Fertility Risk Assessment and Preservation in Male and Female Prepubertal and Adolescent Cancer Patients
the ONA take:
Although cancer is associated with an overall survival rate of 90% to 85% among prepubertal and adolescent patients with cancer, both the malignancy and treatment strategies are associated with long-term effects that necessitate lifelong monitoring. For example, many survivors of cancer experienced during adolescence become infertile due to the disease, radiotherapy, chemotherapy, or surgery. Therefore, clinicians should perform a fertility risk assessment and discuss fertility preservation options with both young male and female patients who are at risk of premature gonadal failure.
In terms of the assessment, clinicians should evaluate the risk of infertility and communicate that risk with the patient and his or her parents. Intrinsic and extrinsic risk factors associated with infertility in this patient population include: pubertal stage; ovarian reserve; tumor type, stage, and location; performance status; ability to undergo fertility-sparing procedures; radiotherapy; surgery; chemotherapy; and dose.
To preserve gonadal function in female patients, patients can opt for the receipt of gonadotropin-releasing hormone analogs, fertility-sparing surgery, ovarian transportation, or orthotopic transplantation of cryopreserved ovarian tissue. Approaches for male fertility preservation include testis-sparing surgery, testicular transposition, and sperm extraction and banking. However, prebuteral boys cannot benefit from sperm banking, and the use of gonadotropin-releasing hormone agonists in prepubertal patients remains controversial.
Clinical Medicine Insights: Oncology
Cancer represents the second cause of death in prepubertal children and adolescents, although it is currently associated with an overall survival rate of 80%–85%. The annual incidence rate is 186.6 per 1 million children and adolescents aged up to 19 years. Both disease and treatment options are associated with life-altering, long-term effects that require monitoring. Infertility is a common issue, and as such, fertility preservation represents an essential part in the management of young patients with cancer who are at risk of premature gonadal failure. This review deals with the up-to-date available data on fertility risk assessment and preservation strategies that should be addressed prior to antineoplastic therapy in this vulnerable subgroup of cancer patients.
Keywords: fertility, risk assessment, preservation, adolescents, cancer, radiotherapy, chemotherapy, surgery
As a result of advances in cancer treatment, the five-year overall survival rate of adolescents and young adults currently stands at 80%–87% for both Europe1 and the United States of America.2 The American Cancer Society estimated that 10,380 new cases of cancer and 1,250 deaths from cancer would occur in 2016 among males and females aged 0–14 years.2 The most common cancers that occur in this age group include leukemias and lymphomas, brain and central nervous system tumors, embryonal tumors, sarcomas of bone and soft tissue, and gonadal germ cell tumors.2 Despite recent advances in the treatments of malignancies that may cure these young cancer patients,3–5 infertility is an important long-term toxicity in both females6 and males.7,8 Infertility is associated with significant psychological distress, with levels of depression twice that of the normal population in both young female9 and male cancer survivors.10 Even for patients who may have not planned to have children, most commonly due to their very young age, the threat of infertility can result in a deep sense of loss and anger.11
Since post-therapy recovery of gonadal function remains unpredictable, it is important to inform patients facing infertility of this possible side effect of their treatment and all the options available to prevent it.12 As survival worries may deviate from important life dreams, it is advisable to anticipate and facilitate the long-term perspectives that may not be readily apparent to young patients in this sensitive situation.13 Not surprisingly, fertility preservation concerns in many instances may influence patients' treatment decisions, as for example in cases of breast cancer,14,15 although the general tendency of both patients and their parents is opposite.16,17
Herein, we present a comprehensive review of fertility risk assessment strategies including medical and surgical strategies that can preserve fertility in prepubertal and pubertal cancer patients.