Preterm birth risk higher among women with early cervical cancer
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Women with early cervical cancer who conceived at least 3 months after fertility-sparing surgery had a high live birth rate, according to results presented at the virtual Society of Gynecologic Oncology Annual Meeting on Women’s Cancer.
However, these women had elevated risks for preterm delivery and neonatal morbidity compared with healthy controls and women who conceived prior to cervical cancer diagnosis, results of the retrospective, population-based cohort study showed.
“These data are important for shared decision-making discussions regarding fertility-sparing surgery for patients with early-stage cervical cancer,” Roni Nitecki, MD, MPH, second-year fellow in the department of gynecologic oncology and reproductive medicine at The University of Texas MD Anderson Cancer Center, said during a presentation.
Approximately 40% of women with cervical cancer are diagnosed prior to age 45 years, and many have not completed childbearing. A considerable percentage of these women will be candidates for fertility-sparing surgery, which has been used increasingly for women with early-stage cervical cancer.
A prior systematic review of 2,777 women with cervical cancer — 944 of whom became pregnant — showed a 55% fertility rate, a 70% live birth rate and a 38% preterm birth rate.
“However, the included studies in the review were small case series, with few pregnancies and without granular obstetric outcomes,” Nitecki said.
Nitecki and colleagues used a population-level database to characterize obstetric outcomes after fertility-sparing surgery for women who conceived and delivered after cancer treatment, and to compare outcomes in this group with those of matched controls.
Researchers linked data from the California Cancer Registry to the California linked birth cohort, which included antepartum and postpartum records for the 9 months prior to delivery and 1 year after delivery.
Nitecki and colleagues identified 4,087 reproductive-age women (18 to 45 years) with stage I cervical cancer reported to the California Cancer Registry from January 2000 through December 2012. Of those, 1,671 (40.9%) had a recorded pregnancy during the study period. Women who did not have cervical cancer but delivered in California during the study period served as the control population.
Researchers established three groups for the analysis.
The cervical cancer cases group included 113 women (median age, 32 years; range, 29-36; 52.2% white; 31.9% Hispanic) who conceived at least 3 months after fertility-sparing surgery and delivered after 23 weeks gestational age. Researchers only assessed first pregnancy after diagnosis.
Most women in this group (62.8%) had squamous cell carcinoma histology.
Researchers propensity score-matched these 113 women with two control groups. The first was a cervical cancer control group, which consisted of 213 women with cervical cancer who conceived at least 1 year prior to diagnosis. The second consisted of 226 healthy controls.
After matching, the distribution of demographic characteristics was similar among all groups. Researchers also matched cases to controls based on obstetric risk factors, including parity and pregnancy type (ie, singleton vs. twin gestation).
Preterm birth — calculated at less than 37 weeks and less than 32 weeks — served as a key outcome measure.
Secondary outcomes included growth restriction, fetal demise, cesarean delivery, severe maternal morbidity as defined by CDC, and neonatal morbidity, defined as any of the following: hypoxic-ischemic encephalopathy, need for respiratory support within 72 hours of life, sepsis/pneumonia, seizure, meconium aspiration syndrome, birth trauma, or intracranial or subgaleal hemorrhage.
Nearly all women (99.1%) in the cervical cancer cases group had live births.
However, women in the cervical cancer cases group were more likely than cervical cancer controls and healthy controls to deliver prior to 32 weeks (5.3% vs. 2.3% vs. 1.3%) or prior to 37 weeks (26.5% vs. 13.1% vs. 8.4%).
The difference in preterm birth prior to 32 weeks reached statistical significance between cervical cancer cases and healthy controls (OR = 4.17; 95% CI, 1.02-16.99) but not between cervical cancer cases and cervical cancer controls.
The difference in preterm birth before 37 weeks reached statistical significance between cervical cancer cases and healthy controls (OR = 3.94; 95% CI, 2.1-7.38), and between cervical cancer cases and cervical cancer controls (OR = 2.39; 95% CI, 1.34-4.25).
Neonatal mortality occurred more frequently among women in the cervical cancer cases group than cervical cancer controls (OR = 2.69; 95% CI, 1.29-5.64) and healthy controls (OR = 2.33; 95% CI, 1.15-4.72).
Researchers reported no significant differences between groups with regard to growth restriction, fetal demise or cesarean section delivery.
Nitecki and colleagues also assessed outcomes by type of fertility-sparing surgery when this information was known. The analysis included 100 women who underwent loop electrosurgical excision procedure or conization, and 10 who underwent trachelectomy.
Results showed higher rates of preterm birth at less than 32 weeks (30% vs. 2%) and preterm birth at less than 37 weeks (80% vs. 20%) among women who underwent trachelectomy, although Nitecki noted this analysis was limited by small numbers.
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Wui-Jin Koh, MD
Dr. Nitecki’s presentation showed increased preterm births and neonatal morbidity. Encouragingly, there was no significant increase in fetal demise or significant maternal morbidity. The researchers appropriately indicate that this information can serve as the basis for counseling and shared decision-making. My question to them is: Can other steps be taken to potentially further mitigate those adverse consequences? There is a suggestion that perhaps there should be an emphasis on less radical surgical processes and better selection of patients. Also, neonatal morbidity was measured at 30 days. Is there a role for better predelivery care and neonatology involvement? How much of that neonatal morbidity is preventable or reversible?
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Nitecki R, et al. Abstract 10654. Presented at: Society of Gynecologic Oncology Annual Meeting on Women’s Cancer (virtual meeting); March 19-25, 2021.
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