Assessment at the end of treatment
We review patients 6 weeks after the completion of therapy. This is to do the following;
- Recheck the sites of original disease
- Doppler US of pelvis
- CXR or CT/MRI if abnormal at presentation
- To advise on the need for contraception for 12 months
- To advise re avoidance of excess sunlight exposure
- To outline the risk of relapse 2-3% overall following Methotrexate, 3% following EMA-CO or the chance of a new molar pregnancy (1:75)
All patients have routine marker follow-up for life.
Post treatment hCG follow-up
Year 1 2-weekly serum and urine hCG for 1-6 months
2 weekly urine hCG for 7-12 months
Year 2 4 weekly urine hCG
Year 3 8 weekly urine hCG
Year 4 3-monthly urine hCG
Year 5 4-monthly urine hCG
Year 6-life 6-monthly urine hCG
Risk of Relapse and late treatment complications
For the majority of patients with trophoblast disease who achieve a serological remission the outlook is very bright in terms of future risks of relapse, the possibility of further pregnancy and only modest long term health risks from the chemotherapy exposure. Once the hCG has fallen to normal, the risk of relapse is less than 5% for patients treated with the low risk protocols and only 3% for patients treated with the high risk EMA/CO regimen. Generally these recurrences occur within the first 12 months after treatment but may occur many years later. Even in this situation trophoblast disease retains the possibility of cure, with further chemotherapy and on occasion surgery to sites of disease often providing satisfactory outcomes.
Subsequent fertility after chemotherapy
Following either low or high risk chemotherapy treatment fertility is usually maintained and regular menstruation restarts 2-6 months after the end of chemotherapy. However chemotherapy treatment does bring the average age of the menopause forward, by approximately 1 year for those treated with methotrexate and 3 years for those treated with EMA/CO (Bower 1996).
We normally recommend that for 12 months after treatment that further pregnancy is avoided to minimise any teratogenic effects on developing oocytes and to minimise the possible confusion from the rising hCG between a new pregnancy and disease relapse. The modest impact on future fertility is reflected in the data demonstrating that 83% of women wishing to conceive after chemotherapy treatment have been able to have at least one live birth. Despite the frequent long exposure to cytotoxic chemotherapy in the high risk group there does not appear to be any significant increase in foetal abnormalities.
Many patients after experiencing one molar pregnancy and particularly those who require chemotherapy are anxious of the problem occurring again in any subsequent pregnancy. Whilst the data suggests that the risk of a further molar pregnancy is about 10 fold higher than in the normal population this only equates to an approximate 1 in 70 risk (Bagshawe 1986). This risk appears to be independent of chemotherapy exposure, being similar for those patients who required chemotherapy and those where the molar pregnancy was cured by evacuation alone.
Other Long term toxicities
With the prolonged follow-up data available from trophoblast disease patients treated from the 1970s onwards, it is clear that the exposure to combination chemotherapy carries some long-term health risks. Data from a study of 1377 patients treated at CXH show that those receiving combination chemotherapy have enhanced risks of developing a second malignancy. From our series of patients the overall relative risk (rr) was increased 1.5 fold and is particularly marked for myeloid leukaemia (rr 16.6), colon cancer (rr 4.6), breast cancer (rr 5.8) and melanoma (rr 3.41) malignancies (Rustin 1996). This database is being updated and as the cohorts of treated patients get older, these risks may further increase. In contrast the patients treated with single agent methotrexate do not appear to have increased risks of second malignancies.
This long-term health concern from the use of combination chemotherapy, reinforces the benefits from surveillance, allowing treatment to be commenced with single agent methotrexate whilst the patient falls within the low risk group.
Personal and Psychological issues
Despite the very high cure rates and the low long term toxicity from chemotherapy treatment, it is perhaps unsurprising that the diagnosis of a molar pregnancy and particularly treatment with chemotherapy can result in a number of psychological sequelae. The areas that lead to stress in the short term are the loss of the pregnancy, the impact of the ‘cancer’ diagnosis, the treatment process and the delay of future pregnancy. During chemotherapy treatment issues regarding potential side effects, emotional problems and fertility concerns are frequent. Other studies have shown that the concerns can remain for many years, with feelings regarding the wish for more children, a lack of control of fertility and an on-going mourning for the lost pregnancy still frequently reported 5-10 years after treatment (Wenzel 2002). Additionally issues regarding self-esteem, and loss of sexual desire can be troublesome for many years after treatment, however overall marital happiness does not seem to be impaired for trophoblast patients and their partners (Wenzel 1992). A number of surveys have demonstrated the wish of many patients to have more support through counselling and support both at diagnosis and continuing after treatment. Through the appointment of clinical nurse specialists and a counsellor we have enhanced the support we are routinely able to give.