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Fertility in Cancer Patients PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Fertility In Cancer Patients” by Ann H. Partridge, MD, MPH.

This medical PowerPoint presentation is about fertility in cancer patients. Cancer treatment, such as chemotherapy, radiation therapy, and surgery, can affect a persons fertility. The impact on fertility depends on several factors, including the type of cancer, the location of the cancer, the stage of cancer, the treatment used, and the persons age and gender.

In women, chemotherapy and radiation therapy can damage the ovaries and reduce the number of eggs. Surgery to remove the uterus, ovaries, or both can also cause infertility. In men, chemotherapy and radiation therapy can damage the testicles and reduce sperm production. Surgery to remove the prostate gland can also cause infertility.

Fortunately, there are options available for preserving fertility in cancer patients. For women, options may include freezing eggs, embryos, or ovarian tissue before cancer treatment. For men, options may include freezing sperm before cancer treatment. These fertility preservation methods may be more successful if done before cancer treatment starts.

If cancer treatment has already affected a persons fertility, there are still options available to help them have children. These options may include using donor eggs, donor sperm, or a surrogate, or using assisted reproductive technologies such as in vitro fertilization (IVF) or intrauterine insemination (IUI).

Its essential to discuss fertility preservation options with a doctor before starting cancer treatment. Cancer patients should also consider speaking with a fertility specialist to understand their options and make informed decisions about their fertility.

Tags : Fertility In Cancer Patients, Cancer treatment, chemotherapy, radiation therapy, Gynaecology, Gynaecology PowerPoint presentation, Gynecologic Oncology, Gynecologic Oncology PowerPoint presentation

Published on : May 29, 2023 | Views : 831 | Downloads : 2

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Slide 1-

Fertility In Cancer Patients Ann H. Partridge, M.D., M.P.H., Dana-Farber Cancer Institute, Harvard Medical School Boston, MA
Slide 2-

The speaker declares no conflict of interest with the topic presented in the lecture.
Slide 3-

The speaker declares that specific brand-name medications and/or off-label, non-FDA-approved uses are discussed in the lecture. Letrozole or tamoxifen for ovarian stimulation I will attempt to avoid bias by discussing the published research in this area only and limitations of it
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Cancer and Future Fertility Patients of reproductive age often find prospect of infertility one of the most difficult components of their disease and treatment Oncology providers focus on survival Can be difficult to assess who is interested in future fertility
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Fertility after cancer poses challenging medical issues and emotional consequences Surveys of cancer survivors have identified an increased risk of emotional distress in those who become infertile because of their treatment Long-term quality of life is affected by unresolved grief and depression
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Fertility Concerns Common 57% of women age 40 and younger at diagnosis of breast cancer recalled concerns about fertility 29% reported that infertility concerns influenced treatment decisions (Partridge et al., JCO 2004)
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Providers May Neglect to Discuss Fertility Only 68% of women age 50 or younger at diagnosis of breast cancer recalled physician discussion of early menopause 34% of women recalled discussion of infertility risk (Duffy et al., JCO 2005)
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American Society of Clinical Oncology Recommendations on Fertility Preservation in People Treated for Cancer Eligible for proven fertility preservation method Male: Female: sperm cryopreservation embryo cryopreservation conservative gynecologic surgery oophoropexy • • • Patient at risk for treatment - induced infertility • Patient interested in fertility preservation options Refer to specialist with expertise in fertility preservation methods Investigational fertility preservation technique* • Cryopreservation of testicular or ovarian tissue • Cryopreservation of oocytes • Ovarian suppression *Clinical trial participation encouraged Eligible for proven fertility preservation method Male: Female: sperm cryopreservation embryo cryopreservation conservative gynecologic surgery oophoropexy • Assessment of risk for infertility • Communication with patient • Patient at risk for treatment - induced infertility • Patient interested in fertility preservation options Refer to specialist with expertise in fertility preservation Investigational fertility preservation technique* • Cryopreservation of testicular or ovarian tissue • Cryopreservation of oocytes • Ovarian suppression *Clinical trial participation encouraged www.asco.org (Lee et al., J Clin Onc; 2006)
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American Society of Clinical Oncology Recommendations on Fertility Preservation in People Treated for Cancer Eligible for proven fertility preservation method Male: Female: sperm cryopreservation embryo cryopreservation conservative gynecologic surgery oophoropexy • • • Patient at risk for treatment - induced infertility • Patient interested in fertility preservation options Refer to specialist with expertise in fertility preservation methods Investigational fertility preservation technique* • Cryopreservation of testicular or ovarian tissue • Cryopreservation of oocytes • Ovarian suppression *Clinical trial participation encouraged Eligible for proven fertility preservation method Male: Female: sperm cryopreservation embryo cryopreservation conservative gynecologic surgery oophoropexy • Assessment of risk for infertility • Communication with patient • Patient at risk for treatment - induced infertility • Patient interested in fertility preservation options Investigational fertility preservation technique* • Cryopreservation of testicular or ovarian tissue • Cryopreservation of oocytes • Ovarian suppression *Clinical trial participation encouraged www.asco.org (Lee et al., J Clin Onc; 2006)
Slide 10-

Risk of Infertility in Men Male infertility can result from: Disease Anatomic problems Primary or secondary hormonal insufficiency Damage or depletion of the germinal stem cells The effects of chemotherapy or radiotherapy include compromised sperm number, motility, morphology, and DNA integrity Azospermia typically surrogate for infertility
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All Cancer Treatments Are not Equal Alkylating agents appear to be most gonadotoxic; cis-platin cumulative dose important Radiation is very damaging: >=2.5 Gy to testis area results in prolonged azospermia External beam to field that includes ovaries
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Men Have Sperm Banking! Sperm cryopreservation involves freezing and banking sperm collected through masturbation, rectal electroejacualtion, testicular aspiration or post-masturbation urine If patient sick or with certain cancers (e.g., testicular cancer and Hodgkins)- sperm quality may be poor prior to treatment Many patients have to start chemotherapy soon enough to limit the number of ejaculates Still reasonable to make every effort to bank sperm- intracytoplasmic sperm injection (ICSI) allows the successful freezing and future use of small sample
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Other “Options” for Men Hormonal Gonadoprotection (e.g. GnRH analogs) The efficacy of gonadoprotection through hormonal manipulations has only been evaluated in very small studies in male cancer patients Evidence suggests hormonal therapy in men is not successful in preserving fertility when highly sterilizing chemotherapy is given Potential future options (not tested in humans yet) Testicular tissue cryopreservation or reimplantation Testis grafting with maturation in SCID mice
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Risk of Infertility in Women Female fertility can be compromised by any treatment that: Decreases the number of primordial follicles Affects hormonal balance Interferes with the functioning of the ovaries, fallopian tubes, uterus or cervix.
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Natural Decline of Oocytes with Age (Lobo, NEJM 2005)
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Chemotherapy-related Amenorrhea CRA may be permanent or temporary CRA is an imperfect surrogate for menopause and infertility Accurate assessment of ovarian function has implications for family planning, contraception treatment in hormone sensitive tumors other survivorship concerns
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Risk of amenorrhea is related to age and treatment (Goodwin et al., J Clin Oncol 1999)
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Ovarian Failure Risk with Cancer Treatments High risk: Total body irradiation, high dose cyclophosphamide, chlorambucil, melphalan, busulfan, nitrogen mustard, procarbazine Intermediate risk: Cisplatin, carboplatin, doxorubicin Low or no risk: Methotrexate, 5-fluorouracil, vincristine, vinblastine, bleomycin, actinomycin Unknown risk: Taxanes, oxaliplatin, irinotecan, monoclonal antibodies, Tyrosine kinase inhibitors (Sonmezer and Oktay, Hum Reprod Update, 2004)
Slide 19-

Risk of Chemotherapy-Related Amenorrhea with Common Breast Cancer Regimens (Goodwin et al., JCO 1999; Burstein, H. J. et al. NEJM 2000; Nabholtz et al., ASCO 2002; Parulekar et al., JCO 2005; Fornier et al., Cancer 2005; Petrek et al, JCO 2006) % women with amenorrhea
Slide 20-

Effects of Newer Treatments: Paclitaxel, Dose Density, and Trastuzumab on CRA (Abusief et al., Breast Cancer Res Treat 2006) Premenopausal women who received adjuvant chemotherapy N=451 Age at diagnosis, mean: 42 years (range 25-55) Follow-up, mean: 34 months (range 6-93)
Slide 21-

Effects of Paclitaxel, Dose Density, andTrastuzumab on CRA (Abusief et al., Breast Cancer Res Treat 2006)
Slide 22-

Issues for Women Who Remain Premenopausal Will a woman be less fertile, even if she continues to menstruate? Will a woman go through menopause earlier (“delayed, premature menopause”)
Slide 23-

Ovarian Reserve in Women Who Remain Premenopausal After Chemotherapy For Early Stage Breast Cancer 20 breast cancer survivors who remained premenopausal after chemotherapy 20 age, gravidity-matched controls Day 2-4 of cycle, measured ovarian reserve (Ruddy et al., Fertility and Sterility, In Press)
Slide 24-

Ovarian Reserve in Survivors Compared to Controls Prospective studies are needed to determine the predictive value of these tests for pregnancy after chemotherapy (Ruddy et al., Fertility and Sterility, In Press)
Slide 25-

Age of Menopause Among Women Who Remain Premenopausal Following Treatment for Early Breast Cancer Long-term data from the International Breast Cancer Study Group (IBCSG) Trials V and VI Included women who had reported menses in months 12-24 after diagnosis N= 767 women 540 women randomized to PeCT (1 cycle CMF) or No CT 227 randomized to CMF x 6 or 7 (Partridge et al, Eur J Ca 2007)
Slide 26-

Age at Menopause by Age at Treatment and Treatment Group (Partridge et al, Eur J Ca 2007) Not clear that these data apply to women treated with more modern regimens
Slide 27-

Effects of Endocrine Therapy Adjuvant endocrine therapy for breast cancer (tamoxifen or ovarian suppression) does not appear to cause permanent amenorrhea or infertility BUT… endocrine therapy usually entails years of treatment when pregnancy contraindicated, and aging during that time compromises fertility
Slide 28-

Fertility Preservation Considerations for Women with Cancer The obvious: weigh the “necessity” of systemic therapy
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Options for Fertility Preservation in Women- Anatomic Fixes Pelvic shielding during radiation Ovarian Transposition surgical repositioning of ovaries away from the radiation field Conservative Gynecologic Surgery (Radical Trachelectomy) surgical removal of the cervix while preserving the uterus
Slide 30-

Other Options for Preserving Fertility for Women with Cancer Ovarian suppression (LHRH agonists) during treatment Cryopreservation of embryos Cryopreservation of ovarian tissue Cryopreservation of oocytes Pharmaceutical protection with anti-apoptotic agents (eg. Sphingosine-1-phosphate) Oocyte donation and gestational surrogacy
Slide 31-

Ovarian Sensitivity to Chemotherapy Normal premenopausal ovary Low level recruitment of primordial follicles Cytotoxic chemotherapy Oocyte toxicity Decreased estradiol Increased FSH Increased follicular recruitment More oocytes at risk
Slide 32-

Ovarian Sensitivity to Chemotherapy Normal premenopausal ovary Low level recruitment of primordial follicles Cytotoxic chemotherapy Oocyte toxicity Decreased estradiol Increased FSH Increased follicular recruitment More oocytes at risk GnRHa
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Summary of Phase II Trials and Case Series GnRH agonist coadministration with chemotherapy is associated with high rates of resumption of menses after chemotherapy Successful pregnancies have occurred following chemotherapy with GnRHa Lack of randomized data Uncontrolled studies tended to have young patient populations
Slide 34-

A randomized trial using the GnRH agonist (triptorelin) during chemotherapy N=49 (12-month f/u on 42 patients, and 18 month on 34 patients) Median age 39 years, range 21–43 Median time to return of menses Triptorelin arm: 6.1 months (range 1–19) Control arm: 4.7 months (range 0–22) (p=0.79) Menstruation resumed post chemotherapy in the respective groups as follows: triptorelin vs control 6 months: 44% vs 60%, 12 months 83% vs 79% 18 months 88% vs 84% (R. Ismail-Khan et al. ASCO 2008)
Slide 35-

Gonadotropin-releasing hormone agonists for prevention of chemotherapy-induced ovarian damage: prospective randomized study N=80 Age range 18-40 Menstruation resumed post chemotherapy (3-8 months) in the respective groups as follows: GnRHa group Control group 35/39 resumed menses 13/39 resumed menses 27 resumed spontaneous ovulation vs. 10 in control group (Badawy et al., Fertility and Sterility, in Press)
Slide 36-

Ongoing Study: SWOG 0230 “POEMS” Premenopausal Stage I, II, IIIA ER-/PR- Breast Cancer Under age 50 Randomization n=416 Standard cyclophosphamide Containing (neo)adjuvant chemotherapy Standard cyclophosphamide Containing (neo)adjuvant chemotherapy Plus monthly goserelin Stratification: Age Chemotherapy CALGB 40401ECOG S0230 IBCSG 34-05
Slide 37-

IVF/Embryo Cryo
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Cryopreservation of Embryos Standardly available: 20-30% pregnancy rate per transfer of 2-3 embryos Requires medical stability, time, and partner/sperm, adequate ovarian reserve Expensive, ethically problematic if patient dies Requires ovarian stimulation prior to systemic breast cancer treatment- concerning in patients with hormone-sensitive cancer Natural cycle IVF has low yield (Oktay et al, JCO, 2005; Partridge & Winer, JCO 2005)
Slide 39-

Comparison of Cycle Characteristics and Embryo Yield Among Tam-IVF (12 patients) TamFSH-IVF (seven patients), and Letrozole-IVF (11 patients) Patients (Oktay et al, JCO, 2005)
Slide 40-

Tamoxifen or aromatase inhibitor stimulation protocols for IVF Increase embryo yield, lower E2 levels with Letrozole, blockage of receptors with Tamoxifen Unclear if mitigates potential risk Preliminary safety data available Number of babies resulting from such strategies that would have not been born otherwise remains unclear (Oktay et al, JCO 2005; Partridge & Winer, JCO 2005; Oktay et al., JCO 2008)
Slide 41-

Oocyte Cryopreservation Requires time and stimulation prior to treatment No requirement for sperm, less ethical concern Experimental- approximately 2% pregnancy rate per thawed oocyte
Slide 42-

Oocyte Cryopreservation Technically difficult MII oocytes: extremely sensitive to temperature changes Crystal formation can cause cytoplasmic damage Cryoprotectants depolymerize meiotic spindle cause aneuploidy Hardening of zona pellucida barrier to fertilization
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Cryopreservation of Ovarian Tissue Requires surgical procedure to remove ovary or piece of ovary May increase risk of infertility in low risk situation Potential for reintroduction of malignant cells at reimplantation Highly experimental- few babies born to date
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Ovarian Cryopreservation Ovarian cortex is frozen in thin slices Primordial follicles are less sensitive to cryodamage because of low metabolic rate absence of zona pellucida high surface-volume ratio
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Ovarian Cryopreservation Resumption of endocrine function has been reported after orthotopic and heterotopic transplantation Embryo was generated from oocytes retrieved from sc transplanted ovarian tissue Two live births reported after orthotopic transplantation of frozen-banked ovarian tissue in lymphoma survivors
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Ovarian Cryopreservation Heterotopic tranplantation technique: Optimal site unknown Most have been to arm or forearm (or suprapubic area) (Oktay K, et al, JAMA, 2001;286:1490-3) - No need for abdominal surgery - Easy monitoring of follicular dvelopment - Easy removal if necessary
Slide 47-

Ovarian Cryopreservation Xenotransplantation: Has been shown feasible in several animal models into immunodeficient mice Concerns: Retroviruses, prions Abnormal oocyte development Abnormal chromatin patterns Benefits: Easier to repeat grafting if needed Easier access for IVF
Slide 48-

Ovarian Cryopreservation Transplanting complete, intact ovary: Has been demonstrated in rats and sheep Recently demonstrated in human, but high risk for ischemia-reperfusion injury No pregnancy demonstrated (Bedaiwy M, et al, Hum Reprod, 2006)
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Sphingosine-1-Phosphate Apoptotic inhibitor blocks pro-apoptotic messenger: ceramide (early messenger that signals apoptosis in response to stress) shown to be beneficial in mice when injected into ovarian bursa sac prior to radiation has not been evaluated in humans (Perez G, et al, Nat Med 1997;3:1228-32)
Slide 50-

Safety and Timing of Pregnancy after Cancer Conventional wisdom is to wait until patient gets through the period of highest risk recurrence Receive optimal therapy (endocrine therapy may be prolonged) No data to suggest harm in pregnancy sooner No evidence for increased risk of disease recurrence associated with most fertility preservation methods and pregnancy- little data! Aside from hereditary genetic syndromes and in-utero exposure to chemotherapy, no evidence for increased risk of cancer or abnormality in progeny
Slide 51-

Conclusions: Fertility Concerns in Cancer Survivors Very complex and difficult issues Limited available data Patient preferences critical in some settings Managing expectations often necessary
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Conclusions: Fertility Concerns in Cancer Survivors (cont.) Address fertility issues up front; include fertility concerns in the risk-benefit analysis Refer to fertility specialists early In the event of pregnancy, consider “high risk” obstetrics management
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Resources ASCO www.asco.org Fertile Hope www.fertilehope.org Lance Armstrong Foundation www.livestrong.org