CERVICAL CANCER DURING PREGNANCY
Sarah D. McDonald, MD,' Wylam Faught, MD, FRCSC,2 Andree Gruslin, MD, FRCSC',3
I Department of Obstetrics, Gynecology and Newborn Care, University of Ottawa, Ottawa ON
2 Gyneoncologist and Chair, Department of Obstetrics and Gynecology, University of Alberta, Edmonton AB
J Assistant Professor, Division of Maternal Fetal Medicine, University of Ottawa, Ottawa ON
Abstract: Cervical cancer is one of the most devastating condi-
tions that can complicate a pregnancy. Stage for stage, treat-
ment for squamous cell cervical cancer is the same as that
given in the non-pregnant patient. Radical surgery is the treat-
ment of choice for the early stages of the disease. Although a
planned delay in therapy may be considered for up to 20
weeks, for stages IA and IB I, it should be implemented cau-
tiously and with the patient's full awareness of the risks. If
delay is considered for higher stages, the patient must be
aware of the paucity of data to support this plan. Chemo-
radiation is the standard treatment for advanced cancer of the
cervix. When acceptable fetal maturity has been reached, a
classical Caesarean section is usually performed prior to defin-
itive treatment.
Resume: Le cancer du col est I'une des complications les plus
devastatrices pouvant apparaitre pendant la grossesse. Le
traitement administre contre Ie cancer du col a cellules
squameuses, a chacun de ses stades, est Ie meme que pour les
patientes qui ne sont pas enceintes. La chirurgie radicale est
Ie traitement de preference aux stades precoces de la ma-
ladie. Bien que, pour les stades IA et IB I, on puisse envisager
la possibilite de retarder Ie traitement pour une periode allant
jusqu'a 20 semaines, cela doit se faire avec prudence et en
s'assurant que la patiente est pleinement consciente des
risques que cela com porte. Si on envisage un delai a des
stades plus avances, la patiente doit savoir qu'iI existe peu de
preuves scientifiques permettant de justifier ce choix. La
chimiotherapie par radiation est Ie traitement habituel pour
les cas de cancer du col avance. Quand Ie fretus a atteint une
maturite suffisante, on pratique generalement une cesarienne
normale avant de commencer I'administration d'un traitement
definitif.
J Obstet Gynaecol Can 2002;24(6):491-8.
KeyWords
Pregnancy, cervical carcinoma, surgery, radiation, chemotherapy
Competing interests: None declared.
Received on November 10, 2001
Revised and accepted on February 19, 2002
JOGC
INTRODUCTION
Contrary to popular belief, cancer complicates pregnancy more
frequently than appendicitis, thyrotoxicosis, and nephrolithia-
sis. 1 Cancer is the leading cause of death among women aged
35 to 54 years and the second most common cause among
women aged 15 to 34 years. 2 With the exception of breast can-
cer, which occurs in 113000 pregnancies, gynaecologic neo-
plasms constitute the most common cancers that complicate
pregnancy (see Table 1).3 Cervical cancer is the most common
of these, with an incidence of 1/2200 pregnancies. 4 This review
outlines the diagnosis and management of squamous cell cer-
vical cancer during pregnancy, in contrast to the older literature
term of "cervical cancer associated with pregnancy," which
included patients diagnosed up to one year postpartum.
SCREENING
Routine antenatal care presents an important opportuniry to
screen women for cervical cancer and its precursors. The
squamocolumnar junction is usually readily accessible due to the
natural eversion of the transformation zone under the influence
of high estrogen levels during pregnancy.s The use of a cyrobrush
is not contraindicated in pregnancy, however, endocervical cur-
rettage should be avoided as it is associated with increased bleed-
ing and the possibility of disruption of the amniotic membranes.
Abnormal cervical cytology complicates 5% of pregnan-
cies. 6 Twenty percent of Pap smears during pregnancy under-
estimate, and 24% overestimate, the final histopathologic
TABLE I
INCIDENCE OF CANCERS
DURING PREGNANCy3,4
Site Incidence
Cervical 1:2200
Breast 1:3000
Ovary 1:5000-25,000
Vulvar 1:8000
Vaginal 1:37,000
Leukemia 1:75,000
Colorectal I: 100,000
JUNE 2002
diagnosis,? which compares well with the 20-45%7 false neg-
ative rate in the non-pregnant population.
COLPOSCOPY AND BIOPSY
The management of an abnormal Pap smear during pregnan-
cy has evolved dramatically during the last three decades. Col-
poscopy combined with selective directed biopsy has largely
replaced cone biopsy and the associated significant morbidity.
Pregnancy-related physiological cervical changes can mimic
neoplastic changes and hence colposcopy should be performed
by an experienced colposcopist. Physiological changes during
pregnancy include increased vascularity and edema and hyper-
plasia of the endocervical glands, as well as eversion of the trans-
formation zone. 1
Colposcopy alone without biopsy frequently underestimates
the severity of the cervical lesion during pregnancy. 6 In a retro-
spective review from a tertiary care centre, 35% of women who
had carcinoma in situ (CIS) were judged by colposcopy to have
only mild to moderate changes. 6 Economos et aL reported from
their retrospective study of 612 pregnant women with abnormal
Pap smears, that 54% oflesions evaluated by colposcopists as
"normal" were actually CIN (cervical intraepithelial neoplasia)
I or II, and 14% oflesions called "low-grade" dysplasia were actu-
ally CIN III.8 Sugimori et aL9 found that 7% of patients with
micro invasive cancer had no colposcopic abnormality, and in
another study, 5 of9 patients with invasive cancer who were fol-
lowed colposcopically during the antepartum were not diagnosed
until the postpartum. 10
Colposcopically directed biopsy has been proven reliable
during pregnancy. A comparison of 117 pregnant women with
234 controls found that the reliability of biopsy was similar,
and colposcopy was rarely unsatisfactory in pregnant women. 1
Several large reviews have supported the safety of colpos-
copic biopsy in the pregnant population. A review of 1064
pregnant patients evaluated with colposcopic biopsy reported a
&lse negative rate of 0.5% and a complication rate of 0.6%.11 Two
other studies totalling 175 patients found no major morbidity
associated with colposcopically directed biopsy during
pregnancy. 6, 12
The management of abnormal Pap smears is outlined in
Figure 1. Women whose Pap smears demonstrate low-grade
squamous intraepitheliallesions (LGSIL) should be assessed

FIGURE I
MANAGEMENT OF THE ABNORMAL PAP SMEAR DURING PREGNANCY

LGSIL HGSIL

Once or twice duri>

antepartum ng ~ Colposcopy
/
<8-12
~ntepartum
weeks

directed biopsy

Unsatisfactory colposcopy,
suspected early invasion, or
adenocarcinoma in situ

Consider coin,
wedge, or cone
biopsy*

Repeat colposcopy
and biopsy 6 weeks
postpartum

LGSIL: Low-grade squamous intraepithelial lesion

HGSIL: High-grade squamous intraepithelial lesion
'Intervention will be influenced by patient's wishes regarding definitive therapy
with colposcopy (and directed biopsy as indicated) upon ini-
tial receipt of the Pap smear report. Reassessment may be con-
sidered during the early third trimester. Women whose Pap
smears demonstrate high-grade squamous intraepitheliallesions
(HGSIL) should be assessed with colposcopy (and directed
biopsy as indicated) upon receipt of the Pap smear report and
every eight to twelve weeks. Once invasion has been ruled out,
the natural history of cervical dysplasia permits delaying treat-
ment until postpartum. 6 It has been suggested that cone bi-
opsy should be performed in the event of an unsatisfactory
colposcopy,5 and suspected early invasion,5 or adenocarci-
noma in situ. However, should the patient, after having been
fully educated and counselled on the issues, choose to delay
treatment for invasive cervical cancer under all circumstances,
cone biopsy may be avoided until her fetus reaches maturity.
For many years it was believed that cervical dysplasia was
sloughed with the trauma of vaginal delivery. Disease persis-
tence following 88% of vaginal deliveries effectively refutes this
notion. 6 Because rates of regression are unclear during preg-
nancy, it is mandatory that all pregnant women with any
degree of dysplasia have a repeat Pap smear and colposcopy
6 to 12 weeks after delivery. I
CONE BIOPSY OF THE CERVIX
Cone biopsy (conization) may be required for diagnosis of inva-
sive cancer during pregnancy. 13 In the non-pregnant popula-
tion, the occurrence of positive margins varies greatly by series
(7.8%_31.8%),14-16 with 14.5%-38%15,17 of these having
residual lesions on retesting. 15-18 While an association seems to
exist between conization in the non-pregnant state and preterm
delivery in a subsequent pregnancy, it is difficult to quantif}r.l
Hence, follow-up colposcopy and appropriate biopsies during
the postpartum are critical. 19
Risks associated with cone biopsy include an abortion rate
ranging from 0_26.7%20,21 when performed during the first
trimester and a perinatal loss of apptoximately 3--6%.2l Coniza-
tion during pregnancy is associated with preterm delivery in as
many as 30.6% of cases. 22 Excessive bleeding, most common-
ly in the third trimester, occurs in 5-14%1 of cone biop-
sies performed during pregnancy, with an average blood loss
in one study of 428 mL. I
While an association seems to exist between conization in
the non-pregnant state and subsequent preterm delivery in a
subsequent pregnancy, it is difficult to quantif}r.1 Many stud-
ies fail to describe the amount of tissue removed at the opera-
tion and the technique that was employed. Furthermore, they
fail to control for other confounding factors known to be asso-
ciated with both cervical dysplasia and preterm delivery, such
as smoking, age at first intercourse, number of sexual partners,
and history of sexually transmitted disease. l After adjusting for
confounding factors, a recent retrospective population-based
JOGC.
cohort study found that women who had had a cone biopsy
for carcinoma in situ were more likely to deliver prematurely
in their subsequent pregnancy, with an odds ratio of 1.6 (95%
CI 1.2-2.0).23 In a case-control study, which matched for risk
factors for preterm delivery, women with a cone height of at
least 10 mm had a higher rate of preterm delivery (OR 11.1)
than those with a height less than 10 mm. 24
The significant morbidity associated with cone biopsy has
prompted the development of alternative biopsy techniques.
Both wedge biopsy for discrete lesions and coin bioPsT5 for ecto-
cervical lesions have been suggested, to avoid excessive trauma
to the endocervical canal and hence to attempt to decrease the
risk of both pregnancy loss and maternal blood loss. An uncon-
trolled trial of cone cerclage in 15 patients suggested a decrease
in hemorrhage. 26 In this series, vasopressin was injected prior to
the cone biopsy, a McDonald suture was placed immediately
after, and the vagina was packed overnight. There were no trans-
fusions, readmissions for bleeding, or abortions. Two patients
underwent spontaneous preterm delivery at 35 and 36 weeks,
respectively, neither of which was precipitous. Three other
patients had planned preterm deliveries, undergoing Caesarean
sections when cone biopsies diagnosed invasion.
The initial optimism that the loop electrosurgical excision
procedure (LEEP) would be a better alternative to cone biopsy
has not been sustained. 27 In a study of20 women at 8-34 weeks
gestational age undergoing LEEP, 14 had dysplasia on LEEP
specimen (6 were either normal or had cervicitis) and 8 of these
involved surgical margins. 27 Nine had residual dysplasia at three
months postpartum. Two patients required blood transfusions
and there was 1 unexplained intrauterine fetal demise (IUFD)
four weeks post-LEEP.
CERVICAL CANCER
The average age of pregnant women with cervical cancer is
31 years,28 compared with 51 years in non-pregnant women. 29
The reasons for the earlier age of development of cervical car-
cinoma in pregnant women are not yet completely delineated
but likely involve earlier exposure to risk factors, such as early
age at first intercourse and multiple sexual partners 30 and pos-
sibly the relative immune system suppression during pregnan-
cy. Ten to 15% of women diagnosed with cervical cancer are in
their childbearing years. 31 Approximately 1-3% of patients with
cervical cancer are diagnosed during pregnancy.28,32
The majority of patients with cervical cancer during preg-
nancy (50-70%)28,30,33 are asymptomatic. In the remainder, vagi-
nal bleeding is the most common symptom, followed by vaginal
discharge and pain.28 Hence, vaginal bleeding in a pregnant
patient should be investigated with a speculum examination of
the cervix and a Pap smear if one has not been recently obtained.
The histologic distribution of cervical cancer during preg-
nancy is similar to that in non-pregnant patients, with squamous
JUNE 2002
cell carcinoma representing 81-87%, adenocarcinoma 7-16%,
and others 4_5%.34-36
The frequency of diagnosis of cervical cancer is approxi-
mately equal among the three trimesters. A large American study
noted that 31 % of women were diagnosed in the first trimester,
34% in the second, and 35% in the third. 34 Of note was a trend
toward later diagnosis among non-insured patients. 34
Clinical stage is the most important prognostic factor in
cervical cancer. 37 ,38 In the above study, 83% of the women were
stage I (29% were stage IA and 54% IB). 34 Cancers more
advanced than stage IB were almost all diagnosed in the sec-
ond or third trimester. An increase in the percentage of cancers
being diagnosed as late stage disease (stages lIB to IVB), from
6.7% in 198434 to 15% in 1990, is disturbing.
No fetal or placental metastases have ever been reported
with cervical cancer. 33
TREATMENT OF CERVICAL CANCER
Stage for stage, the treatment of squamous cell cervical cancer
during pregnancy is the same as in the non-pregnant patient. 32
For stage IAI disease with no evidence of lymphatic or vascu-
lar space invasion, either a LEEP,39 a cone, or a simple hys-
terectomy is performed. 29 A cone biopsy or LEEP with negative
margins for stage IAI would effectively treat the disease,29 allow-
ing a term vaginal delivery with follow-up postpartum. For stage
FIGURE 2
PLANNED DELAY IN THERAPY OF CERVICAL CANCER DURING PREGNANCY
Cone biopsy:
STAGE IA2,IBI
STAGE IAI
~ ~
EXAM + COLPO EXAM + COLPO
Q 4-6 weeks Q 2-4 weeks
~ ~
TERM DELIVERY,
CONSIDER DELAY
Treat 6 weeks
IN TREATMENT
postpartum
Consider SERIAL
MRI q 3-4 weeks
Reprinted from Sood 28 with minor modifications, by permiSSion of the publishers,W. B. Saunders Company.
JOGC
IA2, a modified radical hysterectomy with lymphadenectomy
is usually performed. For stage !BllIA, a radical hysterectomy
with lymphadenectomy is usually preferred to radiation thera-
py in young women because it preserves sexual and ovarian
functions. 4o In addition, pregnancy-induced edema makes the
identification of tissue planes easier. 33,41,42 For bulky !BllIA dis-
ease, chemoradiation is generally preferred. For stage lIB or
higher, chemoradiation is recommended. 29
In early stage disease, at a gestational age less than 20 weeks,
the radical hysterectomy is usually done with the fetus in situ
to decrease blood loss. 1,28 Mter 20 weeks gestational age, the
uterus should be evacuated first, improving the operative expo-
sure for the hysterectomy.28 Depending on the gestational age,
either a high vertical hysterotomy or a classical Caesarean are
recommended to avoid extension into the cancer and a risk of
increased blood loss or dissemination of disease. 28 Recur-
rence of disease in abdominal wall incisions following low
transverse Caesarean sections has been reported. 43
COMPLICATIONS OF SURGERY
It is difficult to assess the true rate of complications in pregnant
patients undergoing radical surgery because many of the stud-
ies are of carcinoma of the cervix "associated" with pregnancy
and include patients up to 18 months postpartum. Further-
more, many studies lack a control group of non-pregnant
STAGE ~ IB2
I I
/ ~
$20 WEEKS >20 WEEKS
Deliver and treat Deliver and treat
within 4 weeks of
diagnosis
JUNE 2002
patients. 41 However, available data suggest that the radical
surgical management of cervical cancer has mortality and early
morbidity rates (mainly fever and lower urinary tract infections)
comparable to those for non-pregnant patients. 28 ,30,41 There
may be slight increases in operating time and blood loss,
although transfusion does not appear to be increased. 30,36 Venous
thromboembolism is the leading maternal cause of death44 and
consideration should be given to heparin prophylaxis.
PLANNED DELAY OF TREATMENT
Since 1966, the concept of delaying treatment for squamous cell
cervical cancer to await fetal maturity has emerged (Figure 2).
Although many reports 30 ,35,41,43,45-55 provide little evidence of
tumour progression during pregnancy, significant concerns
remain. First, the literature consists of a small number of patients,
approximately 34 women with stage IA, 58 with stage IB, and
7 with stage II. Second, the literature is clouded by variable def-
initions of "delay," ranging from 1 to 32 weeks, with the typical
interval being significantly less47 ,48 than the 16-20-week inter-
val proposed in some of the more aggressive reports. 45 Third, the
greatest concern is over the lack of adequate published follow-
up studies, with some patients followed for as little as 2 months
postpartum. 43 A retrospective review from 1980 to 1991 on
delayed therapy in 3 patients with stage IAI and 5 with stage IB
diseases reported them as tumour-free after a median follow-up
of only 23 months. 45 Another study on delayed therapy in 8
patients with stage IB cervical cancer reported them as disease-
free after a mean of only 37 months (range 13-68 months).49
While disease would most likely recur within three years of treat-
ment, it is a concern that results are being reported for patients
who have not received the conventional five-year follow-up. The
single case-control study of 11 patients, who delayed for a mean
of 16 weeks with follow-up ranging from 12 to 360 months
(mean of 148 months), concluded that for early stage I squa-
mous cell carcinoma, planned delay in therapy was safe with no
long-term adverse effects on maternal survival. 36
Particularly concerning are suggestions to delay treatment in
stage II cancer. 43 ,48,52 Although 7 patients with stage II had no
progression of disease during pregnancy,43,48,52 postpartum out-
comes were unspecified in 5 patients. The sixth patient, who
showed no evidence of disease after 11 years, had a "delay" of only
2 weeks. 48 The seventh patient, who received six cycles of plat-
inum-based chemotherapy while delaying therapy for 18 weeks,
experienced recurrent disease at five months postpartum and was
receiving salvage chemotherapy at last published follow-up.43
In summary, a delay of therapy for up to 20 weeks until
fetal maturity is attained does not seem to put the patient at
risk for tumour progression, but even for stage IA and non-
bulky stage IB 1 disease, the available outcome data are not
strong enough to warrant a blanket recommendation for this
management option. The patient must be made aware of the
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paucity of evidence supporting such a delay; the data are retro-
spective, and the outcomes remain unclear, given the short
duration of follow-up and the limited numbers.
CISPLATIN CHEMOTHERAPY AS PART
OF DELAY OF DEFINITIVE TREATMENT
Cisplatin neoadjuvant chemotherapy has been administered in
several case reports for patients with stage IB or higher diseases
who delayed treatment to await fetal maturity.32,56 Three cycles
of single-agent cisplatin chemotherapy for invasive cervical car-
cinoma at 22, 25, and 28 weeks, followed by Caesarean sec-
tionlradical hysterectomy and lymphadenectomy at 32 weeks,
resulted in a healthy infant weighing 2120 g.57 A patient with
stage IB disease, who received cisplatin and vincristine while her
treatment was delayed from 21 to 32 weeks, was disease-free at
two years of follow-up.43 A woman with stage IIA cervical can-
cer, who also received cisplatin and vincristine while her treat-
ment was delayed from 20 to 34 weeks, was found to have
recurrent tumour within five months of delivery.43 Both of these
patients experienced a sufficient reduction in tumour volume
to render radical hysterectomy feasible at the time of Caesar-
ean section. Chemotherapy should be timed to avoid a
hematopoietic nadir at delivery.
Fetal growth restriction and hearing loss have been report-
ed following cisplatin administration in the second and third
trimesters. 58 In a review of 10 pregnant women given multi-
agent chemotherapy for ovarian cancer, 2 infants were growth
restricted and 1 suffered moderate bilateral hearing loss. 58 How-
ever, no such effects were reported in two subsequent papers
describing neoadjuvant cisplatin-based multi-agent chemother-
apy for cervical (2 cases)43 and ovarian (3 cases)59 cancers. The
discrepancies may have been due to higher dosages or more
advanced disease in the first group. Because cisplatin is excret-
ed in breast milk, breastfeeding is contraindicated. 60
CHEMORADIATION
Chemoradiation is the standard treatment of stage IIB (or
higher) squamous cell cervical cancer. Weekly platinum-based
chemotherapy is paired with daily external beam radiation
(teletherapy) and internal beam radiation (brachytherapy) with
both intracavitary (tandem) and vaginal applicators (ovoids).
Radiation, with or without chemotherapy, is also employed as
adjuvant therapy following simple or radical hysterectomy in
high-risk situations, such as positive surgical margins, as well as
for palliation. 61
RADIATION
Teletherapy results in spontaneous abortion in the majority of
first trimester pregnancies within four to five weeks of initiation,
JUNE 2002
 TABLE 2
MANAGEMENT OF SQUAMOUS CELL CERVICAL CANCER DURING PREGNANCY
Stage Management Level of Evidence 66

LGSILlHGSIL Colposcopy and selected directed biopsy antepartum and 6 weeks postpartum. 11-2A
Given the risk of preterm delivery associated with more aggressive cone
biopsies, techniques aiming to remove the least amount of tissue possible for
appropriate diagnosis and treatment should be employed if a cone biopsy is
performed.

Stage I A I cancer Term delivery with Caesarean section for obstetric indications. III
(diagnosed on a cone
biopsy)

Stage IA2 cancer Delayed therapy is a treatment option, followed by Caesarean section and 11-2B
modified radical hysterectomy and lymphadenectomy.

Stage IB I cancer Delayed therapy is a treatment option, followed by Caesarean section or radical 11-2B
hysterectomy and lymphadenectomy.

Non-bulky stage Minimal delay, if any, then radical hysterectomy and lymphadenectomy. Bulky III
IB2111A cancer IB2/11A is probably best treated with chemoradiation.

Stage ~ liB cancer Minimal delay, if any, then chemoradiation. III

Neoadjuvant chemotherapy may be considered for any patient who refuses III
immediate treatment for advanced stage disease.

at doses of 30-50 G y35 and brachytherapy is given afterwards. !
Seventy percent of second trimester pregnancies will abort after
five to nine weeks of radiation. The remainder can be managed
with either a uterine curettage6! or a vertical hysterotomy! prior
to brachytherapy. When the fetus has reached acceptable matu-
rity, classical Caesarean section is usually performed prior to
definitive therapy.
MATERNAL COMPLICATIONS
OF RADIATION THERAPY
Recent studies suggest no increase in maternal radiation com-
plication rates among pregnant patients over non-pregnant
patients, reflecting the advent of newer radiation techniques and
the avoidance of combining surgical procedures with radiation. 6!
A retrospective case-control study comparing pregnant and non-
pregnant patients receiving radiation therapy for invasive cervi-
cal cancer found no significant differences in short-term
radiation-induced toxicity, such as diarrhea, weight loss, nausea,
and cystitis, nor in long-term complications including fistulae,
bowel obstruction, and necrosis. 35 Moreover, no statistically sig-
nificant differences in recurrence or survival rates were found. 35
FETAL COMPLICATIONS OF RADIATION THERAPY
There is a 40% risk of mental retardation when 1 Gy (100 rads)
is delivered between 8 and 15 weeks' gestation. 6! After 20 to 25
weeks' gestation, radiation may damage the fetal bone marrow,
liver, and kidneys, and may increase risks of intrauterine growth
restriction, sterility, and malignancy.6! Doses less than 0.05 Gy
(5 rads), an amount usually sufficient for the pretreatment imag-
ing investigation of cervical cancer, have not been associated
with any fetal complications. 62
MODE OF DELIVERY
The optimal route for delivery in pregnant patients with early stage
squamous cell cervical cancer remains undetermined,34 although
Caesarean section is generally favoured.!,32,63 Maternal risks with
vaginal delivery include: cervical dystocia, hemorrhage, dissemi-
nation of malignancy into the lymphatic and vascular spaces, recur-
rence in episiotomy sites, and compromised survival. 32 In one
study with only 7 patients in the vaginal delivery group and 26 in
the Caesarean section group,34 a lower five-year cumulative sur-
vival was reported with vaginal delivery in comparison with Cae-
sarean section (55% vs. 75%, p-value not reported).34 A
multivariate analysis showed a possible trend (p = 0.08) toward
decreased survival after vaginal delivery.32 In a case-control study
of 56 women with cervical carcinoma during pregnancy (and 27
diagnosed within 6 months of delivery), a multivariate analysis
revealed that vaginal delivery was the most significant predictor of
recurrence (OR6.91, 95% CI 1.45-32.8), with 1 of7 (14%)
recurring post Caesarean section and 10 of 17 (59%) recurring
post vaginal delivery (p = 0.046).63 The authors concluded that
women who deliver vaginally have a significantly worse survival
than those who deliver by Caesarean section (p = 0.001), with a

JOGC JUNE 2002

particularly high risk of distant recurrence. 63 In contrast, a matched
cohort study of39 women with early pregnancy-associated cervi-
cal cancer (including disease diagnosed up to 6 months postpar-
tum) showed that mode of delivery had no effect on survival. 64
The authors noted that the relative risk of dying within five years
was 0.69 (0.25-1.89) for women who delivered abdominally (6
of28), versus those who delivered vaginally (5 of16,p= 0.72).64
PROGNOSIS
The prognosis for stage I squamous cell cervical carcinoma in
the pregnant patient is similar to that of non-pregnant women.
For example, one study with 49 patients found a five-year sur-
vival rate of 88%,34 which compares well with the generally
accepted rate of85% in the non-pregnant population. 65
The limited data available on stage II and higher diseases
suggest that pregnancy may adversely impact on outcome due
to understaging of the disease, a delay in diagnosis, or a delay
in treatment. 6! Seven patients with stage II disease had a five-
year survival rate of 54%,34 which compares unfavourably with
the generally accepted rate of 66% in non-pregnant patients. 65
Two patients with stage III disease and the one stage IV patient
all died within one year of treatment. 34
NONSQUAMOUS CELL CERVICAL CANCER
Seven to 16% of cervical cancers are nonsquamous,28,34 name-
Iyadenocarcinoma, glassy cell and adenosquamous cell carcino-
ma. The paucity of cases makes it impossible to make definitive
recommendations about their management. However, because
most nonsquamous varieties of cervical cancer are more aggres-
sive, definitive treatment should likely be instituted without sig-
nificant delays. A patient with a 6 cm stage IE adenocarcinoma
that was diagnosed at 32 weeks and who delayed treatment for
28 days developed recurrent disease at 24 months, and died 42
months after treatment. 47
CONCLUSION
The frequency with which cervical cancer complicates preg-
nancy must be borne in mind to facilitate its early detection and
effective management. Management is determined by the stage
of disease, gestational age, and patient choices regarding defin-
itive treatment. The risks and benefits of treatment options,
delay in therapy, and the necessity of good follow-up must be
thoroughly discussed with the patient.
The management of squamous cell cervical cancer during
pregnancy is summarized in Table 2. The establishment of
national and international databases of cervical carcinoma in
pregnant women would permit the tracking of outcomes that
could guide research and recommendations based on larger
numbers of patients.
JOGc.
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