Fertility preservation in young patients with cancer

Medical oncologist, Dr Ronwyn van Eeden, highlights the growing need for fertility preservation in young patients with cancer.

Of late, there has been an increase in the number of patients under the age of 49 being treated for cancer; it’s estimated that more than 20 000 are diagnosed annually. 

The efficacy of cancer treatments has also improved with time, and the possibility of long-term survival and cure is an attainable goal, along with good quality of life. Cancer treatments, however, can affect ovarian function and can cause abnormal semen parameters. It can also cause hormonal balances or functional changes to reproductive organs and impaired sexual function in both sexes, depending on the type of treatment given. 

Oncofertility is a complex balance between the oncologist and reproductive medicine specialist to provide effective cancer treatments while giving fertility preservation methods that don’t compromise the outcome of the patient at the same time. 

When to discuss fertility preservation

If you’re of childbearing age and not yet started or completed your family (or unsure or have ambivalent feelings about it), fertility options should always be discussed, irrespective of the type or stage of your cancer.

It’s seldom that initiating cancer treatments are so urgent that there isn’t enough time to explore fertility preservation options first. The type of cancer and aggressiveness always dictates the urgency of treatment, but your team of medical specialists will advise what is feasible. It’s important to weigh out benefits and risks of delaying treatment to pursue fertility treatments and if doing so will have any impact on the success of treatment. 

It’s imperative to have these discussions as early as possible before starting any treatments as even a single treatment can potentially increase the risk of genetic damage to sperm or eggs collected after initiation of therapy. 

Fertility preservation and the stress of the diagnosis can have a huge psychological impact, so it’s important that you seek psychosocial support. There is also consideration given to different cultural and religious beliefs that can be discussed with relevant leaders in your community. 

*Some guidelines recommend GnRH anagonists for patients with breast cancer, particularly hormone receptor negative breast cancer (higher rates of pregnancy in (21% vs 11%). But it is controversial as some guidelines do not recommend it at all therefore not all funders pay for it.

Treatment damage 

There is a large number of different cancer treatments that can have an impact on fertility, such as certain surgeries in the pelvic area, radiation to the pelvis, or to the brain (specifically to the pituitary gland which releases certain hormones responsible for endocrine and fertility function). Chemotherapies can either have a low, intermediate, or high risk for causing infertility. The risk differs according to the dose or regimen of chemotherapy and radiation given.

The risk to fertility of the newer treatments, such as immunotherapy, targeted therapies and antiangiogenic drugs, are largely unknown, but can potentially cause harm so it’s important to consider fertility options.

Pregnancy

The length of time to wait to fall pregnant after completing treatment isn’t clear. Some guidelines suggest waiting two years to detect early cancer recurrences, but the age of the patient and the type of cancer is taken into consideration.

In the era we live in, some women choose to start a family later in life, as education and career development can take preference and advanced age can pose its own risks as well. 

In hormone receptor positive breast cancer, adjuvant treatment can be given for five to 10 years after diagnosis, so for this type of cancer it may be advisable to wait five years at least. 

There is a lack of evidence to say if falling pregnant will increase your risk of recurrence. Some treatments impact the ability to fall pregnant as some therapies can induce menopause. Other problems that can be encountered are breastfeeding problems, depending on the type of surgery to the breasts, and that there may be a possible increased risk of developing obstetric and birth complications. It’s also recommended to have a “washout period” for treatments before falling pregnant as it can affect the foetus.

Genetic abnormality

In younger patients, the risk of genetic abnormality may be slightly higher. Unfortunately, in SA, genetic testing can take up to six to eight weeks to get results. So, for that reason cancer treatment and fertility management can’t wait to get those results first. 

Patients who carry BRCA mutations, for instance, may be offered bilateral prophylactic salpingo-oophorectomy (removal of healthy tubes and ovaries) as a risk reduction strategy for ovarian cancer but ideally only after child-bearing is complete.

Fertility techniques may be different in this population of patients and there is a consideration of a 50% risk of transmitting mutated genes to children. It’s imperative to have genetic counselling first before doing any of these tests. 

Big cost

The biggest challenge in SA is cost. Funders generally don’t cover costs of fertility preservation and it can be expensive. Oncofertility awareness for young patients is important so that in the future this can be covered for young oncology patients and also made available in state for those who can’t afford private medical care. 

References

Fertility preservations and post treatment pregnancies in post pubertal cancer patients: ESMO Clinical practice guidelines. Annals of Oncology (2020), Lambertini M et al.

Fertility preservation in patients with cancer: ASCO clinical practice guideline update. Journal of Clinical Oncology (2018) Oktay K et al.

American Cancer Society: www.cancer.org

Female fertility and cancer and Male Fertility and cancer.

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