typically is seen in non-pregnant women. Many experts recommend performing biopsy only in women with a lesion that is suspicious for high-grade cervical intraepithelial neoplasia. In contrast to cervical biopsy, endocervical curettage (ECC) is not recommended during pregnancy. While data are lacking that ECC is associated with adverse outcomes, the theoretical concern that the procedure could lead to pregnancy-related complications precludes routine performance of ECC.
Cervical excisional procedures, including cold knife conization, large loop excision of the transformation zone (LLETZ), and loop electrosurgical excision procedure (LEEP) are usually only performed during pregnancy to rule out a microinvasive cancer
How are the colposcopy results interpreted?
The understanding of cervical intraepithelial neoplasia (CIN) is rapidly involving. Management of young women with CIN must carefully balance the risks of progression to cancer against the adverse effects of treatment with conization. For management cervical intraepithelial neoplasia is classified as either CIN 1, CIN 2 or CIN 3.
CIN 1 is a heterogenous diagnosis that includes women who may progress to higher grade CIN as well as women with non-oncogenic HPV. The diagnosis of CIN 1 is poorly reproducible. Pregnant women with CIN 1 do not require any further evaluation.
Cervical intraepithelial neoplasia 2 and 3 (CIN 2 and CIN 3) represent moderate to severe cervical intraepithelial neoplasia. The distinction between CIN 2 and 3 is poorly reproducible and as such, these lesions are classified similarly. The underlying risk of progression to invasive cancer is substantial. Pregnant women with a diagnosis of CIN 2 or CIN 3 may either be followed during pregnancy with repeat colposcopy or defer repeat colposcopy until at least 6 weeks postpartum.
For those women who undergo repeat colposcopy during pregnancy the procedure should not be performed more frequently than every 12 weeks. Repeat biopsy is unnecessary unless the appearance of the lesion worsens. An excisional procedure should not be performed unless invasive cancer is suspected.
What signs and symptoms should make you concerned for invasive disease?
Women with microscopic tumors are usually asymptomatic. Among women with clinically visible lesions vaginal bleeding is the most common symptom. Classically, vaginal bleeding is postcoital. Abdominopelvic pain and vaginal discharge may also occur. Women with advanced-stage tumors may have back pain, hydronephrosis or sciatica.
If a diagnosis of cervical cancer is made, how is a pregnant patient treated?
The management of cervical cancer during pregnancy depends primarily on the stage of the cancer and the gestational age of the mother at the time of diagnosis. Cervical cancer is staged using the 2009 International Federation of Gynecology and Obstetrics staging system. The staging of women with cervical cancer relies on clinical examination.
What imaging studies (if any) will be helpful?
Both CT and MRI are anatomic imaging modalities that have been used to evaluate tumor size, parametrial spread and nodal dissemination. A prospective study by the Gynecologic Oncology Group suggested that both tests were only moderately accurate in disease assessment. Computed tomography of the pelvis results in fetal radiation exposure and should be used with caution. In contrast, MRI does not expose the fetus to ionizing radiation and may be safely used during pregnancy. More recently, PET imaging has been widely utilized in women with newly diagnosed cervical cancer. However, as the effects of the radioisotope on the fetus are unknown, PET is contraindicated during pregnancy.
How is treatment of cervical cancer made specific to pregnant women?
Treatment planning for women with invasive cervical cancer must take into account both maternal and fetal considerations. Treatment is predominately guided by the stage of disease and the gestational age of the fetus. As randomized trials are lacking, most recommendations for the treatment of cervical cancer during pregnancy are based on observational studies and expert opinion. In general, women diagnosed prior to 20-24 weeks of gestation are encouraged to receive immediate therapy, while those women diagnosed after 20-24 weeks may delay treatment until delivery which is typically planned at 32-34 weeks depending on the clinical scenario.
What are the various treatments available based on stage?
For Stage IA1 cervical cancer, women who have tumors with a depth of invasion of less than 3 mm and less than 7 mm of lateral spread have an excellent prognosis. Given the increased blood flow to the gravid uterus, cervical excisional procedures such as conization performed during pregnancy can result in substantial blood loss.
Conization is typically reserved for women at less than 20-24 weeks of gestation to confirm the diagnosis of a microinvasive cervical cancer and exclude a more extensive tumor or when invasion is suspected on a cervical biopsy but the results are inconclusive. In general, patients with stage IA1 cervical cancer can defer treatment until delivery.
Treatment of pregnant women with stage IA2, IB1, and small IB2 and IIA cervical cancer at less than 20-24 weeks of gestation may elect to undergo immediate radical hysterectomy, which can be performed either after elective termination or with the fetus in situ. Patients diagnosed after 20-24 weeks of gestation generally defer treatment until the time of delivery. For these patients the timing of delivery should be coordinated with a multidisciplinary team including maternal-fetal medicine experts.
For pregnant women with stage IIB-IVA cervical cancer as well as those women with larger stage IB2-IIA lesions, many experts recommend initiation of treatment immediately in women at less than 20-24 weeks of gestation and delay of therapy until after delivery in women at later gestational ages. While chemoradiation is now the standard of care for non-pregnant patients with advanced-stage cervical cancer, data specifically evaluating combination therapy during pregnancy are largely lacking.
Are alternative treatments available?
Neoadjuvant chemotherapy is a potential therapeutic consideration for patients with cervical cancer who wish to delay treatment. Neoadjuvant treatment has been shown to decrease the size of local tumors and facilitate surgical management. Unfortunately, large studies to describe the effects of chemotherapy in pregnancy are lacking. Some reports have suggested that women treated with chemotherapy are at increased risk for preterm delivery and adverse neonatal outcomes. Treatment early in gestation, particularly with 5-fluorouracil and cyclophosphamide, has been associated with fetal anomalies.
What novel therapeutics are emerging?
Over the course of the last decade there has been an increasing interest in more conservative surgical procedures for cervical cancer. A number of case reports of radical trachelectomy for pregnant women with localized cervical cancer have now been reported. While the application of radical trachelectomy to pregnancy is evolving, in non-pregnant women the procedure is usually reserved for women with tumors less than 2 cm in greatest diameter. In addition to the abdominal approach, radical vaginal trachelectomy has also been performed during pregnancy.
What mode of delivery is recommended for pregnant patients with cervical cancer?
Cesarean delivery is recommended for most women with bulky cervical tumors to decrease the risk of bleeding at the time of delivery. Other reports have suggested that vaginal delivery is safe, particularly for women with microinvasive or small tumors in which the risk of bleeding is less. A potential concern for women who deliver vaginally is local recurrence.
How do you counsel the patient and family on prognosis of cervical cancer in pregnancy?
While it is difficult to directly compare the outcome of pregnant and non-pregnant women with cervical cancer, it appears that pregnancy does not worsen outcomes. Stage appears to be the most important prognostic factor. The effect of delaying treatment on outcome has long been debated. However, in at least one small series of patients with predominantly early-stage disease, treatment delay had no apparent adverse effect on survival.
4. What’s the evidence?
Arbyn, M, Kyrgiou, M, Simoens, C. “Perinatal mortality and other severe adverse pregnancy outcomes associated with treatment of cervical intraepithelial neoplasia: meta-analysis”. BMJ. vol. 337. 2008. pp. a1284
Wright, TC, Massad, LS, Dunton, CJ, Spitzer, M, Wilkinson, EJ. “2006 consensus guidelines for the management of women with cervical intraepithelial neoplasia or adenocarcinoma in situ”. Am J Obstet Gynecol. vol. 197. 2007. pp. 340-5.
Hricak, H, Gatsonis, C, Chi, DS. “Role of imaging in pretreatment evaluation of early invasive cervical cancer: results of the intergroup study American College of Radiology Imaging Network 6651-Gynecologic Oncology Group 183”. J Clin Oncol. vol. 23. 2005. pp. 9329-37.
Colombo, N, Peiretti, M. “Critical review of neoadjuvant chemotherapy followed by surgery for locally advanced cervical cancer”. Int J Gynecol Cancer. vol. 20. 2010. pp. S47-8.
Tewari, K, Cappuccini, F, Gambino, A, Kohler, MF, Pecorelli, S. “Neoadjuvant chemotherapy in the treatment of locally advanced cervical carcinoma in pregnancy: a report of two cases and review of issues specific to the management of cervical carcinoma in pregnancy including planned delay of therapy”. Cancer. vol. 82. 1998. pp. 1529-34.
As the working mom of a three-year-old girl, Gina Zapanta-Murphy, 34, didn’t have time for complications during her second pregnancy.
She knew every pregnancy was different and told herself not to worry, but Gina never got that burst of energy she was expecting in her second trimester. In fact, she was so tired that she spent her 35th birthday in bed, and soon after she noticed a clear, watery discharge that was out of the norm for her. Over the next few weeks, that discharge became so heavy that she needed to wear a pad. After developing a low-grade fever, Gina had a frightening thought: What if her amniotic sac had ruptured and was leaking fluid this whole time?
She called her doctor at PIH Health Women’s Health Center in Whittier, California, who directed her to Labor and Delivery for a pelvic exam. After a series of tests and an ultrasound, OB/GYN Brent J. Gray, M.D., and his team tested the fluid and confirmed that her amniotic sac was intact. They had, however, noticed a little polyp that was biopsied and sent for testing. Gina spent Friday night in the hospital for observation and was released the next morning.
The biopsy results came in three days later, and Gina was sitting down for dinner when she got the call that would change her life. Rather than asking her to come in to break the news, OBGYN Sacha Kang Chou, M.D., told Gina right then that the lesion was in fact cervical cancer.
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“Like most people who don’t have cancer in their lives, I thought cancer equals death sentence,” Gina recalls. But her assumption was wrong: according to the American Cancer Society, the rate of cervical cancer deaths have plummeted 50 percent over the last 40 years thanks to the increased use of regular Pap smears.
After that phone call, Gina scheduled an appointment with her new gynecologic oncologist, Samuel Im, M.D., for two days later. In the meantime, she spent her time pragmatically planning for the worst: Did she have a will? Was her life insurance up to date? Who would help her husband raise the kids?
Though cervical cancer is notoriously slow-growing, being pregnant can kick its growth into high gear due to an increase in blood flow and major hormonal changes. Six weeks into her pregnancy, a pelvic exam had shown no signs of the disease. But her exam at 29 weeks showed stage 1 cervical cancer and a lesion nearly 1.5 centimeters long—that meant Gina’s cancer was growing aggressively, and every day her baby was left to gestate was another day for the cancer to grow. Because of her pregnancy, doctors couldn’t use an MRI to monitor its growth (images are tough to interpret with a fetus in the picture), nor could they physically examine her cancer until the baby was born. With nothing else to do, Gina says her doctors decided to keep an eye on the cancer the best they could, and would aim to deliver as early as possible without putting the baby in harm’s way.
Unfortunately, things didn’t get better from there: At her follow-up appointment two weeks later, Gina learned that her lesion was now nearly 2 centimeters long. The cancer was growing too fast, so Dr. Im decided to push the due date to 34 weeks—they would deliver via C-section and immediately perform a hysterectomy to remove the localized cancer. (Learn more about the real progress in the fight against cacner in Rodale’s A World Without Cancer.)
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Even though it was scary, Gina started preparing for her early delivery under the guidance of the PIH Health Neonatal Intensive Care Unit (NICU) team. “My priority is being around for my girls as long as I’m able to,” she says. “If they had to take off my limbs, I’d have said, ‘Take them off. Do whatever you need to do.’”
After receiving a betamethasone course—two shots of antenatal steroids—prior to the delivery to stimulate growth in the baby’s lungs, delivery day arrived. Gina underwent a series of back-to-back surgeries with obstetricians, surgeons, and oncologists all in the room.
“I begged to stay awake for the delivery, and they let me see my baby girl before I went under for the hysterectomy,” she says. “I remember kissing her little warm face. The next thing I knew, I was waking up in recovery.”
Just 24 hours later, Gina was nursing baby Valentina in the NICU when her final pathology report came back: It was cancer-free. And although she says “the recovery felt like a regular C-section recovery,” it was anything but: Doctors removed her uterus, fallopian tubes, and pelvic lymph nodes, but were able to save her ovaries and keep her from going into immediate menopause. Gina was overjoyed with the news, but knowing she’d never be pregnant again left a sting.
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“I’m not going to cry about it, though,” she says. “Some people aren’t even able to get pregnant. I was lucky enough to have my two girls.”
The mental aftermath of remission isn’t all rainbows and sunshine, though: Every time she has an ache or pain, Gina worries that her disease could be back. But being vigilant about looking into those warning signs isn’t a bad thing: The five-year survival rate for women with cervical cancer is 68 percent, but when it’s detected at an early stage while the cancer is still localized, it jumps to 92 percent. Regardless, Gina’s advice for all women—whether they be young, old, pregnant or not—is the same: “Don’t be scared to face going to the doctor and hearing something that you might not want to hear,” she says. “Be proactive.” It could very well save your life.