Surgical Management of Cervical Cancer Complicating Pregnancy
ABSTRACT & COMMENTARY
Synopsis: Delay in treatment of early invasive cervical cancer for fetal maturity does not increase maternal mortality.
Source: Sood AK, et al. Gynecol Oncol 1996;63:294-298.
Between 1960 and 1994, 30 pregnant women with cervical cancer were managed by surgical techniques at the University of Iowa Medical Center. These women constitute the case material for this study. The cases were appropriately matched to controls with cervical cancer who were not pregnant. Twenty-six of the pregnant patients underwent radical hysterectomy and four were treated with simple hysterectomy, depending on stage of disease.
Fifteen patients presented early in pregnancy and were treated without regard to fetal viability. Fifteen other women were delivered in the third trimester, and 11 of these women had a planned delay in treatment in an attempt to increase neonatal survival. The remaining four patients were treated immediately due to high risk factors. The table compares the cases and controls.
Table 1
Radical Hysterectomy Findings in Pregnant and Nonpregnant Patients with Cervical Cancer
| Cases | Controls | P | |
| 26 | 26 | ||
| Operative time (min) | 302 | 278 | NS |
| Blood loss (cc) | 1493 | 1065 | 0.0005 |
| Transfusion | 20 | 19 | NS |
| LOS | 12 | 10 | NS |
| Complication | 10 | 8 | NS |
While there was a significant difference in blood loss between the pregnant and non-pregnant patients, there was no increase in transfusion. Sood et al also note that transfusion decreased dramatically after 1991, presumably due to increased fear of transmission of HIV through blood-product administration. Of the 11 cases in which delayed treatment occurred, all are currently alive and well with no evidence of disease during an average follow-up of 118 months.
The authors conclude that radical hysterectomy is a safe procedure in pregnancy and that delay of treatment to improve neonatal survival does not jeopardize maternal survival.
COMMENT BY KENNETH L. NOLLER, MD
Invasive cervical cancer is a devastating disease at any time, but particularly so when it is identified in pregnancy. Although it is the most common malignancy diagnosed during a pregnancy, fortunately, it is rare, probably occurring in no more than one in every 2000 pregnancies. Obviously, it is good that so few cases occur. Just as obviously, no medical centereven one with a large catchment area such as the University of Iowawill ever accrue many cases. Thus, the literature is comprised only of small series such as the one reported in this article.
Case series rank rather low in priority when studies are discussed in the context of "evidence-based medicine." Unfortunately, for diseases such as cervical cancer in pregnancy, there will never be higher priority studies. We will need to rely on case series to guide appropriate clinical care. Because several series have now drawn the same conclusions, I believe we can assume that radical hysterectomy in pregnancy is safe and that delay of treatment to ensure better neonatal survival does not adversely affect maternal survival.
I am always amazed at the conflict that often occurs when a pregnant patient is found to have cervical cancer. Typically, the patient is under the care of an OB/GYN or a family physician when the diagnosis is made. Consultations with maternal-fetal medicine, neonatology, gynecologic oncology, and even perhaps radiation or medical oncology always seem to occur. Lots of opinions are written in the chart, and eventually a formal tumor board or "conference" is usually necessary to get all of the principals in the same room to make a decision. Increasingly, these decisions have become easier to make. That is, there is more and more evidence that a delayeven of several monthsin primary therapy is unlikely to adversely affect maternal survival. Thus, more and more women with this disease are able to deliver infants who survive without complications of prematurity.
Let me raise only one caution. If you have a patient with cervical cancer who is pregnant, there seems to be only one major mistake that could be made: waiting in order to increase neonatal survival yet still performing delivery too early, with long-term neonatal consequences due to prematurity. I believe the decision to wait should be made only with the intention of delivering an infant that can be placed in the normal newborn nursery. That is, I do not believe that infants should be delivered at, for example, 26 weeks. If the woman has waited a few weeks already, why not wait until beyond 34 weeks, when survival unencumbered with the consequences of prematurity can be assured?
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content