Reproductive late effects after hematopoietic stem cell transplant in pediatric, adolescent, and young adult cancer survivors

Reproductive late effects after hematopoietic stem cell transplant can have a significant impact on cancer survivors' quality of life. Potential late effects include gonadal insufficiency, genital graft-versus-host disease, uterine injury, psychosexual dysfunction, and an increased risk of breast and cervical cancer in patients treated with total body irradiation. Despite guidelines, screening and treatment are not standardized among at-risk patients. Provider barriers include lack of knowledge of at-risk therapies and evidenced-based guidelines. Patient barriers include a reluctance to report symptoms and lack of awareness of treatment options. System barriers include inefficient implementation of screening tools and poor dissemination of guidelines to providers who serve as the medical home for survivors. This review guides the clinician in identifying and managing reproductive late effects after hematopoietic stem cell transplant to improve outcomes.

Websites about, not for, adolescents? A systematic analysis of online fertility preservation information for adolescent and young adult cancer patients

PURPOSE

Fertility preservation is an increasingly important topic in adolescent and young adult cancer survivorship, yet treatments remain under-utilized, possibly due to lack of awareness and understanding. The internet is widely used by adolescents and young adults and has been proposed to fill knowledge gaps and advance high-quality, more equitable care. As a first step, this study analyzed the quality of current fertility preservation resources online and identified opportunities for improvement.

METHODS

We conducted a systematic analysis of 500 websites to assess the quality, readability, and desirability of website features, and the inclusion of clinically relevant topics.

RESULTS

The majority of the 68 eligible websites were low quality, written at college reading levels, and included few features that younger patients find desirable. Websites mentioned more common fertility preservation treatments than promising experimental treatments, and could be improved with cost information, socioemotional impacts, and other equity-related fertility topics.

CONCLUSIONS

Currently, the majority of fertility preservation websites are about, but not for, adolescent and young adult patients. High-quality educational websites are needed that address outcomes that matter to teens and young adults, with a priority on solutions that prioritize equity.

IMPLICATIONS FOR CANCER SURVIVORS

Adolescent and young adult survivors have limited access to high-quality fertility preservation websites that are designed for their needs. There is a need for the development of fertility preservation websites that are clinically comprehensive, written at appropriate reading levels, inclusive, and desirable. We include specific recommendations that future researchers can use to develop websites that could better address AYA populations and improve the fertility preservation decision making process.

Effects of Ovarian Tissue Cryopreservation on Primary Ovarian Insufficiency in Girls Undergoing Bone Marrow Transplantation

OBJECTIVE

To determine if removing an ovary for ovarian tissue cryopreservation (OTC) increased rates of primary ovarian insufficiency (POI) in girls undergoing bone marrow transplantation (BMT). Institutional review board approval was obtained from all 3 clinical sites.

DESIGN

Multicenter retrospective cohort study SETTING: Academic children's hospitals PATIENTS: Females aged 2-21 who underwent BMT with or without OTC from 2010 to 2017.

INTERVENTIONS

None MAIN OUTCOME MEASURES: Rates of POI in girls who underwent OTC vs those who underwent BMT alone as determined by serum markers, presence of menses, or clinical diagnosis.

RESULTS

A total of 142 patients were identified, 43 who had OTC and 99 with BMT alone. The rate of POI in girls undergoing OTC was 65% vs 41.8% in those who underwent BMT alone (P = .26).

CONCLUSIONS

Although this study was not powered to detect a lack of difference, it is reassuring that there does not seem to be a clinically significant increase in POI in patients undergoing OTC.

Websites about, not for, adolescents? A systematic analysis of online fertility preservation information for adolescent and young adult cancer patients

Purpose Fertility preservation is an increasingly important topic in adolescent and young adult cancer survivorship, yet treatments remain under-utilized, possibly due to lack of awareness and understanding. The internet is widely used by adolescents and young adults and has been proposed to fill knowledge gaps and advance high-quality, more equitable care. As a first step, this study analyzed the quality of current fertility preservation resources online and identified opportunities for improvement. Methods We conducted a systematic analysis of 500 websites to assess the quality, readability, and desirability of website features, and the inclusion of clinically relevant topics. Results The majority of the 68 eligible websites were low quality, written at college reading levels, and included few features that younger patients find desirable. Websites mentioned more common fertility preservation treatments than promising experimental treatments, and could be improved with cost information, socioemotional impacts, and other equity-related fertility topics. Conclusions Currently, the majority of fertility preservation websites are about, but not for, adolescent and young adult patients. High-quality educational websites are needed that address outcomes that matter to teens and young adults, with a priority on solutions that prioritize equity. Implications for Cancer Survivors: Adolescent and young adult survivors have limited access to high-quality fertility preservation websites that are designed for their needs. There is a need for the development of fertility preservation websites that are clinically comprehensive, written at appropriate reading levels, inclusive, and desirable. We include specific recommendations that future researchers can use to develop websites that could better address AYA populations and improve the fertility preservation decision making process.

2019 Pediatric Initiative Network: Progress, Proceedings, and Plans

Impairment of fertility and sexual/reproductive health are common after oncologic therapy, and are known to have negative impacts on romantic relationships and psychosocial well-being among childhood cancer survivors. The Pediatric Initiative Network (PIN) is an international, multidisciplinary group of providers within the Oncofertility Consortium dedicated to preserving and protecting the fertility of children and adolescents at risk for infertility due to medical conditions or treatments. The PIN and its Best Practices and Research committees meet virtually throughout the year, with one annual in-person meeting. The purpose of this "proceedings" is to highlight key discussion points from the annual PIN meeting which took place on November 11, 2019, to 1) provide a context for pediatric groups across the country on what oncofertility programs are currently doing and why, and 2) inform stakeholders of past, present and future initiatives that may be of value to them and the patient populations they serve.

A Pediatric Emergency Department Intervention to Increase Contraception Initiation Among Adolescents

BACKGROUND

The pediatric emergency department (PED) provides care for adolescents at high risk of unintended pregnancy, but little is known regarding the efficacy of PED-based pregnancy prevention interventions. The objectives of this PED-based pilot intervention study were to 1) assess the rate of contraception initiation after contraceptive counseling and appointment facilitation in the PED during the study period, 2) identify barriers to successful contraception initiation, and 3) determine adolescent acceptability of the intervention.

METHODS

This pilot intervention study included females 14 to 19 years of age at risk for unintended pregnancy. Participants received standardized contraceptive counseling and were offered an appointment with gynecology. Participants were followed via electronic medical record and phone to assess contraception initiation and barriers. Chi-square tests were used to examine the association between contraception initiation and participant characteristics.

RESULTS

A total of 144 patients were eligible, and 100 were enrolled. In the PED, 68% (68/100) expressed interest in initiating hormonal contraception, with 70% (48/68) of interested participants indicating that long-acting reversible contraception (LARC) was their preferred method. Twenty-five percent (25/100) of participants initiated contraception during the study period, with 19 participants starting LARC. Thirty-nine percent (22/57) of participants who accepted a gynecology appointment attended that appointment. Barriers to follow-up include transportation and inconvenient follow-up times. Participants were accepting of the intervention with 93% agreeing that the PED is an appropriate place for contraceptive counseling.

CONCLUSIONS

PED contraceptive counseling is acceptable among adolescents and led to successful contraception initiation in 25% of participants. The main barrier to contraception initiation was participant follow-up with the gynecology appointment.

SUN-266 Anti-Mullerian Hormone as a Marker of Ovarian Reserve in Female Pediatric Patients Undergoing Hematopoietic Stem Cell Transplantation

Background/Methods: Gonadal dysfunction leading to infertility is a common complication after hematopoietic stem cell transplant (HSCT). Previous work by our group has shown that there is a significantly higher risk of delayed puberty and premature ovarian insufficiency among girls who receive high intensity, myeloablative conditioning (MAC) regimens compared to reduced intensity conditioning (RIC) regimens. Anti-Müllerian Hormone (AMH) is not regulated by gonadotropins and has minimal inter-cycle variations; therefore, it can be used as a marker of follicular ovarian reserve and aid in fertility counseling. We sought to assess ovarian reserve utilizing AMH levels in a retrospective study of female pediatric patients undergoing HSCT from 2013-2017 who received either MAC or RIC regimens. Results: In total, 100 female patients with a median age of 7 years had AMH levels pre-HSCT, of whom 33 (33%) also had post-HSCT levels. A wide variety of diagnoses were included: 32% had malignancy; 19% had immunodeficiency; 17% had Fanconi anemia (FA), 17% had hemoglobinopathy; 12% had non-FA marrow failure, and 3% had a metabolic disorder. Among those with pre-HSCT AMH levels, 71 (71%) had normal AMH for age, and 29 (29%) had low AMH for age. Of the 33 patients who also had post-HSCT AMH, 24 (72%) had low levels following transplantation. Twenty-five patients had both a normal pre-HSCT AMH and subsequent post-HSCT levels performed, 13 of whom (52%) received a MAC regimen and 12 of whom (48%) received RIC regimen. All (13/13) of the patients who received a MAC regimen had low AMH post-HSCT, while only 25% (3/12) of the patients who received a RIC regimen had low AMH post-HSCT (p=0.0002). Eight patients had both a low pre-HSCT AMH and subsequent post-HSCT AMH levels performed, 5 of whom received a MAC regimen and 3 of whom received a RIC regimen. All subject with low pre-HSCT AMH levels additionally had low post-HSCT AMH regardless of conditioning regimen used. Conclusions: AMH levels can be a useful marker for detection of low ovarian reserve and fertility counseling, especially if trends are followed before and after exposure to alkylating agents used for HSCT preparation. Our data show a significantly higher risk of low, downtrending AMH after exposure to high intensity MAC regimens compared to RIC regimens during childhood HSCT, which likely indicates a greater potential for infertility in patients receiving MAC regimens. These data correlate with a previous analysis demonstrating a significantly higher incidence of premature ovarian insufficiency and delayed puberty among girls receiving MAC regimens vs RIC regimens. Long-term follow up of this cohort will provide more information to understand the effects of HSCT on ovarian function and the utility of AMH as a predictor of future fertility potential.

Fertility preservation options in pediatric and adolescent patients with cancer

The incidence of childhood cancer has steadily increased since the 1950s, with approximately 16,000 children diagnosed each year. However, with the advent of more effective multimodal therapies, childhood cancer survival rates have continued to improve over the past 40 years, with >80% of patients now surviving into adulthood. Fertility preservation (FP) has become an important quality-of-life issue for many survivors of childhood cancer. As a result, the therapeutic options have become less gonadotoxic over time and more patients are being offered FP options. This review examines the indications for consultation, male and female FP options both in the prepubertal patient and adolescent patient, and the unique ethical issues surrounding FP in this vulnerable population. Cancer 2018;124:1867-76. © 2018 American Cancer Society.