Cervical Cancer During Pregnancy
During pregnancy, no therapy is warranted for preinvasive lesions of the cervix, including carcinoma in situ, although expert colposcopy is recommended to exclude invasive cancer.
Treatment of cervical cancer in pregnancy is predicated on the extent of disease and the gestational age at diagnosis. Patients should undergo biopsy as needed and imaging to establish the extent of disease to make the most informed choices. The most appropriate imaging modality in pregnancy is magnetic resonance imaging, when indicated.
Treatment for Stage I Disease
Pregnancy does not alter the course of cervical cancer. As a result, in certain cases, patients may elect to postpone treatment until its effects on the pregnancy are minimized. This may be considered for patients with the more common, and less aggressive histologic subtypes: squamous, adenocarcinoma, and adenosquamous. Patients with high-risk subtypes, such as small cell or neuroendocrine tumors, should be counseled toward immediate treatment despite the effects on the fetus, given their risk of progression.
Patients with early stage (IA) disease may safely undergo fertility-sparing treatments including cervical conization or radical trachelectomy, as indicated. The optimal timing for this procedure is in the second trimester, before viability. Some authors have suggested waiting until the completion of a pregnancy to initiate treatment. For patients with IA2 and IB disease such a delay may also be safe, but because of a risk of lymphatic spread, assessment of lymph-node status should first be ascertained. The status is best determined surgically via a laparoscopic or open lymph-node dissection, which can be safely performed up to approximately 20 weeks of pregnancy.[2,3] In patients without lymphatic spread, waiting for fetal viability to initiate treatment is an option. Patients with positive lymph nodes should be counseled toward immediate treatment.
Treatment for Stages II, III, and IV Disease
For patients with stage II or greater disease, waiting for viability is generally not acceptable. The standard of care is curative intent chemotherapy and radiation therapy. This treatment is toxic to the fetus and without ovarian transposition will render the ovaries nonfunctional after treatment. Evacuation of the fetus should be performed before the initiation of radiation. When this is not possible, the radiation will generally cause a spontaneous abortion 3 to 5 weeks after initiating treatment.
Neoadjuvant chemotherapy has been offered to patients with locally advanced disease as a way to initiate treatment while maintaining the pregnancy. Most chemotherapy agents can be initiated safely in the second trimester of pregnancy and beyond; mild growth restriction of the fetus is the most common side effect. Restriction of growth has been reported in a relatively small number of patients, and data is lacking on long-term outcomes for these women; as a result, this strategy should be considered with caution. Most of the patients in the reports underwent standard treatment (either surgery or radiation) after completion of the pregnancy.
- Morice P, Uzan C, Gouy S, et al.: Gynaecological cancers in pregnancy. Lancet 379 (9815): 558-69, 2012. [PUBMED Abstract]
- Alouini S, Rida K, Mathevet P: Cervical cancer complicating pregnancy: implications of laparoscopic lymphadenectomy. Gynecol Oncol 108 (3): 472-7, 2008. [PUBMED Abstract]
- Favero G, Chiantera V, Oleszczuk A, et al.: Invasive cervical cancer during pregnancy: laparoscopic nodal evaluation before oncologic treatment delay. Gynecol Oncol 118 (2): 123-7, 2010. [PUBMED Abstract]
- Hunter MI, Tewari K, Monk BJ: Cervical neoplasia in pregnancy. Part 2: current treatment of invasive disease. Am J Obstet Gynecol 199 (1): 10-8, 2008. [PUBMED Abstract]