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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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Nardin S, Mora E, Varughese FM, D'Avanzo F, Vachanaram AR, Rossi V, Saggia C, Rubinelli S, Gennari A. Breast Cancer Survivorship, Quality of Life, and Late Toxicities. Front Oncol 2020; 10:864. [PMID: 32612947 PMCID: PMC7308500 DOI: 10.3389/fonc.2020.00864] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 05/01/2020] [Indexed: 12/24/2022] Open
Abstract
Breast cancer is the most frequent cancer in women: in 2018, almost two million cases have been diagnosed all over the world and it represents the principal cause of death from a neoplastic disease in women. In the past years, breast cancer prognosis has significantly improved over time: currently 5-year survival rates are in the range of 90%, and 10-year survival is about 80%. This improvement has been mostly observed in western countries, due to high coverage and compliance with screening programs, leading to early diagnosis, i.e., when the disease is at a subclinical level, and to an improvement in tumor molecular characterization and innovative systemic treatments. Yet the identification of different biological breast cancer subtypes prompted the development of innovative targeted agents and improved treatment personalization. On the other hand, longer survival rates and increasing proportions of cured patients require dedicated strategies to manage long-term sequelae of breast cancer treatments, with particular attention to quality of life. This review analyzes the most important issues, potentially occurring with cancer treatments, concerning long-term sequelae and quality of life, to define a global approach to breast cancer survivorship.
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Affiliation(s)
- Simone Nardin
- Department of Translational Medicine, University of Eastern Piedmont, DIMET, Novara, Italy.,Center for Translational Research on Autoimmune & Allergic Disease - CAAD, Novara, Italy
| | - Edoardo Mora
- Department of Translational Medicine, University of Eastern Piedmont, DIMET, Novara, Italy.,Center for Translational Research on Autoimmune & Allergic Disease - CAAD, Novara, Italy
| | - Feba Mariam Varughese
- Department of Translational Medicine, University of Eastern Piedmont, DIMET, Novara, Italy.,Center for Translational Research on Autoimmune & Allergic Disease - CAAD, Novara, Italy
| | | | - Ajay Ram Vachanaram
- Department of Translational Medicine, University of Eastern Piedmont, DIMET, Novara, Italy.,Center for Translational Research on Autoimmune & Allergic Disease - CAAD, Novara, Italy
| | - Valentina Rossi
- Division of Oncology, Ospedale Maggiore della Carità, Novara, Italy
| | - Chiara Saggia
- Division of Oncology, Ospedale Maggiore della Carità, Novara, Italy
| | - Sara Rubinelli
- Division of Oncology, Ospedale Maggiore della Carità, Novara, Italy
| | - Alessandra Gennari
- Department of Translational Medicine, University of Eastern Piedmont, DIMET, Novara, Italy.,Center for Translational Research on Autoimmune & Allergic Disease - CAAD, Novara, Italy.,Division of Oncology, Ospedale Maggiore della Carità, Novara, Italy
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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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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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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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Lambertini M, Azim HA, Peccatori FA. Fertility Issues in Patients with Breast Cancer or Survivors. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Mahajan N. Fertility preservation in female cancer patients: An overview. J Hum Reprod Sci 2015; 8:3-13. [PMID: 25838742 PMCID: PMC4381379 DOI: 10.4103/0974-1208.153119] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 02/06/2015] [Accepted: 01/29/2015] [Indexed: 12/20/2022] Open
Abstract
Fertility preservation is becoming increasingly important to improve the quality of life in cancer survivors. Despite guidelines suggesting that discussion of fertility preservation should be done prior to starting cancer therapies, there is a lack of implementation in this area. A number of techniques are available for fertility preservation, and they can be used individually or together in the same patient to maximize efficiency. Oocyte and embryo cryopreservation are now established techniques but have their limitations. Ovarian tissue cryopreservation though considered experimental at present, has a wider clinical application and the advantage of keeping the fertility window open for a longer time. Both chemotherapy and radiotherapy have a major impact on reproductive potential and fertility preservation procedures should be carried out prior to these treatments. The need for fertility preservation has to be weighed against morbidity and mortality associated with cancer. There is thus a need for a multidisciplinary collaboration between oncologists and reproductive specialists to improve awareness and availability.
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Affiliation(s)
- Nalini Mahajan
- Department of Reproductive Medicine, Nova IVI Fertilit, New Delhi, India
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8
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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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Martinez M, Rabadan S, Domingo J, Cobo A, Pellicer A, Garcia-Velasco JA. Obstetric outcome after oocyte vitrification and warming for fertility preservation in women with cancer. Reprod Biomed Online 2014; 29:722-8. [DOI: 10.1016/j.rbmo.2014.09.002] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 08/28/2014] [Accepted: 09/03/2014] [Indexed: 11/24/2022]
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10
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Blumenfeld Z, Katz G, Evron A. 'An ounce of prevention is worth a pound of cure': the case for and against GnRH-agonist for fertility preservation. Ann Oncol 2014; 25:1719-1728. [PMID: 24651411 DOI: 10.1093/annonc/mdu036] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The late effects of cancer treatment have recently gained a worldwide interest among reproductive endocrinologists, oncologists, and all health-care providers, and the protection against iatrogenic infertility caused by chemotherapy assumes a high priority. Here, we summarize the case for and against using GnRH-agonist for fertility preservation and minimizing chemotherapy-induced gonadotoxicity. The rationale and philosophy supporting its use is that preventing premature ovarian failure (POF) is preferable to treating it, following the dictum: 'an ounce of prevention is worth a pound of cure'. Despite many publications on this subject, there are many equivocal issues necessitating summary. Until now, 20 studies (15 retrospective and 5 randomized, controlled trials) have reported on 1837 patients treated with GnRH-a in parallel to chemotherapy, showing a significant decrease in POF rate in survivors versus 9 studies reporting on 593 patients, with results not supporting GnRH-a use. Patients treated with GnRH-a in parallel to chemotherapy preserved their cyclic ovarian function in 91% of cases when compared with 41% of controls, with a pregnancy rate of 19-71% in the treated patients. Furthermore, seven meta-analyses have concluded that GnRH-a are beneficial and may decrease the risk of POF in survivors. However, controversy still remains regarding the efficiency of GnRH-a in preserving fertility. Since not all the methods involving fertility preservation are unequivocally successful and safe, these young patients deserve to be informed of all the various modalities to minimize gonadal damage and preserve ovarian function and future fertility. Combining several methods for a specific patient may increase the odds for minimally invasive fertility preservation.
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Affiliation(s)
- Z Blumenfeld
- Reproductive Endocrinology, RAMBAM Health Care Campus, The Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa.
| | - G Katz
- Pinchas Borenstein Talpiot Medical Leadership Program, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Israel
| | - A Evron
- Reproductive Endocrinology, RAMBAM Health Care Campus, The Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa
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Tomasi-Cont N, Lambertini M, Hulsbosch S, Peccatori AF, Amant F. Strategies for fertility preservation in young early breast cancer patients. Breast 2014; 23:503-10. [PMID: 24934638 DOI: 10.1016/j.breast.2014.05.024] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 05/06/2014] [Accepted: 05/15/2014] [Indexed: 12/25/2022] Open
Abstract
Diagnosis of breast cancer in young women poses a threat to fertility. Due to a recent trend of delaying pregnancy, an increasing number of breast cancer patients in reproductive age wish to bear children. Health care providers have the responsibility to know how to manage fertility issues in cancer survivors. Oncofertility counseling is of great importance to many young women diagnosed with cancer and should be managed in a multi-disciplinary background. Most of young breast cancer patients are candidate to receive chemotherapy, which could lead to premature ovarian failure. A baseline evaluation of ovarian reserve may help in considering the different fertility preservation options. The choice of the suitable strategy depends also on age, type of chemotherapy, partner status and patients' motivation. Various options are available, some established such as embryo and oocyte cryopreservation, some still experimental such as ovarian tissue cryopreservation and ovarian suppression with GnRHa during chemotherapy. An early referral to a reproductive specialist should be offered to patients at risk of infertility who are interested in fertility preservation.
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Affiliation(s)
- Nicoletta Tomasi-Cont
- Academic Division of Gynaecology and Obstetrics, Mauriziano Hospital "Umberto I", University of Turin, Turin, Italy; Fertility and Pregnancy Unit, Medical Gynecologic Oncology Division, European Institute of Oncology, Milan, Italy
| | - Matteo Lambertini
- U.O. Oncologia Medica 2, IRCCS AOU San Martino-IST, University of Genoa, Genoa, Italy.
| | - Sofie Hulsbosch
- Multidisciplinary Breast Cancer Center, University Hospitals Leuven and Department of Oncology, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Alessandro Fedro Peccatori
- Fertility and Pregnancy Unit, Medical Gynecologic Oncology Division, European Institute of Oncology, Milan, Italy
| | - Frederic Amant
- Multidisciplinary Breast Cancer Center, University Hospitals Leuven and Department of Oncology, Katholieke Universiteit Leuven, Leuven, Belgium
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Ronn R, Holzer HEG. Oncofertility in Canada: gonadal protection and fertility-sparing strategies. ACTA ACUST UNITED AC 2013; 20:e602-7. [PMID: 24311962 DOI: 10.3747/co.20.1359] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cancer can be a devastating diagnosis. In particular, malignancy and its indicated treatments have profoundly negative effects on the fertility of young cancer patients. Oncofertility has emerged as a new interdisciplinary field to address the issue of gonadotoxicity associated with cancer therapies and to facilitate fertility preservation. In Canada, fertility issues are often inadequately addressed despite the availability of resources. The goal of this four-part series is to facilitate systemic improvements in fertility preservation for adolescent and young adult Canadians with a new diagnosis of cancer. METHODS Here, we review the fertility preservation measures currently available. Medical and surgical strategies are both outlined. RESULTS Fertility-preserving strategies and gonadal protection have demonstrated variable success in a number of approaches. The value of hormone suppression is still in question for women. Progestins for endometrial cancer and alternative chemotherapies are other medical approaches. Gonadal shielding and protective surgical approaches have also been attempted. CONCLUSIONS The techniques discussed here may be selectively considered and integrated into patient care in an attempt to preserve future fertility before initiating cancer treatment.
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Affiliation(s)
- R Ronn
- Department of Obstetrics and Gynecology, Queen's University, Kingston, ON
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Zhang Y, Ding JX, Tao X, Lu ZY, Wang JJ, Feng WW, Hua KQ. Goserelin can inhibit ovarian cancer proliferation and simultaneously protect ovarian function from cisplatin: anin vitroandin vivostudy. J Chemother 2013; 25:96-103. [DOI: 10.1179/1973947813y.0000000069] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Torino F, Barnabei A, De Vecchis L, Sini V, Schittulli F, Marchetti P, Corsello SM. Chemotherapy-induced ovarian toxicity in patients affected by endocrine-responsive early breast cancer. Crit Rev Oncol Hematol 2013; 89:27-42. [PMID: 23953684 DOI: 10.1016/j.critrevonc.2013.07.007] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 06/16/2013] [Accepted: 07/18/2013] [Indexed: 11/30/2022] Open
Abstract
Cytotoxic chemotherapy may variably affect ovarian function depending on age and ovarian reserve at diagnosis, type of chemotherapy and use of tamoxifen. Ascertaining whether a premenopausal patient with endocrine-responsive early breast cancer and chemotherapy-induced amenorrhea has reached menopause is essential not only in order to provide accurate information on residual fertility, but also to appropriately prescribe endocrine therapy. Indeed, aromatase inhibitors are contraindicated in women with residual ovarian reserve. However, the diagnosis of menopause in patients with chemotherapy-induced amenorrhea is challenging, since clinical features, follicle-stimulating hormone and estradiol levels may be inaccurate to this aim. Recent studies demonstrated that the anti-müllerian hormone may improve the assessment of ovarian reserve residual to chemotherapy in women with early breast cancer. Herein, we review the incidence of amenorrhea and menopause induced by cytotoxic chemotherapy in women affected by early breast cancer and the suggested mechanisms that sustain these side-effects. Furthermore, it has been scrutinized the potential of new markers of ovarian reserve that may facilitate the selection of appropriate endocrine treatment for premenopausal women who develop amenorrhea following adjuvant chemotherapy for early breast cancer.
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Affiliation(s)
- Francesco Torino
- Department of Systems Medicine, Chair of Medical Oncology, Tor Vergata University of Rome, Italy
| | - Agnese Barnabei
- Endocrinology Unit, Regina Elena National Cancer Institute, Rome, Italy
| | - Liana De Vecchis
- Department of Systems Medicine, Chair of Medical Oncology, Tor Vergata University of Rome, Italy
| | - Valentina Sini
- Surgical and Medical Department of Clinical Sciences, Biomedical Technologies and Translational Medicine, "Sapienza" University of Rome, Italy
| | | | - Paolo Marchetti
- Department of Clinical and Molecular Medicine, Medical Oncology Division, Sant'Andrea Hospital, "Sapienza" University of Rome and IDI-IRCCS, Rome, Italy
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Lambertini M, Anserini P, Levaggi A, Poggio F, Del Mastro L. Fertility counseling of young breast cancer patients. J Thorac Dis 2013; 5 Suppl 1:S68-80. [PMID: 23819030 DOI: 10.3978/j.issn.2072-1439.2013.05.22] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 05/29/2013] [Indexed: 12/11/2022]
Abstract
Approximately 6% of women with breast cancer are diagnosed before the age of 40. Young age is an independent predictor of adverse outcome and most young breast cancer patients receive systemic treatment with chemotherapy, hormonal therapy or both. The loss or impairment of fertility is a potential side effect of antineoplastic treatments. Due to the rising trend to delaying pregnancy in life, an increasing proportion of young cancer patients who are yet to have a pregnancy will face the problem of iatrogenic menopause in the future. The incidence of anticancer-treatment-related ovarian failure depends on the type of chemotherapy regimen administered, the use of tamoxifen and the age of patients. It rises with increasing age, in the range of 22-61% and 61-97% in women aged <40 years and >40 years respectively. Although there is a clear trend to increasing incidence of ovarian failure with the rise in aging, there may be a small proportion of patients who became amenorrhoeic despite the very young age, thus indicating that also individual factors still unknown may affect the probability of treatment-related ovarian failure. A prompt referral of patients to reproductive counseling and a multidisciplinary team including Oncology and Reproductive Units are essential to face the management of fertility issues in cancer patients. Fertility counseling should include a detailed description of all the available techniques to preserve fertility. The main available fertility preservation techniques, standard and experimental, for young breast cancer patients include: temporary ovarian suppression during chemotherapy with gonadotropin-releasing hormone analogues, embryo cryopreservation, cryopreservation of oocytes and cryopreservation of ovarian tissue. Research efforts are still necessary to improve the efficacy and safety of the available fertility preservation strategies as well as an efficient collaboration between oncologists and gynecologists is necessary to improve patients' access to the strategies themselves.
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Role of mesenchymal stem cell therapy in restoring ovarian function in a rat model of chemotherapy-induced ovarian failure. ACTA ACUST UNITED AC 2013. [DOI: 10.1097/01.ehx.0000423979.18253.10] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wang HL, Huang SC, Jiang WY, Lai HH. Oocyte vitrification in a single woman with diminished ovarian reserve resulting in live birth. Taiwan J Obstet Gynecol 2013; 51:651-3. [PMID: 23276575 DOI: 10.1016/j.tjog.2012.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2012] [Indexed: 10/27/2022] Open
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Blumenfeld Z. Preservation of ovarian function and fertility despite gonadotoxic chemotherapy. Expert Rev Endocrinol Metab 2012; 7:567-576. [PMID: 30780892 DOI: 10.1586/eem.12.40] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The author aims to review the various strategies and avenues for fertility preservation despite gonadotoxic chemotherapy in young women. The recent increase in the survival of young patients has increased the worldwide attempts toward fertility preservation. The currently utilized methods are sperm cryopreservation and banking in male patients, and cryopreservation of embryos, unfertilized oocytes and ovarian tissue, as well as administration of gonadotropin-releasing hormone agonists (GnRH-a) before and during the gonadotoxic chemotherapy in young female patients. For those patients in whom pelvic irradiation is planned, ovariopexy is suggested. Since none of the suggested methods are ideal and none guarantees future fertility, a combination of several methods may optimize patients' chance of fertility preservation. GnRH-a co-treatment may reduce ovarian damage significantly in female patients treated with gonadotoxic chemotherapy. GnRH-a should be considered for women of reproductive age receiving gonadotoxic chemotherapy in addition to assisted reproduction and cryopreservation of embryos, oocytes and ovarian tissue.
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Affiliation(s)
- Zeev Blumenfeld
- a Reproductive Endocrinology, Department of Ob/Gyn, RAMBAM Healthcare Campus, The Rappaport Institute & Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel. ;
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Blumenfeld Z. Fertility preservation. Clin Endocrinol (Oxf) 2012; 76:919-20; author reply 920. [PMID: 22519719 DOI: 10.1111/j.1365-2265.2011.04283.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Torino F, Barnabei A, De Vecchis L, Appetecchia M, Strigari L, Corsello SM. Recognizing menopause in women with amenorrhea induced by cytotoxic chemotherapy for endocrine-responsive early breast cancer. Endocr Relat Cancer 2012; 19:R21-33. [PMID: 22241718 DOI: 10.1530/erc-11-0199] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cytotoxic anticancer treatment may induce amenorrhea or menopause to a variable extent. These side effects may not only impair or impede fertility but also cause sexual dysfunction, bone loss, and menopausal symptoms, with a strikingly negative effect on quality of life in many women. Aromatase inhibitors (AIs) are a recommended adjuvant endocrine treatment option in postmenopausal patients affected by early breast cancer (EBC) but are contraindicated in premenopausal women and in those with residual ovarian function. Women over 40 years of age with chemotherapy-induced amenorrhea (CIA) and routine hormonal levels consistent with menopause may receive an AI as adjuvant endocrine treatment. For these women, the tools available to identify menopause do not appear to be completely reliable. This review focused on the pathophysiology of ovarian toxicity induced by cytotoxic agents and on potentially useful methods to diagnose chemotherapy-induced menopause in patients treated with adjuvant chemotherapy for endocrine-responsive EBC. Moreover, practical approaches are proposed to distinguish true menopausal women, who would benefit from AIs, from those with transient or persistent CIA.
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Affiliation(s)
- Francesco Torino
- Department of Internal Medicine, Chair of Medical Oncology, University of Rome Tor Vergata, Rome, Italy
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Domingo J, Guillén V, Ayllón Y, Martínez M, Muñoz E, Pellicer A, Garcia-Velasco JA. Ovarian response to controlled ovarian hyperstimulation in cancer patients is diminished even before oncological treatment. Fertil Steril 2012; 97:930-4. [PMID: 22283969 DOI: 10.1016/j.fertnstert.2012.01.093] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 12/27/2011] [Accepted: 01/05/2012] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the results of controlled ovarian stimulation before chemotherapy for oocyte vitrification to preserve fertility in women diagnosed with cancer and compare them with a historical control group. DESIGN A retrospective, multicenter, observational study performed between March 2007 and January 2011. SETTING University-affiliated infertility clinics. PATIENT(S) Of 272 patients affected by cancer in our Fertility Preservation Program, 223 women underwent a stimulated cycle for oocyte vitrification according to our protocols before cancer treatment. Their results were compared with a historical control group of 98 patients diagnosed with male factor infertility who were stimulated for a conventional IVF cycle. INTERVENTION(S) Controlled ovarian stimulation and oocyte retrieval. MAIN OUTCOME MEASURE(S) Days of stimulation, total dose of gonadotropins, estrogen levels, and number of oocytes retrieved and vitrified. RESULT(S) No differences were found in days of stimulation, but significant differences in E(2) levels and the number of retrieved oocytes were measured, especially in the hormone-dependent cancer group. CONCLUSION(S) Patients with hormone-dependent cancer had a weaker response to controlled ovarian stimulation compared with patients with non-hormone-dependent cancer. Whether the oncological disease already affects the ovaries before chemo-/radiotherapy remains to be elucidated.
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Blumenfeld Z. Chemotherapy and fertility. Best Pract Res Clin Obstet Gynaecol 2012; 26:379-90. [PMID: 22281514 DOI: 10.1016/j.bpobgyn.2011.11.008] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Accepted: 11/25/2011] [Indexed: 11/29/2022]
Abstract
The overall increase in cancer prevalence and the significant increase in long-term survival have generated worldwide interest in preserving fertility in young women exposed to gonadotoxic chemo- and radiotherapy. Infertility represents one of the main long-term consequences of combination chemotherapy given for lymphoma, leukaemia and other malignancies in young women. The gonadotoxic effect of various chemotherapeutic agents is diverse, may involve a variety of pathophysiologic mechanisms, and is not unequivocally understood. Proliferating cells, such as in tissues with high turnover (i.e. bone marrow, gastrointestinal tract and growing ovarian follicles) are more vulnerable to the toxic effect of alkylating agents. These agents may also be cytotoxic to cells at rest, as they are not cell-cycle specific. Alkylating agents, the most gonadotoxic chemotherapeutic medications, cause dose-dependent, direct destruction of oocytes and follicular depletion, and may bring about cortical fibrosis and ovarian blood-vessel damage. The reported rate of premature ovarian failure after various diseases and chemotherapeutic protocols differ enormously, and depend mainly on the chemotherapeutic protocol used and age range of the woman. Several options have been proposed for preserving female fertility, despite gonadotoxic chemotherapy: ovarian transposition, cryopreservation of embryos, unfertilised metaphase-II oocytes and ovarian tissue, and administration of gonadotropin-releasing hormone agonistic analogs in an attempt to decrease the gonadotoxic effects of chemotherapy by simulating a prepubertal hormonal milieu. None of these methods is ideal and none guarantees future fertility in all survivors; therefore, a combination of methods is recommended for maximising women's chances of future fertility.
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Affiliation(s)
- Zeev Blumenfeld
- Department of Obstetrics and Gynaecology, RAMBAM Health Care Campus, The Rappaport Institute, Technion - Israel Institute of Technology, Haifa Israel.
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Xu M, Pavone ME, Woodruff T. Fruitful progress to fertility: preserving oocytes from chemodestruction. Nat Med 2011; 17:1562-3. [PMID: 22146461 DOI: 10.1038/nm.2595] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Min Xu
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Blumenfeld Z. Preservation of ovarian function and minimizing premature ovarian failure during chemotherapy using gonadotropin-releasing hormone analogs. WOMEN'S HEALTH (LONDON, ENGLAND) 2011; 7:635-640. [PMID: 22040206 DOI: 10.2217/whe.11.72] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Evaluation of: Del Mastro L, Boni L, Michelotti A et al. Effect of the gonadotropin-releasing hormone analogue triptorelin on the occurrence of chemotherapy-induced early menopause in premenopausal women with breast cancer: a randomized trial. JAMA 306(3), 269-276 (2011). This study is a randomized, open-label, Phase III trial, conducted in 16 Italian centers that enrolled 281 patients between 2003 and 2008. The recruited patients were prospectively and randomly allocated to either chemotherapy alone or combined with monthly triptorelin gonadotropin-releasing hormone analog, started before chemotherapy and repeated every month throughout chemotherapy. The clinical and tumor characteristics of the patients in the control or treatment groups were similar. A total of 12 months after ending chemotherapy, the premature ovarian failure rate was 25.9% in the chemotherapy-alone group versus 8.9% in the chemotherapy and gonadotropin-releasing hormone analog group, an absolute difference of -17% (95% CI: -26 to -7.9%; p < 0.001). The odds ratio for treatment-induced premature ovarian failure was 0.28 (95% CI: 0.14-0.59; p < 0.001). The authors concluded that use of gonadotropin-releasing hormone analog chemotherapy in premenopausal breast cancer patients can significantly reduce the occurrence of chemotherapy-induced early menopause.
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Affiliation(s)
- Zeev Blumenfeld
- Department of Obstetrics & Gynecology, Rappaport Research Institute, Technion-Faculty of Medicine, Haifa, Israel.
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