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.