Abstract
Objective: to evaluate the desire for parenthood and reproductive outcomes following fertility-sparing treatment for invasive cervical cancer including Vaginal Radical Trachelectomy (VRT), Radical Hysterectomy (RH) and chemoradiotherapy.
Design Retrospective cohort study
Setting Tertiary referral center in the Netherlands
Population patients <45 years with invasive cervical cancer desiring to maintain reproductive potential.
Methods Clinicopathologic and reproductive outcomes were retrieved from medical files and postal questionnaires for patients treated between 2009 – 2020.
Main outcome measures Survival, recurrences, fertility and pregnancy outcomes
Results : 75 patients were identified of whom 34 underwent VRT, 9 RH and 32 had (chemo)radiotherapy. 26 patients started fertility preservation (FP) procedures of whom 23 (88.5%) successfully preserved fertility. After a median follow-up of 49 months, 5 patients developed recurrent disease and died. Reproductive outcomes were available for 58 patients of whom 89.6% maintained their desire for parenthood. Following VRT, 15 patients conceived 21 pregnancies which resulted in 15 live-births, yielding a pregnancy rate of 61.9% and live-birth rate of 75.0%. Following RH or (chemo)radiotherapy, 3 surrogate pregnancies were established (21.4%) using frozen-thawed oocytes (n=2) and ovarian tissue fragments (n=1) with good neonatal outcomes.
Conclusions Many cervical cancer patients maintain the desire to become parents after cancer treatment. Vaginal Radical Trachelectomy and Fertility Preservation enable young women with invasive cervical cancer to become a parent after cancer treatment. Structural and timely fertility counseling is of the essence when attempting fertility-sparing treatment and should be available to all.
Keywords cervical cancer / oncofertility / trachelectomy / fertility preservation / surrogacyIntroduction
Cervical cancer is the fourth most common cancer among women worldwide and affects women at a significantly younger age than most other malignancies. Approximately 42% of the women diagnosed with cervical cancer is ≤ 45 years 1, 2. Combined with a trend towards delayed childbearing, many of these women may not have completed their desire for parenthood at time of cancer diagnosis. Recent studies on the effects of treatment-associated infertility and quality of life among young cancer survivors have quantified the impact of treatment-induced infertility, resulting in long-lasting emotional and physical distress 3, 4. Together with the improved survival rates for cervical cancer, fertility-sparing treatment options are becoming increasingly for these women 5.
Standard treatment for invasive cervical cancer includes radical hysterectomy (RH) with pelvic lymphadenectomy for early-stage disease and chemoradiotherapy for advanced stage-disease. Both with obvious implications for fertility 6. The past two decades, fertility-sparing treatment options have been introduced in the management of invasive cervical cancer. These include Vaginal Radical Trachelectomy (VRT) and fertility preservation (FP) for more advanced disease. Studies showed that VRT is an oncologically safe treatment alternative in carefully selected patients with overall good obstetric and neonatal outcomes 7, 8. When requiring RH or chemoradiotherapy, biological parenthood is feasible through fertility preservation (FP) and a surrogate. While all these treatment options enable patients to have a biological offspring after cancer treatment, well-known complications following VRT include infertility and prematurity9 . Furthermore, little is known about reproductive outcomes following FP and gestational surrogacy pregnancies due to the experimental nature of these procedures.
To date no studies have addressed the desire for parenthood after cancer treatment among cervical cancer survivors nor did they address reproductive outcomes for all patients with invasive cervical cancer including both fertility-sparing surgery and fertility preservation.
The aim of this study is to evaluate fertility-sparing management for invasive cervical cancer as a whole, addressing the desire for parenthood and reproductive outcomes of patients who underwent either fertility-sparing surgery or fertility preservation. These data will provide both patients and clinicians with realistic expectations regarding reproductive intentions and outcomes in cervical cancer treatment and therefore improve counseling in newly diagnosed cervical cancer patients.