The Psychosocial Impact of Cancer-Related Infertility on Women

Fertility Preservation in the Era of Immuno-Oncology: Lights and Shadows

In recent years, immuno-oncology has revolutionized the cancer treatment field by harnessing the immune system's power to counteract cancer cells. While this innovative approach holds great promise for improving cancer outcomes, it also raises important considerations related to fertility and reproductive toxicity. In fact, most young females receiving gonadotoxic anti-cancer treatments undergo iatrogenic ovarian exhaustion, resulting in a permanent illness that precludes the vocation of motherhood as a natural female sexual identity. Although commonly used, oocyte cryopreservation for future in vitro fertilization and even ovarian cortex transplantation are considered unsafe procedures in cancer patients due to their oncogenic risks; whereas, ovarian stem cells might support neo-oogenesis, providing a novel stemness model of regenerative medicine for future fertility preservation programs in oncology. Recent scientific evidence has postulated that immune checkpoint inhibitors (ICIs) might in some way reduce fertility by inducing either primary or secondary hypogonadism, whose incidence and mechanisms are not yet known. Therefore, considering the lack of data, it is currently not possible to define the most suitable FP procedure for young patients who are candidates for ICIs. In this report, we will investigate the few available data concerning the molecular regulation of ICI therapy and their resulting gonadal toxicity, to hypothesize the most suitable fertility preservation strategy for patients receiving these drugs.

The Impact of Tyrosine Kinase Inhibitors on Fatherhood in Patients With Chronic Myeloid Leukemia: A Mixed-Method Study

INTRODUCTION

Multiple studies have demonstrated that tyrosine kinase inhibitors (TKIs) exert a significant extent of control over chronic myeloid leukemia (CML), as evidenced by studies such as the population-based Swedish CML registry, which found that patients reaching age 70 had a relative survival rate close to one when compared to the general population. Consequently, new perspectives on the safety of treatments have emerged, particularly in the context of their impact on fatherhood in men. According to the authors, this is the first study to examine the effect of TKIs on fatherhood in CML patients.  Methods: A single-center, mixed-design study (retrospective data review and phone interviews) was conducted with CML male patients in the chronic or accelerated phase, evaluating the effect of imatinib, dasatinib, and nilotinib on their fatherhood, irrespective of whether they were administered as a first, second, or third line of treatment.

RESULTS

The study included interviews with 150 patients. Included were 27 patients. The average age was approximately 44.5 years. One hundred percent of the patients were in the chronic phase. The median age at first conception following TKI therapy was 36, and the median duration of TKI therapy was approximately seven years. The total number of offspring was 49; 98% were born at term and had a normal birth weight. No reports of stillbirths, fetal deaths, or congenital malformations were made. All the offspring grew and developed normally. No CML-related cancers were reported in any of the newborns.

CONCLUSION

Around 98% of male CML patients receiving imatinib, dasatinib, or nilotinib did not experience a negative impact on their fatherhood or the health of their children. However, improved education for patients beginning treatment with TKIs addresses the potential psychological worry of having an unfavorable effect on their fertility or offspring, which may increase medication adherence.

A conceptual model of fertility concerns among adolescents and young adults with cancer

OBJECTIVE

For adolescents and young adults (AYAs), cancer-related fertility concerns (FC) are salient, disruptive, and complex. Clinical communication about FC and fertility preservation options are suboptimal, increasing patient distress. The purpose of this study is to construct a conceptual model of FC among AYAs with cancer to inform future measurement development.

METHODS

Concept elicitation interviews were conducted with a purposive sample of stakeholders: 36 AYAs (10 adolescents, 12 emerging adults, and 14 young adults), 36 AYA oncology health care providers, and 12 content experts in cancer-related infertility. The constant comparative method was used to identify themes and properties that illustrate AYAs' conceptualization and/or experience of FC.

RESULTS

Thirteen themes characterized FC among AYAs with cancer, varying by stakeholder group and domain affiliations. Themes were grouped by four domains (e.g., affective, information, coping, and logistical), which organized the conceptual model. Affective experiences were further determined to be an important component within the other three domains. AYAs' fertility and fertility preservation experiences were shaped by communication factors and timing factors including placement along the lifespan/cancer continuum.

CONCLUSIONS

AYA FC are characterized by uncertainty and confusion that may contribute to future decisional regret or magnify feelings of loss. Results add to previous research by examining individual, relational, and health care factors that fluctuate to inform fertility preservation perceptions and decision-making across the AYA age spectrum. Findings will be used to develop and test new self-report measures of FC among AYAs with cancer and survivors using classic and modern measurement theory approaches.

Fertilitätserhalt bei Patienten in der Dermatoonkologie – Eine aktuelle Übersicht

Bei vielen Patienten, die an einem Malignom erkranken, ist die Familienplanung noch nicht abgeschlossen, sodass für den Erhalt des fertilen Potenzials Maßnahmen der Fertilitätsprotektion sinnvoll sind. Durch eine Polychemotherapie, unabhängig ob im neoadjuvanten oder adjuvanten Setting, Molekular- oder Immuntherapien kann es zu einer irreversiblen Schädigung der Follikel bzw. Spermatogenese kommen, was u. U. zu einer permanenten Infertilität führen kann. Abhängig von der verwendeten Therapie und der altersabhängigen Ovarialreserve der Frau muss das gonadotoxische Risiko als niedrig, mittel oder hoch eingeschätzt werden. Möglichkeiten des Fertilitäserhalts sind: a) die Kryokonservierung von fertilisierten oder unfertilisierten Oozyten. Hierbei werden nach ovarieller Hyperstimulation reife Oozyten mittels transvaginaler Follikelaspiration gewonnen und im Anschluss entweder unfertilisiert oder nach erfolgter IVF- oder ICSI-Behandlung kryokonserviert. Bei b) der Kryokonservierung von Ovarialgewebe wird mithilfe eines laparoskopischen Eingriffs etwa 50 % des Ovarkortex eines Ovars reseziert und kryokonserviert. Die Verwendung von c) GnRH-Agonisten als medikamentöse Therapieoption unternimmt den Versuch einer endokrinen Ovarialsuppression, um Oozyten, Granulosa- und Thekazellen vor dem zytotoxischen Einfluss der jeweiligen Therapie zu schützen. Bei männlichen Patienten können Spermien vor Therapiebeginn kryokonserviert werden.

An evaluation of oncofertility decision support resources among breast cancer patients and health care providers

BACKGROUND

Cancer patients of reproductive age are at risk of infertility as a result of their treatment. Oncofertility decision support resources can assist patients with fertility decision-making before treatment yet available oncofertility resources contain varying levels of detail and different fertility options. The key information/sections needed in oncofertility resources remain unclear. To explore the information needs for oncofertility decision-making before cancer treatment, we aimed to evaluate existing oncofertility decision support resources with breast cancer patients and providers.

METHODS

We conducted 30 to 90-min interviews that included a survey questionnaire and open-ended questions with patients and providers between March and June 2016. Interviews were transcribed verbatim. Analysis involved descriptive statistics for survey responses and thematic analysis of qualitative data.

RESULTS

A total of 16 participants completed interviews. Key information perceived by most participants as necessary for fertility decision-making included tailored post-treatment pregnancy rates, cost ranges and financial assistance for the fertility options based on patients' situation. However, patient and provider participants expressed differing opinions on the inclusion of all before and after treatment fertility options and the amount of fertility information required at diagnosis.

CONCLUSION

The evaluation identified fertility information needs among patients in addition to providers' views on patient needs. While existing oncofertility resources contain information perceived as necessary for decision-making there is an opportunity to use these findings to create or enhance resources to better meet the needs of patients. Additionally, patients and providers differing views on information needs highlight the opportunity for provider training to ensure better communication using resources in clinic to understand specific patient needs.

Fertility Preservation in Female Patients with Breast Cancer - a Current Overview

Many premenopausal patients who develop breast cancer have not yet completed their family planning, so measures of fertility protection to preserve their fertile potential would be beneficial. Polychemotherapy causes irreversible damage to the ovarian follicles – irrespective of whether in a neoadjuvant or adjuvant setting – and this can sometimes result in permanent infertility. Depending on which cytostatic agents are used and on the age-related ovarian reserve of the woman, gonadotoxic risk must be classified as low, moderate or high. Options of fertility preservation include: a) cryopreservation of fertilised or unfertilised oocytes. After ovarian hyperstimulation, mature oocytes are retrieved by transvaginal follicle aspiration, after which they are cryopreserved, either unfertilised or on completion of IVF or ICSI treatment. During b) cryopreservation of ovarian tissue, about 50% of the ovarian cortex of one ovary is resected with the aid of a laparoscopic procedure and cryopreserved. The application of c) GnRH agonists as a medicinal therapy option is an attempt at endocrine ovarian suppression in order to protect oocytes, granulosa cells and theca cells from the cytotoxic effect of chemotherapy.

Observational study of the development and evaluation of a fertility preservation patient decision aid for teenage and adult women diagnosed with cancer: the Cancer, Fertility and Me research protocol

INTRODUCTION

Women diagnosed with cancer and facing potentially sterilising cancer treatment have to make time-pressured decisions regarding fertility preservation with specialist fertility services while undergoing treatment of their cancer with oncology services. Oncologists identify a need for resources enabling them to support women's fertility preservation decisions more effectively; women report wanting more specialist information to make these decisions. The overall aim of the 'Cancer, Fertility and Me' study is to develop and evaluate a new evidence-based patient decision aid (PtDA) for women with any cancer considering fertility preservation to address this unmet need.

METHODS AND ANALYSIS

This is a prospective mixed-method observational study including women of reproductive age (16 years +) with a new diagnosis of any cancer across two regional cancer and fertility centres in Yorkshire, UK. The research involves three stages. In stage 1, the aim is to develop the PtDA using a systematic method of evidence synthesis and multidisciplinary expert review of current clinical practice and patient information. In stage 2, the aim is to assess the face validity of the PtDA. Feedback on its content and format will be ascertained using questionnaires and interviews with patients, user groups and key stakeholders. Finally, in stage 3 the acceptability of using this resource when integrated into usual cancer care pathways at the point of cancer diagnosis and treatment planning will be evaluated. This will involve a quantitative and qualitative evaluation of the PtDA in clinical practice. Measures chosen include using count data of the PtDAs administered in clinics and accessed online, decisional and patient-reported outcome measures and qualitative feedback. Quantitative data will be analysed using descriptive statistics, paired sample t-tests and CIs; interviews will be analysed using thematic analysis.

ETHICS AND DISSEMINATION

Research Ethics Committee approval (Ref: 16/EM/0122) and Health Research Authority approval (Ref: 194751) has been granted. Findings will be published in open access peer-reviewed journals, presented at conferences for academic and health professional audiences, with feedback to health professionals and program managers. The Cancer, Fertility and Me patient decision aid (PtDA) will be disseminated via a diverse range of open-access media, study and charity websites, professional organisations and academic sources. External endorsement will be sought from the International Patient Decision Aid Standards (IPDAS) Collaboration inventory of PtDAs and other relevant professional organisations, for example, the British Fertility Society.

TRIAL REGISTRATION NUMBER

NCT02753296; pre-results.

Desire for children, difficulties achieving a pregnancy, and infertility distress 3 to 7 years after cancer diagnosis

PURPOSE

The aim was to investigate desire for children, difficulties achieving a pregnancy, and infertility distress among survivors 3 to 7 years after cancer treatment in reproductive age.

METHODS

Cancer survivors were identified in national population-based cancer registries. Eligible subjects presented with selected cancer diagnoses between 2003 and 2007 between the ages of 18 to 45. A postal questionnaire including study-specific questions, the Short-Form 36 Health Survey and the Fertility Problem Inventory, was sent to 810 survivors, and 484 participated (60 % response).

RESULTS

Most survivors who had a pretreatment desire for children still wanted children 3-7 years after treatment, and this group was characterized by young age and being childless at diagnosis. In addition, a substantial group of survivors (n = 55, 17 %) that did not have a pretreatment desire for children had changed their mind about wanting children after treatment. About a third of the survivors with a desire to have children had experienced difficulties achieving a pregnancy after the cancer treatment, and an unfulfilled desire to have children was associated with worse mental health. Survivors presently facing difficulties achieving a pregnancy reported moderate levels of infertility distress and expressed low interest in using gamete donation.

CONCLUSIONS

Health professionals in cancer care need to be aware that patients' plans for future children may change, particularly if they are young and childless. All patients of reproductive age should be provided with adequate information about the impact of cancer treatment on future fertility and fertility preservation.

Factors associated with pregnancy attempts among female young adult cancer survivors

PURPOSE

Little is known about pregnancy attempts among female young cancer survivors (YCS). We sought to determine fertility preservation (FP), demographic, cancer, and reproductive characteristics associated with pregnancy attempts after cancer.

METHODS

We recruited 251 female YCS (ages 18-44) to complete a survey on reproductive health outcomes. We used log-binomial regression models to estimate relative risks (RR) for characteristics associated with pregnancy attempts.

RESULTS

For the entire cohort, median time since cancer diagnosis was 2.4 years (interquartile range 4.0). Fifty-two YCS (21%) attempted pregnancy after cancer diagnosis. In unadjusted analyses, lack of FP therapy prior to cancer treatment, older age, partnered relationship, higher income, no history of stem cell or bone marrow transplant, and longer duration of survivorship were significantly associated with pregnancy attempts. In multivariable analyses, YCS who did not undergo FP therapy were more than twice as likely to attempt pregnancy as those who did undergo FP therapy (RR 2.4, 95% confidence interval (CI) 1.3, 4.3). Partnered status (RR 7.1, 95% CI 2.5, 20.2) and >2 years since cancer diagnosis (RR 2.3, 95% CI 1.3, 4.1) were also significantly associated with attempts.

CONCLUSIONS

In YCS, milestones including partnered relationships and longer duration of cancer survivorship are important to attempting pregnancy. A novel, inverse association between FP therapy and pregnancy attempts warrants further study.

IMPLICATIONS FOR CANCER SURVIVORS

Pregnancy attempts after cancer were more likely after attaining both social- and cancer-related milestones. As these milestones require time, YCS should be made aware of their potential for concomitant, premature loss of fertility in order to preserve their range of fertility options.