Traditional surgeries for gynecologic cancers can be lifesaving, but for younger women they can also cause infertility or induce surgical menopause. Fertility preservation guidelines for patients with cancer from the American Society of Clinical Oncology (ASCO) state that, for women of reproductive age, oncologists should discuss infertility risks and fertility preservation options (or refer these patients to a specialist) (J Clin Oncol 2018; doi: 10.1200/JCO.2018.78.1914). But the research is evolving around what fertility preservation or assisted reproductive options are feasible or recommended.
The changing science led Jaden Kohn, MD, MPH, resident physician in Gynecology and Obstetrics at Johns Hopkins School of Medicine, and her colleagues to conduct and publish a review of the latest evidence, which was published online ahead of print in The Journal of Minimally Invasive Gynecology (2021; doi: https://doi.org/10.1016/j.jmig.2020.12.027).
"This review was needed to provide a contemporary update of fertility-sparing treatments with focus on innovative surgical techniques and evolving clinical trial data," Kohn told Oncology Times.
The aforementioned clinical practice guidelines from ASCO were published in 2018. According to the new review, here's what the latest data shows about fertility-sparing surgery in gynecologic cancers, according to Kohn:
* For cervical cancer: If the main treatment is surgery, options can include removal of part of the cervix (cone) or all of the cervix (trachelectomy), while leaving the uterus in place. If the main treatment is radiation, fertility-sparing surgery can include repositioning the ovaries out of the path of the radiation so that the ovaries can continue to function (which preserves the opportunity for later egg retrieval and in vitro fertilization).
* For early-stage endometrial cancer with a low grade (low aggressiveness of the tumor): Fertility-preserving treatments can include hormone-only treatment without removing any of the gynecologic organs, or can include removal of the uterus (hysterectomy) while leaving the ovaries in place.
* For ovarian cancer: Fertility-sparing treatment options depend on which type of ovarian cancer the patient has. In many cases, these surgeries can remove only one ovary, while preserving the other ovary and the uterus.
Kohn noted that, in general, it is only women with earlier-stage cancers who are candidates for these options. There are more specific recommendations in the JMIG article.
"Our review summarizes the findings of excellent research that suggests fertility-sparing treatments have acceptable or similar outcomes compared with more aggressive surgeries and that successful pregnancies have occurred following these treatments," Kohn said.
Others point out, however, that it's important patients and clinicians keep in mind that neither is this review (nor any other recent one) the end of the story when it comes to fertility preservation best practices for gynecologic cancers.
Research Limitations
One important limitation for the research included in this review and other available data is that it is all retrospective, said Pedro Ramirez, MD, Professor and Director of Minimally Invasive Surgical Research & Education in the Department of Gynecologic Oncology at The University of Texas MD Anderson Cancer Center.
"It's important to highlight that there are weaknesses to retrospective data," Ramirez told Oncology Times. "In addition, most women who are selected for fertility-sparing surgery are at very low risk for having disease recurrence. [That's what makes them a good candidate for fertility-sparing treatment in the first place]. Therefore, certainly in that setting, acceptable rates of disease-free survival and overall survival are more likely."
Also, when you're only looking at retrospective data where there was no pre-surgical evaluation of fertility potential, there's no way to know if decreased fertility outcomes are a result of the fertility-reserving surgery or a pre-existing fertility issue, said Ramirez, who is also Editor-in-Chief of the International Journal of Gynecological Cancer.
And then, what are the post-surgical pregnancy outcomes? "There is a gap in the data with regards to obstetrical outcomes and management of pregnancy after these patients are able to get pregnant," Ramirez said.
Data Continues Evolving
Sometimes for younger women with gynecological cancers, providers or patients make the assumption that there's not an effective option to both treat the cancer and preserve fertility, said Kutluk Oktay, PhD, MD, Professor of Obstetrics and Gynecology and Reproductive Services, as well as Director of the Laboratory of Molecular Reproduction and Fertility Preservation at Yale University School of Medicine. "But this review shows that is not the case."
Oktay also co-chaired the ASCO committee that developed the 2018 fertility preservation guidelines and researches fertility preservation in ovarian cancer. He said the review does an "excellent" job of evaluating the latest data: "It should serve as a very good guide for cancer doctors." But at the same time, clinicians and patients need to be aware that this field is an evolving one and the research is always progressing. "It's a moving target."
Kohn noted that some questions for future research to address include whether cryopreservation of eggs, embryos, or ovarian tissue is safe for patients with ovarian malignancies and whether less-invasive surgical techniques can be used in more advanced stage cervical cancers.
It's really important that patients have frank conversations with their doctors about their fertility needs and treatment options. It's important for gynecological oncologists to stay abreast of research updates on these topics; and it's important for oncologists to refer patients to specialists when more expertise is needed, which may include gynecologic cancer specialists, fertility specialists, or reproductive endocrinologists who specialize in fertility preservation, according to Oktay.
Ramirez agrees. "Making sure to find the right physician is extremely important," he said. "And then I think it is [also important] to have a frank conversation about not only the details of the procedure, but also the immediate postoperative outcomes with regard to complications-because some of these surgeries for surgical approaches have unique complications."
Sarah DiGiulio is a contributing writer.