Cervical cancer in pregnancy
- Amer Karam, MD
Amer Karam, MD
- Clinical Associate Professor
- Associate Director and Director of Outreach
- Division of Gynecologic Oncology
- Department of Obstetrics and Gynecology
- Stanford University School of Medicine
- Section Editors
- Susan M Ramin, MD
Susan M Ramin, MD
- Section Editor — Obstetrics
- The American Board of Obstetrics and Gynecology (ABOG)
- Don S Dizon, MD, FACP
Don S Dizon, MD, FACP
- Section Editor – Gynecologic Oncology
- Clinical Co-Director, Gynecologic Oncology
- Founder and Director, The Oncology Sexual Health Clinic
- Massachusetts General Hospital Cancer Center
- Associate Professor of Medicine
- Harvard Medical School
- Deputy Editors
- Sadhna R Vora, MD
Sadhna R Vora, MD
- Deputy Editor — Oncology
- Instructor in Medicine
- Harvard Medical School
- Vanessa A Barss, MD, FACOG
Vanessa A Barss, MD, FACOG
- Senior Deputy Editor — UpToDate
- Deputy Editor — Obstetrics, Gynecology and Women's Health
- Associate Clinical Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
One to 3 percent of women diagnosed with cervical cancer are pregnant or postpartum at the time of diagnosis [1,2]. About one-half of these cases are diagnosed prenatally, and the other half are diagnosed in the 12 months after delivery . Cervical cancer is one of the most common malignancies in pregnancy, with an estimated incidence of 0.8 to 1.5 cases per 10,000 births [3-6].
Most patients are diagnosed at an early stage of disease [7,8]. This is probably a result of routine prenatal screening, but it is also possible that advanced stage disease interferes with conception. Stage for stage, the course of disease and prognosis of cervical cancer in pregnant patients are similar to those of nonpregnant patients [8,9].
There are no data from large randomized trials upon which to base recommendations for the care of pregnant patients with cervical cancer. Therefore, management is based upon evidence from randomized trials in nonpregnant women, findings from observational studies of pregnant women, and the unique medical and ethical considerations underlying each individual case. Treatment should be individualized and based on the stage of cancer, the woman's desire to continue pregnancy, and the risks of modifying or delaying therapy during pregnancy.
Cervical cancer is often first suspected when a screening test for the disease is abnormal . While they have not been studied directly, the performance characteristics of the Papanicolaou (Pap) test do not appear to differ significantly between pregnant and nonpregnant women . Overall, the rate of significant cytological abnormalities among obstetrical patients has been reported to be 5 to 8 percent and is similar to that of the nonpregnant population [1,7].
Symptoms and signs of cervical carcinoma in pregnancy are dependent upon the clinical stage and lesion size. In two series, all pregnant patients with stage IA and 50 percent of those with stage IB carcinoma were asymptomatic at the time of diagnosis and had their disease detected by routine cancer screening (table 1) [6,11]. Patients with symptomatic stage IB disease presented with abnormal vaginal bleeding or discharge; patients with more advanced disease also presented with pelvic pain, sciatica-type leg pain, flank pain, chronic anemia, and shortness of breath. Since many of these symptoms are similar to those associated with a normal pregnancy, the diagnosis of cervical cancer may be delayed in pregnant women.
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- CLINICAL PRESENTATION
- DIAGNOSTIC EVALUATION
- Women with clinical findings
- Women with abnormal cervical cytology
- - Colposcopy
- Indications for and performance of conization
- Physical examination
- Imaging studies
- MANAGEMENT OF PREINVASIVE DISEASE
- MANAGEMENT OF INVASIVE DISEASE
- Pregnancy termination
- Pregnancies not terminated
- - Gestational age less than 22 to 25 weeks at diagnosis
- No evidence of nodal involvement
- - Microinvasive disease (Stage IA1)
- - Stage IA2 to IB1 tumor <2 cm
- - Stage IB1 (Tumor 2 cm or larger) and higher
- Positive nodal involvement
- - Gestational age 22 to 25 weeks or later
- Stage IA to IB1 tumor <2 cm
- Stage greater than IB1 (Tumor 2 cm or larger)
- - Surveillance during pregnancy
- - Considerations about delivery
- - Definitive treatment for cervical cancer
- WOMEN WITH METASTATIC DISEASE
- SYSTEMIC THERAPY IN PREGNANCY
- SUMMARY AND RECOMMENDATIONS