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Goodbye Cancer, Hello Baby!

Fertility-sparing treatments for gynaecological cancers

Pregnant Woman And Partner Having 4D Ultrasound ScanIn the past, treatment for cancers which affect the female reproductive organs – the uterus, cervix and ovaries – would generally result in permanent infertility in most women. To make things worse, it has been shown that about 10% of cancers occur in women younger than 40 years.

Fortunately, medical innovation has allowed women who strongly desire fertility to continue to have children even if they are diagnosed with cancer. The caveat for this is that they have to be diagnosed during an early stage of disease.

Cervical Cancer

Cervical cancer is the tenth most common cancer affecting women in Singapore. Women who are diagnosed with micro-invasive cancer (Stage IAI) can be cured by a simple cone biopsy of the cervix. This surgery essentially removes only the part of the cervix which harbours the cancer cells, sparing the rest of the normal cervix.

However, this surgery may result in an increased risk of miscarriage or premature births as a result of an incompetent cervix. For women who are diagnosed with Stage IA2 to IBI cancer of the cervix, the standard treatment would invariably result in infertility as the uterus would have to be surgically removed together with the cervix (known as Wertheim’s radical hysterectomy).

iStock_000041824426_LargeThe good news is that an innovative surgical technique called radical trachelectomy has been developed to preserve fertility in young women diagnosed at this stage of cancer. In this novel surgery, the cervix and its surrounding attachments are excised, and the uterus is reattached back to the vagina. This technique has been shown to be as safe as the standard Wertheim’s radical hysterectomy, with the risk of recurrent cancer at 4.7%.

Studies have shown that for women who have undergone this procedure and conceived, their risk of miscarriage is high, at 30% in the first two trimesters, and the risk of premature births is 35%. Nevertheless, this type of treatment has allowed many women to have children, while in the past, loss of fertility was inevitable.

Beyond Stage IB2, fertility-sparing surgery will not be effective.

Ovarian Cancer

Ovarian cancer, the fifth most common cancer in Singapore, is considered the most lethal gynaecological cancer, with more than 60% of women being diagnosed at advanced stages. There are several types of ovarian cancers and the most common form, epithelial ovarian cancer, strikes mainly women who are approaching menopause.

The standard treatment entails removal of the uterus and the ovaries. However, in the small group of young women who are diagnosed with this form of cancer, fertility-sparing surgery is possible if there is no evidence of a spread of cancer to the other ovary, and there is no clinical or radiological evidence of cancer elsewhere in the body (i.e. Stage IA cancer). If the uterus and the other ovary are spared, the patient must be aware that the risk of cancer recurrence is about 10%, and there is a 2.5% chance of cancer in the other ovary.

Another form of ovarian cancer known as germ cell cancers occur mainly in young women and children, and accounts for 10% of all ovarian cancers. This type of cancer is extremely chemo-sensitive, with an excellent chance of cure, hence fertility-sparing surgery with conservation of the other ovary is usually possible even in advanced stages.

Uterine Cancer

Uterine cancer is the fourth most common cancer affecting Singapore women, and about 5% of women who are diagnosed, are younger than 40 years. The standard management, which is hysterectomy, would lead to loss of fertility as the womb and ovaries are removed to cure it.

The most common type of uterine cancer is endometrial cancer, that is, cancer that affects the inner lining of the uterus. Recent clinical studies show that it is possible to conserve fertility in young women diagnosed with early endometrial cancer with high doses of anti-cancer hormone treatment, such as megestrol acetate. The criteria includes low grade endometrial cancer and there must not be any spread of cancer beyond the lining of the uterus (i.e. clinical Stage IA).

Most studies show a median time for regression of cancer within six to nine months. Failure to do so means that fertility-sparing treatment has failed, and the patient has to undergo a hysterectomy. Any young woman who undergoes this form of treatment must be aware that this is not standard treatment and that the chance of regression is about 76%. Furthermore, even if there is successful regression, there is a 40% rate of recurrence. Hence, all women are encouraged to seek fertility treatment after the cancer has regressed.iStock_000012913570_Large

In a meta-analysis of 408 women with early endometrial cancer, the live birth rate was 28%. For women diagnosed with other types of uterine cancers, such as leiomyosarcomas, fertility-sparing treatment is contra-indicated.

With the latest advancements in medical knowledge and surgical techniques, many women who are diagnosed with early stage gynaecological cancers are now able to undergo fertility-sparing treatment, and have children without compromising their health.

IN A NUTSHELL

  • Cervical cancer: A novel surgical technique excises the cervix and its attachments, then reattaches the uterus back to the vagina.
  • Ovarian cancer: Surgery can be limited to only the affected ovary, sparing the uterus and other ovary.
  • Uterine cancer: Early endometrial cancer can be treated with high doses of anti-cancer hormone.
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Dr Timothy Lim is the Head and Senior Consultant, Department of Gynaecological Oncology at KK Women’s and Children’s Hospital.
Posted by ezyhealth on Feb 3 2015. Filed under Medical Section. You can follow any responses to this entry through the RSS 2.0. Both comments and pings are currently closed.

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