Cervical Cancer and Fertility Preservation

M. D. Anderson Cancer Center
Cancer Newsline Audio Podcast Series
Date: December 29, 2008
Duration: 0 / 13:58

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Host Lisa Garvin:

Welcome to Cancer Newsline a weekly podcast series from the University of Texas M. D. Anderson Cancer center. Cancer Newsline helps you stay current with the news on cancer research diagnosis treatment and prevention. Providing the latest information on reducing your families cancer risk. I’m Lisa Garvin.

Today we are talking with Pedro Ramirez, M.D. and Michael Frumovitz, M.D., from the same department, will be talking about a surgical procedure that may help some women with cervical cancer retain their fertility while still receiving the best treatment for their cancer.

So my first question is, explain what is a radical trachelectomy.

Pedro Ramirez, M.D.:

Sure, thank you for having us Lisa. A radical trachelectomy is a procedure where we remove the cervix, the tissue immediately next to the tissue, which is called the parametrial tissue, the upper two centimeters of the vagina and we are actually re attaching the uterus to the upper aspect of the remaining vagina so that women will be able to be treated for their cervical cancer and at the same time be able to maintain fertility. Along with this procedure every patient also undergoes an evaluation of their pelvic lymph nodes, so a pelvic lymphadenectomy is also done.

Garvin:

Now how was this procedure developed? I mean… I know that a lot more women are trying to retain their fertility, so how did this come about?

Dr. Ramirez:

Well this came about when one of the original pioneers of the procedure was the late French surgeon Dr. Danielle Dargent. But the idea behind this procedure came from the fact that obviously young women with cervical cancer, early stage cervical cancer traditionally did not have the option of preserving their fertility because of the fact that the standard traditional treatment for these women had been a radical hysterectomy. Now the fact that obviously a large percentage of women who develop cervical cancer, are still seeking fertility given by the fact that nearly 43-45 percent of women diagnosed with cervical cancer are younger than 45 years of age. We wanted to develop a procedure where these women would be able to still maintain their fertility while still being treated for their cervical cancer.

Garvin:

Great… Dr. Frumovitz, how exactly does this retain their fertility? I mean you’re taking out just the fundus of the cervix?

Michael Frumovitz, M.D., M.P.H.:

Well the uterus is really broken into two separate anatomic structures. The fundus of a uterus is what holds a baby when a baby grows. the cervix is the exterior portion of the uterus that is in the vagina and is really the mechanism for keep the cervix shut while the baby is growing the cervix is the portion of the uterus that opens and dilates during pregnancy. These cervical cancers tend to affect that portion of the uterus the cervical portion of the uterus that is in the vagina and not the fundus of the uterus. So you can often just remove the cervix retaining the fundus of the uterus for future fertility.

Garvin:

How does this change pregnancy for women who have this procedure? Does it now become a high risk pregnancy, do they have to take certain precautions?

Dr. Frumovitz:

Well yes it does become a high risk pregnancy. Because again as I mentioned the cervix is that portion of the uterus that keeps the baby in that stays closed and shut. At the end of the procedure we put in what is called a cerclage which is a stitch that closes that bottom part of the fundus of the uterus to try to prevent pre-term labor and early delivery of the baby.

Garvin:

Who are the best candidates, and either one of you can answer this, who are the best candidates for a radical trachelectomy?

Dr. Ramirez:

We certainly ideally young women who are diagnosed with very early stage cervical cancers so typically the lesions in the cervix that we are looking at meaning the size of the tumor is a tumor that is less than two centimeters. Typically there are multiple different cell types of cell types that could be developing in terms of the diagnosis of a cervical cancer but generally are patients with a squamous carcinoma or adenocarcinoma other types of histologies meaning other cell types of cervical cancer that are considered high risk ideally would not be candidates for this procedure. So again squamous carcinoma, a patient with adenocarcinoma a lesion that is typically less than two centimeters. And certainly the patients routinely undergo an evaluation by MRI to assure that the tumor does not extend into the lower segment of the uterus. So those patients would be ideal candidates, the ones in whom the tumor does not extend into the lower segment of the uterus…confined to the lip of the cervix.

Garvin:

Are we doing more of these here at M. D. Anderson?

Dr. Ramirez:

Yes actually we are. And I think that it’s not only because of the increasing proficiency of our faculty in doing this procedure, but also fortunately, it’s because of increasing awareness that patients have about the option for this procedure. Increasing awareness by referring physicians that certainly many of their patients are candidates for this procedure. One of the arguments that was made initially regarding this procedure was the fact that perhaps we wouldn’t have many patients that would be candidates for this procedure. And interestingly there was a recent study out of Memorial Sloan Kettering in New York. Where they looked at all patients that underwent a radical hysterectomy and looked back at their characteristics to determine how many of their patients would have been candidates for a radical trachelectomy, the fertility sparing procedure. And they found that 48% of women who underwent a radical hysterectomy would have been candidates for a radical trachelectomy.

Garvin:

Is this standard treatment Dr. Frumovitz? I mean, can you get this at any cancer center or do you have to go to a big academic center like ours?

Dr. Frumovitz:

I think it would be hard to call it standard treatment, but its certainly becoming more and more popular. There are only a handful of centers in the country that are performing this procedure, in which we are one of them.

Garvin:

Is it laparoscopic?

Dr. Frumovitz:

Well it can be done multiple ways. It can be done vaginally like a vaginal hysterectomy. It can be done abdominally like a cesarean section scar with a low transverse scar or bikini scar. And it now be done robotically, and if you come to M. D. Anderson it will typically be done either through a bikini incision or robotically.

Garvin:

Now as far as the study data. Of course you’ve got to weight any treatment like this against negative or positive margins and that kind of thing. How is it comparing with standard treatment like removal of the cervix?

Dr. Ramirez:

I think that’s a very, very important question because one of the things that always comes up is the fact that when you’re going to deviate from the standard treatment you want to assure that you’re not going to compromise the oncologic outcome of your patients. So one of the arguments that was made initially was that such a deviation from a radical hysterectomy would potentially increase the risk of recurrence and potentially increase the risk of patients dying from this disease. Fortunately, what’s been found is that the recurrence rate and the death rate after a radical trachelectomy is actually the same or lower than after a radical hysterectomy. So you are not compromising patient outcome at all. So in terms of numbers, the recurrence rate typically is around 4 percent, of patients having recurrences after this procedure and the death rate after this procedure is about 2 percent. So certainly those numbers are even more favorable then after a radical hysterectomy, granted these are very selected patients, so therefore these are patients in whom we think they are certainly going to do much better than patients that would have had a radical hysterectomy.

Garvin:

How many procedures would you say you do in a typical year here at M. D. Anderson?

Dr. Ramirez:

It varies. I mean I think that we, over the last year or so, we have probably done more. But generally this is a procedure that perhaps we are doing, on average, were doing about one every three months or so and again we will have months where we will perform two in one month so it really varies as to which patients are candidates for that and the referral pattern. And those types of things - certainly it’s an option that we have available and favorably we see a lot more patients asking about the procedure now.

Garvin:

Dr. Frumovitz, are there any further refinements as far as the procedure goes down the road… I mean, is there still study being done?

Dr. Frumovitz:

There’s still lots of studies being done with this procedure. Not only the best approach, but also whether or not we can expand our criteria for selection to maybe to tumors that are a little larger than two centimeters, or maybe tumors that are a grade three, which tend to have been a contra indication. So we're beginning to expand the inclusion criteria for who we might offer these procedures to.

Dr. Ramirez:

The other thing also if I may add… one of the things that we are finding is that the radical hysterectomy has been offered as the standard treatment for patients with early stage disease so stage 1a2, stage 1b1, that means basically tumors less than four centimeters. We have been finding that that type of aggressiveness may not be necessary in well selected patients. So even now we’re looking at selecting patients who may not even need a radical trachelectomy because there are some associated potential side effects or complications from this procedure. But one of the things that we’re finding is that in a certain number of patients, those patients may not even need a radical trachelectomy they may even have an even much simpler approach called a simple trachelectomy or even just a conization for the treatment of their disease. That certainly would decrease the morbidity associated with this procedure and still treat the patients effectively. We are actually one of the principal sites for a new study that is going to be conducted actually evaluating this highly selected group of patients for an even less invasive approach.

Garvin:

Let’s talk about the side effects. What are the typical side effects for this procedure?

Dr. Ramirez:

Well certainly, as with any surgical procedure, the routine potential complications are there. But specific to this particular procedure are the fact that obviously the woman doesn’t have her cervix, so in that there may be complications in terms of irregularity in their monthly cycle. There may be the complication of something called ammenoria where the patient is not able to menstruate because the remaining cervix constricts and basically doesn’t allow the natural flow of the natural menses to flow from the uterus to the vagina. Conversely, also the fact that you may have an increased risk of pregnancy loss, and I think that depends on the amount of cervix that is removed, and so I think those are some of the major factors that we need to explain to our patients.

Garvin:

Have women reported any sexual side effects, like loss of sensation or anything like that?

Dr. Ramirez:

No.

Garvin:

Just in closing, I think we’ve covered everything, but is there anything else you would like to say to the audience today?

Dr. Ramirez:

I think that one of the questions that often comes up is well you have gone through this procedure now what is the likelihood that I am going to be able to get pregnant and have a normal pregnancy? And one of the things that I want to reassure the women and physicians or anyone listening in the audience is that when patients undergo this procedure they have at least 70 – 80 percent chance of becoming pregnant spontaneously, certainly those are very favorable outcomes, and a large percentage of those patients depending on the study anywhere between 40-70 percent of patients actually reach a term pregnancy with a normal baby.

Garvin:

Any final thought from you Dr. Frumovitz?

Dr. Frumovitz:

I think this is a very exciting procedure that we have to offer with young women with cervix cancer. In the past this was essentially an end to their fertility. And now, even with cervix cancer, we’re able to retain their fertility and offer them hope for fertility.

Garvin:

Thank you both for joining us today.

Dr. Ramirez and Dr. Frumovitz:

Thank you for having us.

Garvin:

If you have questions about anything you’ve heard today on Cancer Newsline, contact ask M. D. Anderson at 1-877-MDA-6789 or online www.mdanderson.org/ask. Thank you for listening to this episode of Cancer Newsline. Tune in next week for the next podcast in our series.

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