Câncer de colo uterino na gestação / Cervical cancer in pregnancy

PONTOS-CHAVE • A incidência de câncer durante a gestação tem aumentado devido à tendência das mulheres em postergar a gravidez. O câncer de colo de útero é a terceira neoplasia mais comumente diagnosticada durante o período gestacional. • O rastreamento e o diagnóstico devem se dar como nas pacientes não gestantes; a citologia oncótica cervical é o exame obrigatório do pré-natal, e a colposcopia com biópsia pode ser realizada em qualquer período da gestação. • A gestação complicada pelo diagnóstico de um câncer deve sempre ser conduzida em centro de referência e por equipe multidisciplinar. • A interrupção da gestação em situações específicas, para tratamento-padrão, é respaldada por lei. • A quimioterapia neoadjuvante é uma alternativa segura de tratamento durante a gestação, para permitir alcançar a maturidade fetal. Apresenta altas taxas de resposta, sendo relatada progressão neoplásica durante a gestação em apenas 2,9% dos casos. O risco de malformações fetais decorrentes da quimioterapia é semelhante ao da população geral. Contudo, a quimioterapia está associada a restrição de crescimento intraútero, baixo peso ao nascer e mielotoxicidade neonatal. • Na ausência de progressão de doença, deve-se levar a gestação até o termo.

Evaluation of a new foetal shielding device for pregnant brain tumour patients.

BACKGROUND: The present study aimed to propose a new foetal shielding device for pregnant cancer patients to reduce the foetal dose associated with treatment techniques using multiple gantry angles, such as intensity-modulated radiation therapy (IMRT) or volumetric modulated arc therapy (VMAT). METHODS: Three shielding structures were designed to minimise the scattered and leaked radiation from various gantry angles and radiation scattering within the patient. The base-plate part that can be placed on the treatment couch was designed to reduce the scattered and leaked radiation generated at gantry angles located near 180°. A body shielding part that can cover the lower chest and abdomen was designed, and a neck-shielding structure was added to reduce the internal and external radiation scattering from the treatment area. Evaluation plans were generated to assess the foetal dose reduction by the foetal shielding device in terms of the shielding material thickness, distance from the field edge, and shielding component using the flattened 6 MV photon beam (6MV) and flattening filter-free 6 MV photon beam (6MV-FFF). In addition, the effectiveness of the foetal shielding device was evaluated in a pregnant brain tumour patient. RESULTS: The shielding material consisting of three parts was placed on frames composed of four arch shapes with a vertical curved structure, connection bar at the top position, and base plate. Each shielding part resulted in reductions in the radiation dose according to the treatment technique, as the thickness of the shielding material increased and the foetal dose decreased. In addition, a foetal dose reduction of approximately 50% was confirmed at 50 cm from the field edge by using the designed shielding device in most delivery techniques. In patients, the newly designed shielding structures can effectively eliminate up to about 49% of the foetal dose generated from various gantry angles used in VMAT or IMRT. CONCLUSIONS: We designed a foetal shielding device consisting of three parts to effectively reduce the dose delivered to the foetus, and evaluated the device with various treatment techniques for a pregnant patient with brain tumour. The foetal shielding device shielded the scattered/leaked radiation from the treatment machine, and also effectively reduced internal scattering from the treatment area in the patient.

Fertility considerations in targeted biologic therapy with tyrosine kinase inhibitors: a review.

PURPOSE: To review the impact of tyrosine kinase inhibitors (TKIs) on fertility in men and women, embryo development, and early pregnancy, and discuss considerations for fertility preservation in patients taking TKIs. METHODS: A comprehensive literature search using the PubMed database was performed through February 2021 to evaluate the current literature on imatinib, nilotinib, dasatinib, and bosutinib as it relates to fertility and reproduction. Published case series were analyzed for pregnancy outcomes. RESULTS: TKIs adversely affect oocyte and sperm maturation, gonadal function, and overall fertility potential in a self-limited manner. There are insufficient studies regarding long-term consequences on fertility after discontinuation of TKIs. A total of 396 women and 236 men were on a first- or second-generation TKI at the time of conception. Of the women with detailed pregnancy and delivery outcomes (n = 361), 51% (186/361) resulted in a term birth of a normal infant, 4.3% (16/361) of pregnancies had a pregnancy complication, and 5% (20/361) of pregnancies resulted in the live birth of an infant with a congenital anomaly. About 22% of pregnant women (87/396) elected to undergo a termination of pregnancy, while 16% (63/396) of pregnancies ended in a spontaneous abortion. In contrast, of the 236 men, 87% conceived pregnancies which resulted in term deliveries of normal infants. Elective terminations, miscarriage rate, pregnancy complication rate, and incidence of a congenital malformation were all less than those seen in females (4%, 3%, 2%, and 2.5%, respectively). CONCLUSION: Women should be advised to avoid conception while taking a TKI. Women on TKIs who are considering pregnancy should be encouraged to plan the pregnancy to minimize inadvertent first trimester exposure. In women who conceive while taking TKIs, the serious risk of relapse due to discontinuation of TKI should be balanced against the potential risks to the fetus. The risk of teratogenicity to a fathered pregnancy with TKI use is considerably lower. Fertility preservation for a woman taking a TKI can be considered to plan a pregnancy with a minimal TKI-free period. With careful monitoring, providers may consider a TKI washout period followed by controlled ovarian stimulation to cryopreserve oocytes or embryos, with a plan to resume TKIs until ready to conceive or to transfer an embryo to achieve pregnancy quickly. Fertility preservation is also indicated if a patient on TKI is requiring a gonadotoxic therapy or reproductive surgery impacting fertility.

Ulipristal acetate before in vitro fertilization: efficacy in infertile women with submucous fibroids.

BACKGROUND: The presence of submucous fibroids strongly impacts on IVF results, therefore, these patients should be considered for surgical or medical treatment. The aim of this study was to assess the role of Ulipristal acetate (UPA), a selective progesterone receptor modulator, in restoring uterine cavity deformation due to submucous fibroids, in infertile patients attempting an IVF treatment. The secondary study outcome was to evaluate the impact of preconception UPA treatment on rate of biochemical pregnancy, ongoing pregnancy, and live birth compared to a control group without fibroids. METHODS: Infertile patients with submucosal fibroid (Type 1 and Type 2 according to FIGO classification) were enrolled in the study as fibroids group and received 1 to 3 treatment cycles of UPA, according to their response, as reflected by fibroid volume reduction and restoration of normal uterine cavity. Patients in control group were randomly selected from a general IVF cohort by a ratio of 2:1 with fibroids group, matched by age, BMI, type and cause of infertility and antral follicle count. The impact of UPA on fibroids volume reduction was evaluated. IVF outcome was compared between groups. RESULTS: Twenty-six patients underwent UPA treatment revealed a mean volume reduction of their fibroids of 41%. A total of 15 (57.6%) biochemical pregnancy were obtained, resulting in 13 (50%) ongoing pregnancy and 9 (34.6%) healthy babies were already delivered. Similar results were obtained in control group. CONCLUSION: Restoration of normal uterine cavity by UPA treatment prior to IVF treatment avoids surgery and establishes a pregnancy rate comparable to a control group without fibroids.

[Maternal deaths in Sweden: Diagnostics and clinical management could be improved]. / Mödradöd i Sverige: Vården hade många gånger kunnat vara bättre - Lärdomar från 11 års extern kollegial granskning.

MM-ARG, the Swedish maternal maternity mortality group within SFOG (Swedish Society of Obstetrics and Gynecology) has, since 2008, surveyed and analysed maternal deaths in Sweden with the aim to find and give feedback on lessons learned to the medical professions.  MM-ARG consists of obstetricians, midwives and anesthetists and the strength of the working model is that the profession itself takes responsibility for the scrutiny.  A summary of 67 known maternal deaths from 2007‒2017 is presented. Direct causes of death are dominated by hypertensive disease/preeclampsia, followed by thromboembolic disease, sepsis and obstetric bleeding. Indirect death, where a known or unknown underlying disease is exacerbated by pregnancy, is dominated by cardiovascular disease. This review shows that the diagnostics and clinical management could be improved. Besides obstetrics/gynecology, maternal mortality affects other specialties and thus holds important lessons to many.

Secondary cervical cancer prevention in routine prenatal care - coverage, results and lessons for the future.

OBJECTIVES: Cervical cancer is the fourth most common type of cancer among women worldwide and one of the most common malignancies diagnosed in gravidas. Therefore, routine antenatal Pap smear is such an important examination. The aim of the study was to assess the prevalence of Pap smear performance during prenatal care and to determine possible factors affecting it. MATERIAL AND METHODS: A self-composed questionnaire was distributed among 638 women managed in a tertiary obstetric referral center. 33 questions regarded cervical cancer prevention and risk factors. RESULTS: 96.9% of respondents had undergone Pap smear and 80.6% had it performed during pregnancy. For 11.5% women Pap smear in pregnancy was the first one in their life. The most common reasons for lack of Pap smear performance were: no subjective need to perform it (40.9%), no doctor's recommendation (28.6%) and lack of gynecological care (16.3%). Among professionally active women the percentage of those who had not undergone Pap smear during pregnancy was statistically higher (28.5%) than among those who were on sick leave (13.5%) (p = 0.0003). Also, younger women were at risk of less frequent participation in cervical cancer screening CONCLUSIONS: Although performance of Pap smear among surveyed patients was relatively high, there was a significant group of women who had undergone their first test during pregnancy, which makes secondary cervical cancer prevention in prenatal care a useful prophylactic strategy. Special attention should be given to younger and professionally active women.

Young Women with Breast Cancer: Fertility Preservation Options and Management of Pregnancy-Associated Breast Cancer.

BACKGROUND: Breast cancer is the most common malignancy diagnosed in women of childbearing age. A breast cancer diagnosis in this young patient population can be uniquely complex to navigate when considering the potential impact of fertility loss associated with specific gonadotoxic therapies. Another unique challenge for young breast cancer patients is pregnancy-associated breast cancer (PABC), which occurs in approximately 1 of every 3000 pregnancies. Pregnancy adds a layer of complexity to breast cancer treatment planning as many therapies can affect the developing fetus. These two clinical challenges require nuanced multidisciplinary approaches to facilitate optimal treatment outcomes. We sought to review and summarize the management strategy options for both fertility preservation and PABC. METHODS: A guideline and literature review was performed for fertility preservation, young patients with breast cancer, and pregnancy-associated breast cancer. RESULTS: Fertility preservation options, both established and experimental, are detailed. Suggested clinical practice guidelines for PABC are also presented, which delineate breast cancer treatment recommendations based on pregnancy trimester. CONCLUSION: A multidisciplinary approach to patient care, including oncologists and early referral to reproductive specialists, can provide young breast cancer patients with options for fertility preservation. Under the guidance of a multidisciplinary treatment team, PABC can also be diagnosed and treated to permit the best possible outcomes for the mother and the developing fetus.

Venous thromboembolism and women's health.

The prevention and treatment of venous thromboembolism (VTE) poses distinct gender-specific challenges. Women of childbearing age are at an increased risk of VTE secondary to the transient risk factors of combined hormonal contraception (CHC) and pregnancy. Cancers specific to women are associated with a significant burden of VTE; whilst the incidence of VTE in localised breast cancer is 5 per 1000 person-years, more cases are seen due to the prevalence of breast cancer. Treatment of VTE in women can be complicated by abnormal uterine bleeding, now increasingly reported with direct oral anticoagulants (DOACs) as well as vitamin K antagonists. Divergence between international guidelines regarding the use of CHC following an oestrogen-associated VTE and appropriate withdrawal of such contraception requires clarification for clinicians. Additionally, there is uncertainty as to whether to consider such events provoked or unprovoked and, consequently, the optimal duration of treatment in these women remains unclear. During pregnancy and the puerperium, the traditional anticoagulants remain the agents of choice with no further advances in DOAC safety data, and similarly in lactation. Further studies evaluating the safety and optimal treatment strategies in these women are awaited.

Use of emergency contraception among female young adult cancer survivors.

OBJECTIVE: To test whether emergency contraception use in reproductive-aged cancer survivors is higher than in the general U.S. population and evaluate factors associated with use among survivors. DESIGN: A retrospective cohort study compared emergency contraception use between cancer survivors in the Reproductive Window Study on ovarian function after cancer and in the general population in the 2006-2010 National Survey for Family Growth. In a cross-sectional analysis of survivors, multivariable models were used to test associations between participant characteristics and emergency contraception use. SETTING: Not applicable. PATIENT(S): A total of 616 female cancer survivors aged 18-40. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Self-reported emergency contraception use. RESULT(S): The mean age of survivors was 33.4 ± 4.7, at a mean 7.5 years since diagnosis. Breast cancer (22%), Hodgkin lymphoma (18%), and leukemia (8%) were the most common cancers. Since diagnosis, 156 (25.3%) used emergency contraception, 60% because of not otherwise using contraception. Age-adjusted prevalence of use was higher in survivors than in the general population (28.3% [95% confidence interval (CI) 24.7-31.9] vs. 12.0% [95% CI 11.1-12.9]). In multivariable analysis among survivors, nonwhite race (prevalence ratio [PR] 1.3, 95% CI 1.0-1.8), breast cancer (PR 0.6, 95% CI 0.4-1.0), partnered relationship (PR 0.6, 95% CI 0.5-0.9), and older age (age 36-40 vs. 31-35; PR 0.7, 95% CI 0.5-1.0) were associated with emergency contraception. CONCLUSION(S): Female young adult cancer survivors were significantly more likely to use emergency contraception compared with the general population. Populations including nonwhite survivors have a higher risk, suggesting differences in family planning care. Strategies to improve contraception and decrease the need for emergency contraception are needed.

Cervical Cancer: Evaluation and Management.

Human papillomavirus infection is the precursor for the development of cervical cancer and is detectable in 99.7% of squamous cell carcinoma and adenocarcinoma cases. Early detection of precancerous lesions with Papanicolaou testing remains the primary mechanism for cancer prevention. Once cervical cancer is diagnosed, treatment may involve surgery, radiation therapy, chemotherapy, or a combination. The choice of therapy depends on the stage of disease, lymph node involvement, patient comorbidities, and risk factors for recurrence. Early-stage, microinvasive disease may be treated with surgery alone if margins are negative and there is no lymph node involvement; adjuvant chemoradiation should be considered for other early-stage disease. Locally advanced disease is often treated with chemoradiation. The addition of bevacizumab, an antivascular endothelial growth factor monoclonal antibody, to combination chemotherapy improves survival among patients with recurrent, persistent, or metastatic cervical cancer. Disease stage and lymph node involvement are the most prognostic factors. Pregnancy status and desire to preserve fertility should be considered when developing a treatment strategy. After treatment, close follow-up with a gynecologist-oncologist for pelvic examinations at regular intervals is recommended to assess for recurrence.

Fertility and pregnancy issues in BRCA-mutated breast cancer patients.

Fertility and pregnancy-related issues represent one of the main areas of concerns for young women with breast cancer. Carrying a germline deleterious BRCA mutation adds additional burden on this regard due to the specific issues that should be considered during the oncofertility counseling of this special patient group. Despite the availability of a growing amount of data in the general breast cancer population on the feasibility and safety of fertility preservation and pregnancy after diagnosis, numerous challenges remain for BRCA-mutated breast cancer patients in whom very limited studies have been performed so far. Therefore, studies aiming to address the specific issues of these patients, including the impact of the mutation on their fertility potential, the safety and efficacy of the different strategies for fertility preservation, and the feasibility of having a pregnancy after diagnosis, should be considered a research priority. The aim of the present manuscript is to perform an in depth overview on the role of BRCA mutations in breast cancer with a specific focus on their impact on reproductive potential, and to discuss the fertility and pregnancy issues faced by BRCA-mutated breast cancer patients. The final goal of this manuscript is to highlight current and upcoming knowledge in this field for trying to help physicians dealing with these patients during oncofertility counseling.

[Evaluation of French practices regarding cytologic cervical cancer screening during pregnancy: A bicentric retrospective cohort study]. / Analyse de la pratique du frottis cervico-utérin de dépistage pendant la grossesse en France: étude bicentrique rétrospective de cohorte.

OBJECTIVES: To evaluate the practice of cytologic cervical cancer screening during the follow-up of pregnancy. MATERIALS AND METHODS: A retrospective cohort study was conducted from July to November 2013. During this period, 300 women attending to the obstetrical department of two universitary hospitals were randomly included immediately after their delivery. RESULTS: Among included women, 155 (51.7%) had a normal cervical cytology performed within the past 3 years. Overall, 75 (25%) women had a cervical cytology performed during their pregnancy. Although patients who did not have a cervical cytology performed within the past 3 years were significantly more likely to have a cervical cytology performed during the follow up of their pregnancy (AOR: 2.30; 95% CI: 1.03-5.26; P=0.049), only 39 (26.9%) of the 145 women who did not have a cervical cytology performed within the last 3 years had a catch up cytology performed. Age 25 or older had no significant influence on the probability that a cervical cytology had been performed during pregnancy (ORA: 1.11; 95% CI: 0.51-2.43; P=0.786). CONCLUSION: Although the follow-up of pregnancy allows for the catch up of non attendant women to cytologic cervical cancer screening, such catch up remains insufficient and most of cervical cytologies performed during pregnancy are done irrespectively of the current guidelines.

Abnormal cervical cancer screening in pregnancy and preterm delivery.

BACKGROUND: Preterm delivery is a major cause of neonatal morbidity and mortality. Human papillomavirus (HPV) infection is common in reproductive-aged women. We hypothesised that abnormal cervical cancer screening tests, as a proxy for HPV infection, would be associated with preterm delivery. METHODS: We conducted a retrospective cohort study of women delivering liveborn singletons beyond 20 weeks gestation, who had a Papanicolaou (Pap) test within 1 year prior to delivery. Women with abnormal Pap or positive high-risk HPV tests, classified as having 'abnormal screening', were compared with women classified as having 'normal screening' in bivariate analysis for overall preterm delivery at less than 37 weeks gestation. Using Poisson regression, we report unadjusted (RR) and adjusted (aRR) risk ratios for spontaneous preterm delivery due to preterm labour and preterm premature rupture of membranes. RESULTS: Among 2686 women meeting criteria for analysis, 213 (8%) had abnormal screening. Women with abnormal screening, compared with normal screening, were not more likely to deliver preterm (12.2% vs. 9.8%, RR 1.3 [95% confidence interval (CI) 0.9, 1.8], aRR 1.2 [95% CI 0.8, 1.7]). Women with abnormal screening, however, were at greater risk for spontaneous preterm delivery in unadjusted and adjusted analysis (8.9% vs. 4.5%; RR 2.0 [95% CI 1.2, 3.2], aRR 1.8 [95% CI 1.1, 2.9]). CONCLUSIONS: There was no difference in risk of overall preterm delivery in women with abnormal compared with normal cervical cancer screening tests. Our data suggest, however, that abnormal screening in pregnancy may be associated with spontaneous preterm delivery.

Impact of pregnancy on prognosis of differentiated thyroid cancer: clinical and molecular features.

OBJECTIVE: Differentiated thyroid cancer (DTC) commonly occurs in women of child-bearing age and represents the second most frequent tumor diagnosed during pregnancy only behind breast cancer. It is possible that associated physiological changes could favor tumor development and growth. However, few data are available about the outcome of DTC related to pregnancy, leading to conflicting results. METHODS: Among the study population, 340 patients with DTC <45 years old were retrospectively studied. Patients were divided into three groups according to the time of tumor diagnosis in respect of pregnancy. Group 1, diagnosis of DTC at least 2 years after delivery; group 2, diagnosis during pregnancy or within the second year after delivery; and group 3, nulliparous patients at the time of diagnosis. We evaluated clinical outcome and immunohistochemical expression of estrogen receptor α (ERα), ERß, progesterone receptor, and aromatase. We also analyzed the gene expression of NIS (SLC5A5) and the prevalence of BRAF(V600E) mutations. RESULTS: Persistence/recurrence of disease was significantly higher in group 2 patients than control groups (P=0.023). No significant differences were observed in other clinical parameters. Furthermore, no differences among the groups were recorded about ER pattern, NIS expression, and BRAF mutations. CONCLUSIONS: Persistence/recurrence of DTC is significantly higher in pregnant patients, suggesting that pregnancy could really exert a negative prognostic role in patients with DTC. The underlying mechanisms are not yet clarified and further studies are required. Our results suggest that a more careful follow-up is needed when diagnosis of DTC occurs during pregnancy or shortly after.

Mechanism and preclinical prevention of increased breast cancer risk caused by pregnancy.

While a first pregnancy before age 22 lowers breast cancer risk, a pregnancy after age 35 significantly increases life-long breast cancer risk. Pregnancy causes several changes to the normal breast that raise barriers to transformation, but how pregnancy can also increase cancer risk remains unclear. We show in mice that pregnancy has different effects on the few early lesions that have already developed in the otherwise normal breast-it causes apoptosis evasion and accelerated progression to cancer. The apoptosis evasion is due to the normally tightly controlled STAT5 signaling going astray-these precancerous cells activate STAT5 in response to pregnancy/lactation hormones and maintain STAT5 activation even during involution, thus preventing the apoptosis normally initiated by oncoprotein and involution. Short-term anti-STAT5 treatment of lactation-completed mice bearing early lesions eliminates the increased risk after a pregnancy. This chemoprevention strategy has important implications for preventing increased human breast cancer risk caused by pregnancy. DOI: http://dx.doi.org/10.7554/eLife.00996.001.

Targeting the link between late pregnancy and breast cancer.

Why does a first pregnancy after age 35 increase the risk of breast cancer, and what can be done to combat this?

Neurological manifestations of phaeochromocytomas and secretory paragangliomas: a reappraisal.

OBJECTIVE: To determine the frequency and range of neurological manifestations of phaeochromocytomas and secretory paragangliomas. METHODS: A retrospective review of case notes of patients admitted to Auckland Hospital from 1985 to 2011 with a discharge diagnosis of phaeochromocytoma or secretory paraganglioma. RESULTS: Ninety-three patients were admitted with a phaeochromocytoma or secretory paraganglioma. Sixty-eight patients (73%) had neurological symptoms, but only 15 patients (16%) received a neurological consultation. Neurological manifestations occurred in three main clinical contexts. First, paroxysmal symptoms occurred in 66 of 93 patients (71%). Neurological symptoms were common features of these attacks and included headache (47 patients), anxiety (24 patients), tremulousness (15 patients) and dizziness (12 patients). The headaches typically had an explosive onset. Delay in diagnosis was common. Second, 28 patients (30%) had an acute crisis, which was associated with neurological symptoms in 11 (39%) of the episodes: headache (10 patients); seizures (five patients); strokes (three patients); delirium (three patients) and subarachnoid haemorrhage (one patient). Third, five of six patients with a head and neck secretory paraganglioma had neurological symptoms related to infiltration of the middle ear or compression of cranial nerves. Reversible cerebral vasoconstriction syndrome (RCVS) was documented in three patients. CONCLUSIONS: Neurological manifestations of phaeochromocytomas and secretory paragangliomas were common, and these tumours can present with various neurological manifestations. The paroxysmal symptoms can be incorrectly attributed to other headache syndromes, panic attacks or cerebral vasculitis. RCVS may play a role in the pathogenesis of the neurological symptoms associated with acute crises and paroxysmal attacks.

An international series on abdominal radical trachelectomy: 101 patients and 28 pregnancies.

OBJECTIVES: Abdominal radical trachelectomy (ART) is a type C resection (uterine vessels ligated at origin from the hypogastric vessels). Questions arise as to whether fertility is maintained after ART, particularly when uterine vessels are sacrificed. We report an international series on ART to describe fertility and oncologic outcomes. METHODS: Databases at 3 institutions were queried to identify patients planned for ART from 1999 to 2011. Clinical and demographic data were gathered. RESULTS: One hundred one patients underwent ART. Mean age was 31 years (range, 19-43 years). Histologic classifications were adenocarcinoma (n = 54), squamous cell carcinoma (n = 40), adenosquamous carcinoma (n = 6), and clear cell carcinoma (n = 1). Twenty patients (20%) required conversion to hysterectomy (10 margins and 10 nodes). Eight patients underwent completion hysterectomy owing to the following: positive margins on final pathology (n = 3), patient's choice (n = 4), or recurrence (n = 1). Postoperatively, 20 patients (20%) received adjuvant chemotherapy and/or radiation (4 final pathology margins and 16 nodes). Four patients (4%) had recurrence and lived 22 to 35 months after diagnosis. Of the 70 women who had neither hysterectomy nor adjuvant therapy, 38 (54%) attempted pregnancy and 28 (74%) achieved pregnancy. Thirty-one pregnancies resulted in 16 (52%) third trimester deliveries. Six patients are currently pregnant with outcomes pending. CONCLUSIONS: These data demonstrate that ART preserves fertility and maintains excellent oncologic outcomes. Most women (74%) attempting pregnancy after ART are able to achieve pregnancy and deliver in the third trimester (52%). Preservation of the uterine vasculature is not necessary for fertility; obstetrical outcomes are similar to those of the historical vaginal radical trachelectomy cohorts.

Patient perceptions of reproductive health counseling at the time of cancer diagnosis: a qualitative study of female California cancer survivors.

PURPOSE: We sought to determine what women recall about reproductive health risks (RHR) from cancer therapy at the time of cancer diagnosis in order to identify barriers to reproductive health counseling (RHC) and fertility preservation (FP). METHODS: Data were obtained by surveying 1,041 female cancer survivors from the California Cancer Registry. Inclusion criteria included women age 18-40 with a diagnosis of leukemia, Hodgkin's disease, non-Hodgkin's lymphoma, breast or GI cancer diagnosed between 1993 and 2007. Women were asked to respond to an open-ended question: "what did your doctor tell you about how cancer treatment could affect your ability to get pregnant?" Framework analysis was used to identify themes surrounding patient perceptions of RHC. RESULTS: Of the patients, 51.8 % (361 out of 697) recalled receiving reproductive health counseling and 12.2 % (85 out of 697) recalled receiving FP counseling. Of the patients, 45.3 % (277 out of 612) reported that uncertain prognosis, risk of recurrence or vertical transmission, age, parity, or uncertain desire may have prevented them from receiving timely and essential information on RHRs. Communication barriers included omission of information, failure to disclose RHRs, and presentation of incorrect information on FP. DISCUSSION: In a sample of women diagnosed with cancer of reproductive age, almost half did not recall counseling on RHRs and few recalled FP counseling. Communication barriers between physicians and patients regarding fertility may lead to uninformed (reproductive health) RH decisions. IMPLICATIONS FOR CANCER SURVIVORS: Many women may not receive adequate information about RHRs or FP at the time of cancer diagnosis. Advancements in reproductive technology and emerging organizations that cover financial costs of FP have dramatically changed what options women have to preserve their fertility. Routine and thoughtful RHR and FP counseling, as well as collaborative cancer care will help ensure that women diagnosed with cancer are provided with the services and information they need to make an informed choice about their reproductive future.