Maintaining Fertility in the Face of Cervical Cancer
The irony was this: Raquel Rivas had gone to her family doctor that day to tell him that she and her husband, Tony, wanted to start a family. But that’s not what they ended up talking about.
During Rivas’ physical exam, the doctor discovered changes in her cervix so obvious that it was almost surely cervical cancer. It looked to be aggressive, he told Rivas; she would probably need to undergo a hysterectomy.
“ ‘I’ll never be a mommy.’ Those were the first words out of my mouth,” says Rivas, 28, recalling that day almost three years ago.
But she is on track to be a mommy, thanks to an experimental new surgical technique for cervical cancer that spares the uterus and preserves fertility. Rivas underwent the surgery, called a radical trachelectomy, at USC Norris Cancer Center a few weeks after her diagnosis. She is now 18 weeks pregnant with twins.
“I don’t hesitate to share my experience with anyone,” she says. “I’m just amazed at how lucky I am.”
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With fewer than 100 cases reported in the medical literature, several questions remain about the value of radical trachelectomy: most notably, the pivotal issue of whether preserving the uterus increases the risk of the cancer returning. But the chance to preserve fertility is of such importance in younger women that doctors at USC and elsewhere are eager for consumers to know that the procedure is an option for a small number of cervical cancer patients whose disease is not extensive.
The new surgery is part of a trend in oncology in which surgeons are trying to remove less tissue and still keep cure rates high. For example, many breast cancer cases that used to be treated with mastectomy (removal of the breast) are now treated with a lumpectomy (removal of just the part of the breast containing the tumor).
“Uterine, cervical and vulvar cancers are generally highly treatable,” says Dr. Linda Roman, Rivas’ surgeon at USC. “But when we do these radical procedures we impact sexuality, fertility, functioning. There is more attention to women’s sexuality now, and women have been vocal about that. So I think doctors are saying maybe we can do less [in surgery] and still treat the cancer.”
The experimental procedure is being done by gynecological oncologists at a few of the major teaching and research institutions across the country, says Dr. Jonathan S. Berek, chief of gynecological oncology at UCLA’s Jonsson Comprehensive Cancer Center.
“Radical trachelectomy is for people with very small [cancerous] lesions and who have a strong desire to preserve childbearing,” he says. “My experience is that, for the handful of women we have done this for, many others have asked about it but didn’t qualify. It’s for a limited population of cervical cancer patients.”
Cervical cancer is diagnosed in about 65,000 Americans a year. In most cases, the cancer is detected in a Pap smear test and is found at a very early stage. Treatment for these noninvasive cancers involves destroying only some cervical tissue.
About 12,800 cases of cervical cancer annually are more advanced, or “invasive,” cases in which the disease has spread beyond microscopic cell changes. In such cases, treatment typically involves the surgical removal of the patient’s cervix and uterus.
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Radical trachelectomy may be appropriate in cases where the cancerous lesions are beyond the early, microscopic stage but are still confined to only a small area in the cervix.
Candidates must also have a strong desire to become pregnant, Roman says. And both she and other doctors performing the technique emphasize that, as of now, the uterus-sparing option should only be considered when the patient wants to have children.
“The radical hysterectomy [in which the uterus is removed] cures the cancer in 85% to 90% of cases,” Roman says. “There have not been enough cases of radical trachelectomy followed long enough to tell us that the results are as good. Because we are lacking this data, there is a risk involved. All that can be said so far, based on about 100 cases in the literature, is that most people have done fine.”
There is also a dearth of data on whether the procedure affects fertility.
“In addition to not knowing how safe it is, we really don’t know how likely it is that these patients are fertile,” Berek says.
Before undergoing the surgery, a woman and her partner should undergo testing to make sure they have a good chance of conceiving.
Since the surgery destroys the production of cervical mucus that is a necessary component of conception through sexual intercourse, women who wish to become pregnant may need some fertility treatment to conceive.
Patients who are concerned about having children should also be advised of other options, such as undergoing the standard hysterectomy and using a surrogate to carry a child that is still the genetic child of the patient and her partner, says Dr. Beth Karlan, director of gynecological oncology at Cedars-Sinai Medical Center and a professor at UCLA.
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The uterus is typically removed in cases of invasive cervical cancer because the cervix and uterus share the same blood supply, which may allow cancer cells to move freely from the cervix to the uterus. In the radical trachelectomy, surgeons remove part of the cervix and some surrounding tissue. The surgery is done through the vagina. It does not affect the vagina and leaves the top part of the cervix and the uterus intact.
Because the trachelectomy affects cervical mucus, Rivas and her husband required artificial insemination to conceive and underwent four attempts before conceiving. And, because her cervix is weakened, Rivas will spend much of her pregnancy resting in bed.
She isn’t complaining, however.
“It’s a true miracle,” she says of her pregnancy. “It was a difficult decision to make about which surgery to have. And even since then, I was always analyzing things, wondering if I’d made the right decision.”
Not anymore. When she found she was pregnant, Rivas called her health care team at Norris.
“It was a really nice thing to share with them,” she says.
