Fertility sparing treatment should always be discussed with women with gynaecological cancer who wish to preserve their childbearing ability, says a new Scientific Impact Paper published by the Royal College of Obstetricians and Gynaecologists (RCOG).
The need to consider fertility sparing treatment for women with gynaecological malignancy has gone up over the years as women are increasingly delaying conception. In the UK, there are annually over 1000 women with cervical cancer, 120 with endometrial cancer and over 500 with ovarian cancer before the age of 45, says the paper.
This new Scientific Impact Paper (SIP) looks at gynaecological cancers and the different fertility sparing treatments available for women. Management of these women is complex and requires input from a multidisciplinary team, state the authors. They also emphasise the importance of women receiving accurate information in order for them to make informed decisions as sometimes the balance between chances of compromising survival and preserving fertility is a fine one.
The paper looks at cervical cancer and radical trachelectomy, a fertility sparing procedure which involves removing the cervix and upper vagina leaving the uterus to allow conception. Previous studies have indicated that radical vaginal trachelectomy (RVT) should be used for smaller tumours; for larger tumours, treatment can be performed abdominally or laparoscopically.
Endometrial cancer is also explored in the paper. Fertility rates tend to be lower amongst women who develop endometrial cancer, however, assisted conception can be offered. Once conception is achieved there is no evidence to suggest a difference in pregnancy outcomes says the paper.
For women with ovarian cancer, recently published NICE guidelines recommend that information and help should be made available to patients about fertility where appropriate. Depending on the severity of the cancer and if it is contained in one ovary, fertility sparing surgery may be offered to women who wish to consider it, says the paper.
The paper also discussed when fertility sparing surgery may not be appropriate. In some cases women can be offered ovarian tissue retrieval and cryopreservation (storage of frozen tissue), ovarian stimulation and IVF and/or egg freezing. Assisted conception techniques would usually be undertaken in the window between primary surgery and the start of chemotherapy or radiotherapy, states the paper. However, despite these advances and improving success rates there are no guarantees that these methods will result in a successful pregnancy, say the authors.
This field of medicine is fast changing and expert advice and help from fertility specialists alongside the oncology team is needed in order to give the patient the best chance of future childbearing, say the authors.
The paper concludes by saying fertility sparing surgery should always be discussed with patients in appropriate cases. However management of these women is complex and requires input from a multidisciplinary team.
Dr Sadaf Ghaem-Maghami, Gynaecological Oncology Centre, Imperial College London and co-author of the paper says:
“Women with gynaecological cancers need to be given ample information in order to make decisions about future fertility as sometimes the balance between chances of compromising survival and preserving fertility can be difficult. A US study has indicated that women are not always counselled on the effect of cancer treatment on fertility and this needs to be communicated more.
“The role of specialist gynaecological oncology nurses is invaluable in supporting women with their decision-making and close working with fertility specialists is also essential if women are to be given the best chance of achieving a successful pregnancy.
“We are seeing more and more cases of women developing cancers at an age when they still may wish to start a family. Women with gynaecological cancers can potentially go on to have a successful pregnancy after fertility sparing treatments. It is important that these women are given appropriate choices for their treatment within the context of a multidisciplinary team approach within a specialist cancer centre.
“Currently there is a lack of prospective data in the literature regarding outcome from many of the procedures and treatments for gynaecological cancers discussed in this paper and more effort should be focused in this direction.”
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The full SIP can be found here.
About RCOG Scientific Impact Papers
RCOG Scientific Impact Papers (formerly SAC Opinion papers) are produced by the Scientific Advisory Committee. They are up-to-date reviews of emerging or controversial scientific issues of relevance to obstetrics and gynaecology, together with the implications for future practice. These documents have been rebranded to raise awareness of the issues in obstetrics and gynaecology discussed in the documents and to more accurately reflect their content and remit of the Committee.