Cancer and contraception


Guideline Developer(s)

Society of Family Planning

Date Released

2012 Sep

Full Text Guideline

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Appropriate contraception for women who have been diagnosed with cancer
  • Although ovarian and endometrial cancers are hormonally mediated, the use of progestin-containing contraceptives (whether or not they contain estrogen) actually reduces the risk of these cancers.
  • Use of either the copper T380A intrauterine device (IUD) or the levonorgestrel intrauterine system (IUS) appears to reduce risk of endometrial cancer.
Potential Harms

Not stated

Rating Scheme for the Strength of the Recommendations

Levels of Recommendations

Level A: Recommendations are based on good and consistent scientific evidence.

Level B: Recommendations are based on limited or inconsistent scientific evidence.

Level C: Recommendations are based primarily on consensus and expert opinion.

Qualifying Statements

Qualifying Statements

This evidence-based review should help to guide clinicians providing this care, but it is not intended to dictate clinical care.

Methodology

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

PubMed and Google Scholar were searched in English for publications regarding contraception and cancer between 1981 and 2011. In addition, reference lists of identified manuscripts were searched for any additional studies that might be relevant. The authors also searched the Cochrane Clinical Register of Controlled Trials and clinicaltrials.gov, although randomized trials in this area are challenging to perform.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force:

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Methods Used to Analyze the Evidence

Review
Review of Published Meta-Analyses

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Not stated

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Internal Peer Review

Description of Method of Guideline Validation

These guidelines were reviewed and approved by the Board of Directors of the Society of Family Planning.

Identifying Information and Availability

Bibliographic Source(s)

Patel A, Schwarz EB, Society of Family Planning. Cancer and contraception. Contraception. 2012 Sep;86(3):191-8. [111 references] PubMed

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

The Society of Family Planning receives no direct support from pharmaceutical companies or other industries.

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Authors: Ashlesha Patel, MD, MPH; E. Bimla Schwarz, MD, MS, with assistance from Mini Sreedevi, MD, and Alicia Roston, MPH

Financial Disclosures/Conflicts of Interest

Ashlesha Patel, MD, MPH; Mini Sreedevi, MD; E. Bimla Schwarz, MD, MS; and Alicia Roston, MPH, report no significant relationship with industry relative to these guidelines.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Society of Family Planning Web site.

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on January 13, 2014. The information was verified by the guideline developer on February 10, 2014.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Scope

Disease/Condition(s)
  • Unintended pregnancy
  • Cancer (including breast cancer)
Guideline Category

Management
Prevention
Risk Assessment
Treatment

Clinical Specialty

Family Practice
Hematology
Internal Medicine
Obstetrics and Gynecology
Oncology
Preventive Medicine
Radiation Oncology

Intended Users

Advanced Practice Nurses
Health Care Providers
Physician Assistants
Physicians
Public Health Departments

Guideline Objective(s)

To review the medical literature regarding cancer and contraception

Target Population

Reproductive-aged women who need contraception after diagnosis of or treatment for cancer

Interventions and Practices Considered

Contraceptive methods, including:

  • Combined hormonal contraceptive methods (containing estrogen and progestin)
  • Copper T380A intrauterine device (IUD)
  • Levonorgestrel-containing intrauterine system (IUS)
  • Progestin-only contraception
  • Emergency contraceptive pills
Major Outcomes Considered
  • Risk of cancer recurrence
  • Risk of breast cancer
  • Risk of venous thromboembolism (VTE)
  • Risk of anemia
  • Risk of osteoporosis and fractures
  • Risk of infection with intrauterine devices (IUDs)
  • Future fertility
  • Mortality
  • Quality of life
  • Survival rates

Recommendations

Major Recommendations

The levels of the recommendations (A, B, C) are defined at the end of the "Major Recommendations" field.

Conclusions and Recommendations

All women seeking contraception should be provided with information about the relative effectiveness of available contraceptives with typical use. For most women who are being treated for cancer, highly effective reversible contraceptives, such as intrauterine or implantable contraceptives, are recommended. For women who have been cancer-free for at least 6 months and have no history of hormonally mediated cancers, chest wall irradiation, anemia, osteoporosis or venous thromboembolism (VTE), the use of any method of contraception can be recommended.

The following recommendations are based on good and consistent scientific evidence (Level A):

  • Combined hormonal contraceptive methods (containing estrogen and progestin) should be avoided by women with active cancer or who have been treated for cancer in the last 6 months due to the increased risk of VTE.
  • For women with a history of breast cancer, the copper T380A intrauterine device (IUD), a highly effective, hormone-free method, is recommended.
  • For women with anemia, the levonorgestrel-containing intrauterine system (IUS) may be used to minimize menstrual blood loss.

The following recommendations are based on limited or inconsistent scientific evidence (Level B):

  • For women with breast cancer treated with tamoxifen, the levonorgestrel-containing IUS provides highly effective contraception and reduces tamoxifen-induced endometrial changes without increasing the risk of breast cancer recurrence.
  • For women with a history of chest wall irradiation, systemic estrogen and progestin should be avoided.
  • Women with osteopenia or osteoporosis should avoid injectable progestin-only contraceptives.
  • Estrogen-containing contraception may be beneficial to women with osteopenia or osteoporosis.
  • Women with immunosuppression may safely use intrauterine contraception.
  • Emergency contraceptive pills may be used by women at risk of breast cancer or breast cancer recurrence who decline emergency placement of a copper T380A IUD.

Definitions:

Levels of Recommendations

Level A: Recommendations are based on good and consistent scientific evidence.

Level B: Recommendations are based on limited or inconsistent scientific evidence.

Level C: Recommendations are based primarily on consensus and expert opinion.

Clinical Algorithm(s)

None provided

Contraindications

Contraindications

For women with breast cancer, exogenous estrogen and progestins are not recommended due to concerns that they may increase the risk of cancer recurrence.

See the "Major Recommendations" field for other contraceptive interventions that should be in specific cancer patient populations.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Living with Illness
Staying Healthy

IOM Domain

Effectiveness
Patient-centeredness
Safety

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