ORLANDO, FL—“A low but definite risk of gonadal failure is associated with initial cytotoxic treatment of most hematologic malignancies and interventions to preserve fertility are best undertaken before initiating therapy,” Alison Loren, MD, MS, of the University of Pennsylvania Abramson Cancer Center in Philadelphia, PA, told attendees at the 57th American Society of Hematology (ASH) Annual Meeting.1
“It is critical to be able to identify patients who are not candidates for immediate fertility preservation due to their clinical status,” she added. “These patients should be referred to a reproductive specialist after completion of therapy.”
Patients diagnosed with a hematologic malignancy have a “dual crisis,” both the diagnosis itself as well as threats to fertility, leading to increased emotional distress.
The more than 1 million survivors of hematologic cancers represent 7% of all cancer survivors; among these, 75% with acute lymphoblastic leukemia and 64% with Hodgkin lymphoma are younger than 50.
In addition, 110,000 are survivors of hematopoietic cell transplantation (HCT), with 45% of allogeneic HCT and 25% of autologous HCT survivors younger than 40.
“HCT of any kind is associated with a substantial risk for permanent gonadal failure,” she said. “Even if gonadal failure is not immediate, there is a shortened fertility window for women. Conversely, men frequently recover spermatogenesis over time. Contraception upon starting therapy is essential, especially for men.”
Patients with chronic myelogenous leukemia (CML) require “special consideration,” she said. About 25% are younger than 50 and many are treated lifelong with tyrosine kinase inhibitors (TKIs). However, the U.S. Food and Drug Administration has determined TKIs to be pregnancy category D, meaning “there is positive evidence of human fetal risk.” Because of this, women with CML who desire to become pregnant should achieve a major molecular response for more than 2 years and then discontinue the TKI for conception and gestation. Although still anecdotal, “accumulating data suggest that men may father children safely while on TKIs,” Dr. Loren said.
Studies have shown patients referred to fertility services have reduced regret and increased life satisfaction, even if they do not take advantage of them.
Fertility preservation methods include embryo and egg banking for women and sperm banking and gonadal shielding for men.
“Oncofertility program building and facilitated referrals from hematologists to reproductive specialists are essential to achieve the best outcomes,” she concluded.
1. Loren A. Fertility Issues in Patients with Hematologic Malignancies. 57th American Society of Hematology (ASH) Annual Meeting. [oral presentation] December 5, 2015.