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Magaton IM, Arecco L, Mariamidze E, Jankovic K, Stana M, Buzzatti G, Trevisan L, Scavone G, Ottonello S, Fregatti P, Massarotti C, von Wolff M, Lambertini M. Fertility and Pregnancy-Related Issues in Young BRCA Carriers With Breast Cancer. Breast Cancer (Auckl) 2024; 18:11782234241261429. [PMID: 38882447 PMCID: PMC11179469 DOI: 10.1177/11782234241261429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 05/06/2024] [Indexed: 06/18/2024] Open
Abstract
Approximately 10% to 15% of breast cancer cases in young women are diagnosed in patients harbouring germline (g) pathogenic or likely pathogenic variants (PVs) in the BReast CAncer 1 (BRCA1) or BReast CAncer 2 (BRCA2) genes. Preclinical and clinical studies showed a potential negative effect of germline BRCA1/2 (gBRCA1/2) PVs on ovarian reserve and reproductive potential, even before starting anticancer therapies. The aim of this article is to summarize the current literature on the fertility potential of young gBRCA1/2 PVs carriers with breast cancer and the risk of gonadotoxicity associated with anticancer treatments. Moreover, we describe the available evidence on the efficacy of fertility preservation techniques in young gBRCA1/2 PVs carriers and the safety data on having a pregnancy after breast cancer treatment.
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Affiliation(s)
- Isotta Martha Magaton
- Division of Gynaecological Endocrinology and Reproductive Medicine, University Women's Hospital, Inselspital, Bern, Switzerland
- Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Luca Arecco
- Department of Internal Medicine and Medical Specialties (DIMI), School of Medicine, University of Genoa, Genoa, Italy
| | - Elene Mariamidze
- Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Medical Oncology & Hematology, Todua Clinic, Tbilisi, Georgien
| | - Kristina Jankovic
- Department of Medical Oncology, University Clinic Center Nis, Nis, Serbia
| | - Mihaela Stana
- Department of Medical Oncology, Elysee Hospital, Alba Iulia, Romania
| | - Giulia Buzzatti
- Department of Medical Oncology, Unit of Hereditary Cancer, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Lucia Trevisan
- Department of Medical Oncology, Unit of Hereditary Cancer, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Graziana Scavone
- Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Silvia Ottonello
- Departent of Experimental Medicine (DIMES), University of Genoa, Genoa, Italy
| | - Piero Fregatti
- Department of Surgery, U.O.C. Clinica di Chirurgia Senologica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostic (DISC), School of Medicine, University of Genoa, Genoa, Italy
| | - Claudia Massarotti
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI Department), University of Genoa, Genoa, Italy
- Academic Unit of Obstetrics and Gynecology, Maternal-Child Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Michael von Wolff
- Division of Gynaecological Endocrinology and Reproductive Medicine, University Women's Hospital, Inselspital, Bern, Switzerland
| | - Matteo Lambertini
- Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Internal Medicine and Medical Specialties (DIMI), School of Medicine, University of Genoa, Genoa, Italy
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Hoyos-Martinez A, Scheurer ME, Allen-Rhoades W, Okcu MF, Horne VE. Leuprolide Protects Ovarian Reserve in Adolescents Undergoing Gonadotoxic Therapy. J Adolesc Young Adult Oncol 2023; 12:828-834. [PMID: 36976803 DOI: 10.1089/jayao.2022.0128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Purpose: Treatment sequelae compromising reproductive health are highly prevalent in childhood cancer survivors, and a main determinant of health and quality of life. Follicular reserve determines ovarian function life span; thus, its preservation is important in the care of female survivors. Anti-Müllerian hormone (AMH) is a biomarker to measure functional ovarian reserve. We aimed to evaluate the effect of leuprolide during gonadotoxic therapy on pubertal females' post-treatment functional ovarian reserve using AMH levels. Methods: We conducted a single-center retrospective study including all pubertal females who had undergone gonadotoxic treatments between January 2010 and April 2020, and had an AMH level after completion of therapy. We used multivariable linear regressions to compare AMH-level beta coefficients in patients stratified by gonadotoxic risk, adjusting for leuprolide use. Results: Fifty-two females meeting study eligibility were included, of which 35 received leuprolide. The use of leuprolide was associated with higher post-treatment AMH levels in the lower gonadotoxic risk group (beta 2.74, 95% CI 0.97-4.51; p = 0.004). This association was lost in the higher gonadotoxic risk groups. Conclusions: Leuprolide may have a protective effect on the functional ovarian reserve. However, this is limited by increasing treatment gonadotoxicity. Larger, prospective studies are needed to elucidate the potential benefits of gonadotropin-releasing hormone agonist on preservation of ovarian reserve among children receiving gonadotoxic therapies, as cancer survivors.
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Affiliation(s)
- Alfonso Hoyos-Martinez
- Divisions of Pediatric Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Michael E Scheurer
- Divisions of Pediatric Oncology and Hematology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Wendy Allen-Rhoades
- Division of Pediatric Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - M Fatih Okcu
- Divisions of Pediatric Oncology and Hematology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Vincent E Horne
- Divisions of Pediatric Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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Minoia C, Viviani S, Silvestris E, Palini S, Parissone F, De Palma G, Fedina A, Cormio G, Guarini A, Gini G, Montano L, Merli F, Peccatori FA. Fertility preservation and monitoring in adult patients diagnosed with lymphoma: consensus-based practical recommendations by the Fondazione Italiana Linfomi & Società Italiana della Riproduzione Umana. Front Oncol 2023; 13:1252433. [PMID: 37766870 PMCID: PMC10520955 DOI: 10.3389/fonc.2023.1252433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/21/2023] [Indexed: 09/29/2023] Open
Abstract
Introduction Fertility preservation (FP) and monitoring has considerable relevance in the multidisciplinary approach to cancer patients. In these consensus-based practical recommendations, the scientific societies Fondazione Italiana Linfomi (FIL) and Società Italiana della Riproduzione Umana (SIRU) reviewed the main aspects and identified the optimal paths which aim to preserve and monitor fertility in patients diagnosed with lymphoma at the different phases of the disease and during long-term survivorship. Methods For the Panel, eleven experts were selected for their expertise in research and clinical practice on onco-fertility and lymphoma. The Panel's activity was supervised by a chairman. A series of rank-ordering key questions were proposed according to their clinical relevance and discussed among the Panel, focusing on patients diagnosed with non-Hodgkin's lymphomas and Hodgkin lymphoma. Agreement among all the Panelists on the content and terminology of the statements was evaluated by a web-based questionnaire according to the Delphi methodology. Results From the literature review a total of 78 questions or sentences, divided into the 6 areas of interest, were identified. By applying the Gwet's AC, k was: Section 1: 0,934 (Very good); Section 2: 0,958 (Very good); Section 3: 0,863 (Very good); Section 4: 0,649 (Good); Section 5: 0,936 (Very good); Section 6 raw agreement 100%. Two rounds of Delphi allowed to provide the maximum agreement. All statements were newly discussed in a round robin way and confirmed for the drafting of the final recommendations. Discussion These recommendations would be useful for onco-hematologists, gynecologists, urologists, and general practice physicians who take care of young lymphoma patients to guarantee an evidence-based oncofertility assessment and treatment during the oncologic pathway.
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Affiliation(s)
- Carla Minoia
- Hematology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Bari, Italy
| | - Simonetta Viviani
- Division of Onco-Hematology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Erica Silvestris
- Gynecologic Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Bari, Italy
| | - Simone Palini
- Physiopathology of Reproduction Unit, Cervesi Hospital, Cattolica, Italy
| | - Francesca Parissone
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Universitaria Integrata di Verona, Università di Verona, Verona, Italy
| | - Giuseppe De Palma
- Institutional BioBank, Experimental Oncology and Biobank Management Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Bari, Italy
| | - Anna Fedina
- Data Office Fondazione Italiana Linfomi, Alessandria, Italy
| | - Gennaro Cormio
- IRCCS Istituto Tumori Departiment of Interdisciplinary Medicine (DIM), University of Bari, Bari, Italy
| | - Attilio Guarini
- Hematology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Bari, Italy
| | - Guido Gini
- Clinic of Hematology Azienda Ospedaliera Universitaria (AOU) delle Marche, Ancona, Italy
| | - Luigi Montano
- Andrology Unit and Service of Lifestyle Medicine in UroAndrology, Local Health Authority (ASL), Salerno, Italy
| | - Francesco Merli
- Hematology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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Han R, Song Z, Li H, Wang C, Zhang L, Yang X. Analysis of the benefit of gonadotropin-releasing hormone agonist treatment in premenopausal women undergoing hematopoietic cell transplantation. Sci Rep 2023; 13:14497. [PMID: 37666835 PMCID: PMC10477207 DOI: 10.1038/s41598-023-40778-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 08/16/2023] [Indexed: 09/06/2023] Open
Abstract
Gonadotropin-releasing hormone agonist (GnRHa) appears to exhibit ovarian protection during chemotherapy for malignant tumors. The purpose of this study was to analyze the benefits of GnRHa in premenopausal women undergoing hematopoietic cell transplantation (HSCT). Candidates for myeloablative chemotherapy HSCT requiring fertility preservation in the Gynecological Endocrinology Clinic of Peking University People's Hospital from December 2011 to December 2021 were retrospectively analyzed. Patients who chose to receive GnRHa treatment were given at least 2 courses of a 3.75-mg dose of a GnRHa before myeloablative chemotherapy, and patients who chose not to receive GnRHa treatment were included in the control group. All patients were monitored for menstruation return and menopause-related symptoms, and ovarian function tests [follicle-stimulating hormone (FSH), luteinizing hormone, and estradiol] were performed 6-12 months after HSCT. In addition, we assessed the vaginal bleeding of patients in the laminar air-flow room (LAFR). A total of 234 cases were included in this study: 77 cases in the treatment group and 157 cases in the control group. The incidence of vaginal bleeding in the LAFR in the treatment group was significantly lower than that in the control group (24.68% vs. 79.62%, P < 0.001). The menopausal symptoms of the patients in the treatment group were reduced after transplantation (46.75% vs. 19.75%, P < 0.001). There was no difference in visible follicles by follow-up ultrasound in the two groups after HSCT (16.88% vs. 13.38%, P = 0.474). The level of FSH at 6-12 months after transplantation was lower (98.00 mIU/ml vs. 117.53 mIU/ml, P = 0.001). The proportion of patients with FSH < 40 mIU/ml did not differ between the two groups. One patient in the treatment group recovered spontaneous menstruation, while none recovered spontaneous menstruation in the control group (1.30% vs. 0%, P = 0.329). The use of GnRHa may relieve menopause-related symptoms and reduce vaginal bleeding in the LAFR and breakthrough bleeding after transplantation. GnRHa treatment can reduce the level of FSH after myeloablative chemotherapy, but it cannot reduce the incidence of premature ovarian failure in women of reproductive age following myeloablative HSCT.
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Affiliation(s)
- Ruxue Han
- Department of Gynecology and Obstetrics, Peking University People's Hospital, Beijing, China
| | - Ziyi Song
- Department of Gynecology and Obstetrics, Peking University People's Hospital, Beijing, China
| | - Huiling Li
- Department of Gynecology and Obstetrics, Peking University People's Hospital, Beijing, China
| | - Chaohua Wang
- Department of Gynecology and Obstetrics, Peking University People's Hospital, Beijing, China.
| | - Leping Zhang
- Department of Pediatrics, Peking University People's Hospital, Beijing, China
| | - Xin Yang
- Department of Gynecology and Obstetrics, Peking University People's Hospital, Beijing, China.
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Wu M, Xue L, Guo Y, Dong X, Chen Z, Wei S, Yi X, Li Y, Zhang J, Zhou S, Wu M, Lou X, Dai J, Xia F, Wang S. Microenvironmentally Responsive Chemotherapeutic Prodrugs and CHEK2 Inhibitors Self-Assembled Micelles: Protecting Fertility and Enhancing Chemotherapy. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2023; 35:e2210017. [PMID: 36528787 DOI: 10.1002/adma.202210017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/30/2022] [Indexed: 06/17/2023]
Abstract
Chemotherapy is a widely used and effective adjuvant treatment for cancer, and it has unavoidable damage to female fertility, with statistics showing 38% of women who have received chemotherapy are infertile. How to reduce fertility toxicity while enhancing the oncologic chemotherapy is a clinical challenge. Herein, co-delivery micelles (BML@PMP) are developed, which are composed of a reduction-sensitive paclitaxel prodrug (PMP) for chemotherapy and a CHEK2 inhibitor (BML277) for both fertility protection and chemotherapy enhancement. BML@PMP achieves fertility protection through three actions: (1) Due to the enhanced permeability and retention (EPR) effect, BML@PMP is more enriched in the tumor, while very little in the ovary (about 1/10th of the tumor). (2) Glutathione (GSH) triggers the release of PTX, and with low levels of GSH in the ovary, the amount of PTX released in the ovary is correspondingly reduced. (3) BML277 inhibits oocyte apoptosis by inhibiting the CHEK2-TAp63α pathway. Because of the different downstream targets of CHEK2 in tumor cells and oocytes, BML277 also enhances chemotherapeutic efficacy by reducing DNA damage repair which is activated through the CHEK2 pathway. This bidirectional effect of CHEK2 inhibitor-based co-delivery system represents a promising strategy for improving oncology treatment indices and preventing chemotherapy-associated fertility damage.
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Affiliation(s)
- Meng Wu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Wuhan, 430030, China
- Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Wuhan, 430030, China
| | - Liru Xue
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Wuhan, 430030, China
- Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Wuhan, 430030, China
| | - Yican Guo
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Wuhan, 430030, China
- Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Wuhan, 430030, China
| | - Xiaoqi Dong
- State Key Laboratory of Biogeology and Environmental Geology, Faculty of Materials Science and Chemistry, China University of Geosciences, Wuhan, 430074, China
| | - Zhaojun Chen
- State Key Laboratory of Biogeology and Environmental Geology, Faculty of Materials Science and Chemistry, China University of Geosciences, Wuhan, 430074, China
| | - Simin Wei
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Wuhan, 430030, China
- Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Wuhan, 430030, China
| | - Xiaoqing Yi
- Key Laboratory of Biomaterials and Biofabrication in Tissue Engineering of Jiangxi Province, Gannan Medical University, Ganzhou, 341000, China
| | - Yinuo Li
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Wuhan, 430030, China
- Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Wuhan, 430030, China
| | - Jinjin Zhang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Wuhan, 430030, China
- Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Wuhan, 430030, China
| | - Su Zhou
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Wuhan, 430030, China
- Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Wuhan, 430030, China
| | - Mingfu Wu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Wuhan, 430030, China
- Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Wuhan, 430030, China
| | - Xiaoding Lou
- State Key Laboratory of Biogeology and Environmental Geology, Faculty of Materials Science and Chemistry, China University of Geosciences, Wuhan, 430074, China
| | - Jun Dai
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Wuhan, 430030, China
- Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Wuhan, 430030, China
| | - Fan Xia
- State Key Laboratory of Biogeology and Environmental Geology, Faculty of Materials Science and Chemistry, China University of Geosciences, Wuhan, 430074, China
| | - Shixuan Wang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Wuhan, 430030, China
- Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Wuhan, 430030, China
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Borges VF. The Expanded Role of Ovarian Suppression for Young Women's Breast Cancer: An Era of Patient-Tailored Decision Making. J Natl Cancer Inst 2021; 114:342-344. [PMID: 34850044 DOI: 10.1093/jnci/djab214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 11/16/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Virginia F Borges
- Division of Medical Oncology, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
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Abstract
Ovarian cancer is more frequent in post-menopausal women, however it can also occur in young premenopausal women. After diagnosis and cancer staging, health care providers should address the possibility of infertility and might offer fertility preservation options. Chemotherapy, frequently used when treating ovarian cancer, has proven to cause extensive ovarian damage. Standard surgery may be aggressive and the recurrence risk may not be relevant enough to opt for these approaches. Fertility sparing surgery has been progressively accepted and many alternative surgical approaches have proven to be successful in both cancer treatment, fertility preservation and low recurrence rates. Though there are several techniques available for fertility preservation in cancer patients, when dealing with ovarian cancer patients, oocyte and embryo cryopreservation are the only suitable. Ovarian tissue cryopreservation has been largely studied, but no data on ovarian cancer patients exist, due to the risk of reimplanting cancer cells.
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Affiliation(s)
| | - Ana Sofia Pais
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Reproductive Medicine Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Teresa Almeida Santos
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Reproductive Medicine Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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Dolmans MM, Taylor HS, Rodriguez-Wallberg KA, Blumenfeld Z, Lambertini M, von Wolff M, Donnez J. Utility of gonadotropin-releasing hormone agonists for fertility preservation in women receiving chemotherapy: pros and cons. Fertil Steril 2021; 114:725-738. [PMID: 33040981 DOI: 10.1016/j.fertnstert.2020.08.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Marie-Madeleine Dolmans
- Pôle de Gynécologie, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain, Brussels, Belgium; Gynecology Department, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Hugh S Taylor
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Kenny A Rodriguez-Wallberg
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden; Department of Reproductive Medicine, Division of Gynecology and Reproduction, Karolinska University Hospital, Stockholm, Sweden
| | - Zeev Blumenfeld
- Department of Reproductive Endocrinology, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Matteo Lambertini
- Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy
| | | | - Jacques Donnez
- Société de Recherche pour l'Infertilité, Brussels, Belgium; Catholic University of Louvain, Brussels, Belgium.
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Brancati S, Gozzo L, Longo L, Vitale DC, Russo G, Drago F. Fertility Preservation in Female Pediatric Patients With Cancer: A Clinical and Regulatory Issue. Front Oncol 2021; 11:641450. [PMID: 33796467 PMCID: PMC8008167 DOI: 10.3389/fonc.2021.641450] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/29/2021] [Indexed: 12/22/2022] Open
Abstract
Fertility preservation represents one important goal of cancer patients’ management due to the high impact on health and quality of life of survivors. The available preventive measures cannot be performed in all patients and are not feasible in all health-care facilities. Therefore, the pharmacological treatment with GnRHa has become a valuable non-invasive and well-tolerated alternative, especially in those who cannot access to cryopreservation options due to clinical and/or logistic issues. Supporting data demonstrate a significant advantage for the survivors who received GnRHa in the long-term maintenance of ovarian function and preservation of fertility. The prevention of the risk of ovarian failure with GnRHa is a typical off-label use, defined as the administration of a medicinal product not in accordance with the authorized product information. Italy has officially recognized the off-label use of GnRHa in adult women at risk of premature and permanent menopause following chemotherapy. However, fertility preservation still represents an unmet medical need in adolescents who cannot access to other treatment options.
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Affiliation(s)
- Serena Brancati
- Clinical Pharmacology Unit/Regional Pharmacovigilance Centre, University Hospital of Catania, Catania, Italy
| | - Lucia Gozzo
- Clinical Pharmacology Unit/Regional Pharmacovigilance Centre, University Hospital of Catania, Catania, Italy.,Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Laura Longo
- Clinical Pharmacology Unit/Regional Pharmacovigilance Centre, University Hospital of Catania, Catania, Italy
| | - Daniela Cristina Vitale
- Clinical Pharmacology Unit/Regional Pharmacovigilance Centre, University Hospital of Catania, Catania, Italy
| | - Giovanna Russo
- Pediatric Onco-Hematology, University Hospital of Catania, Catania, Italy
| | - Filippo Drago
- Clinical Pharmacology Unit/Regional Pharmacovigilance Centre, University Hospital of Catania, Catania, Italy.,Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy.,Centre for Research and Consultancy in HTA and drug Regulatory Affairs (CERD), University of Catania, Catania, Italy
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Fertility preservation for cancer patients: treatment gaps and considerations in patients' choices. Arch Gynecol Obstet 2021; 303:1617-1623. [PMID: 33544203 DOI: 10.1007/s00404-021-05985-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 01/22/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Women with cancer may desire fertility preservation (FP) prior to initiating cancer treatment, but undergoing FP may result in treatment delays. This study sought to determine whether such delays existed in our population and which factors were associated with patients' decision to proceed with FP. METHODS This was a historical cohort study performed at Montefiore Medical Center's Institute for Reproductive Medicine and Health. Reproductive age women diagnosed with cancer and consulted for FP were included. The main outcome measure was the number of days between FP consultation and cancer treatment initiation. Factors associated with patients' decisions to proceed with FP were also analyzed. RESULTS Thirty out of 51 women in our study underwent FP including embryo cryopreservation, oocyte cryopreservation, ovarian tissue cryopreservation (OTC), both oocyte and embryo cryopreservation, or GnRH agonist treatment. The majority of women who underwent FP chose embryo cryopreservation (36.7%), followed by oocyte cryopreservation (33.3%). Of the 20 patients with partners who underwent FP, 13 (65%) froze embryos. Only 4 of the 30 women who underwent FP had all, or a portion of their services, covered by insurance. The mean treatment delay was 18 days (p = 0.007), with a mean consultation to oncologic treatment gap of 23 ± 16.8 and 41.4 ± 25.9 days in the non-FP and FP groups, respectively. CONCLUSION Women with cancer diagnosis who underwent FP prior to initiating cancer treatment experienced a statistically significant delay in initiating cancer treatment. However, the clinical significance of this finding is unknown since FP treatments have not been associated with increased recurrence or mortality.
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Silvestris E, Cormio G, Skrypets T, Dellino M, Paradiso AV, Guarini A, Minoia C. Novel aspects on gonadotoxicity and fertility preservation in lymphoproliferative neoplasms. Crit Rev Oncol Hematol 2020; 151:102981. [PMID: 32485429 DOI: 10.1016/j.critrevonc.2020.102981] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 04/21/2020] [Accepted: 05/07/2020] [Indexed: 12/22/2022] Open
Abstract
The topic of fertility preservation in patients with a lymphoproliferative disease offers new aspects of debate, due to the introduction of novel chemotherapeutic regimens and small molecules in the clinical landscape. Cancer related infertility is mostly dependent on gonadotoxic treatments and fertile female patients are today addressed to the oocyte cryopreservation or to ovarian cortex fragment cryopreservation. These methods present advantages and disadvantages, which will be discussed in the present review, together with the options for male patients. The recent discovery of functional ovarian stem cells (OCSs) in woman ovarian cortex, opens new avenues offering a innovative procedure for fertility preservation through as model of regenerative medicine. Here, we review the gonadotoxic potential of "classical" chemotherapeutic treatments as well as of "novel" targeted therapies actually employed for lymphoproliferative neoplasms in young patients and revisit both the today available and future chances to preserve and restore fertility after the cancer healing.
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Affiliation(s)
- Erica Silvestris
- Gynecologic Oncology Unit, IRCCS Istituto Tumori "Giovanni Paolo II" 70124 Bari, Italy.
| | - Gennaro Cormio
- Gynecologic Oncology Unit, IRCCS Istituto Tumori "Giovanni Paolo II" 70124 Bari, Italy; Department of Biomedical Sciences and Human Oncology, Unit of Obstetrics and Gynecology, University of Bari Aldo Moro, Bari, Italy.
| | - Tetiana Skrypets
- Haematology Unit, National Cancer Center, IRCCS Istituto Tumori "Giovanni Paolo II", viale O. Flacco 65, Bari, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Italy.
| | - Miriam Dellino
- Gynecologic Oncology Unit, IRCCS Istituto Tumori "Giovanni Paolo II" 70124 Bari, Italy.
| | - Angelo Virgilio Paradiso
- Institutional BioBank, Experimental Oncology and Biobank Management Unit, IRCCS Istituto Tumori "Giovanni Paolo II", Bari, Italy.
| | - Attilio Guarini
- Haematology Unit, National Cancer Center, IRCCS Istituto Tumori "Giovanni Paolo II", viale O. Flacco 65, Bari, Italy.
| | - Carla Minoia
- Haematology Unit, National Cancer Center, IRCCS Istituto Tumori "Giovanni Paolo II", viale O. Flacco 65, Bari, Italy.
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12
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Fertilitätsprotektion – jetzt auch Kassenleistung. GYNAKOLOGISCHE ENDOKRINOLOGIE 2019. [DOI: 10.1007/s10304-019-00269-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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13
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Blumenfeld Z. Fertility Preservation Using GnRH Agonists: Rationale, Possible Mechanisms, and Explanation of Controversy. CLINICAL MEDICINE INSIGHTS. REPRODUCTIVE HEALTH 2019; 13:1179558119870163. [PMID: 31488958 PMCID: PMC6710670 DOI: 10.1177/1179558119870163] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 07/18/2019] [Indexed: 12/15/2022]
Abstract
The only clinically accepted method of fertility preservation in young women facing gonadotoxic chemo- and/or radiotherapy for malignant or autoimmune diseases is cryopreservation of embryos or unfertilized ova, whereas cryopreservation of ovarian tissue for future reimplantation, or in vitro maturation of follicles, and the use of gonadotropin-releasing hormone agonists (GnRHa) are still considered investigational, by several authorities. Whereas previous publications have raised the fear of GnRHa's possible detrimental effects in patients with hormone receptor-positive breast cancers, recent randomized controlled trials (RCTs) have shown that it either improves or does not affect disease-free survival (DFS) in such patients. This review summarizes the pros and cons of GnRHa co-treatment for fertility preservation, suggesting 5 theoretical mechanisms for GnRHa action: (1) simulating the prepubertal hypogonadotropic milieu, (2) direct effect on GnRH receptors, (3) decreased ovarian perfusion, (4) upregulation of an ovarian-protecting molecule such as sphingosine-1-phosphate, and (5) protecting a possible germinative stem cell. We try to explain the reasons for the discrepancy between most publications that support the use of GnRHa for fertility preservation and the minority of publications that did not support its efficiency.
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Affiliation(s)
- Zeev Blumenfeld
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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14
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Du B, Liu LH, Lv YJ, Ai H. Systems Pharmacology Uncovers Multiple Mechanisms of Erxian Decoction () for Treatment of Premature Ovarian Failure. Chin J Integr Med 2019; 26:106-113. [PMID: 31385218 DOI: 10.1007/s11655-019-3201-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To predict the chemical compositions and drug targets and to systematically dissect the pharmacological mechanism of Erxian Decoction (, EXD) as a treatment for premature ovarian failure (POF) using a systems pharmacology approach. METHODS The compounds present in EXD were obtained from three databases. The active ingredient was identified by analyzing the values of oral bioavailability (OB), drug-likeness (DL), and Lipinski's rule (LR). The active ingredients were further searched in research articles, drug targets in the DrugBank database, and the C-T and T-P networks, as well as by pathway analysis using the Cytoscape platform. RESULTS A total of 728 compounds were identified in EXD. Of these, 59 were identified as active compounds that conformed to the criteria with OB ⩾30% and DL ⩾0.18. By further searches in the literature, 126 related targets were identified that could interact with the active compounds. Additionally, it was found that the beneficial effects of EXD in POF are probably exerted via regulation of the immune system, modulation of estrogen levels, and anti-oxidative activities, and that it may act in a synergistic or cooperative manner with other therapeutic agents. CONCLUSIONS The systems pharmacology approach is a comprehensive system that was used to elucidate the pharmacological mechanism of EXD as a treatment for POF. The results of this study will also facilitate the application of traditional medicine in modern treatment strategies.
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Affiliation(s)
- Bo Du
- Key laboratory of Follicular Development and Reproductive Health of Liaoning Province, Jinzhou Medical University, Jinzhou, Liaoning Province, 121000, China
- Department of Gynecology and Obstetrics, Third Affiliated Hospital of Jinzhou Medical University, Jinzhou, Liaoning Province, 121000, China
| | - Li-Hong Liu
- Key laboratory of Follicular Development and Reproductive Health of Liaoning Province, Jinzhou Medical University, Jinzhou, Liaoning Province, 121000, China
- Department of Gynecology and Obstetrics, Third Affiliated Hospital of Jinzhou Medical University, Jinzhou, Liaoning Province, 121000, China
| | - Yu-Juan Lv
- Key laboratory of Follicular Development and Reproductive Health of Liaoning Province, Jinzhou Medical University, Jinzhou, Liaoning Province, 121000, China
| | - Hao Ai
- Key laboratory of Follicular Development and Reproductive Health of Liaoning Province, Jinzhou Medical University, Jinzhou, Liaoning Province, 121000, China.
- Department of Gynecology and Obstetrics, Third Affiliated Hospital of Jinzhou Medical University, Jinzhou, Liaoning Province, 121000, China.
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15
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Gini G, Annibali O, Lupasco D, Bocci C, Tomarchio V, Sampaolo M, Trappolini S, Tafuri MA, Cacciagiù S, Ciccarone M, Barucca A, Sarlo C, Vincenzi B, Avvisati G, Leoni P, Olivieri A. Gonadal Function Recovery and Fertility in Women Treated with Chemo- and/or Radiotherapy for Hodgkin's and Non-Hodgkin Lymphoma. Chemotherapy 2019; 64:36-41. [PMID: 31117081 DOI: 10.1159/000499535] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 03/12/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Fertility and gonadal function represent one of the most important aspects for long-term lymphoma survivors. AIMS The aim of our study was to determine possible risk factors, such as age at treatment, chemotherapeutic regimen, protection with oral contraceptives (OCs), and gonadotropin-releasing hormone (GnRH) analogues in female patients treated for Hodgkin's lymphoma (HL) or non-Hodgkin lymphoma (NHL) at a reproductive age. METHODS Patients between the age of 16 and 50 years at the time of HL or NHL diagnosis were selected. Eligible patients were requested to respond to a questionnaire by phone interview about fertility, menstrual status, sexual aspects, and treatment with OCs or GnRH analogues during chemotherapy. RESULTS The resumption of menstrual activity was associated with the use of the OCs and GnRH analogues during chemotherapy (p = 0.008 and 0.034, respectively). At univariate analysis, the use of OCs during chemotherapy was associated with a lower risk of amenorrhea (prevalence ratio [PR] = 0.37; 95% CI 0.17-0.82). A higher age at the time of treatment correlated positively with therapy-induced amenorrhea, with a difference of 12.8 years between the mean age at diagnosis of the women with therapy-induced amenorrhea and those who resumed their menses. Amenorrhea was significantly higher in women receiving R-CHOP than in women treated with ABVD (PR = 6.00; 95% CI 2.32-15.54). Moreover, NHL had an infertility PR of 1.51 (95% CI 0.86-2.45) at multivariate analysis compared to HL. CONCLUSIONS This study suggests a possible role of pharmacological prophylaxis with OCs and GnRH analogues.
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Affiliation(s)
- Guido Gini
- Unit of Hematology, AUO Ospedali Riuniti, Università Politecnica delle Marche, Ancona, Italy
| | - Ombretta Annibali
- Unit of Hematology and Stem Cell Transplantation, Campus Bio-Medico University, Rome, Italy,
| | - Diana Lupasco
- Unit of Hematology, AUO Ospedali Riuniti, Università Politecnica delle Marche, Ancona, Italy
| | - Caterina Bocci
- Unit of Hematology, AUO Ospedali Riuniti, Università Politecnica delle Marche, Ancona, Italy
| | - Valeria Tomarchio
- Unit of Hematology and Stem Cell Transplantation, Campus Bio-Medico University, Rome, Italy
| | - Michela Sampaolo
- Unit of Hematology, AUO Ospedali Riuniti, Università Politecnica delle Marche, Ancona, Italy
| | - Silvia Trappolini
- Unit of Hematology, AUO Ospedali Riuniti, Università Politecnica delle Marche, Ancona, Italy
| | | | - Sonia Cacciagiù
- Unit of Hematology, AUO Ospedali Riuniti, Università Politecnica delle Marche, Ancona, Italy
| | - Mariavita Ciccarone
- Unit of Gynecology, Ospedale San Carlo di Nancy, Rome, Italy.,Associazione Gemme Dormienti ONLUS, Rome, Italy
| | - Alessandra Barucca
- Unit of Hematology, AUO Ospedali Riuniti, Università Politecnica delle Marche, Ancona, Italy
| | - Chiara Sarlo
- Unit of Hematology and Stem Cell Transplantation, Campus Bio-Medico University, Rome, Italy
| | - Bruno Vincenzi
- Medical Oncology, University Campus Bio Medico, Rome, Italy
| | - Giuseppe Avvisati
- Unit of Hematology and Stem Cell Transplantation, Campus Bio-Medico University, Rome, Italy
| | - Pietro Leoni
- Unit of Hematology, AUO Ospedali Riuniti, Università Politecnica delle Marche, Ancona, Italy
| | - Attilio Olivieri
- Unit of Hematology, AUO Ospedali Riuniti, Università Politecnica delle Marche, Ancona, Italy
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Lambertini M, Richard F, Nguyen B, Viglietti G, Villarreal-Garza C. Ovarian Function and Fertility Preservation in Breast Cancer: Should Gonadotropin-Releasing Hormone Agonist be administered to All Premenopausal Patients Receiving Chemotherapy? CLINICAL MEDICINE INSIGHTS. REPRODUCTIVE HEALTH 2019; 13:1179558119828393. [PMID: 30886529 PMCID: PMC6410390 DOI: 10.1177/1179558119828393] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 01/10/2019] [Indexed: 11/15/2022]
Abstract
Chemotherapy-induced premature ovarian insufficiency (POI) is one of the potential drawbacks of chemotherapy use of particular concern for newly diagnosed premenopausal breast cancer patients. Temporary ovarian suppression obtained pharmacologically with the administration of a gonadotropin-releasing hormone agonist (GnRHa) during chemotherapy has been specifically developed as a method to counteract chemotherapy-induced gonadotoxicity with the main goal of diminishing the risk of POI. In recent years, important clinical evidence has become available on the efficacy and safety of this strategy that should now be considered a standard option for ovarian function preservation in premenopausal breast cancer patients, including women who are not interested in conceiving after treatment or that would not be candidates for fertility preservation strategies because of their age. Nevertheless, in women interested in fertility preservation, this is not an alternative to gamete cryopreservation, which remains as the first option to be offered. In this setting, temporary ovarian suppression with GnRHa during chemotherapy should be also proposed following gamete cryopreservation or to women who have no access, refuse, or have contraindications to surgical fertility preservation techniques. In this article, we present an overview about the role of temporary ovarian suppression with GnRHa during chemotherapy in breast cancer patients by addressing the available clinical evidence with the aim of identifying both the best candidates for the use of this strategy and the still existing gray zones requiring further investigation.
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Affiliation(s)
- Matteo Lambertini
- Department of Medical Oncology, U.O.C. Clinica di Oncologia Medica, Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - François Richard
- Breast Cancer Translational Research Laboratory, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B), Brussels, Belgium
| | - Bastien Nguyen
- Breast Cancer Translational Research Laboratory, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B), Brussels, Belgium
| | - Giulia Viglietti
- Breast Cancer Translational Research Laboratory, Institut Jules Bordet, Université Libre de Bruxelles (U.L.B), Brussels, Belgium
| | - Cynthia Villarreal-Garza
- Centro de Cancer de Mama del Hospital Zambrano Hellion, Tecnologico de Monterrey, Nuevo Leon, Mexico.,Departamento de Investigacion y de Tumores Mamarios del Instituto Nacional de Cancerologia, Mexico City, Mexico
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17
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Tomao F, Di Pinto A, Sassu CM, Bardhi E, Di Donato V, Muzii L, Petrella MC, Peccatori FA, Panici PB. Fertility preservation in ovarian tumours. Ecancermedicalscience 2018; 12:885. [PMID: 30679952 PMCID: PMC6345054 DOI: 10.3332/ecancer.2018.885] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Indexed: 12/14/2022] Open
Abstract
A considerable number of patients with a cancer diagnosis are of childbearing age and have not satisfied their desire for a family. Despite ovarian cancer (OC) usually occurring in older patients, 3%-14% are diagnosed at a fertile age with the overall 5-year survival rate being 91.2% in women ≤44 years of age when it is found at 1A-B stage. In this scenario, testing the safety and the efficacy of fertility sparing strategies in OC patients is very important overall in terms of quality of life. Unfortunately, the lack of randomised trials to validate conservative approaches does not guarantee the safety of fertility preservation strategies. However, evidence-based data from descriptive series suggest that in selected cases, the preservation of the uterus and at least one part of the ovary does not lead to a high risk of relapse. This conservative surgery helps to maintain organ function, giving patients of childbearing age the possibility to preserve their fertility. We hereby analysed the main evidence from the international literature on this topic in order to highlight the selected criteria for conservative management of OC patients, including healthy BRCA mutations carriers.
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Affiliation(s)
- Federica Tomao
- Department of Gynaecological and Obstetrical Sciences and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Anna Di Pinto
- Department of Gynaecological and Obstetrical Sciences and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Carolina Maria Sassu
- Department of Gynaecological and Obstetrical Sciences and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Erlisa Bardhi
- Department of Gynaecological and Obstetrical Sciences and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Violante Di Donato
- Department of Gynaecological and Obstetrical Sciences and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Ludovico Muzii
- Department of Gynaecological and Obstetrical Sciences and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | | | | | - Pierluigi Benedetti Panici
- Department of Gynaecological and Obstetrical Sciences and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
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18
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Blumenfeld Z. Fertility Preservation by Endocrine Suppression of Ovarian Function Using Gonadotropin-Releasing Hormone Agonists: The End of the Controversy? J Clin Oncol 2018; 36:1895-1897. [DOI: 10.1200/jco.2018.78.9347] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Zeev Blumenfeld
- Zeev Blumenfeld, Technion–Israel Institute of Technology, Haifa, Israel
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19
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Abstract
BACKGROUND Triptorelin, a gonadotropin releasing hormone analogue, can be administered to postpubertal female individuals with cancer who receive chemotherapy to obtain menstrual suppression and decrease the risk of hemorrhage caused by thrombocytopenia. Our goal was to assess whether triptorelin also has a protective role against the gonadotoxicity of chemotherapy. PATIENTS AND METHODS This retrospective observational study includes all postmenarchal female patients who presented to our Unit from 2000 to 2015 and received chemotherapy for cancer. They were administered depot triptorelin. We evaluated long-term ovarian function in order to detect clinical signs of ovarian damage, miscarriages, and pregnancies. Laboratory follow-up consisted in dosing serum follicle stimulating hormone, luteinizing hormone, prolactin, estradiol, and progesterone. Ultrasound of the ovaries was performed as well. RESULTS Of 36 evaluable patients, 9 received hematopoietic stem cell transplantation (HSCT). The remaining 27 patients maintained normal ovarian function at clinical, laboratory, and ultrasound assessment. Five of them achieved spontaneous physiological pregnancy. Four of the 9 patients who underwent HSCT developed premature ovarian failure. CONCLUSION Our study suggests that gonadotropin releasing hormone-a administered during chemotherapy can prevent premature ovarian failure in patients treated without HSCT and that it is not enough to preserve the ovarian function during HSCT. Hence, a prospective randomized trial with a larger population would be recommended.
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20
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Hickman LC, Llarena NC, Valentine LN, Liu X, Falcone T. Preservation of gonadal function in women undergoing chemotherapy: a systematic review and meta-analysis of the potential role for gonadotropin-releasing hormone agonists. J Assist Reprod Genet 2018; 35:571-581. [PMID: 29470701 PMCID: PMC5949114 DOI: 10.1007/s10815-018-1128-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/23/2018] [Indexed: 01/15/2023] Open
Abstract
PURPOSE To evaluate the available randomized controlled trials (RCTs) in the literature investigating the use of gonadotropin-releasing hormone agonist (GnRHa) co-treatment for ovarian preservation in women receiving chemotherapy. METHODS A systematic review of the literature was performed from 1960 through 2017 to identify relevant RCTs. Included patients had lymphoma, ovarian cancer, or breast cancer. The primary outcome was the proportion of women who retained ovarian function after chemotherapy. Extracted data points included study design, patient characteristics, and proportion of women who developed premature ovarian failure (POF). A risk of bias assessment was performed according to the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. The pooled odds ratio was calculated, and outcomes of individual studies were compared using the random-effects model with the inverse-variance method and the DerSimonian-Laird estimator. RESULTS Twenty-nine RCTs were identified, and 10 met criteria for inclusion in the meta-analysis. An analysis of patients who did not develop POF after chemotherapy revealed eight studies supporting the use of GnRHa (OR 1.83; 95% CI 1.34-2.49). The duration of benefit of GnRHa is unclear. An analysis of three studies with outcome data at 2 years revealed a non-significant OR of 0.53 (95% CI 0.22-1.30) for the preservation of ovarian function with GnRHa treatment. CONCLUSION GnRHa may have a protective effect against the development of POF after gonadotoxic chemotherapy; however, the duration of benefit is unclear and requires further study.
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Affiliation(s)
- Lisa C Hickman
- Department of Obstetrics/Gynecology, Cleveland Clinic Foundation, 9500 Euclid Avenue, A81, Cleveland, OH, 44195, USA
| | - Natalia C Llarena
- Department of Obstetrics/Gynecology, Cleveland Clinic Foundation, 9500 Euclid Avenue, A81, Cleveland, OH, 44195, USA
| | - Lindsey N Valentine
- Department of Obstetrics/Gynecology, Cleveland Clinic Foundation, 9500 Euclid Avenue, A81, Cleveland, OH, 44195, USA
| | - Xiaobo Liu
- Department of Quantitative Health Science, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Tommaso Falcone
- Department of Obstetrics/Gynecology, Cleveland Clinic Foundation, 9500 Euclid Avenue, A81, Cleveland, OH, 44195, USA.
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Affiliation(s)
- Zeev Blumenfeld
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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22
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Abstract
PURPOSE OF REVIEW Fertility preservation has recently gained a worldwide interest among fertility specialists, oncologists, and all healthcare providers. Thus, the protection against iatrogenic infertility caused by chemotherapy assumes a high priority. Specifically, the issue of endocrine prevention of gonadotoxicity is still a controversial subject. RECENT FINDINGS During the last year, many publications on this subject appeared, swinging the pendulum toward the beneficial role of gonadotropin-releasing hormone agonist (GnRHa) cotreatment for fertility preservation despite gonadotoxic chemotherapy. Here, we summarize the recent publications on fertility preservation and minimizing chemotherapy-induced gonadotoxicity. SUMMARY More than 10 recent meta-analyses have concluded that GnRHa is beneficial and may decrease the risk of premature ovarian failure and increase the pregnancy rate in survivors. Furthermore, two recent international meetings of experts have concluded that GnRHa is effective and should be offered to every young woman facing gonadotoxic chemotherapy.
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23
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Cima LN, Colita A, Fica S. Perspectives on the co-treatment with GnRHa in female patients undergoing hematopoietic stem cell transplantation. Endocr Connect 2017; 6:R162-R170. [PMID: 28947558 PMCID: PMC5655684 DOI: 10.1530/ec-17-0246] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 09/25/2017] [Indexed: 11/08/2022]
Abstract
Outcomes after hematopoietic stem cell transplantation (HSCT) for patients with both malignant and nonmalignant diseases have improved significantly in recent years. However, the endocrine system is highly susceptible to damage by the high-dose chemotherapy and/or irradiation used in the conditioning regimen before HSCT. Ovarian failure and subsequent infertility are frequent complications that long-term HSCT survivors and their partners face with a negative impact on their QoL. Several meta-analyses of randomized clinical trials showed that gonadotropin-releasing hormone agonist (GnRHa) administration in advance of starting standard chemotherapy decreases the risk of gonadal dysfunction and infertility in cancer patients, but GnRHa use for ovarian protection in HSCT patients is not fully determined. In this review, we are discussing the potential preservation of ovarian function and fertility in pubertal girls/premenopausal women who undergo HSCT using GnRHa in parallel with conditioning chemotherapy, focusing on the current data available and making some special remarks regarding the use of GnRHa.
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Affiliation(s)
| | - Anca Colita
- Carol Davila University of Medicine and PharmacyBucharest, Romania
- Hematology DepartmentFundeni Hospital, Bucharest, Romania
| | - Simona Fica
- Carol Davila University of Medicine and PharmacyBucharest, Romania
- Endocrine DepartmentElias Hospital, Bucharest, Romania
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24
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Saraf AJ, Nahata L. Fertility counseling and preservation: considerations for the pediatric endocrinologist. Transl Pediatr 2017; 6:313-322. [PMID: 29184812 PMCID: PMC5682384 DOI: 10.21037/tp.2017.07.02] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Infertility is a distressing consequence of numerous pediatric medical conditions and treatments. The field of pediatric fertility preservation has expanded rapidly over the past decade, and clinical guidelines emphasize the importance of discussing infertility risk and fertility preservation options with patients and families in a timely manner. Understanding the various mechanisms and presentations of fertility issues across diagnoses is imperative to provide counseling to patients and families, and identify individuals who may benefit from fertility preservation. The goals of this manuscript are to outline current fertility preservation options in pediatrics, review populations at-risk for infertility that are seen in pediatric endocrinology, and discuss other important issues related to fertility preservation including ethical considerations.
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Affiliation(s)
- Amanda J Saraf
- Division of Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Leena Nahata
- Division of Endocrinology, Nationwide Children's Hospital, Columbus, OH, USA.,Center for Biobehavioral Health, the Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
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25
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Fertility and pregnancy issues in BRCA -mutated breast cancer patients. Cancer Treat Rev 2017; 59:61-70. [DOI: 10.1016/j.ctrv.2017.07.001] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/04/2017] [Accepted: 07/05/2017] [Indexed: 01/08/2023]
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26
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Blumenfeld Z. Investigational and experimental GnRH analogs and associated neurotransmitters. Expert Opin Investig Drugs 2017; 26:661-667. [DOI: 10.1080/13543784.2017.1323869] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Zeev Blumenfeld
- Reproductive Endocrinology, Ob/Gyn, Rappaport Faculty of Medicine, Technion – Israel Institute of Technology, Haifa, Israel
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27
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28
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Blumenfeld Z. Endocrine prevention of chemotherapy-induced ovarian failure. Future Oncol 2016; 12:1671-4. [DOI: 10.2217/fon-2016-0182] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Zeev Blumenfeld
- Reproductive Endocrinology, RAMBAM Health Care Campus, The Rappaport Faculty of Medicine, Technion – Israel Institute of Technology, Haifa, 31096 Israel
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29
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Rose SR, Horne VE, Howell J, Lawson SA, Rutter MM, Trotman GE, Corathers SD. Late endocrine effects of childhood cancer. Nat Rev Endocrinol 2016; 12:319-36. [PMID: 27032982 DOI: 10.1038/nrendo.2016.45] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
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.
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Affiliation(s)
- Susan R Rose
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, Ohio 45229, USA
| | - Vincent E Horne
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, Ohio 45229, USA
| | - Jonathan Howell
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, Ohio 45229, USA
| | - Sarah A Lawson
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, Ohio 45229, USA
| | - Meilan M Rutter
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, Ohio 45229, USA
| | - Gylynthia E Trotman
- Division of Pediatric and Adolescent Gynecology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, Ohio 45229, USA
| | - Sarah D Corathers
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, Ohio 45229, USA
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Treatment of Endometriosis with the GnRHa Deslorelin and Add-Back Estradiol and Supplementary Testosterone. BIOMED RESEARCH INTERNATIONAL 2015; 2015:934164. [PMID: 26881208 PMCID: PMC4736002 DOI: 10.1155/2015/934164] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 12/16/2015] [Indexed: 01/01/2023]
Abstract
Background. This randomized, multicenter, open-label clinical trial was intended to generate pilot data on the efficacy and safety of the gonadotropin-releasing hormone agonist (GnRHa) deslorelin (D) with low-dose estradiol ± testosterone (E2 ± T) add-back for endometriosis-related pelvic pain. Methods. Women with pelvic pain and laparoscopically confirmed endometriosis were treated with a six-month course of daily intranasal D with concurrent administration of either transdermal E2, intranasal E2, or intranasal E2 + T. Efficacy data included evaluation of dyspareunia, dysmenorrhea, pelvic pain, tenderness, and induration. Cognition and quality of life were also assessed. Safety parameters included assessment of endometrial hyperplasia, bone mineral density (BMD), and hot flashes. Results. Endometriosis symptoms and signs scores decreased in all treatment arms from a baseline average of 7.4 to 2.5 after 3 months of treatment and 3.4 after 6 months. BMD changes and incidence of hot flashes were minimal, and no endometrial hyperplasia was observed. Patient-reported outcomes showed significant improvement across multiple domains. Conclusions. Daily intranasal D with low dose E2 ± T add-back resulted in significant reduction in severity of endometriosis symptoms and signs with few safety signals and minimal hypoestrogenic symptoms that would be expected with the use of a GnRHa alone.
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Maggi R, Cariboni AM, Marelli MM, Moretti RM, Andrè V, Marzagalli M, Limonta P. GnRH and GnRH receptors in the pathophysiology of the human female reproductive system. Hum Reprod Update 2015; 22:358-81. [PMID: 26715597 DOI: 10.1093/humupd/dmv059] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 12/03/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Human reproduction depends on an intact hypothalamic-pituitary-gonadal (HPG) axis. Hypothalamic gonadotrophin-releasing hormone (GnRH) has been recognized, since its identification in 1971, as the central regulator of the production and release of the pituitary gonadotrophins that, in turn, regulate the gonadal functions and the production of sex steroids. The characteristic peculiar development, distribution and episodic activity of GnRH-producing neurons have solicited an interdisciplinary interest on the etiopathogenesis of several reproductive diseases. The more recent identification of a GnRH/GnRH receptor (GnRHR) system in both the human endometrium and ovary has widened the spectrum of action of the peptide and of its analogues beyond its hypothalamic function. METHODS An analysis of research and review articles published in international journals until June 2015 has been carried out to comprehensively summarize both the well established and the most recent knowledge on the physiopathology of the GnRH system in the central and peripheral control of female reproductive functions and diseases. RESULTS This review focuses on the role of GnRH neurons in the control of the reproductive axis. New knowledge is accumulating on the genetic programme that drives GnRH neuron development to ameliorate the diagnosis and treatment of GnRH deficiency and consequent delayed or absent puberty. Moreover, a better understanding of the mechanisms controlling the episodic release of GnRH during the onset of puberty and the ovulatory cycle has enabled the pharmacological use of GnRH itself or its synthetic analogues (agonists and antagonists) to either stimulate or to block the gonadotrophin secretion and modulate the functions of the reproductive axis in several reproductive diseases and in assisted reproduction technology. Several inputs from other neuronal populations, as well as metabolic, somatic and age-related signals, may greatly affect the functions of the GnRH pulse generator during the female lifespan; their modulation may offer new possible strategies for diagnostic and therapeutic interventions. A GnRH/GnRHR system is also expressed in female reproductive tissues (e.g. endometrium and ovary), both in normal and pathological conditions. The expression of this system in the human endometrium and ovary supports its physiological regulatory role in the processes of trophoblast invasion of the maternal endometrium and embryo implantation as well as of follicular development and corpus luteum functions. The GnRH/GnRHR system that is expressed in diseased tissues of the female reproductive tract (both benign and malignant) is at present considered an effective molecular target for the development of novel therapeutic approaches for these pathologies. GnRH agonists are also considered as a promising therapeutic approach to counteract ovarian failure in young female patients undergoing chemotherapy. CONCLUSIONS Increasing knowledge about the regulation of GnRH pulsatile release, as well as the therapeutic use of its analogues, offers interesting new perspectives in the diagnosis, treatment and outcome of female reproductive disorders, including tumoral and iatrogenic diseases.
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Affiliation(s)
- Roberto Maggi
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti, 9, 20133 Milano, Italy
| | - Anna Maria Cariboni
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti, 9, 20133 Milano, Italy
| | - Marina Montagnani Marelli
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti, 9, 20133 Milano, Italy
| | - Roberta Manuela Moretti
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti, 9, 20133 Milano, Italy
| | - Valentina Andrè
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti, 9, 20133 Milano, Italy
| | - Monica Marzagalli
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti, 9, 20133 Milano, Italy
| | - Patrizia Limonta
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti, 9, 20133 Milano, Italy
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Blumenfeld Z, Zur H, Dann EJ. Gonadotropin-Releasing Hormone Agonist Cotreatment During Chemotherapy May Increase Pregnancy Rate in Survivors. Oncologist 2015; 20:1283-9. [PMID: 26463871 DOI: 10.1634/theoncologist.2015-0223] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 08/13/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The use of gonadotropin-releasing hormone analogs (GnRHas) for fertility preservation is not unequivocally accepted. It is controversial whether GnRHa can increase the pregnancy rate in survivors. PATIENTS AND METHODS This is a retrospective cohort study. Every patient referred for fertility preservation was offered cryopreservation of embryos, ova, and ovarian tissue and GnRHa. The patients were consecutively included. The primary outcome was spontaneous pregnancies. The secondary outcome was cyclic ovarian function (COF) versus premature ovarian failure (POF). These outcomes were assessed 2 years or more after chemotherapy. RESULTS We compared 286 patients who received gonadotropin-releasing hormone agonist (GnRHa) with chemotherapy with 188 patients who were treated with chemotherapy alone. Ovarian function could be determined in 217 patients. Overall, 87% (127 of 146) of the patients in the GnRHa group retained COF and 13% (19 of 146) suffered POF, whereas in the control group, 49% (35 of 71) experienced COF and 51% (36 of 71) suffered POF (p = .0001). The odds ratio (OR) for preserving COF was 6.87 for the patients who received GnRHa (95% confidence interval [CI] 3.4-13.4). Overall 60% (112 of 188) of the survivors conceived: 69.3% (84 of 122) of the patients in the GnRHa group compared with 42.4% (28 of 66) in the control group (p = .006). In the GnRHa group, 123 healthy newborns were delivered, versus 40 in the controls. Spontaneous pregnancies occurred in 65.6% (80 of 122) of the survivors in the GnRHa group versus 37.9% (25 of 66) in the control group (p = .0004, OR 3.12, 95% CI 1.7-5.8). CONCLUSION Adding GnRHa to chemotherapy significantly increases the OR for spontaneous conception, in addition to COF. It is suggested that GnRHa cotreatment should be added before and during gonadotoxic chemotherapy. IMPLICATIONS FOR PRACTICE The use of gonadotropin-releasing hormone analogs (GnRHa) for fertility preservation is not unequivocally accepted and is even controversial. This study compared 286 patients who received GnRHa with chemotherapy with 188 patients who were treated with chemotherapy alone. Ovarian function could be determined in 217 patients. The odds ratio for preserving cyclic ovarian function was 6.87 for the patients who received GnRHa. Furthermore, the total and spontaneous pregnancy rate was significantly higher for those who received the agonist (p = .006). Adding GnRHa to chemotherapy significantly increased the odds ratio for spontaneous conception, in addition to preserving regular ovarian function. It is suggested that GnRHa cotreatment should be administered to young women in conjunction with gonadotoxic chemotherapy.
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Affiliation(s)
- Zeev Blumenfeld
- Department of Gynecology and Obstetrics, Rambam Health Care Campus and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel Department of Reproductive Endocrinology, Rambam Health Care Campus and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Hilli Zur
- Department of Reproductive Endocrinology, Rambam Health Care Campus and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Eldad J Dann
- Department of Hematology, Rambam Health Care Campus and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Llarena NC, Estevez SL, Tucker SL, Jeruss JS. Impact of Fertility Concerns on Tamoxifen Initiation and Persistence. J Natl Cancer Inst 2015; 107:986599. [PMID: 26307641 PMCID: PMC5825683 DOI: 10.1093/jnci/djv202] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 04/08/2015] [Accepted: 06/26/2015] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Adjuvant tamoxifen reduces breast cancer recurrence risk and mortality; however, initiation and treatment persistence are poor for younger patients. We hypothesized that a unique set of factors, including fertility concerns, would contribute to the poor tamoxifen use among premenopausal patients. METHODS From 2007 to 2012, 515 premenopausal patients younger than age 45 years, with stage 0 to III hormone receptor-positive breast cancer, for whom tamoxifen was recommended, were identified. Clinical and pathologic tumor characteristics, treatment regimens, and fertility concerns were recorded. Clinical factors associated with tamoxifen noninitiation and discontinuation were identified using univariate and multivariable analysis. After the recommendation for tamoxifen, patient reasons for tamoxifen noninitiation or discontinuation were also documented. All statistical tests were two-sided. RESULTS Based on multivariable analysis, fertility concerns were statistically associated with both noninitiation (odds ratio = 5.04, 95% confidence interval (CI) = 2.29 to 11.07) and early discontinuation (hazard ratio = 1.78, 95% CI = 1.09 to 3.38) of tamoxifen. Other independent predictors of noninitiation included a diagnosis of ductal carcinoma in situ, declining radiation, and not receiving chemotherapy (stage I-III). Additionally, smoking and not receiving radiation therapy were statistically significant predictors of early withdrawal from therapy. Primary patient reasons for noninitiation and early discontinuation included concerns about side effects and fertility. CONCLUSION This study provided insight into factors associated with tamoxifen use for reproductive-aged breast cancer survivors, with a new focus on fertility. Fertility concerns negatively impacted tamoxifen initiation and continuation among premenopausal patients. Interventions to optimize treatment initiation and persistence for young cancer patients should include access to fertility preservation options.
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Affiliation(s)
| | | | - Susan L Tucker
- Department of Bioinformatics and Computational Biology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jacqueline S Jeruss
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
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Luskin MR, Banerjee R, Del Percio S, Loren AW. A Pound of Cure Requires An Ounce (or More) of Prevention: Survivorship and Complications of Therapy for Hematologic Malignancies. Curr Hematol Malig Rep 2015; 10:225-36. [PMID: 26162948 DOI: 10.1007/s11899-015-0274-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Patients treated for a hematologic malignancy are at risk for treatment-related complications. As the goal of therapy is frequently curative, treatments are especially intensive and long-term toxicity is common. Chemotherapy and radiation are associated with increased risk for cardiac and pulmonary disease, endocrine disorders, infertility, sexual dysfunction, second cancers, and psychosocial distress. The risk for each complication is dictated by patient characteristics including age, co-morbidities, and genetic predispositions, as well as the specifics of therapy. Survivors of pediatric cancers and allogeneic hematopoietic stem cell transplantation have unique risks due to vulnerable age at time of toxic exposure and ongoing immune dysfunction, respectively.
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Affiliation(s)
- Marlise R Luskin
- Division of Hematology-Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA,
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Waimey KE, Smith BM, Confino R, Jeruss JS, Pavone ME. Understanding Fertility in Young Female Cancer Patients. J Womens Health (Larchmt) 2015; 24:812-8. [PMID: 26075731 DOI: 10.1089/jwh.2015.5194] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Young women diagnosed with cancer today have a greater chance of long-term survival than ever before. Successful survivorship for this group of patients includes maintaining a high quality of life after a cancer diagnosis and treatment; however, lifesaving treatments such as chemotherapy, radiation, and surgery can impact survivors by impairing reproductive and endocrine health. Studies demonstrate that future fertility is a concern for many women diagnosed with cancer, but physician knowledge and attitudinal barriers can still prevent females from receiving care. Today, fertility preservation is an option for girls and women facing a cancer diagnosis, and emerging research is providing clinicians with an increasing number of reproductive and hormonal management tools. Physicians can play an important role in fertility by working closely with oncologists, providing patients with information about fertility preservation options prior to the start of cancer treatment, monitoring reproductive capacity after treatment, and working with cancer survivors to explore potential avenues to parenthood.
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Affiliation(s)
- Kate E Waimey
- 1 Strategic Foundation Initiatives, University of Chicago , Chicago, Illinois
| | - Brigid M Smith
- 2 Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University , Chicago, Illinois
| | - Rafael Confino
- 2 Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University , Chicago, Illinois
| | - Jacqueline S Jeruss
- 3 Division of Surgical Oncology, Department of Surgery, University of Michigan , Ann Arbor, Michigan
| | - Mary Ellen Pavone
- 2 Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University , Chicago, Illinois
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Banerjee R, Tsiapali E. Occurrence and recall rates of fertility discussions with young breast cancer patients. Support Care Cancer 2015; 24:163-171. [PMID: 25967235 DOI: 10.1007/s00520-015-2758-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 04/27/2015] [Indexed: 12/21/2022]
Abstract
PURPOSE Fertility preservation is an important issue for premenopausal cancer patients; however, not all patients receive counseling about chemotherapy-induced infertility and potential mitigation strategies. We aimed to identify characteristics of premenopausal breast cancer patients less likely to receive fertility counseling. We also investigated patient recall of chart-documented fertility discussions and patient attitudes toward fertility preservation. METHODS The study was approved by our institution's Institutional Review Board. All female patients with invasive primary breast cancer of any type, aged 40 or younger at the time of diagnosis, who were diagnosed during or up to 5 years prior to the study period were eligible. The study was conducted between February 2012 and October 2013. Enrolled patients completed an anonymous survey, and their medical charts were subsequently reviewed to identify provider documentation of fertility discussions, referral to fertility specialists, or implementation of fertility preservation. Patient comments regarding their fertility were solicited and examined thematically. RESULTS Forty-nine patients consented to participate. Fertility discussions were documented by providers in 55% of patients. Patients aged over 35 and multiparous patients were significantly less likely than their counterparts (p < 0.01 in both cases) to have had chart-documented fertility discussions. Only 52% of patients with chart-documented discussions recalled having had such a conversation. Patient comments highlighted the difficulty of considering fertility at the time of diagnosis and also the risks and obstacles facing fertility preservation. CONCLUSIONS Despite increasing awareness, fertility is not universally discussed with premenopausal breast cancer patients at the time of diagnosis; older and multiparous patients are at particular risk of not receiving fertility counseling. Even when such discussions are documented, only about half of patients recall the conversation. Patient-reported barriers to fertility preservation include lack of education combined with the stress of diagnosis, financial costs, and perceived treatment toxicities.
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Affiliation(s)
- Rahul Banerjee
- Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ekaterini Tsiapali
- Medstar Regional Breast Health Program at Medstar Southern Maryland Hospital Center, Department of Surgery, Georgetown University, Washington, DC, USA. .,, 7501 Surratts Road, Suite 303, Clinton, MD, 20735, USA.
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Barni S, Collovà E, Frassoldati A, Amoroso D. Adjuvant hormonal therapy and fertility preservation in premenopausal breast cancer: a survey among Italian oncologists. Future Oncol 2015; 11:1181-9. [PMID: 25832875 DOI: 10.2217/fon.14.289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Increasing age of first pregnancy among Italian women with premenopausal breast cancer makes adjuvant hormonal therapy a hot topic, justifying a survey on the therapeutic approach of Italian oncologists. MATERIALS & METHODS From April to July 2012, an 11-item electronic questionnaire was submitted to Italian oncologists and 611 out of 974 invited filled questionnaires were collected from all over Italy. RESULTS In total, 97.7% of patients aged <40 years needing only hormonal therapy would receive both tamoxifen and luteinizing hormone-releasing hormone agonists (LHRHa); 2.3% tamoxifen or LHRHa alone. For the majority of oncologists LHRHa was also the preferred choice to preserving fertility. CONCLUSION Results are rather consistent with major guidelines but with a greater use of LHRHa and aromatase inhibitor.
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Affiliation(s)
- Sandro Barni
- UO Oncologia Medica, Azienda Ospedaliera Treviglio, Treviglio BG, Italy
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Blumenfeld Z, Evron A. Preserving fertility when choosing chemotherapy regimens - the role of gonadotropin-releasing hormone agonists. Expert Opin Pharmacother 2015; 16:1009-20. [PMID: 25826240 DOI: 10.1517/14656566.2015.1031654] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION The late effects of cancer treatment have recently gained a worldwide ubiquitous interest among reproductive endocrinologists, oncologists, and all health care providers. Despite many publications on this subject, there are many equivocal issues necessitating summary. The case for and against using GnRH-agonist for fertility preservation is summarized with the rationale that preventing ovarian failure may be better than treating it. AREAS COVERED We searched Medline in the last 10 years using terms: 'fertility preservation', 'female chemotherapy', 'Gonadotropin-releasing hormone (GnRH) analogues', 'GnRH agonists' 'gonadotoxicity', and 'cancer treatment'. We included mainly publications from the past 7 years, but did not exclude previous, commonly referenced publications. Here, we summarize the various methods available for fertility preservation and minimizing chemotherapy induced gonadotoxicity. EXPERT OPINION Until now, 20 studies (15 retrospective and 5 randomized controlled trial) have reported on 2038 patients treated with GnRH-a in parallel to chemotherapy, showing a significant decrease in premature ovarian failure (POF) rate in survivors versus 8 studies reporting on 509 patients, with negative results. Patients treated with GnRH-a in parallel to chemotherapy preserved their cyclic ovarian function in 91% of cases as compared to 41% of controls, with a pregnancy rate of 19 - 71% in the treated patients. Furthermore, over 10 recent meta-analyses have concluded that GnRH-a are beneficial and may decrease the risk of POF in survivors. Because most of the methods involving ovarian or egg cryopreservation are not yet clinically established and unequivocally successful, these young patients deserve to be informed with all the various modalities to minimize gonadal damage and preserve ovarian function and future fertility. Combining the various modalities for a specific patient may increase the odds of preservation of future fertility.
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Affiliation(s)
- Zeev Blumenfeld
- Reproductive Endocrinology, Rambam Health Care Campus, Department Obstetrics and Gynecology, Technion - Israel Institute of Technology, The Rappaport Faculty of Medicine , 8 Ha'Aliyah St, Haifa, 31096 , Israel +972 4 7772577 ; +972 4 7773243 ; ;
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Tan SJ, Lee LJ, Tzeng CR, Wang CW, Hsu MI, Chen CH. Targeted anti-apoptosis activity for ovarian protection against chemotherapy-induced ovarian gonadotoxicity. Reprod Biomed Online 2014; 29:612-20. [DOI: 10.1016/j.rbmo.2014.07.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 07/05/2014] [Accepted: 07/08/2014] [Indexed: 11/28/2022]
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Affiliation(s)
- Zeev Blumenfeld
- Department of Obstetrics and Gynecology, Reproductive Endocrinology, Rambam Health Care Campus, The Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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