Creating a continuum of care: integrating obstetricians and gynecologists in the care of young cancer patients

Cancer therapy can be lifesaving but significantly diminish female reproductive potential. This review provides an overview of the deleterious effects of cancer treatments on reproductive function, the fertility preservation options currently available for young women, and the outcomes of pregnancy after cancer treatment. In addition, special considerations for women who are diagnosed with cancer during pregnancy are discussed. To optimize the continuum of care for the patient, new corridors of communication between obstetricians, gynecologists, and oncology specialists must be developed to ensure the best outcomes for the patient, both in terms of cancer treatment and fertility preservation.     

Late reproductive effects of cancer treatment

This chapter discusses the most commonly observed gynaecological/reproductive issues in young people who have survived or undergone treatment for cancer. We also discuss the reproductive impact of treatments for some cancers and the options for maintaining fertility in men and women. The options available to any particular cancer survivor will depend on his or her age at the time of diagnosis and treatment, the cancer type and primary site, the stage and the type of treatment.     

Options of fertility preservation in female cancer patients

Modern combination chemotherapy and radiotherapy regimens have a substantial negative impact on reproduction. Premature ovarian failure and other poor reproductive outcomes subsequent to cancer therapies are being recognized. Furthermore, beside malignancies, treatment of certain precancerous and benign conditions such as myelodysplasia, aplastic anemia, and systemic lupus erythematosus may necessitate administration of high-dose chemotherapeutics with and without stem cell transplantation. Therefore, preservation of gonadal function and fertility has become one of the major quality of life issues for cancer survivors at reproductive ages. In this review, premature ovarian failure and other adverse reproductive outcomes in female patients who receive chemotherapy and radiation will be discussed and the options to preserve their fertility will be delineated. After completion of the educational activity, the reader will be better able to distinguish the experimental approaches to minimizing gonadotoxic therapy, and use the most effective treatment options.     

子宫内膜癌保留生育功能的治疗

未生育的年轻子宫内膜癌患者常常寻找保留生育功能的治疗方法。本文的主要目的是复习有关子宫内膜癌患者保留生育功能治疗的相关文献,探讨适合进行保留生育功能治疗的患者特征、治疗前的评估、治疗方案、疗效以及妊娠率。     

Fertility Preservation in Young Women with Breast Cancer

Approximately 10,000 cases of breast cancer are diagnosed in women younger than 40 years of age each year in the United States. This creates a population of young women with breast cancer who may have not started or completed their family. Given that technology and treatment have improved outcomes for these women, quality of life issues, such as fertility preservation, must be considered. This review examines breast cancer patient and physician attitudes toward fertility preservation, ovarian toxicity of chemotherapeutic agents, fertility preservation options for breast cancer patients, and the safety of subsequent pregnancies for these women.     

Reproductive possibilities for the child with cancer

As the population of childhood cancer survivors steadily increases, currently estimated at 26,000 in the UK, investigators are focusing on improving our understanding of the late side effects associated with successful cancer therapy. Long-term survivors are at risk of developing a number of late sequelae including impaired fertility, adverse pregnancy outcomes and health problems in the offspring. Although not the highest priority at diagnosis, loss of fertility is one of the most devastating consequences of cytotoxic therapy for the long-term survivors. In this article we consider the late reproductive sequelae following treatment for childhood cancer and discuss the options for fertility preservation.     

Fertility preserving options in patients with gynecologic malignancies

A proportion of reproductive age women are affected by gynecologic malignancies. This patient population is faced with difficult decisions, related to their cancer care and treatment, as well as future childbearing potential. Therefore, it is important for gynecologists to be familiar with fertility sparing management options in patients with cervical, ovarian, and endometrial cancer. In addition to understanding the surgical approaches available, providers should be able to counsel patients regarding their eligibility for and the indications and limitations of fertility sparing therapy for gynecologic cancer, allowing for appropriate referrals. A comprehensive PUBMED literature search was conducted using the key words "fertility preservation," "cervical cancer," "endometrial cancer," "ovarian cancer," "borderline tumor of the ovary," "germ cell tumor," "obstetrical outcomes," "chemotherapy," and "radiation." The following review summarizes fertility sparing options for patients with cervical, ovarian and endometrial cancer, with an emphasis on appropriate patient selection, oncologic, and obstetric outcomes.     

Present and future fertility preservation strategies for female cancer patients

As survival rates with cancer treatment are steadily increasing, many women are now facing sterility due to treatment induced ovarian failure. This review will attempt to summarize the options for trying to preserve fertility in these patients. The optimal approach depends on the type of cancer, the type of treatment (e.g., radiation and/or chemotherapy), time available till onset of treatment, patient's age, and whether the patient has a partner. Ovarian transposition remains the standard of care for women undergoing pelvic radiation, although it has been suggested that it may be combined with ovarian tissue cryopreservation. For patients about to receive chemotherapy or whole body radiation, in vitro fertilization (IVF) with embryo cryopreservation is a well established treatment with a good success rate. However, it requires delaying cancer treatment for 2 to 4 weeks and a partner or willingness to use donor sperm. When these criteria cannot be met, more experimental options include oocyte cryopreservation for later IVF and ovarian tissue cryopreservation. The tissue may be autotransplanted back to the pelvis, when the patient is in remission, to attempt spontaneous conception or subcutaneously for easy access of follicle aspiration for IVF. Alternatively, it may be xenografted to immunocompromised mice to induce follicle maturation in preparation for retrieval for IVF. Emerging treatment options for fertility preservation include medication to prevent chemotherapy-induced oocyte damage and oocyte construction from somatic cell nuclei. IVF with donor oocyte remains an established option with a very high success rate for those who fail to conceive with the above measures or who elect not to avail themselves to experimental procedures. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to demonstrate knowledge about fertility preservation when counseling appropriate female cancer patients, recall current clinical strategies to assist women cancer patients to try to maintain their fertility if they wish, and appraise future strategies as they develop.     

Fertility preservation in men with cancer

Due to recent advances in medical technologies, cancer has become more curable and chronic, and post-treatment quality of life, including male fertility, has become an important issue. Cancer itself can affect spermatogenesis through complex interactions, and cancer treatment such as surgery, radiotherapy and chemotherapy, all have certain detrimental effects on spermatogenesis. Currently, sperm cryopreservation before cancer treatment is the mainstay of fertility preservation, and is recommended by numerous guidelines. Although fertility preservation should be discussed with all cancer patients before treatment, it still remains underused. Postpubertal patients who are unable to bank sperm may undergo testicular sperm extraction before treatment. For prepubertal boys, there is no clinically established guideline for fertility preservation. Investigations such as spermatogonial stem cell culture are ongoing, and may lead to clinical options for fertility preservation in the future.     

Reproductive outcomes for survivors of childhood cancer

Because of remarkable progress in therapy, long-term survival is expected for 80% of children and adolescents diagnosed with cancer. Infertility remains one of the most common and life-altering complications experienced by adults treated for cancer during childhood. Surgery, radiation, or chemotherapy that negatively affects any component of the hypothalamic-pituitary-gonadal axis may compromise reproductive outcomes in childhood cancer survivors. The risk of infertility is generally related to the tissues or organs involved in cancer and the specific type, dose, and combination of cytotoxic therapy. In addition to anticancer therapy, age at treatment, sex, and likely genetic factors influence the risk of permanent infertility. When possible, contemporary protocols limit cumulative doses of cytotoxic therapy in an effort to optimize reproductive potential. If sterilizing therapy is required for cancer control, then fertility preservation measures should be explored before initiation of therapy. For childhood cancer survivors who maintain fertility, health risks to offspring resulting from their cancer treatment are major concerns. Radiation affecting ovarian and uterine function has been linked to pregnancy complications, including spontaneous abortion, preterm labor, fetal malposition, and low birth weight. The risk of congenital malformations, genetic disorders, and cancer appears to be low, with the exception of cancer risk in offspring born to survivors with germline cancer-predisposing mutations. This review summarizes research about cancer treatment factors affecting fertility and pregnancy outcomes of childhood cancer survivors. The data presented should facilitate the delivery of preventive counseling and age- and sex-appropriate interventions to optimize reproductive outcomes in childhood cancer survivors.     

Medical, ethical, and legal considerations in fertility preservation

The past 2 decades have seen a significant rise in cancer survival rates, and an increasing proportion of survivors at reproductive age are interested in childbearing. Although assisted reproduction provides physicians with an array of potential possibilities to help patients whose fertility is compromised by cancer treatment, there is still a dearth of regulation regarding the application of this technology. The present paper reviews the current options for fertility preservation, with a particular focus on the legal and ethical challenges that confront providers of this type of care.     

Consult and procedure incidence outcomes following establishment of a fertility preservation program for children with cancer

PurposeFertility is a quality of life outcome adversely affected by cancer therapy. Many childhood cancer patients, however, are not offered options to preserve their fertility. Providers acknowledge difficulty discussing impaired fertility to patients due to lack of knowledge of available options. Our objective was to review the impact of a pediatric multidisciplinary fertility preservation program on providers’ fertility preservation counseling and discussion of options.MethodsA retrospective medical chart review was conducted for pediatric cancer patients prior to and following program establishment. Fertility preservation discussions, consults, and incidence were noted. Following filtering and stratification, 198 and 237 patients were seen prior to and following program establishment, respectively.ResultsFollowing program establishment, provider–patient discussions of impaired fertility (p = 0.007), fertility preservation consults (p = 0.01), and incidence of fertility preservation procedures (p < 0.001) increased among patients. Furthermore, the number of patients who received fertility preservation consults after receiving gonadotoxic treatment decreased (p < 0.001). This trend was particularly noted in pre-pubertal and female patients, for whom fertility preservation options are limited without an established program.ConclusionThe establishment of a formal program greatly improved access to fertility preservation consults and procedures in children with cancer.     

Knowledge about and attitude towards fertility preservation in young female cancer patients: a cross-sectional online survey

Recent advances in cancer therapy have resulted in an increased number of long-term cancer survivors. However, because of their treatment, women might be confronted with impaired fertility. The options of fertility preservation (FP) techniques are increasing. The goal of this study was to assess knowledge about, and attitudes towards, fertility preservation in young female cancer patients. A cross-sectional online survey was conducted including 155 former female cancer patients from English and German speaking countries. The survey consists of questions about attitude towards, and knowledge about, fertility preservation. Results show that knowledge about fertility preservation was limited among participants. Positive attitudes towards fertility preservation significantly outweighed negative attitudes. Knowledge and attitude did not differ according to language or different healthcare systems. Confidence of knowledge was significantly higher in women who underwent any FP procedure compared to those who did not. Greater emphasis should be placed on counselling opportunities, the provision of adequate information and supporting material. A better understanding of these issues will hopefully enhance patients’ decision-making about FP options and assist the development of strategies to improve quality of care.     

Fertilitätserhalt bei Krebs

Survival rates of female cancer patients are improving steadily. Clinicians are increasingly confronted with the long-term effects of chemotherapy and radiotherapy on the fertility of young women. Premature ovarian failure in women who wish to become pregnant is devastating both for the patient and her partner. In the case of predictable loss of gonadal function due to a planned cancer treatment fertility preservation options should be offered to the patient. Current methods of fertility preservation include conventional reproductive techniques as well as GnRH analogue treatment, cryopreservation of oocytes and cryopreservation of ovarian tissue. Most of these techniques are still experimental and should only be decided after individual and patient-specific informed consent as well as interdisciplinary counselling.     

Fertility preservation options for women with malignancies

Cancer is not rare in younger women. There has been a remarkable improvement in the survival rates due to progress in cancer treatment. The necessary treatment for most of the common cancer types occurring in younger women implies either removal of the reproductive organs or cytotoxic treatment that could partially or definitively affect reproductive function. Early loss of ovarian function not only puts the patients at risk for menopause-related complications at a very young age, but is also associated with loss of fertility. Further, women in the western hemisphere have been delaying initiation of childbearing to later in life. The results of these changes have led to an increase in patients facing the risk of premature ovarian failure, and therefore seeking help in preserving their fertility. This increase in demand has resulted in a proliferation of techniques to preserve fertility. Indeed, the number of options is increasing; some are more established procedures, such as embryo cryopreservation, and some are still experimental, such as ovarian cryopreservation. Because of the variations in type and dose of chemotherapy, the type of cancer, the time available before onset of treatment, the patient's age and the partner status, each case is unique and requires a different strategy of fertility preservation. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to recall the potential early loss of ovarian function secondary to radiotherapy and/or chemotherapy for cancer at a young age; explain the increasing demands for fertility preservation; and summarize the limited number of proven, safe, and efficacious methods.     

各种根治性宫颈切除术手术关键点及特点比较

根治性宫颈切除术(RT)是一种较新的手术方法,在治疗早期宫颈癌的同时允许患者保留生育功能.RT主要有阴式和腹式两种术式.文章就不同术式的手术适应证、手术关键步骤、肿瘤学安全性和术后生育结果等热点问题进行探讨.     

Oocyte cryopreservation as a fertility preservation measure for cancer patients

Advances in cancer treatment have allowed women to live longer, fuller lives. However, gonadotoxic therapies used to effect cancer ‘cures’ often significantly impair a woman’s reproductive potential. Thus, in accordance with improved survival rates, there is an increase in demand for fertility preservation. Initially, fertility preservation was limited to embryo cryopreservation; therefore, the number of patients enrolling was relatively low. Recently, substantial improvements have increased available options, specifically oocyte cryopreservation, thereby expanding and altering the make-up of the patient population undergoing treatment for fertility preservation. Patient diversity requires the treating physician(s) to be cognizant of issues specific to cancer type and stage. Furthermore, patients often have comorbidities which must be attended to and addressed. Although not all patients will be candidates for, or will elect to pursue, fertility preservation, all should receive counselling regarding their options. This practice will ensure that the reproductive rights of those patients facing impending sterility are maintained. Here, fertility preservation protocols, practices and special considerations, categorized by most frequently encountered cancer types, are reviewed to guide reproductive endocrinologists in the management of fertility preservation in such patients. The formation of a multidisciplinary patient-structured team will ensure a successful, yet safe, fertility-preservation outcome.Advances in cancer treatment have allowed women to live longer, fuller lives. However, therapies used to treat cancer often significantly impair a woman’s future ability to have children by damaging her eggs or removing key reproductive organs. Given that women are now often living well beyond their cancer diagnosis and treatment, there is an increased interest in preserving reproductive potential. Thus, the field of fertility preservation has been developed and continues to grow. Initially, fertility preservation was limited to freezing embryos formed by combining an egg with spermatozoa. One drawback of this approach is that it requires both female and male contributions. Recently, substantial improvements have expanded the available options, including freezing unfertilized eggs, affording female patients fertility preservation without a requisite male partner or donor. Cancer patients vary widely, requiring the treating physician(s) to be cognizant of issues specific to individual cancer types and extent of disease. Furthermore, cancer patients often have co-existing medical conditions which must be attended to and addressed. Although not all patients will be candidates for, or elect to pursue, fertility preservation, all should receive counselling regarding their options. This will ensure that the reproductive rights of cancer patients facing impending sterility are maintained. Here, we review fertility preservation protocols, practices and special considerations, categorized by the most commonly encountered cancer types, to guide physicians in the management of fertility preservation in such patients. We advocate the formation of a multidisciplinary patient-structured team to ensure a successful and safe fertility-preservation outcome.     

Ovarian function preservation in the cancer patient

OBJECTIVE: To review the clinical modalities that are available to women receiving potentially sterilizing cancer therapy. DESIGN: The MEDLINE database was reviewed for all publications on medication, surgery, or assisted reproductive technology that could potentially preserve fertility in women who are receiving cancer therapy. CONCLUSION(S): There are many options available to a patient undergoing a treatment that will negatively impact her fertility. Many procedures and medical interventions have been proven successful both in terms of ovarian function and pregnancy rates. Other techniques have great potential but do not have long-term clinical data. It is important that the patient's primary care physician understand the methods available to preserve fertility in cancer patients and communicate this information to the patient.     

Laparoscopic Ovarian Transposition Before Pelvic Cancer Treatment: Ovarian Function and Fertility Preservation

Survivors of pelvic cancer treatment live with the ramifications of pelvic radiation for many years after their cure. Several options are available to preserve ovarian function and fertility in reproductive age women undergoing pelvic radiation. Laparoscopic ovarian transposition is an under-utilized, yet fairly simple surgical procedure to relocate the ovaries away from the radiation field. Although randomized-controlled trials on the outcomes of ovarian transposition are scarce, there is a growing body of evidence on the risks and benefits of this procedure, in terms of prevention of premature ovarian failure, and potentially preserving fertility. In this review, we summarize the available data on the indications, patient selection and outcomes of ovarian transposition, as well as illustrate the technique of the procedure.     

Challenges and controversies in the conservative management of uterine and ovarian cancer

Uterine cancer is the fifth most common cancer in women worldwide with an estimated 320,000 annual diagnoses. Its most common form, endometrioid adenocarcinoma of the endometrium (endometrial adenocarcinoma [EAC]), is thought to develop through excessive proliferation of endometrial glands, and then increasing steadily in incidence. The current standard treatment for EAC is hysterectomy, which is often curative. However, it may be unacceptably expensive for women with severe medical comorbidities, those who are at risk of intra- and postoperative adverse events and those who desire fertility.Ovarian cancer is the most malignant of all gynaecological cancers, but patients with disease limited to one ovary and patients with non-epithelial tumours may expect a good prognosis. A selected group of young patients who desire fertility may be well treated with conservative surgery.This chapter reviews patient selection, diagnosis, pre-treatment evaluation, treatment options, surveillance and risk of relapse.