Cervical cancer remains one of the most common gynecological malignancies and the second most common cancer among women in India, with over 95,000 newly diagnosed cases and over 60,000 deaths each year.
The common age group affected by cervical cancer is in the reproductive age range of 35 to 44 years, with around 15% of diagnoses occurring in women over 60. With regular and intensive screening programs, cervical cancer can be diagnosed at an early stage. The high global mortality rate could be significantly reduced through a comprehensive approach including prevention, early diagnosis, effective screening, and appropriate treatment.
Cervical Cancer Staging
The stage of cancer indicates how far it has spread in the body and helps doctors determine the complexity of the condition and suitable treatment options.
After diagnosis, cervical cancer staging is determined by:
- Understanding how far the cancer has spread within the cervix.
- Determining if the cancer has spread to nearby lymph nodes or other nearby or distant organs.
The FIGO (International Federation of Gynecology and Obstetrics) staging system is commonly used for cancers of the female reproductive system, including cervical cancer.
Treatment for Cervical Cancer
The main treatment modalities for cervical cancer include:
- Early stages (1A1 to 1B1): Surgery is the primary treatment.
- Stages 1B2 to IVA: Radiation therapy combined with concurrent chemotherapy, followed by intracavitary brachytherapy.
- Metastatic cases: Chemotherapy is considered.
Fertility Sparing in Patients with Cervical Cancer
Since cervical cancer often affects women in their reproductive years, fertility preservation is a crucial concern. Unfortunately, standard treatments like radical hysterectomy or radiotherapy often result in infertility due to removal of the uterus or damage to ovarian function.
Due to limited healthcare access, socioeconomic factors, and lack of screening—especially in rural areas—many patients are diagnosed at advanced stages, reducing fertility preservation options.
Fertility-sparing options are generally limited to early-stage cancers: IA1, IA2, IB1, and IB2.
Selection Criteria for Fertility-Sparing Surgery
Potential candidates should be:
- Under 40 years of age.
- Diagnosed with stage IA1, IA2, IB1, or IB2 (confirmed via MRI or PET-CT scan).
Cone Biopsy or LLETZ
This procedure involves removing a cone-shaped piece of abnormal cervical tissue. It is suitable only for very early-stage cancer (stage IA1). Healing typically takes 4 to 6 weeks.
Radical Trachelectomy
In this surgery, the entire cervix, parametrial tissue, and upper part of the vagina are removed. A permanent suture is placed around the internal cervical os to keep it closed.
Women are usually advised to wait 6 to 12 months after either procedure before attempting conception to allow full tissue healing.
There is an increased risk of premature birth or low birth weight, depending on how much cervical tissue is removed. Due to the permanent suture, delivery must be via cesarean section. While successful pregnancies are possible, there remains a risk of miscarriage or preterm labor.
Pregnancy Options After Radical Hysterectomy or Radiation Therapy
Treatments like radical hysterectomy or radiotherapy typically result in infertility due to removal or damage to the uterus and ovaries.
However, assisted reproductive technologies offer hope for biologically related children:
Embryo Cryopreservation
This long-established method involves stimulating the ovaries to produce eggs, retrieving them, fertilizing with partner or donor sperm, and freezing the resulting embryos for future use.
Limitations:
- Requires delaying cancer treatment by several weeks.
- Needs sperm from a partner or donor.
- Not feasible for all patients.
Oocyte Cryopreservation
Freezing unfertilized eggs before treatment. This option is ideal for women without a partner.
Ovarian Cryopreservation
Still under investigation. Involves freezing ovarian tissue for later transplantation. Not yet widely available.
Gestational Surrogacy
Since the uterus may be removed or damaged, a gestational carrier (surrogate) is required to carry the pregnancy using the patient’s embryos or eggs.
Ovarian Transposition
Before radiotherapy, the ovaries can be surgically moved out of the radiation field (via laparoscopic surgery) to preserve ovarian function and prevent early menopause.