Decrease fertility in persons with CC

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• Fertility rates based on CD4 count but not cervical cancer disease state

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Gynecologic cancers in pregnancy: guidelines based on a third international consensus meeting. Amant et al. 2019. 30(10:1601-1612

• cervical incidence during pregnancy is 1.4-4.6 per 100,000, with variation "likely to reflect differences in underlying cervical incidence rates across population and screening programs"
• incidence rate calculated using data from papers studying persons in Australia, California, US, Italy, Swedish Multi-Generation Register and the National Cancer Register from 1963 to 2007 ... none in Africa or specific to populations with high HIV-prevalence
• some of these sources include treatment for cancer
• cervical cancer incidence during pregnancy will likely increase as women delay pregnancy and noninvasive prenatal testing is available
• uncertainty due to lack of data, often obstetrical and oncological registries are not linked, lack of info on miscarriage/termination of pregnancy
• cervical cancer incidence during pregnancy likely to be higher in settings with high HIV prevalence due to accelerated cancer onset

A few of the sources used to calculate the above incidence rate:

• S. Eibye, S.K. Kjær, L. Mellemkjær Incidence of pregnancy-associated cancer in Denmark, 1977-2006. Obstet Gynecol, 122 (3) (2013), pp. 608-617

• data from Denmark, 1977-2006

• define pregnancy-associated cancer as that diagnosed during pregnancy and up to 1 year after end of pregnancy

• incidence rate of CC during pregnancy: 4.0 (crude), 4.5 (age-standardized)

• incidence rate of CC during pregnancy with live birth: 3.8 (crude); 3.6 (age-standardized)

• Y.Y. Lee, C.L. Roberts, T. Dobbins, et al. Incidence and outcomes of pregnancy-associated cancer in Australia, 1994-2008: a population-based linkage study. BJOG, 119 (13) (2012), pp. 1572-1582

• perinatal death rates were similar among women with or without cancer, but poor data

• J.L. Dalrymple, W.M. Gilbert, G.S. Leiserowitz, et al. Pregnancy-associated cervical cancer: obstetric outcomes. J Matern Fetal Neonatal Med, 17 (4) (2005), pp. 269-276

• In the prenatal/delivery group, there were significantly higher rates of fetal deaths compared to non-cancer controls (OR: 5.5). Within the postpartum group, fetal death rates remained significantly higher (OR: 3.0). Neonatal and infant death rates in both groups were not increased.

Two parts to this question. In the case of HIV, fertility is reduced from the earliest asymptomatic stage of HIV infection resulting from both a reduced incidence of recognized pregnancy and increased fetal loss.

• decreased fertility due to non-viable pregnancy
• decreased fertility due to decreased sexual activity

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Sexual activity data describes women during treatment vs. before treatment with cervical cancer.

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Going to leave this as is for now because there is no data on sexual behavior change in women with cervical cancer before diagnosis.

The largest effects will be seen in women living with HIV who get cervical cancer sooner. We already decrease fertility with HIV and decreasing CD4 count.