Photo by Dean Forbes
It's a sad statement about a key cancer-survivorship issue: Little more than half of patients recall ever hearing anything from a health-care provider about their risks of infertility related to cancer treatment. Every day, patients are left unaware, uneducated and unknowingly infertile in their quest to rid their bodies of cancer.
Dr. Stephanie Lee, an oncologist in the Clinical Research Division, believes it doesn't have to be this way. As co-chair of an expert panel convened by the American Society of Clinical Oncology (ASCO), she helped develop guidelines for physicians and patients about fertility preservation for those undergoing cancer treatment. The group urged oncologists to address the possibility of infertility with patients of childbearing age. The earlier in the process that discussions, planning and referrals to reproductive specialists occur, the greater the options available.
Published online last month, the recommendations appear in the June 20 issue of the Journal of Clinical Oncology. The guidelines are the first in a series from ASCO to address post-cancer quality-of-life issues.
About 10 percent of the nation's 10 million cancer survivors are diagnosed during their reproductive years. Approximately 55,000 people under the age of 35 were diagnosed with cancer in 2005. Some, but not all, cancer treatments affect fertility, either permanently or temporarily.
"We wanted to bring this issue to light and to provide reasonable guidance to physicians who could incorporate this into their practice. We want to spare survivors from looking back and saying, 'I didn't realize I could have done something and now it's too late,'" said Lee, who worked on the guidelines while at Dana-Farber Cancer Institute. "It's just another potential complication of treatment, except maybe you could do something about this, if you want to. We shouldn't let that opportunity go."
The panel based their practice recommendations on a systematic review of 276 scientific articles published on related topics for about the last 20 years.
They noted that the impact of cancer treatment on fertility depends on several factors, including the type and dose of medication and how it's given, the dose of radiation and the area being irradiated, the type of cancer, the patient's age and gender, and whether the patient had fertility issues prior to cancer treatment. Generally, younger patients and those receiving lower drug doses have a better chance of regaining fertility.
Chemotherapy is designed to kill rapidly dividing cells throughout the body. Cancer cells divide rapidly, but so do sperm cells in men and the cells surrounding ripening eggs in women. Thus, most people experience at least temporary infertility during treatment. If chemotherapy or radiation harm the earliest sperm and egg cells, permanent infertility or premature menopause may result. The guidelines provide information about which chemotherapy agents may have the most impact on fertility.
Radiation therapy also destroys rapidly dividing cells in or around its target area. If the radiation field includes the brain, it may affect fertility by damaging areas that control hormone production. High-dose, full-body radiation or radiation aimed close to or at the pelvic region can also cause infertility by directly harming reproductive organs. The panel's recommendations include protective options like shields for covering reproductive parts, or a simple surgical procedure called ovarian transposition in which the ovaries are temporarily moved away from the uterus and held in place by a few stitches to shelter them from radiation.
Obviously, surgery to remove part or all of the reproductive system causes infertility, too. Experimental options exist, such as freezing and later reimplanting ovarian tissue after cancer treatment.
Lee said the number of patients rendered infertile from cancer treatment is likely underestimated. "Fertility is hard to measure until you try to conceive," she said. Surrogate markers — sperm count for men and whether women are menstruating — are not necessarily accurate measures. Having periods, for instance, does not guarantee fertility.
Dr. Julie Gralow, director of the Hutchinson Center/University of Washington's Breast Cancer Research Institute, said when she sees younger women with breast cancer — which isn't often — she always broaches the fertility topic. "We talk about the possibility of early menopause due to chemo in young women, and we ask about plans for future pregnancies," she said. "I have several patients who have had healthy children after chemo for breast cancer, and others have adopted."
The panel concluded the two methods of fertility preservation with the highest likelihood of success in cancer patients are embryo cryopreservation for women and sperm cryopreservation for men. The first involves the harvesting of eggs, followed by in-vitro fertilization and freezing of embryos for later use. Sperm cryopreservation, also known as sperm banking, is the freezing and storing of sperm for later use.
"For men, sperm banking is pretty easy. Oncologists can refer a man directly to a sperm bank," Lee said. "I wish there was something for women akin to the sperm banks; unfortunately, there's not. Female options get very, very complicated very quickly. Embryo cryopreservation is widely available, but most insurers do not cover it. A lot of people may not have the wherewithal to go that whole distance. Procedures for women are invasive and involve anesthesia and recovery time."
Despite the potential cost and effort, studies suggest that retaining fertility is a key goal of many patients. "It's an important issue for survivors, but many doctors will admit it's not one of their top concerns," Lee said. "We're not trying to be militant or invade the doctor-patient relationship. But it only takes five seconds to mention it and to let the patient know that if they want more information, there's more out there."
Lee, who joined the Center in January, researches stem-cell transplantation and blood malignancy outcomes. She also works on issues related to medical decision making and doctor-patient communication. Lee collaborates with Drs. Debra Friedman and Karen Syrjala for the new LIVESTRONG Survivorship Center of Excellence. Lee will also serve as an attending physician in Long-Term Follow-Up and inpatient services.
Amidst a career helping patients deal with dreaded diagnoses, Lee relished the hopeful optimism of the guidelines. "Having children is such a celebration of life," she said. "On one hand, you've just been diagnosed with cancer; on the other hand, you want to believe that you're going to survive, and maybe you'll be at a point someday where you can see a future with a family. What's more going back to normal than having a baby?"