How malignancy impacts contraception and sterilization choice

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According to a recent study published in Acta Obstetricia et Gynecologica Scandinavica, preferred contraception method or sterilization at delivery differs among patients with malignancy based on malignancy type.

Invasive cancer has a 5.8% chance of developing in women by age 49 years. These patients need family planning and specialized counseling, but certain common cancers in this age group are not addressed in guides on safe contraception methods for women presenting with various conditions.

From 2016 to 2019, 70 in 100,000 births in the United States were impacted by cancer, with similar or higher rates observed worldwide. As maternal age rises, experts have predicted these rates will increase.

There are multiple complications of administering cancer treatments before or during pregnancy, such as chemotherapy significantly increasing prematurity, growth restriction, and fetal anomaly when used during pregnancy. Individual disease factors will influence patient fertility goals, indicating a need for unique contraceptive counseling.

It is unclear how cancer impacts contraception choices during pregnancy. However, long-acting reversible contraception (LARC) and surgical sterilization have been seen as effective contraception methods. To determine the association between malignancy diagnosis and LARC and surgical sterilization use, investigators conducted a cross-sectional study.

Data on patients in the United States was obtained from the Healthcare Cost and Utilization Project's National Inpatient Sample. This data includes approximately 20% of discharges from participating hospitals across 48 states, representing over 97% of hospital discharge data in the United States.

Participants were aged 15 to 54 years and completed in-hospital vaginal and cesarean deliveries from January 2017 to December 2020. Malignancies evaluated included leukemia, breast cancer, lymphoma, cervical cancer, thyroid cancer, and melanoma. 

Malignancies were determined using definitions from the National Cancer Institute. Exclusion criteria included having a peripartum hysterectomy, dying during the index hospital admission for delivery, and having multiple outcome events.

LARC use or undergoing permanent surgical sterilization through bilateral salpingectomy or bilateral tubal ligation (BTL) at the index hospital admission were the primary outcomes of the study. Outcome measures included subdermal implant alone, intrauterine device (IUD) alone, BTL alone or bilateral salpingectomy alone, and no LARC or surgical sterilization.

Non-pregnancy covariates included patient race and ethnicity, age, medical comorbidity, primary payer, uterine factor, and medical comorbidity. Pregnancy covariates included fetal factors, chorioamnionitis, and maternal factors. Delivery covariates included hospital location and teaching status, gestational age, delivery route, and severe maternal morbidity.

There were 14,265,319 pregnant patients with no malignancy, 1605 with breast cancer, 1190 with leukemia, 1120 with lymphoma, 715 with thyroid cancer, 670 with cervical cancer, and 400 with melanoma included in the analysis. These patients were aged a mean 29, 34, 30, 31, 31, 31, and 32 years respectively.

A hypertensive disorder rate over 20% was seen in patients with lymphoma, leukemia, cervical cancer, and melanoma. Pregestational diabetes was seen most often in the thyroid cancer group, while gestational diabetes was most common in the thyroid cancer and lymphoma groups.

The cervical cancer and breast cancer groups had disproportionately high rates of preterm delivery compared to other groups. Cesarean delivery was seen in almost 2/3 of cervical cancer patients, which is significantly higher than other groups.

For patients with no malignancy, bilateral salpingectomy use was seen in 50.8 per 1000 deliveries, BTL use in 10.1 per 1000, IUD in 5.6 per 1000, and subdermal implant in 3.5 per 1000. Bilateral salpingectomy was more likely in patients with breast cancer than those with no malignancy, especially in White and younger patients and those with cesarean delivery.

Patients with leukemia were more likely to use a subdermal implant, while those with lymphoma were more likely to undergo a bilateral salpingectomy and those with thyroid cancer were more likely to undergo a BTL. LARC use was not seen in the cervical cancer or melanoma group, but bilateral salpingectomy and BTL were more common in these groups respectively.

These results indicated variation in contraception or sterilization choices based on malignancy. Investigators recommended practice guidelines be developed for contraception and sterilization decision making.

Reference

Harris CA, Mandelbaum RS, Rau AR, et al. Contraception and sterilization selection at delivery among pregnant patients with malignancy. Acta Obstet Gynecol Scand. 2023. doi:10.1111/aogs.14654