“Twistin' the night away”: Fertility preservation in young adult female cancer survivors

The population of cancer survivors is increasing worldwide. Treatment advances over the last decades have resulted in long disease-free periods after cancer treatment, as well as full recoveries. In Italy in 2010, a total of 2,587,347 patients survived after a cancer diagnosis.1 The occurrence of cancer and/or the long-term and late effects of cancer treatment, which may impact various aspects of the quality of life of cancer survivors, has become of peculiar increasing interest. In their recent article, Benedict et al focused on unmet information regarding fertility preservation (FP) and subsequent decisional conflict in a population of young adult female cancer survivors.2 The authors reported on 346 patients, with the majority residing not too far from health care services in suburban/urban areas, who most often were diagnosed with lymphoma, breast cancer, gynecologic cancer, and leukemia (ie, potentially curable cancers). Only 16% of the patients underwent pretreatment FP but, more surprisingly, approximately 30% of the survey respondents who were young women were not informed about FP, whereas 29% reported themselves to be distressed or overwhelmed and 27% were worried by the cost of FP procedures. Moreover, only 13% of the study subgroup of 179 women reported that they were informed regarding FP options. Consequently, this lack of information was found to be the major cause of patient decisional conflict.2 These data (especially those regarding the lack of information) should cause us to reflect. If we consider FP as a primary goal at the same level as cancer cure for female health, we believe it is no longer possible that each single patient with cancer does not receive at least the information regarding FP methods at the clinician's disposal and adequate psychological support to address fertility issues. Therefore, we propose the presence in each cancer institute of physicians with expertise in FP along with psychologists working side by side with oncologists and counseling females who desire to become pregnant after cancer treatment. These experts should be part of a multidisciplinary team at the time of cancer diagnosis (because some interventions are possible and effective only before the initiation of treatment), and should be key actors to whom primary care physicians will refer cancer survivors for a consultation regarding FP at the end of cancer treatment.3, 4 A pathway of care similar to that proposed herein is well established and working in our National Cancer Institute in Aviano, Italy. In particular, the ultimate goal of this multidisciplinary evaluation is to inform female patients about: 1) their personal risk of infertility and early menopause; 2) the opportunities at their disposal with regard to methods of FP, both established and still-experimental techniques,5 and referral to FP clinics; 3) the infertility risk of each therapeutic intervention (ie, need for gynecologic surgery, doses of alkylating agents, inclusion of ovaries in the radiotherapy fields) so that, in the presence of more than one effective alternative treatment, patient decisions can be driven by fertility concerns; 4) the evaluation of the number of antral follicles and ovarian volumes, ascertained through transvaginal ultrasound before the initiation of treatment in women after the onset of puberty6, 7; 5) the measurement of anti-Mullerian hormone levels, which constitutes a reliable indirect serum marker of ovarian function both before the initiation of treatment and afterward7, 8; 6) the coexistence of causes of infertility other than cancer (ie, hypothalamic pituitary causes, polycystic ovary syndrome, uterine or outflow tract disorders, tubal defects, and endometriosis); 7) the presence of lifestyle infertility risk factors such as smoking, alcohol abuse, and obesity; and 8) the issue of costs related to FP modalities. Furthermore, psychological support should be fundamental to address unresolved internal conflicts at baseline, to evaluate the patient's cultural environment and sexual attitudes, to reduce anxiety, and to help young females in decision making. We are well aware that in the United States, due to the lack of a national health insurance program ensuring all citizens a minimum level of coverage, not all young women diagnosed with cancer can afford the costs associated with FP procedures. However, we want to emphasize again that in our opinion, but also as suggested by Benedict et al,2 the salient point is rather the lack of information. We believe that information regarding FP should no longer be an unmet goal in the health care of young women, and we propose a pathway of care with the goal “to twist the night away” reducing patients' discomfort and anxiety concerning their reproductive life decisions during cancer care. No specific funding was disclosed. The authors made no disclosures. Ernesto Zanet, MD Rosanna Ciancia, MD Mariagrazia Michieli, MD Unit of Cell Therapy and High Dose Chemotherapy CRO Aviano National Cancer Institute Aviano, Italy Umberto Tirelli, MD Division of Medical Oncology A CRO Aviano National Cancer Institute Aviano, Italy

Topic: Reproductive Biology and Fertility
Subfield: Public Health, Environmental and Occupational Health
Field: Medicine
Domain: Health Sciences