Fertility-Sparing Treatment for Early-Stage Cervical, Ovarian, and Endometrial Malignancies

Approximately 21% of gynecologic malignancies are diagnosed in women younger than 40 years, raising the importance of future fertility in discussions of informed consent before cancer therapy. Fertility-preserving procedures in patients diagnosed with cancer remain relatively rare. In addition, the access to such procedures is impacted by geographic location, socioeconomic status, race, age, level of education, and insurance status. This Clinical Expert Series aims to discuss the ideal candidate for fertility-sparing treatment, review surgical and medical approaches to fertility sparing and their oncologic outcomes, discuss surveillance, and review pregnancy outcomes. The American Society of Clinical Oncology and National Comprehensive Cancer Network (NCCN) guidelines recommend fertility-sparing surgery be restricted to low-risk reproductive-aged patients diagnosed with cervical cancer. These patients are characterized as those with FIGO 2018 stage IA1 to IB2 and low-risk histology. Promising data are emerging on the potential for neoadjuvant chemotherapy followed by fertility-sparing surgery in premenopausal women with tumors measuring between 2 and 4 cm. Approximately 43% of patients with cervical cancer are diagnosed before age 45, and the risk of recurrence after primary treatment increases with large tumor size, nodal metastases, and certain histologic types. For ovarian cancer, NCCN guidelines advise consideration of conservation of at least the uterus and 1 or both ovaries for patients with early-stage disease and/or low-risk tumors who wish to preserve fertility. Approximately 12% of ovarian cancer patients will receive a diagnosis in their reproductive years. Although at odds with accurate surgical staging, the Society of Gynecologic Oncology and the NCCN describe an ideal candidate for endometrial cancer fertility-sparing treatment as 1 strongly desiring fertility, with a well-differentiated (grade 1) tumor, no evidence of myometrial invasion (stage 1A), no contraindications for medical management, and accepting the risks of not having standard of care treatment. Approximately 6% of endometrial cancer patients will receive a diagnosis before age 45. Data on pregnancy rates and outcomes after fertility-sparing procedures remain limited. Given limitations in data, informed consent discussions should include discussion of expectations and communication surrounding intraoperative findings that may require changes to initial treatment plans resulting in infertility. Analysis of pregnancy outcomes and live-birth rate can be made more difficult in this patient population given the clinical reasons why a patient opting for fertility-sparing surgery would not attempt to conceive later, including disease recurrence. The majority of reproductive-age women with early-stage cervical cancer can expect to have a live birth in the future, although there is increased risk of preterm labor and birth. The majority of reproductive-age women with germ cell ovarian tumors that were treated with chemotherapy in addition to fertility-sparing treatment can conceive spontaneously; however, the data are more limited regarding obstetric outcomes. Reproductive-aged women treated for endometrial cancer who respond to hormonal therapy often require fertility services to achieve pregnancy. Shared decision making regarding fertility-sparing medical and surgical therapy may give appropriate patients the opportunity to go through with their family planning goals without compromising long-term oncologic outcomes.

Automated summary

Approximately 21% of gynecologic malignancies are diagnosed in women younger than 40 years, highlighting the importance of discussing future fertility before cancer therapy, although fertility-preserving procedures in cancer patients are relatively uncommon. Access to such procedures is influenced by various factors. Current guidelines provide specific recommendations for fertility-sparing treatment for different types of gynecologic cancers.