Female reproductive health after childhood, adolescent, and young adult cancers: guidelines for the assessment and management of female reproductive complications

Recommendations for assessing ovarian health and fertility potential in survivors of childhood cancer

Most children diagnosed with cancer survive for many years after treatment. However, the fertility potential of these patients may suffer due to their oncologic therapies. Certain chemotherapies and radiation are more likely to be detrimental to gonadal function, and put patients at risk of acute or premature ovarian failure. Prepubertal cancer patients will need different follow-up and testing from their post-pubertal counterparts. This review will present evidence to help patients, family members and physicians determine who is most at risk of ovarian insufficiency and how to monitor childhood cancer survivors. It will discuss the impact of age at diagnosis and cancer therapies on reproductive outcomes, and guide caregivers and patients on monitoring gonadal function after therapy.

Caring for survivors of childhood cancer: it takes a village

PURPOSE OF REVIEW

Over 80% of children diagnosed with cancer are now cured. The burgeoning population of survivors of childhood cancer experiences high rates of morbidity and mortality due to 'late-effects' of treatment. These can be defined as any consequence of treatment that persists beyond or develops after the completion of cancer therapy. Awareness of late-effects is critically important for pediatricians and adult providers alike, as late-effects impact children in proximity to cancer treatment, as well as adults many decades removed. This review presents the importance of lifelong follow-up care for survivors, highlights existing screening guidelines, and reviews various models of survivor care.

RECENT FINDINGS

National and international guidelines have been developed to standardize screening for survivors, and multiple models of survivorship care exist. The optimal model likely depends on individual factors, including the survivor's needs and preferences, as well as local resources. Key strategies for the successful care of survivors include accurate risk-stratification for specific late-effects, individualized screening plans, education of survivors and professionals, clear communication between providers, and well coordinated transition of care across services.

SUMMARY

Early identification and management of late-effects are important for survivors of childhood cancer. Providers should be familiar with the risks for specific late-effects and have access to screening guidelines. The strengths and weaknesses of care models, along with individual circumstances, should be considered in designing the optimal approach to care for each survivor.

Fertility preservation in women with malignancies: the accuracy of antral follicle count collected randomly during the menstrual cycle in predicting the number of oocytes retrieved

PURPOSE

To evaluate the capacity of random antral follicle count (AFC), i.e., AFC recorded at any time during the menstrual cycle, to predict the number of retrieved mature oocytes in women with malignancies undergoing random start ovarian hyperstimulation METHODS: A consecutive series of 72 women with malignancies who underwent ovarian hyperstimulation aimed at egg freezing between July 2014 and December 2016 was retrospectively reviewed. A standardized random start protocol was used for all women. AFC and serum AMH were systematically assessed prior to initiating ovarian hyperstimulation. The main outcome was the retrieval of ≥ 10 mature oocytes. The accuracy of random AFC was tested with the c-statistics (area under the ROC curve).

RESULTS

For the whole cohort, the c-statistics for the prediction of ≥ 10 mature oocytes using AFC and serum AMH were similar. Specifically, the areas under the curve were 0.76 (95%CI 0.66-0.87) and 0.82 (95%CI 0.72-0.92), respectively (p = ns). Moreover, when considering the subgroup of women recruited after day 5 of the cycle (proper random start, n = 52), the areas under the curve did not also differ. Specifically, they resulted in 0.77 (95%CI 0.64-0.89) and 0.83 (95%CI 0.72-0.95), respectively (p = ns).

CONCLUSIONS

AFC collected at any time during the menstrual cycle can provide valuable information for the counseling of women with malignancies scheduled for oocyte cryopreservation. Its reliability appears to be non-inferior to that of serum AMH.

Fertility Among Female Survivors of Childhood, Adolescent, and Young Adult Cancer: Protocol for Two Pan-European Studies (PanCareLIFE)

Background

Despite a significant number of studies on female fertility following childhood, adolescent, and young adult (CAYA) cancer, studies establishing precise (dose-related) estimates of treatment-related risks are still scarce. Previous studies have been underpowered, did not include detailed treatment information, or were based on self-report only without any hormonal assessments. More precise assessments of who is at risk for sub- or infertility are needed.

Objective

The objective of our study is to describe the design and methods of 2 studies on female fertility (a cohort study and a nested case-control study) among female survivors of CAYA cancer performed within the European PanCareLIFE project.

Methods

For the cohort study, which aims to evaluate the overall risk of fertility impairment, as well as the risk for specific subgroups of female CAYA cancer survivors, 13 institutions from 9 countries provide data on fertility impairment. Survivors are defined as being fertility impaired if they meet at least one of 8 different criteria based on self-reported and hormonal data. For the nested case-control study, which aims to identify specific treatment-related risk factors associated with fertility impairment in addition to possible dose-response relationships, cases (fertility impaired survivors) are selected from the cohort study and matched to controls (survivors without fertility impairment) on a 1:2 basis.

Results

Of the 10,964 survivors invited for the cohort study, data are available from 6619 survivors, either questionnaire-based only (n=4979), hormonal-based only (n=72), or both (n=1568). For the nested case-control study, a total of 450 cases and 882 controls are identified.

Conclusions

Results of both PanCareLIFE fertility studies will provide detailed insight into the risk of fertility impairment following CAYA cancer and diagnostic- or treatment-related factors associated with an increased risk. This will help clinicians to adequately counsel both girls and young women, who are about to start anticancer treatment, as well as adult female CAYA cancer survivors, concerning future parenthood and to timely refer them for fertility preservation. Ultimately, we aim to empower patients and survivors and improve their quality of life.

Registered Report Identifier

RR1-10.2196/10824

Use of a Small Animal Radiation Research Platform (SARRP) facilitates analysis of systemic versus targeted radiation effects in the mouse ovary

BACKGROUND

Radiation exposure is known to cause accelerated aging and damage to the ovary, but the contribution of indirect versus direct effects is not well understood. We used the Small Animal Radiation Research Platform (SARRP) (Xstrahl) to deliver radiation to precise fields equivalent to clinical practice, allowing us to investigate systemic versus targeted damage in a structure as small as the mouse ovary. The X-ray dose was kept constant at 1 Gy, but the field varied. Mice either received total body irradiation (TBI), radiation targeted to both ovaries (T2), or radiation targeted to one ovary (left) while the contralateral ovary (right) was spared (T1). Sham mice, handled similarly to the other cohorts but not exposed to radiation, served as controls. Two weeks post-exposure, ovaries were harvested and analyzed histologically to identify and count follicles within each ovary.

RESULTS

Radiation significantly reduced primordial follicles in the TBI and T2 cohorts compared to the Sham cohort. There were no significant differences between these two irradiated groups. These findings suggest that at 1 Gy, the extent of damage to the ovary caused by radiation is similar despite the different delivery methods. When investigating the T1 cohort, targeted ovaries showed a significant decrease in primordial and growing follicles compared to non-targeted contralateral ovaries.

CONCLUSIONS

These findings demonstrate that the SARRP is an effective strategy for delivering precise ionizing radiation to small organs such as mouse ovaries. Such tools will facilitate identifying the relative risks to ovarian function associated with different radiation fields as well as screening the efficacy of emerging fertoprotective agents.

Hypothalamic-Pituitary and Growth Disorders in Survivors of Childhood Cancer: An Endocrine Society Clinical Practice Guideline

OBJECTIVE

To formulate clinical practice guidelines for the endocrine treatment of hypothalamic-pituitary and growth disorders in survivors of childhood cancer.

PARTICIPANTS

An Endocrine Society-appointed guideline writing committee of six medical experts and a methodologist.

CONCLUSIONS

Due to remarkable improvements in childhood cancer treatment and supportive care during the past several decades, 5-year survival rates for childhood cancer currently are >80%. However, by virtue of their disease and its treatments, childhood cancer survivors are at increased risk for a wide range of serious health conditions, including disorders of the endocrine system. Recent data indicate that 40% to 50% of survivors will develop an endocrine disorder during their lifetime. Risk factors for endocrine complications include both host (e.g., age, sex) and treatment factors (e.g., radiation). Radiation exposure to key endocrine organs (e.g., hypothalamus, pituitary, thyroid, and gonads) places cancer survivors at the highest risk of developing an endocrine abnormality over time; these endocrinopathies can develop decades following cancer treatment, underscoring the importance of lifelong surveillance. The following guideline addresses the diagnosis and treatment of hypothalamic-pituitary and growth disorders commonly encountered in childhood cancer survivors.

Endocrine Late Effects in Childhood Cancer Survivors

Endocrine complications are highly prevalent in childhood cancer survivors. Approximately 50% of survivors will experience at least one hormonal disorder over the course of their lives. Endocrine complications often are observed in survivors previously treated with radiation to the head, neck, or pelvis. We provide an overview the most common endocrine late effects seen in survivors, including hypothalamic-pituitary dysfunction, primary thyroid dysfunction, obesity, diabetes mellitus, metabolic syndrome, and decreased bone mineral density. Primary gonadal injury is discussed elsewhere in this series. Given a variable latency interval, a systematic approach where individuals are periodically screened on the basis of their risk factors can help to improve health outcomes by prompt diagnosis and treatment of evolving endocrinopathies. These recommendations must be revised in the future given changes and improvements in cancer treatment over time.

Vaginal development and sexual functioning in young women after stem cell transplantation, chemotherapy, and/or radiotherapy for childhood hematological diseases

To study vaginal development and sexual functioning in young women after childhood hemopoietic stem cell transplantation (HSCT) and radio/chemotherapy. Observational case-control study on 30 young sexually active women survived after HSCT and/or radio/chemotherapy for childhood malignancies or hematologic diseases and 48 controls matched for age. Female Sexual Function Index was lower (median 24.05, IQR = 17.30-28.30 vs. 29.00, IQR = 25.30-31.40, p = 0.001), Female Sexual Distress Scale higher (median 16.00, IQR = 8.00-23.00 vs. 2.00, IQR = 0.00-4.00, p < 0.001), vaginal length shorter (mean difference = 21.1 mm; 95% CI = 19.3-23, p < .001) and vaginal maturation index worst in cases than in controls. Subjects treated by irradiation before HSCT had lower FSFI (median 21.85, IQR = 9.60-31.10 vs. 24.90, IQR = 17.30-28.30) and shorter vaginal length (median 45.55, IQR = 42.60-45.80 vs. 50.10, IQR = 45.30-52.90) compared to those who had not received conditioning treatment (p-values = 0.004 and p = 0.05, respectively). Compared to untreated subjects, women receiving hormonal replacement therapy had higher overall FSFI (p = 0.02), lower FSDS (0.04), and better VMI. Gonadotoxic therapies have adverse effects on vaginal development, sexual functioning, and distress in young females. Hormonal replacement therapy should be shortly considered after main gonodatoxic treatments to improve vaginal and sex health.

Cancer Survivorship in Adults

With the favorable trend regarding survival of cancer in the Western world, there is an increasing focus among patients, clinicians, researchers, and politicians regarding cancer survivors' health and well-being. The number of survivors grows rapidly, and more than 3% of the adult populations in Western countries have survived cancer for 5 years or more. Cancer survivors are at increased risk for a variety of late effects after treatment, some life-threatening such as secondary cancer and cardiac diseases, while others mainly have negative impact on daily functioning and health-related quality of life (HRQOL). The latter factors include fatigue, anxiety disorders, sexual problems, insomnia, and reduced work ability, while depression does not seem to be more common among survivors than in the general population. Life style factors are highly relevant for cancer survivors concerning risk of relapse and somatic comorbidity. The field of cancer survivorship research has grown rapidly. How to best integrate the knowledge of the field into clinical practice with adequate follow-up of cancer survivors at risk for developing late effects, is still an unresolved question, although several models are under consideration.

Reprint of: Efficacy and safety of different doses of dezocine for preemptive analgesia in gynecological laparoscopic surgeries: A prospective, double blind and randomized controlled clinical trial

BACKGROUND

The incidence of reproductive system tumors in Chinese females is increasing year by year, with the trend of younger onset ages. Laparoscopic surgery has been recognized by the majority of medical staff and patients, but the postoperative pain still exists. Therefore, it has become the focus of attention of medical workers to take effective analgesia measures to alleviate postoperative pain as well as to improve the degree of comfort and satisfaction for the patients.

OBJECTIVES

The research objective was to study the effect of different doses of dezocine preemptive analgesia on the safety and the pain post laparoscopic surgeries, in order to explore the best dose of dezocine for postoperative analgesia in gynecological laparoscopic surgeries.

METHODS

Gynecological laparoscopic surgery patients conformed to the criteria (n = 390) were randomly divided into three groups (group A, B and C) by the methods of randomized, double-blind studies. 0.1 mg/kg, 0.15 mg/kg or 0.2 mg/kg dezocine was intravenously injected 15 min before surgeries for preemptive analgesia. VAS score, Ramsay score and MMSE score were used to evaluate the efficacy and safety of dezocine in preemptive analgesia and sedation, and the use of adjuvant analgesic drugs and the incidence of adverse reactions were also observed.

RESULTS

The VAS scores of the 0.15 mg/kg and 0.2 mg/kg dezocine groups were significantly lower than that of the 0.1 mg/kg group at 2h, 4h, 6h, 8h, 12h and 24h post-surgery, and the difference was statistically significant (p < 0.05). There was no statistically significant difference between the 0.15 mg/kg and 0.2 mg/kg groups (p > 0.05) except for the 12h time point. The MMSE scores 12h post-surgery of the three groups were compared with those 12h prior-to-surgery, and the differences were not statistically significant (p > 0.05) and no increase in the incidence of cognitive impairment was observed. The use rate of analgesic drugs in the 0.1 mg/kg group was significantly higher than those in the 0.15 mg/kg and 0.2 mg/kg groups, and the difference was statistically significant (p < 0.05). There were no significant differences in the incidence of adverse events between the three groups (P > 0.05).

CONCLUSIONS

The analgesia and sedation effects of dezocine were enhanced with the increase of usage dose, which suggested that the effects of dezocine were dose-dependent. Intravenous injection of 0.15 mg/kg dezocine 15 min before gynecological laparoscopic surgery showed better analgesic and sedative effects as well as less adverse reactions, and should be the appropriate dose to be used in the preemptive analgesia in gynecological laparoscopic surgeries.

The role of melatonin on chemotherapy-induced reproductive toxicity

Objectives

Reproductive malfunctions after chemotherapy still are a reason of reducing fertility and need specialized intensive care. The aim of this review was to investigate the effect of melatonin on the reproductive system under threatening with chemotherapeutic drugs.

Methods

To find the role of melatonin in the reproductive system during chemotherapy, a full systematic literature search was carried out based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in the electronic databases up to 17 April 2017 using search terms in the titles and abstracts. A total of 380 articles are screened according to our inclusion and exclusion criteria. Finally, 18 articles were included in this study.

Key findings

It has been cleared that melatonin has bilateral effects on reproductive cells. Melatonin protects normal cells via mechanisms, including decrease in oxidative stress, apoptosis, inflammation and modulating mitochondrial function, and sexual hormones. Furthermore, melatonin with antiproliferative properties and direct effects on its receptors improves reproductive injury and function during chemotherapy. On the other hand, melatonin sensitizes the effects of chemotherapeutic drugs and enhances chemotherapy-induced toxicity in cancerous cells through increasing apoptosis, oxidative stress and mitochondrial malfunction.

Conclusions

The study provides evidence of the bilateral role of melatonin in the reproductive system during chemotherapy.

Efficacy and safety of different doses of dezocine for preemptive analgesia in gynecological laparoscopic surgeries: A prospective, double blind and randomized controlled clinical trial

BACKGROUND

The incidence of reproductive system tumors in Chinese females is increasing year by year, with the trend of younger onset ages. Laparoscopic surgery has been recognized by the majority of medical staff and patients, but the postoperative pain still exists. Therefore, it has become the focus of attention of medical workers to take effective analgesia measures to alleviate postoperative pain as well as to improve the degree of comfort and satisfaction for the patients.

OBJECTIVES

The research objective was to study the effect of different doses of dezocine preemptive analgesia on the safety and the pain post laparoscopic surgeries, in order to explore the best dose of dezocine for postoperative analgesia in gynecological laparoscopic surgeries.

METHODS

Gynecological laparoscopic surgery patients conformed to the criteria (n = 390) were randomly divided into three groups (group A, B and C) by the methods of randomized, double-blind studies. 0.1 mg/kg, 0.15 mg/kg or 0.2 mg/kg dezocine was intravenously injected 15 min before surgeries for preemptive analgesia. VAS score, Ramsay score and MMSE score were used to evaluate the efficacy and safety of dezocine in preemptive analgesia and sedation, and the use of adjuvant analgesic drugs and the incidence of adverse reactions were also observed.

RESULTS

The VAS scores of the 0.15 mg/kg and 0.2 mg/kg dezocine groups were significantly lower than that of the 0.1 mg/kg group at 2h, 4h, 6h, 8h, 12h and 24h post-surgery, and the difference was statistically significant (p < 0.05). There was no statistically significant difference between the 0.15 mg/kg and 0.2 mg/kg groups (p > 0.05) except for the 12h time point. The MMSE scores 12h post-surgery of the three groups were compared with those 12h prior-to-surgery, and the differences were not statistically significant (p > 0.05) and no increase in the incidence of cognitive impairment was observed. The use rate of analgesic drugs in the 0.1 mg/kg group was significantly higher than those in the 0.15 mg/kg and 0.2 mg/kg groups, and the difference was statistically significant (p < 0.05). There were no significant differences in the incidence of adverse events between the three groups (P > 0.05).

CONCLUSIONS

The analgesia and sedation effects of dezocine were enhanced with the increase of usage dose, which suggested that the effects of dezocine were dose-dependent. Intravenous injection of 0.15 mg/kg dezocine 15 min before gynecological laparoscopic surgery showed better analgesic and sedative effects as well as less adverse reactions, and should be the appropriate dose to be used in the preemptive analgesia in gynecological laparoscopic surgeries.

Fertility preservation in post-pubescent female cancer patients: A practical guideline for clinicians

Increasing accessibility of fertility preservation (FP) options has permitted women to retain fertility following anticancer therapies. Several published guidelines have made recommendations for FP however their implementation into practice is currently unknown. In this review, we aim to provide oncology clinicians practical information about FP options for post-pubescent female cancer patients and recommendations for care delivery in order to answer preliminary questions and help triage whether FP referral is appropriate. Herein, we present a resource for oncology providers to guide them with FP discussions. Key points that are discussed in this critical review include: i) All cancer patients beginning a new plan of care should be informed of potential fertility risk. ii) If a woman requests further information on FP interventions, referral to a FP clinic should be made. iii) Given the evolving technologies in this area, patients should be informed of those which are proven and unproven, with oocyte and embryo preservation recognized as standard practice. iv) Random start (independent of menstrual cycle day) techniques are available to minimize oncologic treatment delays. v) Specific protocols for ovarian stimulation may be center-specific. vi) There is unlikely an increased cancer recurrence risk as a result of stimulation protocols in women with hormone-sensitive cancers. vii) Lastly, given the absence of consensus in the literature, routine use of GnRH analogs is not recommended for all cancer patients, however may be considered in select cases, such as high-risk women in whom definitive FP is not possible or feasible.

Preservation of Fertility or Ovarian Function in Patients with Breast Cancer or Gynecologic and Internal Malignancies

Because of the efficacy of systemic therapies, neoplasias which occur in pediatric and adolescent patients and in young adults have high cure rates. This means that fulfilling their wish to have children has become a more pressing concern, particularly among young women with malignant tumors. Premature ovarian failure is also a not insignificant problem as it has a lasting detrimental effect on quality of life. Every oncology patient who may potentially wish to have children should be informed about their options for preserving fertility prior to starting treatment. The rates of patient who received detailed briefing on this point remain low. This review presents the effects of different chemotherapeutic drugs on gonadal function together with an overview of currently valid recommendations on fertility preservation. Risk groups are defined and the specific approaches for malignancies of various organ systems are described. Cryopreservation of oocytes, fertilized embryos and ovarian tissue are fertility-preserving options for girls/young women. The data on the benefits of administering GnRH analogs for ovarian protection prior to starting chemotherapy are not clear. In postpubertal boys or male cancer patients, the standard approach is to cryopreserve sperm before starting therapy. The cryopreservation of testicular tissue is possible for prepubertal boys, however in-vitro sperm maturation is still in its experimental stages. This review also presents existing drug options for the preservation of ovarian function in oncology patients prior to chemotherapy, particularly for patients with (hormone-sensitive) breast cancer, and looks at the special issues of fertility-preserving surgery and radiation therapy in patients with gynecologic malignancies.

Premature Ovarian Insufficiency in Childhood Cancer Survivors: A Report From the St. Jude Lifetime Cohort

CONTEXT

Long-term follow-up data on premature ovarian insufficiency (POI) in childhood cancer survivors are limited.

OBJECTIVE

To describe the prevalence of POI, its risk factors, and associated long-term adverse health outcomes.

DESIGN

Cross-sectional.

SETTING

The St. Jude Lifetime Cohort Study, an established cohort in a tertiary care center.

PATIENTS

Nine hundred twenty-one participants (median age, 31.7 years) were evaluated at a median of 24.0 years after cancer diagnosis.

MAIN OUTCOME MEASURE

POI was defined by persistent amenorrhea combined with a follicle-stimulating hormone level >30 IU/L before age 40. Multivariable Cox regression was used to study associations between demographic or treatment-related risk factors and POI. Multivariable logistic regression was used to study associations between POI and markers for cardiovascular disease, bone mineral density (BMD), and frailty. Exposure to alkylating agents was quantified using the validated cyclophosphamide equivalent dose (CED).

RESULTS

The prevalence of POI was 10.9%. Independent risk factors for POI included ovarian radiotherapy at any dose and CED ≥8000 mg/m2. Patients with a body mass index ≥30 kg/m2 at the time of the St. Jude Lifetime Cohort assessment were less likely to have a diagnosis of POI. Low BMD and frailty were independently associated with POI.

CONCLUSION

High-dose alkylating agents and ovarian radiotherapy at any dose are associated with POI. Patients at the highest risk should be offered fertility preservation whenever feasible. POI contributes to poor general health outcomes in childhood cancer survivors; further studies are needed to investigate the role of sex hormone replacement in improving such outcomes.

DIAGNOSIS OF ENDOCRINE DISEASE: Endocrine late-effects of childhood cancer and its treatments

Endocrine complications are frequently observed in childhood cancer survivors (CCS). One of two CCS will experience at least one endocrine complication during the course of his/her lifespan, most commonly as a late-effect of cancer treatments, especially radiotherapy and alkylating agent chemotherapy. Endocrine late-effects include impairments of the hypothalamus/pituitary, thyroid and gonads, as well as decreased bone mineral density and metabolic derangements leading to obesity and/or diabetes mellitus. A systematic approach where CCS are screened for endocrine late-effects based on their cancer history and treatment exposures may improve health outcomes by allowing the early diagnosis and treatment of these complications.

Targeted therapy for soft tissue sarcomas in adolescents and young adults

Soft tissue sarcomas (STSs) are a heterogeneous group of tumors originating from the mesenchyme. Even though they affect individuals in all age groups, the prevalence of subtypes of STSs changes significantly from childhood through adolescence into adulthood. The mainstay of therapy is surgery, with or without the addition of chemotherapy and/or radiation therapy. These treatment modalities are associated, in many cases, with significant morbidity and, given the heterogeneity of tumor histologies encompassed by the term "STS", have not uniformly improved outcomes. Moreover, some subgroups of STSs appear to be more, and others less, responsive to conventional chemotherapy agents. Over the last two decades, our understanding of the biology of STSs is slowly increasing, allowing for the development of more targeted therapies. We review the new treatment modalities that have been tested on patients with STSs, with a special focus on adolescents and young adults, a group of patients that is often underrepresented in clinical trials and has not received the dedicated attention it deserves, given the significant differences in biology and treatment response in comparison to children and adults.

"My choice": breast cancer patients recollect doctors fertility preservation recommendations

PURPOSE

The increasing rates of early-onset breast cancer (BC) and of woman survival render fertility preservation (FP) a pressing issue. We probe women's experiences of FP counseling and decision making, aiming to identify emergent counseling patterns.

METHODS

Semi-structured interviews were conducted with 16 women, who had been diagnosed with BC at the ages of 24-38, 1 to 5 years prior to the interview. BC survivors were recruited through posts in online fora, consented to participate, and were invited to tell their FP stories. The transcribed interviews were analyzed thematically, using the phenomenological paradigm.

FINDINGS

Doctors' FP recommendations belong into three categories: (a) direct clinical rationale-grounding recommendations in the woman's clinical condition by direct reference to tumor characteristics and prognosis, (b) indirect clinical rationale-reference to the woman's clinical condition by outlining a pressing time-frame, and (c) sociodemographic rationale-focus on the woman's family status. Women's responses revealed primarily detachment and compliance alongside initiative and proactivism.

CONCLUSION AND IMPLICATIONS FOR CANCER SURVIVORS

Beyond its contribution to women's future ability to conceive, FP may constitute an arena of personal autonomy and a coping resource for young BC patients. Raising awareness to this significance may sensitize healthcare providers to the role that FP may play in the moment of cancer diagnosis in adding, alongside sickness and prognosis, a focus on family future planning. As such, FP may affect women's quality of life and even survival.

Fertility Awareness Counseling for Adolescent Girls; Guiding Conception: The Right Time, Right Weight, and Right Way

STUDY OBJECTIVE

To provide a detailed summary of fertility awareness counseling pearls for healthy teens and those with fertility-relevant comorbidities, and to assist providers in offering such counseling to adolescents and young adult women. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Comprehensive literature review of English-language studies relating to fertility in pediatric and adolescent female patients (ages 13-21 years), and evidence-based dialogue guide.

RESULTS

The literature indicates that although adolescents are interested in discussing sexuality and reproduction, this is commonly overlooked during the standard office medical visit. As a result, adolescents often turn to less reliable sources and hold a variety of reproductive misconceptions and a sense of lack of control over future fertility. We found no studies that examined the routine provision of fertility awareness counseling with healthy adolescents. There are a multitude of specific gynecologic and medical conditions that have ramifications for fertility. We detail these comprehensively, and provide a dialogue guide to assist with fertility awareness counseling for the female adolescent, containing specific information and indications for referral.

CONCLUSION

Providers caring for adolescent girls have the opportunity to enhance fertility awareness as part of a larger reproductive health conversation that adolescents desire, and from which they might benefit. Identifying potential future fertility issues, understanding age-related fertility decline, and aiding in health optimization before future conception might empower the adolescent to make informed reproductive decisions. We provide an algorithm to use with adolescents to discuss the "right time, right weight, right way" to pursue childbearing.

SEOM Clinical Guideline of fertility preservation and reproduction in cancer patients (2016)

Chemotherapy and radiotherapy often result in reduced fertility in cancer patients. With increasing survival rates, fertility is an important quality-of-life concern for many young cancer patients. Around 70–75% of young cancer survivors are interested in parenthood but the numbers of patients who access fertility preservation techniques prior to treatment are significantly lower. Moreover, despite existing guidelines, healthcare professionals do not address fertility preservation issues adequately. There is a critical need for improvements in clinical care to ensure patients are well informed about infertility risks and fertility preservation options and to support them in their reproductive decision-making prior to cancer treatment.

Adoption consideration and concerns among young adult female cancer survivors

PURPOSE

We compared adoption consideration between female young adult cancer survivors and women of the same age in the general US population, hypothesizing that cancer survivors who desired children would report greater interest in adoption than an age-adjusted general population sample who desired children.

METHODS

After age-standardizing the cancer survivor cohort to match the age distribution of the 2006-2010 National Survey for Family Growth (NSFG), we estimated adoption consideration among women age 18-35 years who wanted a (another) child in the two cohorts overall and within age groups. We assessed characteristics and concerns related to adoption consideration among cancer survivors.

RESULTS

Among cancer survivors, 81.6 % (95 % CI 75.7-87.6) reported that they would consider adoption compared to 40.3 % (95 % CI 40.3-40.3) of women in the general population. While over 80 % of the cancer survivor sample reported that they would consider adoption, only 15 % of cancer survivors reported no concerns about adoption. The most common concerns were desire for a biological child (48 %), expense (45 %), adoption agency candidacy (41 %), and needing more information (39 %).

CONCLUSION

We observed a twofold higher interest in adoption when comparing the cancer survivor with the general population, suggesting that adoption is a consideration for many young women who have survived cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Adoption is an important family-building option for those who want to have a child but are unable to or choose not to have a biological child. However, young adult survivors may need more support to understand and navigate this process.

Pediatric and Teen Ovarian Tissue Removed for Cryopreservation Contains Follicles Irrespective of Age, Disease Diagnosis, Treatment History, and Specimen Processing Methods

PURPOSE

Fertility preservation in a pediatric and teen female population is challenging because standard technologies of egg and embryo freezing may not be possible due to premenarcheal status. Ovarian tissue cryopreservation (OTC) with the intent of future ovarian tissue transplantation or in vitro follicle growth may be the only option to preserve fertility. The purpose of this study was to add to the general understanding of primordial follicle dynamics in young patients.

METHODS

First, the unique infrastructure of the Oncofertility Consortium National Physicians Cooperative (OC-NPC) is described, which simultaneously drives clinical fertility preservation and basic research to explore and expand the reproductive options for those in need. Then, the OC-NPC research resource is used to perform a histological evaluation of ovarian tissue from 24 participants younger than 18 years of age.

RESULTS

Primordial follicles, which comprise the ovarian reserve, were observed in all participant tissues, irrespective of variables, including age, diagnosis, previous treatment history, tissue size, and tissue processing methods. Primordial follicles were present in ovarian tissue, even in participants who had a previous history of exposure to chemotherapy and/or radiation treatment regimens, which placed them at risk for iatrogenic infertility or premature ovarian failure.

CONCLUSION

Primordial follicles were observed in ovarian tissue from all participants examined, despite population and tissue heterogeneity. These results increase the understanding of human follicle dynamics and support OTC as a promising fertility preservation modality in the young female population. Future studies to evaluate follicle quality within these tissues are warranted.

Low Anti-Müllerian Hormone in Pediatric Cancer Survivors in the Early Years after Gonadotoxic Therapy

STUDY OBJECTIVE

To obtain anti-Müllerian hormone (AMH) levels in female childhood cancer survivors and determine the association of therapeutic exposures with diminished ovarian reserve (DOR).

DESIGN

Cross-sectional study.

SETTING

Academic medical center.

PARTICIPANTS

Forty-nine survivors (mean age = 14.9 years, SD = 3.3 years; mean time without therapy = 7.5 years, SD = 3.6 years) who received alkylator/heavy metal chemotherapy, and/or radiation exposure to the ovaries with 2 or more years without therapy were recruited.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

AMH, follicle stimulating hormone (FSH) levels (random), and therapeutic characteristics such as cyclophosphamide equivalent dose (CED), heavy metal exposure, and bilateral ovarian radiation exposure were determined for each subject. DOR was defined as a low AMH (less than the fifth percentile for age-matched controls), and premature ovarian insufficiency as an FSH greater than 40 IU/L with AMH less than the fifth percentile.

RESULTS

Fourteen subjects (28.6%) had DOR, and 5 (10.2%) had premature ovarian insufficiency. Those with a low AMH were more likely exposed to a higher CED (P = .001) and/or bilateral ovarian radiation exposure (P = .048). In the multivariate model of DOR adjusted for age at diagnosis, DOR was associated with bilateral radiation (odds ratio = 39.9; 95% confidence interval 2.1-759.7; P = .04). There was a nonsignificant trend with increasing odds of low AMH with increased CED.

CONCLUSION

DOR, defined by an AMH less than the fifth percentile, was observed in more than one-quarter of pediatric cancer survivors exposed to gonadotoxic cancer therapy and was significantly associated with bilateral ovarian irradiation. Identifying risk factors for low AMH prompts AMH and FSH surveillance in the early years after cancer therapy and, if needed, early referral to a reproductive specialist.

Late endocrine effects of childhood cancer

The cure rate for paediatric malignancies is increasing, and most patients who have cancer during childhood survive and enter adulthood. Surveillance for late endocrine effects after childhood cancer is required to ensure early diagnosis and treatment and to optimize physical, cognitive and psychosocial health. The degree of risk of endocrine deficiency is related to the child's sex and their age at the time the tumour is diagnosed, as well as to tumour location and characteristics and the therapies used (surgery, chemotherapy or radiation therapy). Potential endocrine problems can include growth hormone deficiency, hypothyroidism (primary or central), adrenocorticotropin deficiency, hyperprolactinaemia, precocious puberty, hypogonadism (primary or central), altered fertility and/or sexual function, low BMD, the metabolic syndrome and hypothalamic obesity. Optimal endocrine care for survivors of childhood cancer should be delivered in a multidisciplinary setting, providing continuity from acute cancer treatment to long-term follow-up of late endocrine effects throughout the lifespan. Endocrine therapies are important to improve long-term quality of life for survivors of childhood cancer.

Primary Gonadal Insufficiency in Male and Female Childhood Cancer Survivors in a Long-Term Follow-Up Clinic

PURPOSE

Childhood cancer survivors (CCS) are at increased risk of primary gonadal insufficiency (PGI). This study evaluated the prevalence and clinical characteristics of PGI in CCS.

METHODS

In this single-center, retrospective, observational, longitudinal study, we characterized CCS with PGI attending the oncology Long-Term Follow-Up (LTFU) Clinic at an Australian university hospital (January 2012-August 2014). From a cohort of 276 CCS, 54 (32 males) met criteria for PGI: elevated gonadotropins plus low estradiol/amenorrhoea (females) or low testosterone/small testicles for age (males).

RESULTS

Median age at primary diagnosis was 4.8 years (inter-quartile range [IQR] 3.0-9.7 years) and at LTFU, it was 22.3 years (IQR 18.2-25.7 years). Fifty-three participants (98.1%) were treated with known highly gonadotoxic therapies: alkylating chemotherapy (96.3%), radiotherapy (70.3%), total body irradiation (29.6%), bone marrow transplantation (51.9%), or multimodal protocols (68.5%). At primary diagnosis, 86.7% participants were Tanner stage I and at LTFU, 89.1% participants were Tanner stage V. More females (95.5%; n = 21) than males (40.6%; n = 13) were treated with hormone development therapy (HDT) (p < 0.01). Of these, more than half (n = 18; 7 males) required pubertal induction. There was no significant difference in serum luteinizing hormone/follicle stimulating hormone (LH/FSH), testosterone/estradiol between those untreated and those treated with HDT. Among those on HDT, 60.7% had persistently elevated FSH±LH and 33.3% had low testosterone or estradiol. Six males had semen analysis (five azoospermic, one oligospermic). Psychological assessment was documented in 61.1% of participants, and two-thirds reported fertility concerns.

CONCLUSION

PGI is an evolving phenotype that is common in CCS. Suboptimal treatment and non-adherence occur frequently. Ongoing assessment is essential to ensure prompt diagnosis, adequate intervention and to promote HDT adherence.

Late Effects Surveillance Recommendations among Survivors of Childhood Hematopoietic Cell Transplantation: A Children's Oncology Group Report

Hematopoietic cell transplantation (HCT) is an important curative treatment for children with high-risk hematologic malignancies, solid tumors, and, increasingly, nonmalignant diseases. Given improvements in care, there are a growing number of long-term survivors of pediatric HCT. Compared with childhood cancer survivors who did not undergo transplantation, HCT survivors have a substantially increased burden of serious chronic conditions and impairments involving virtually every organ system and overall quality of life. This likely reflects the joint contributions of pretransplantation treatment exposures and organ dysfunction, the transplantation conditioning regimen, and any post-transplantation graft-versus-host disease (GVHD). In response, the Children's Oncology Group (COG) has created long-term follow-up guidelines (www.survivorshipguidelines.org) for survivors of childhood, adolescent, and young adult cancer, including those who were treated with HCT. Guideline task forces, consisting of HCT specialists, other pediatric oncologists, radiation oncologists, organ-specific subspecialists, nurses, social workers, other health care professionals, and patient advocates systematically reviewed the literature with regards to late effects after childhood cancer and HCT since 2002, with the most recent review completed in 2013. For the most recent review cycle, over 800 articles from the medical literature relevant to childhood cancer and HCT survivorship were reviewed, including 586 original research articles. Provided herein is an organ system-based overview that emphasizes the most relevant COG recommendations (with accompanying evidence grade) for the long-term follow-up care of childhood HCT survivors (regardless of current age) based on a rigorous review of the available evidence. These recommendations cover both autologous and allogeneic HCT survivors, those who underwent transplantation for nonmalignant diseases, and those with a history of chronic GVHD.

Physical examination of the female cancer patient with sexual concerns: What oncologists and patients should expect from consultation with a specialist

Answer questions and earn CME/CNE Sexual concerns are prevalent in women with cancer or cancer history and are a factor in patient decision making about cancer treatment and risk-reduction options. Physical examination of the female cancer patient with sexual concerns, regardless of the type or site of her cancer, is an essential and early component of a comprehensive evaluation and effective treatment plan. Specialized practices are emerging that focus specifically on evaluation and treatment of women with cancer and sexual function problems. As part of a specialized evaluation, oncologists and their patients should expect a thorough physical examination to identify or rule out physical causes of sexual problems or dysfunction. This review provides oncology professionals with a description of the physical examination of the female cancer patient with sexual function concerns. This description aims to inform anticipatory guidance for the patient and to assist in interpreting specialists' findings and recommendations. In centers or regions where specialized care is not yet available, this review can also be used by oncology practices to educate and support health care providers interested in expanding their practices to treat women with cancer and sexual function concerns. CA Cancer J Clin 2016;66:241-263. © 2016 American Cancer Society.

Pregnancy after chemotherapy in male and female survivors of childhood cancer treated between 1970 and 1999: a report from the Childhood Cancer Survivor Study cohort

BACKGROUND

The effect of many contemporary chemotherapeutic drugs on pregnancy and livebirth is not well established. We aimed to establish the effects of these drugs on pregnancy in male and female survivors of childhood cancer not exposed to pelvic or cranial radiotherapy.

METHODS

We used data from a subset of the Childhood Cancer Survivor Study cohort, which followed 5-year survivors of the most common types of childhood cancer who were diagnosed before age 21 years and treated at 27 institutions in the USA and Canada between 1970 and 1999. We extracted doses of 14 alkylating and similar DNA interstrand crosslinking drugs from medical records. We used sex-specific Cox models to establish the independent effects of each drug and the cumulative cyclophosphamide equivalent dose of all drugs in relation to pregnancies and livebirths occurring between ages 15 years and 44 years. We included siblings of survivors as a comparison group.

FINDINGS

We included 10 938 survivors and 3949 siblings. After a median follow-up of 8 years (IQR 4-12) from cohort entry or at age 15 years, whichever was later, 4149 (38%) survivors reported having or siring a pregnancy, of whom 3453 (83%) individuals reported at least one livebirth. After a median follow-up of 10 years (IQR 6-15), 2445 (62%) siblings reported having or siring a pregnancy, of whom 2201 (90%) individuals reported at least one livebirth. In multivariable analysis, survivors had a decreased likelihood of siring or having a pregnancy versus siblings (male survivors: hazard ratio [HR] 0·63, 95% CI 0·58-0·68; p<0·0001; female survivors: 0·87, 0·81-0·94; p<0·0001) or of having a livebirth (male survivors: 0·63, 0·58-0·69; p<0·0001; female survivors: 0·82, 0·76-0·89; p<0·0001). In male survivors, reduced likelihood of pregnancy was associated with upper tertile doses of cyclophosphamide (HR 0·60, 95% CI 0·51-0·71; p<0·0001), ifosfamide (0·42, 0·23-0·79; p=0·0069), procarbazine (0·30, 0·20-0·46; p<0·0001) and cisplatin (0·56, 0·39-0·82; p=0·0023). Cyclophosphamide equivalent dose in male survivors was significantly associated with a decreased likelihood of siring a pregnancy (per 5000 mg/m(2) increments: HR 0·82, 95% CI 0·79-0·86; p<0·0001). However, in female survivors, only busulfan (<450 mg/m(2) HR 0·22, 95% CI 0·06-0·79; p=0·020; ≥450 mg/m(2) 0·14, 0·03-0·55; p=0·0051) and doses of lomustine equal to or greater than 411 mg/m(2) (0·41, 0·17-0·98; p=0·046) were significantly associated with reduced pregnancy; cyclophosphamide equivalent dose was associated with risk only at the highest doses in analyses categorised by quartile (upper quartile vs no exposure: HR 0·85, 95% CI 0·74-0·98; p=0·023). Results for livebirth were similar to those for pregnancy.

INTERPRETATION

Greater doses of contemporary alkylating drugs and cisplatin were associated with a decreased likelihood of siring a pregnancy in male survivors of childhood cancer. However, our findings should provide reassurance to most female survivors treated with chemotherapy without radiotherapy to the pelvis or brain, given that chemotherapy-specific effects on pregnancy were generally few. Nevertheless, consideration of fertility preservation before cancer treatment remains important to maximise the reproductive potential of all adolescents newly diagnosed with cancer.

FUNDING

National Cancer Institute, National Institutes of Health, and the American Lebanese-Syrian Associated Charities.

Young female cancer survivors' use of fertility care after completing cancer treatment

PURPOSE

The purpose of the present study is to investigate factors associated with female young adult cancer survivors' (YCSs) use of fertility care (FC), including consultation or fertility treatment, after completing their cancer treatment.

METHODS

In this cross-sectional study, females between that ages of 18 and 35 years who had been diagnosed with childhood, adolescent, or young adult cancers completed a 20-min web-based survey that included demographics, reproductive history, use of FC, fertility-related informational needs, and reproductive concerns.

RESULTS

A total of 204 participants completed the survey. Participants' mean age was 28.3 ± 4.5 years. Thirty (15 %) participants reported using FC after cancer treatment. The majority of participants recalled not receiving enough information about fertility preservation options at the time of cancer diagnosis (73 %). In multivariable analysis, those with higher concerns about having children because of perceived risk to their personal health (P = 0.003) were less likely to report use of FC after cancer treatment. Those who had used FC before cancer treatment (P = 0.003) and who felt less fertile than age-matched women (P = 0.02) were more likely to use FC after their cancer treatment.

CONCLUSIONS

While most YCSs in this cohort believed that they did not receive enough information about fertility and most wanted to have children, the vast majority did not seek FC. The findings of this study offer further evidence of the need for improved education and emotional support regarding reproductive options after cancer treatment is completed. Targeted discussions with YCSs about appropriate post-treatment FC options may improve providers' capacity to help YCSs meet their parenthood goals.

Gonadal Function and Fertility Among Survivors of Childhood Cancer

Reproductive health and fertility are of great importance to the increasing number of survivors of childhood cancer, approximately 70% of whom are estimated to be over 20 years old. This article reviews the various treatment exposures that have been associated with makers of gonadal injury and decreased fertility in childhood cancer survivors. Identifying risk factors that decrease fertility is essential in proper counseling and timely referral for interventions that may allow for future fertility in high-risk populations.

Fertility Preservation in Children and Adolescents

Fertility preservation is the process by which either oocytes (eggs) or sperm undergo an intervention to preserve their use for future attempts at conception. Consideration of fertility preservation in the pediatric and adolescent population is important, as future childbearing is usually a central life goal. For postpubertal girls, both oocyte and embryo cryopreservation are standard of care and for postpubertal boys, sperm cryopreservation continues to be recommended. Although all the risks are unknown, it appears that fertility preservation in most cases does not worsen prognosis, allows for the birth of healthy children, and does not increase the chance of recurrence.

Impact of Tailored Education on Awareness of Personal Risk for Therapy-Related Complications Among Childhood Cancer Survivors

Purpose

Survivors of childhood cancer carry a substantial burden of long-term morbidity; personal risk awareness is critical to ensure survivors' engagement in early detection/management of complications. The impact of education provided in survivorship clinics on survivors' understanding of their personal health risks is unclear.

Methods

Patients diagnosed with cancer at age 21 years or younger and at 2 or more years off therapy completed questionnaires about awareness of personal risk for therapy-related complications at T0 (first survivorship clinic visit) and at T1 to T5 (subsequent visits). After questionnaire completion at each clinic visit, survivors received education tailored to personal risk.

Results

A total of 369 survivors completed 1,248 visits (median, three visits; range, one to six visits). The median age at cancer diagnosis was 11 years (range, 0 to 21 years); the median age at T0 was 24 years (range, 5 to 57 years); 38% were white; 45% had leukemia; and 34% received hematopoietic cell transplantation. The cohort was at risk for a median of six (range, one to nine) complications. Awareness increased from 38.6% at T0 to 66.3% at T3. Generalized estimating equations (that adjusted for diagnosis, hematopoietic cell transplantation, race/ethnicity, and patient/parent education) showed significant gains in awareness from T0 to T1 (P < .001), T1 to T2 (P = .03), and T2 to T3 (P < .001) but no significant gain thereafter through T5 (P = .7). Predictors of low awareness included education less than a college degree (odds ratio [OR], 1.9; P = .02), longer time from diagnosis (OR, 1.03/year; P = .04), diagnosis of leukemia (OR, 2.1; P = .004), nonwhite race (OR, 2.8; P < .001), and risk for six or fewer complications (OR, 2.1; P = .002).

Conclusion

Risk-based education in a survivorship clinic significantly increases awareness of personal health risk through three sessions, with saturation thereafter. Vulnerable populations with minimal gain in awareness identified in this study could inform targeted interventions.

Perceptions of Infertility Risks Among Female Pediatric Cancer Survivors Following Gonadotoxic Therapy

Research has established that childhood cancer treatments can place survivors at risk for reproductive health problems, yet little is known about pediatric survivors' perceptions of their risk for infertility and worry about future family planning. The purpose of this study was to explore factors that affect awareness of risk for and worry about infertility among female pediatric cancer survivors aged 10 to 21 (N=48) and their parents (N=41) following exposure to treatments associated with reproductive late effects. The majority of female childhood cancer survivors (71%) and their parents (95%) reported worry about infertility following gonadotoxic therapy. Cross-sectional data indicated that survivors' awareness of risk for and worry about infertility increase during adolescence, whereas parents' awareness of risk and worry generally remain constant throughout their daughters' development. Survivor worry about infertility was predicted by a variety of factors, yet parent worry about infertility was only associated with increased gonadotoxic radiation exposure. Overall, these findings reinforce the necessity of developmentally appropriate education about reproductive health risks and fertility preservation options across the continuum of pediatric oncology care from diagnosis to survivorship.

TRANSITION IN ENDOCRINOLOGY: Hypogonadism in adolescence

Puberty is a remarkable developmental process with the activation of the hypothalamic-pituitary-gonadal axis culminating in reproductive capacity. It is accompanied by cognitive, psychological, emotional, and sociocultural changes. There is wide variation in the timing of pubertal onset, and this process is affected by genetic and environmental influences. Disrupted puberty (delayed or absent) leading to hypogonadism may be caused by congenital or acquired etiologies and can have significant impact on both physical and psychosocial well-being. While adolescence is a time of growing autonomy and independence, it is also a time of vulnerability and thus, the impact of hypogonadism can have lasting effects. This review highlights the various forms of hypogonadism in adolescence and the clinical challenges in differentiating normal variants of puberty from pathological states. In addition, hormonal treatment, concerns regarding fertility, emotional support, and effective transition to adult care are discussed.

An approach to fertility preservation in prepubertal and postpubertal females: a critical review of current literature

Advancements in childhood cancer treatment have led to increasing survivorship, creating a greater emphasis on long-term management of patients, including quality of life and side effects from therapy; foremost of which is preserving fertility. The American Society of Clinical Oncology (ASCO) recently revised their guidelines and recommend fertility preservation options be discussed at the earliest possible opportunity for newly diagnosed patients, including methods available for children that remain investigational. Herein, we discuss the current barriers to and the impact of these guidelines for pediatric oncologists caring for young female patients, and provide some suggestions on how to approach this complicated topic.

Approaches to reduce the long-term burden of treatment-related complications in survivors of childhood cancer

Advances in diagnostics, treatment strategies, and supportive care have contributed to a marked improvement in outcomes for children with cancer. This has resulted in a growing number of long-term childhood cancer survivors. Currently there are over 360,000 individuals who are survivors of childhood cancer in the United States. However, treatment for patients with childhood cancer with chemotherapy, radiation, and/or hematopoietic stem cell transplantation can result in health-related complications that may not become evident until years after completion of treatment. As a result, several initiatives have been established to help standardize the surveillance for treatment-related late effects in childhood cancer survivors. This review highlights emerging concepts related to commonly reported late effects, such as subsequent malignant neoplasms, cardiovascular disease, and endocrinopathies. It also discusses relevant population-based screening strategies to mitigate the long-term health-related burden in vulnerable populations of survivors.

Fertility preservation and reproductive health in the pediatric, adolescent, and young adult female cancer patient

PURPOSE OF REVIEW

As treatments for malignancies become increasingly successful, emphasis on quality of life in survivorship becomes important. Of equal importance is the role of gonadotoxic agents in the management of chronic medical conditions, such as nonmalignant blood disorders and rheumatologic and genetic conditions. Gonadotoxic agents have long-term effects to include ovarian insufficiency, pubertal arrest and subsequent infertility.

RECENT FINDINGS

In 2004, ovarian tissue cryopreservation emerged as an investigational but viable option for prepubertal patients and those unable to undergo ovarian stimulation. In 2012, oocyte preservation became standard therapy for patients without a partner or who elected not to use donor sperm or freeze embryos. Ovarian reserve testing with antimullerian hormone to assess fertility after gonadotoxic therapy is a rapidly growing area of interest with potentially significant benefits in personalizing the approach to fertility preservation.

SUMMARY

A systematic approach to fertility preservation prior to treatment in all patients receiving gonadotoxic agents optimizes care. Fertility preservation strategies can restore hormonal function and preserve reproductive potential. Future research in personalizing approach to care is critical to meeting the needs of this patient population.

[Gonadal function after treatment for a childhood or adolescent cancer]

Due to high cure rate in childhood and adolescent cancer, fertility preservation is a major concern. Chemotherapy, radiotherapy and surgery may alter gonadal function, and uterine cavity in women. In women, combined toxicity affecting both endocrine function and ovulation are observed leading to premature ovarian insufficiency. In men, spermatogenesis is frequently affected whereas endocrine function is almost always preserved. The current article focuses on investigations concerning gonadal function after treatment for a cancer during childhood or adolescence and treatment of subsequent infertility or hypogonadism. Nevertheless, those therapeutic are still limited and pretherapeutic preservation of fertility is preferred when possible.

Adolescent and Young Adult (AYA) Oncology in the United States: A Specialty in Its Late Adolescence

Over the last 30 years, it has become apparent that oncology patients ages 15 to 39 have not reaped the same rewards of improved survival that we have seen in younger and older patients. As a result, in 2006 the Adolescent and Young Adult (AYA) Oncology Progress Review Group convened and examined the factors that impact the care of the 70,000 new cases per year (approximately 7% of all new cases) in the United States and published their findings. The reasons for inferior survival gains are of course multiple and include the settings in which patients are cared for, clinical trial enrollment, insurance coverage, varied treatment of sarcomas, varied treatment of acute lymphoblastic leukemia, the psychosocial impact of cancer and cancer survivorship. A new area of a yet-to-be completely defined subspecialty was born out of this meeting: AYA oncology. As a medical community we realized that these patients do not fit neatly into the pediatric nor adult world and, therefore, require a unique approach which many individuals, oncology centers, advocacy groups, and cooperative trial groups have started to address. This group of dedicated providers and advocates has made strides but there is still much work to be done on the local, national, and international level to make up for shortcomings in the medical system and improve outcomes. We review key components of AYA cancer care in 2015 that all providers should be aware of, how far we have come, where this movement is headed, and the obstacles that continue to stand in the way of better cure rates and quality of life after cure for this unique group of patients. Like an adolescent maturing into adulthood, this movement has learned from the past and is focused on moving into the future to achieve its goals.

Evidence to incorporate inclusive reproductive health measures in guidelines for childhood and adolescent cancer survivors

OBJECTIVE

Female childhood cancer survivors are at an increased risk of reproductive health impairment. We compared reproductive health outcomes with the recommended standard in a cohort of childhood cancer survivors.

STUDY DESIGN AND PARTICIPANTS

A retrospective chart review of 222 female childhood cancer survivors aged 21 years or younger that presented to a tertiary referral center between 1997-2008 was initiated. The main outcome measures were the compliance with the American Society of Clinical Oncology guidelines for childhood cancer survivor management of reproductive health. In particular, we evaluated menstrual cycle regularity, fertility preservation counseling, and endocrine profile, as defined by follicle stimulating hormone (FSH) and anti-mullerian hormone (AMH) levels as surrogate markers for ovarian reserve. Secondary outcomes were to study the contribution of survivor clinics in enforcing these guidelines.

RESULTS

Of 136 patients older than 13 years at their last visit, 58 patients (43%) had FSH data available and none had AMH data. Patients were stratified into 3 groups according to FSH levels. Forty of 58 patients (69%) have normal ovarian reserve (FSH level < 10), 10 of 58 patients (17%) have decreased ovarian reserve (FSH levels 10-40), and 8 of 58 patients (14%) have premature menopause, defined as FSH > 40. Most patients with amenorrhea have elevated FSH levels indicating primary ovarian insufficiency, while 3 patients (2.2%) have low FSH levels consistent with hypothalamic amenorrhea. None of the patients were counseled on fertility preservation.

CONCLUSIONS

Reproductive health follow-up in children with cancer, including FSH and AMH measurement when indicated, should be established and strictly adhered.