Opinion on Significance of Fertility Cancer Cure

Mengjiao Li^*
*Correspondence: Mengjiao Li, Center for Cancer Sciences, Nanyang, P.R. China, Email:

Introduction

Cure is undoubtedly the most important endpoint of cancer treatment. However, in recent years we have witnessed a trend toward the inclusion of quality of life into the management schema. For instance, more attention is now directed to preservation of organ function, such as limb-preserving surgery in melanoma. Attention is also directed to preservation of body image, as seen in breast cancer surgery, in which radical mastectomy, standard in the 1970s, is now largely replaced by simple mastectomy and consideration of lumpectomy, which in turn may be replaced in the future by excisional biopsy or cryotherapy. The concept of sentinel node mapping, initially developed in melanoma, is showing considerable promise in breast and vulvar cancer. In the future, the complete lymph node dissection may be replaced by the removal of the sentinel node only and thus avoid the side effects of the lymphadenectomy. Preservation of reproductive function is also an important issue in the management of several cancers, and over the past 30 years, conservative surgical management of gynaecologic malignancies has evolved to preserve fertility?

Description

In ovarian cancer treatment, the treatment of germ cell tumours is a good example of conservative management. These tumours are nearly always unilateral, usually occur in young women, and are extremely sensitive to chemotherapy, so only the affected adnexa are surgically removed and formal staging is completed. Even in advanced stage disease, conservative surgical management is recommended since successful pregnancies have occurred after surgery and chemotherapy. Similarly, in borderline epithelial ovarian tumours, only the affected adnexa is removed, without formal staging, in tumours clinically involving the ovary. Even in selected cases of early-stage epithelial ovarian cancer involving one adnexa, conservative surgical treatment can be offered. So the automatic total abdominal hysterectomy/bilateral salpingooophorectomy that many young women had in the past should not happen today in women desirous of fertility conservation. With regards to endometrial cancer treatment, there is an increasing literature supporting a trial of hormonal reversal of the neoplastic process in young women with stage I endometrial cancer who wish to preserve their fertility. Although controversial, the approach can be successful and several normal pregnancies have been reported so far.

Finally, in the last decade, the management of cervical cancer has been revolutionized by the combination of advanced laparoscopic techniques, which allow a complete pelvic and para-aortic lymph node dissection, and vaginal radical surgery, which has led to the innovative vaginal radical trachelectomy procedure. This new approach preserves the body of the uterus for future pregnancy, removing only the affected part of the cervix, along with the parametrium, in patients with small lesions and negative lymph nodes. Our group was the first to perform the procedure in North America and to report the first birth following a trachelectomy. Covens Toronto also reported good results at another Canadian centre. Data recently collected from four teams in the world totalling over 200 cases indicate a recurrence rate of less than 5% following this procedure, which is comparable to the results published with the standard radical hysterectomy (for comparable size lesions).

Conclusion

Although the rate of second trimester loss is higher than the overall obstetrics rates, over 90 pregnancies have been reported from the above teams, with the majority of babies born near term by elective Caesarean section. Fertility preservation in the context of cancer treatment has also become an important issue in other malignancies. For instance, as the longterm outcome of several childhood neoplasias has greatly improved, we are now seeing many cancer survivors who wish to have children. Yet many of these individuals did not realize what the long-term effect of their cancer treatment might be on their fertility. In a survey of cancer survivors at the Cleveland Clinic, it is reported that only 57% of patients received information regarding infertility and cancer [1-5].

In the United States, in the year 2000, it was estimated that between 180,000 and 200,000 survivors of childhood cancer were living, and by the year 2003, 1 in 1000 young adults will be survivors of childhood malignancy. Breast cancer is another malignancy where fertility preservation is a major issue. Indeed, as the prognosis of young women affected with breast cancer has improved, many of these women are contemplating ways to preserve their fertility against the effects of chemotherapy on their ovarian function. As the Clinical Practice Guidelines on Breast Cancer, Pregnancy, and Breast feeding published in this issue detail further, existing data do not suggest that pregnancy contributes.

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