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UMC physician saving cancer victims' fertility



Photos by Chris Richards / Staff

"I was so grateful": Alexandra Orton puts daughter Hannah down for a nap. Hannah was born 16 months after Orton's UMC trachelectomy.



By Carla McClain  ARIZONA DAILY STAR  February 1, 2004
What took the young woman's breath away was not so much the devastating news that she had cancer, but that it meant she would never again bear a child.
"When the doctor told me that, I just remember my face turning very warm, and I was close to tears. I was so upset, so discouraged," said Alexandra Orton, 31, who badly wanted to have a child, but faced treatment for cervical cancer that would leave her barren.
"I knew it was impossible, but I went home and prayed - just prayed that somehow, some way I could have another baby."
Against the longest of odds, Orton's prayer was answered.
Today, she holds her 3-month-old miracle-baby Hannah in her arms, born 16 months after Orton underwent an extremely rare surgery at University Medical Center that removed her cancer - but saved her fertility.
Though fewer than 300 of these prodecures have been performed worldwide at only a handful of medical centers, the procedure - known as a trachelectomy - is being done by Dr. Kenneth Hatch, UMC's chief of obstetrics/gynecology, and the only physician in Arizona trained to do it.
Instead of the standard operation for early stage cervical cancer - a full hysterectomy removing the cervix (the mouth of the uterus), the upper uterus, lymph nodes and sometimes the ovaries - a trachelectomy takes out only the cervix and lymph nodes. The upper part of the uterus is left intact in the body, so a baby can be conceived and carried.
Surgically complicated
Perhaps surprisingly, the three-hour surgery to do that is far more difficult than taking out the whole works - one of the reasons so few surgeons have attempted it.
There is greater risk of injuring the urinary tract, leaving a leaky bladder. Also, it is more difficult to reach the pelvic lymph nodes if the uterus is not removed.
"It is surgically complicated, which is why it is not done everywhere," said Hatch, who has done 14 trachelectomies in Tucson, with three of those women - including Orton - so far going on to deliver babies.
"But with great outcomes like we had with Alexandra, I want to be able to offer this to the right patients for it. It has worked out really, really well for her."
At 31, wanting to have a child, and with a small, early stage cancer, Orton was the perfect candidate for a trachelectomy. Not all cervical cancer patients are.
"If the cancer is too big - greater than 1 1/2 inches - we go to a full hysterectomy," said Hatch. "We don't take any chances with that. We select these patients carefully. It is better to have a live woman than a baby with a dead mother."
What doctors worry about when they do not remove the upper uterus is a higher risk of recurring cancer, because the uterus may contain cancer cells from the cervix.
But so far, that has not happened. In fact, after about a decade of worldwide experience with trachelectomies, the recurrence rates are lower - about 3 percent - than with full hysterectomy, with a 5 percent recurrence.
"That is because the cancers are smaller to begin with," said Hatch. "So it turns out to be as safe as a hysterectomy, if not safer."
Moving past cancer
Although the rates of cervical cancer have dropped dramatically in the past three decades - by 70 percent - because of the widespread use of the Pap smear test to screen for it, it still strikes some 12,400 American women every year, killing about 5,000. In Pima County last year, nearly 70 women were diagnosed with this cancer, with more than 20 deaths.
Orton, for example, has always had annual Pap tests. In the spring of 2002, however, not only did the test come back abnormal, follow-up tests revealed a rapidly growing, full-fledged cancer.
But she is among the 50 percent of all cervical-cancer victims whose disease is caught early enough to be cured with surgery alone. And fortunately, she is one of the 10 percent with small enough cancers to safely undergo trachelectomy, giving them the chance to have babies.
But even with the uterus saved, a trachelectomy does not guarantee fertility. Surgery can cause scarring, interfering with conception and pregnancy, Hatch said.
"We tell these women they have a 30 to 50 percent chance of fertility, compared to about 80 percent in the overall population," he said.
After discovering Hatch, and undergoing her trachelectomy in the summer of 2002, it took Orton about eight months to get pregnant.
"I was so grateful, so thankful, so overjoyed. My prayers had been answered," she said. She and her husband had always wanted a second child, to join their 5-year old son, Joshua. "The relief just floods you. I didn't realize how scared I was, that I might never have a child again, until I knew I would.
"I'm just so positive about this experience, I want to make sure other women know this can be done. I had no clue it was an option, and that it was available here, so I went through a lot of stress."
But Orton did experience one of the major risks of childbirth after trachelectomy - a premature baby. Hannah, born in October, was about six weeks early, and spent her first hours on a breathing machine and her first month dependent on oxygen.
It is the cervix, at the bottom of the uterus, that holds the baby in during pregnancy. When it is removed, the uterus is stitched, but those stitches loosen during the stress of pregnancy, resulting in a fairly high rate of miscarriages and premature births - about 25 percent to 30 percent.
For that reason, all post-trachelectomy pregnancies are considered high risk, and babies are delivered by Caesarean section.
Born at more than 5 pounds, Hannah was a good-sized preemie, and has fully recovered from her too-early start, her mother said.
Creating an option
Since the first trachelectomy was done in the early 1990s in France, about 300 have been performed worldwide. Of those, 85 women have gone on to have 123 babies.
The University of Toronto last year concluded the largest study of pregnancies after trachelectomy. The study of 80 women found that after the procedure, 39 attempted to conceive, 18 had viable pregnancies and four miscarried. Twelve women delivered full-term babies and six delivered prematurely.
"These findings provide encouragement for cervical-cancer patients who hope to maintain their fertility," said the University of Toronto's Dr. Allan Covens, who presented the results at the recent annual meeting of the Society of Gynecologic Oncologists in New Orleans.
However, for many physicians in this specialty the surgery is still considered experimental, with only a few hundred patients so far to study for definitive outcomes.
"I think that's still true for most doctors, and it may be why not very many are doing it," said Tucson gynecologist Dr. Edward Miller. "But Kenneth Hatch is a world-class doctor and a top-notch researcher. He is certainly not the lunatic fringe.
"So I think as long as the cancer is confirmed in a very early stage, this is a reasonable option, because as far as we know now, the recurrence rates are no worse. But it's an option everyone is still studying."
Tucson fertility specialist Dr. Scot Hutchison is delighted to have trachelectomy available in Tucson, and is now preparing to help a Tucson woman who had it become pregnant.
"I think it's great. What these women had to do before this was recover their eggs, then use a surrogate mother. That's really expensive, up to $20,000, and no insurance covers it," he said. As cancer treatment, trachelectomy is covered by insurance.
With women often delaying childbirth now, the chance that cervical cancer could threaten that choice is much greater than in past years, he noted.
"These women now have a chance," Hutchison said. "This is the thing to do if they want to have kids, absolutely."

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