Is it safe for patients in remission for Ewing sarcoma to use combination birth control, such as ethinyl estradiol and levonorgestrel?

Combination Birth Control for Patients in Remission from Ewing Sarcoma

Combination birth control methods containing ethinyl estradiol and levonorgestrel are safe and appropriate for patients in remission from Ewing sarcoma. 1

Safety Considerations for Cancer Survivors

• The National Comprehensive Cancer Network (NCCN) guidelines support the use of contraception for cancer survivors who have been free of cancer for at least 6 months and have no history of hormonally mediated cancers, chest radiation therapy, anemia, osteoporosis, or venous thromboembolism (VTE) 1
• For patients in remission from Ewing sarcoma specifically, there are no contraindications to using combination hormonal contraceptives as the disease is not hormonally mediated 1
• Ewing sarcoma is characterized by specific translocations involving EWS and ETS partner genes, not by hormonal influences, making hormonal contraception a safe option for these patients 2, 3

Contraceptive Options for Ewing Sarcoma Survivors

• Combined oral contraceptives (COCs) containing ethinyl estradiol and levonorgestrel are an effective option with a typical-use failure rate of 9% 1
• Many adolescent medicine providers recommend starting with a COC containing 30-35 μg of ethinyl estradiol and a progestin such as levonorgestrel or norgestimate 1
• Long-acting reversible contraception (LARC) methods such as intrauterine devices (IUDs) are also excellent options with higher adherence rates (86% vs. 55% for oral contraceptives) 1

Benefits of Combination Birth Control

• Combination hormonal contraceptives offer several non-contraceptive benefits that may be particularly valuable for cancer survivors, including:
  • Decreased menstrual cramping and blood loss 1
  • Improvement in acne 1
  • Protection against endometrial and ovarian cancers with use for more than 3 years 1
• Extended or continuous cycle regimens may be beneficial for patients with conditions such as anemia or severe dysmenorrhea 1

Special Considerations for Cancer Survivors

• Fertility preservation should be discussed with all patients before cancer treatment, as some therapies for Ewing sarcoma may affect fertility 1
• For patients who have undergone chemotherapy or radiation therapy, fertility status may be uncertain, making reliable contraception particularly important 1
• Contraception counseling should be initiated early, ideally before starting cancer therapy 1, 4

Potential Contraindications and Cautions

• Combined hormonal contraceptives should be avoided in patients with:
  • Active cancer or those treated for cancer in the past 6 months due to increased risk of VTE 1
  • History of VTE 1
  • Uncontrolled hypertension (systolic ≥160 mm Hg or diastolic ≥100 mm Hg) 1
  • Migraine with aura at any age 1
• For Ewing sarcoma survivors beyond 6 months post-treatment without these risk factors, combination birth control is appropriate 1

Clinical Algorithm for Contraceptive Selection in Ewing Sarcoma Survivors

1. Assess time since completion of cancer treatment (should be ≥6 months for hormonal methods) 1
2. Screen for contraindications to estrogen-containing contraceptives (history of VTE, uncontrolled hypertension, migraine with aura) 1
3. If no contraindications exist, combination methods containing ethinyl estradiol and levonorgestrel are appropriate 1
4. For patients with contraindications to estrogen, consider progestin-only methods or non-hormonal options such as copper IUDs 1
5. For patients desiring the highest efficacy, recommend LARC methods (IUDs or implants) 1

Combination birth control methods are safe, effective, and provide additional health benefits for patients in remission from Ewing sarcoma, making them an excellent contraceptive choice when no specific contraindications exist.