In our fifth post in this series, we discussed a case of a woman who had a high-grade intraepithelial abnormality (HSIL) found on her intake Pap test and was subsequently diagnosed with minimally invasive cervical cancer (stage 1A1) during her pregnancy and the successful outcome of management for both her and her baby. Her case illustrates the importance of early detection and the value of routine screening by the Pap test during pregnancy, thorough evaluation by trained providers regarding the extent of the disease once an abnormality is detected, and participation of the patient with proper counseling in the management decisions that were ‘right’ for her.
In many ways, this woman was quite fortunate to have become pregnant. She was in her early 30’s and had been in a stable relationship with a single partner for many years. She had stopped having annual Pap tests because she had "never had an abnormal one" and was not aware of any time in her life that she might have contracted HPV, although she had had other sexual partners in the years before she was married. If she had not gotten pregnant, she may well have become one of the unnecessary tragedies of her cancer being diagnosed at a stage when the outcome would probably have not been so favorable.
Indeed, two cases in the past year of women who were not so fortunate were actually the impetus for this series on cervical cancer in pregnancy. One is an acquaintance of a woman with whom I work and the other is a local television personality in the Charlotte, NC area who has shared her story publicly. It is my understanding that both women have a very aggressive and somewhat unusual form of cervical cancer called ‘neuroendocrine small cell cervical carcinoma.’ These tumors look and behave more like ‘oat cell carcinomas’ of the lung in that they grow very rapidly, are often not detected until they have deeply invaded, and are poorly responsive to therapy. Indeed, in both cases their cancers were already stage II/III at the time of diagnosis. The five-year survival with these cancers under the best of circumstances is less than 15%. Aware of this poor chance of survival, even if they underwent early pregnancy termination and began the most aggressive treatment currently available, both women elected to carry on with their pregnancies, deferred treatment that might harm their babies, and planned early deliveries, but at a gestational age when it was unlikely their babies would have serious consequences of prematurity. The decisions all these women had to make epitomize the full range and complexity of the problems dealing with cancer in pregnancy.
Women in the age range of 30-50 years are at greatest risk for developing cervical cancer because once infected with an oncogenic HPV type earlier in life, it can take years for this to culminate in a malignancy. Even when high-grade intraepithelial lesions are present, they are rarely associated with any signs or symptoms to warn of a potential problem. Eighty percent or more of cervical cancers are squamous cell tumors, these are often are relatively slow-growing compared to other malignancies, and some women may not have any significant signs or symptoms of disease until an advanced stage is reached.
Many women will develop an abnormal malodorous watery or blood-tinged discharge from their vaginas as one of the first signs of invasive cervical cancer and this is often followed by intermittent, painless bleeding that at first might only occur after intercourse. In most cases, the bleeding will eventually increase in amount, frequency, and duration, often becoming continuous with time, but this might not happen until the tumor has become quite large and/or deeply invasive. Some women may not notice anything unusual at all until they develop persistent bladder or rectal pressure, pain in the flank or a leg, bloody urine or difficulty voiding, rectal bleeding or difficulty passing stool, or swelling in one or both legs. These latter symptoms are indicative of deeply invasive disease involving pelvic organs and are likely to be accompanied by lymph node involvement and a poorer prognosis.
Although, I do not have the expertise to discuss the current management of advanced cervical cancer in pregnancy, there are a few observations I have made over time in helping to care for these women with the GYN Oncologists. Women who are diagnosed in pregnancy with an advanced stage of cervical cancer have significant challenges before them and decisions that will have to be made. Nowhere in the practice of medicine is it more important to provide adequate counseling and support than it is under these circumstances and that can usually only be accomplished by a well-integrated multidisciplinary team that might include among others: specialists in oncology, maternal-fetal medicine, and neonatology; trained counselors; and at times, specialists in infertility, personal physicians, clergy, and even an institutional ethical review board.
The diagnosis of any malignancy during pregnancy immediately places the woman and her unsuspecting baby in an unwelcome state of unanticipated conflict. How she chooses to balance her innate feelings of altruism versus self-preservation may have a significant impact on her own survival and the outcome of the baby. Information with which she is provided must be accurate, explained in terms that she can comprehend, and must be presented in as unbiased and consistent a fashion as possible. In this regard, members of any ‘multidisciplinary team’ must be in agreement with regard to the information she is given. Providers must respect that the final interpretation and choices based on the information is, ultimately, the woman’s prerogative and will be made against the background of her own make-up, including her personal beliefs, faith, other family concerns, and even friends. Among the issues that need to be addressed are:
What is the presumptive diagnosis?
What other procedures need to be done to establish the clinical stage of the cancer?
Which if any of these diagnostic procedures can be done in pregnancy and what deleterious affects might they have on the baby?
Will pregnancy limit the interpretation of these studies?
What is the natural history and prognosis of the cancer by stage of disease in women who are not pregnant?
Does pregnancy increase the risk of disease progression apart from any delays in treatment?
What are the treatment strategies and their comparative results in women who are not pregnant?
Which of the treatment options can be started in pregnancy?
What are the known or suspected affects of different forms of treatment on the baby and do these differ by developmental stage of the baby?
Would prospects for survival be improved by ending the pregnancy early? How much?
If no treatment is started during the pregnancy, what is the prognosis for delivering a live and healthy baby?
Will treatment decrease the risk of complications during pregnancy and improve the prospects for delivering a healthy baby?
What are survival and complication rates for babies at different gestational ages?
Are there promising experimental treatments available and under what conditions could they be tried in pregnancy or in the post-partum period?
What is the best route of delivery?
What procedures can be done at the time of delivery to improve diagnosis or prognosis?
Are there reasonable options available to spare/preserve fertility or to allow for the birth of another baby even if this requires a ‘surrogate’ carrier?
This concludes our series on cervical dysplasia and cancer during pregnancy. If readers would like to share their personal experiences in this regard, I know there are many other women out there who would appreciate your thoughts. Thanks for reading!