Speaker: Younger patients with cancer deserve prompt fertility preservation counseling

Young patients with cancer preparing to undergo treatment that may impair reproductive function should receive prompt counseling on fertility preservation options and referral to specialists, according to Douglas B. Fair, MD, MS.

“Future family building is extremely important to our patients,” Fair, director of the sarcoma and musculoskeletal tumor program at Primary Children’s Hospital and medical director of the survivorship program at Huntsman Cancer Institute of University of Utah, said during a presentation at the NCCN 2021 Virtual Annual Conference. “In fact, research tells us that even patients who choose not to pursue fertility preservation, but who at least have a quality discussion about their options, report less regret and better psychological outcomes in survivorship and rate higher quality of oncology care. Despite there being barriers with basic knowledge, we can vastly improve care for these patients by discussing their risk for infertility and the options available to them.”

Recognize barriers 

Survivors of pediatric cancer could face a myriad of immediate and delayed adverse effects from treatment, including infertility.

“The good news is that while cancer survival has increased, there have also been incredible advances in fertility preservation, which our patients with cancer can greatly benefit from,” Fair said. “Our job as oncologists in serving our patients best is to know about fertility preservation options, educate our patients on fertility preservation and, when appropriate, refer them to a reproductive specialist. All of this should be done before starting cancer treatment.”

It is first imperative to recognize the barriers to fertility preservation among adolescents and young adults with cancer, Fair added.

“This includes a lack of adequate knowledge among health care providers — oncologists are not discussing fertility preservation nearly enough,” he said.

According to Fair, the four main barriers to fertility preservation are provider education, including disclosure of risks and discussion of options; timely referrals to reproductive specialists; geographic availability of services; and financial barriers, including high costs and lack of insurance coverage. 

“Fertility preservation for most patients with cancer is not covered by insurance,” Fair said. “Although it is not our job as physicians to solve financial problems, it is important that we understand that few insurance providers cover fertility preservation, making this one of the biggest barriers to fertility preservation for our patients. The good news is that the issue around lack of insurance coverage is gaining a lot of positive momentum and change is happening. Physicians should look into any changes in this area that are happening in the state they practice in.” 

Risk assessment

The data on true infertility risks associated with certain treatments is incredibly hard, if not impossible, to obtain for a variety of reasons, Fair said. 

“For one, we do not have perfect laboratory or clinical surrogates for fertility. Two, the outcome of interest — desired live births — occurs years after finishing therapy, so studying patients that far after therapy is challenging. Lastly, there are many additional factors that play into how and when a couple may want to attempt to have children, not to mention the other critical variable in this equation — the fertility of the survivor’s partner.”

Despite these challenges, he added, oncofertility specialists have created an imperfect risk stratification system.

“Meacham and colleagues of the Oncofertility Consortium created a risk assessment tool for men and women survivors of pediatric cancer. It is an important and easy tool to use, but is also imperfect as it lacks ideal data,” Fair said. “However, performing an imperfect risk assessment is better than not doing one at all. Not to mention, when communicating with a reproductive specialist, they will likely need help in risk assessment. Although they may be experts in performing fertility preservation, they may not be aware of the nuances and risk stratification for [patients with cancer] based on therapy exposure.”

Available strategies

Fair discussed current available strategies for fertility preservation among female and male patients with cancer.

Available methods for females include:

• embryo cryopreservation — post-pubertal only;
• oocyte cryopreservation — post-pubertal only;
• ovarian tissue cryopreservation — both pre- and post-pubertal; and
• ovarian transposition — both pre- and post-pubertal.

“It also is important to note that GnRH agonists are not a fertility preservation therapy. Given the evidence of efficacy, GnRH agonists may be offered to [patients with breast cancer] to reduce the risk for premature ovarian insufficiency but should not be used in place of other infertility preservation alternatives,” Fair said. 

He added that vast improvements in oocyte cryopreservation and thawing are an exciting development of the last decade. 

“In the past, embryos were more successful than oocytes, but due to a change in technique in freezing embryos, the success rate of oocyte preservation is now on par with embryos,” he said. “This is a game-changer, because now women with or without a partner can choose to freeze their eggs with confidence.”

Fertility preservation strategies available for males include:

• sperm banking — post-pubertal only;
• testicular sperm extraction — post-pubertal only;
• testicular tissue cryopreservation — both pre- and post-pubertal; and
• testicular shielding from radiation — both pre- and post-pubertal.

Testicular tissue cryopreservation for prepubertal males is considered experimental and should be conducted under research protocols, Fair said, adding that the most cost-effective and accessible option for men is sperm banking. 

“Must-read resources include the 2019 American Society for Reproductive Medicine’s report on fertility preservation and the Recommendations for Fertility Preservation in Child and Young Adult Cancer by Mulder and colleagues published in The Lancet Oncology. Just like Meacham’s work, these are high-yielding practical manuscripts,” Fair said. “Remember, our patients want to have the discussion about fertility preservation regardless of whether or not they see a reproductive specialist, and we do not have to be an expert in this field to provide top-level care. There are many fertility preservation options available today for both males and females.” 

References:

Fair D. Advances in oncofertility: Fertility preservation options for adolescents and young adults with cancer. Presented at: NCCN 2021 Virtual Annual Conference; March 18-20, 2021.
Meacham LR, et al. J Adolesc Young Adult Oncol. 2020;doi:10.1089/jayao.2020.0012.
MulderRL,et al. Lancet Oncol. 2021;doi:10.1016/S1470-2045(20)30582-9.
MulderRL, et al. Lancet Oncol. 2021;doi:10.1016/S1470-2045(20)30594-5.
Mulder RL, et al. Lancet Oncol. 2021;doi:10.1016/S1470-2045(20)30595-7.
Practice Committee of the American Society for Reproductive Medicine. Fertil Steril. 2019;doi:10.1016/j.fertnstert.2019.09.013.

Source: Healio By Jennifer Southall

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