MD Anderson Cancer Center
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Lisa Garvin: Welcome to Cancer Newsline, A podcast series from the University of Texas MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment and prevention providing the latest information on reducing your family's cancer risk. I'm your host Lisa Garvin and today our subject is fertility in cancer patients. I have two guests today to address the topic. We have Dr. Anna Franklin who is an assistant professor of pediatrics here at MD Anderson and also Donna Bell who is a nurse practitioner in the pediatrics area. Welcome to you both. Dr. Franklin obviously fertility is an issue for some cancer patients. How--how big of an issue is it?
Dr. Anna Franklin: It can be quite a big issue for patients and studies have been shown that it causes a lot of distress for patients that have gone through their cancer treatment and then found out they were not able to have biological children on their own. And some of them it was never discussed. Some of them it may have been discussed and may haven't remembered that it was discussed because they were overwhelmed by the cancer diagnosis. So we're trying now to see patients before they start treatment and discuss the potential risks of infertility and talk about potential options those patients may have.
Lisa Garvin: Do you find that maybe parents, you know, obviously their children aren't of childbearing age, do you find that they kind of blow off the issue because there's so much else going on? Donna, what have you seen?
Donna Bell: Though it's really something that's in the back of their mind first and foremost it's this life threatening diagnosis that they've received and that's kind of their first priority on the list of things to take care of but that question is always there. The parents that we've seen of young children wanna know. They wanna know what their risk of infertility for their children is for the future. Many of them begin a grieving process. They talk about the loss of what they think they're normal. Their child's normal growth and development will be and the ability for them to have biologic children in the future. And so there's a lot of grief that's associated with that and that's why we feel that starting that conversation early and giving that information really helps parents to fought--to go through that in a more --in a healthier manner and really helps them share the information with their children as well.
Lisa Garvin: Because I would think that, you know, as you said there's a lot going on with the cancer diagnosis. Is it something that parents are proactive about or do you as clinicians have to bring it up?
Dr. Anna Franklin: Again I think it varies from family to family. We had one patient that we saw with our fertility consultation service where the mother have had issues with fertility that were not related to cancer. And so she was aware that the cancer diagnosis and treatment of her daughter's cancer may affect her daughter's fertility. And so that was a big issue for her where as other once are completely unaware. But as we explain to them potential side effects of chemotherapy or radiation or surgery, one of the things that does come up is the risk of infertility.
Lisa Garvin: And as far as you're dealing with an adolescent and young adult population so these are people who have not started families, obviously. So is that pretty much the target population or do you have like younger child bearing women who also get cancer?
Dr. Anna Franklin: It runs the spectrum so we have patients that haven't even thought about having children until we say you may loose your fertility and then they have to think whether or not they want children. And then we have--some people that know they wanna be parents and they would like to do what they can to preserve their fertility and then we have some patients that already have one or two children but thought they would always have more. And they wanna know what they can do to help that process.
Lisa Garvin: Is the child part of the conversation Donna or does it depend on the age? Obviously, young children I guess parents are making that decision for them.
Donna Bell: Well, we really hold the parents that's the expert on the child and so if they feel that their child is developmentally appropriate and mature to be involved in these conversations then we go ahead and include them in those conversations. But we really look to the parent to assess at what level the child is and whether that conversation has had with the child in conjunction with the--with the mother and father.
Lisa Garvin: Let's talk about specific cancer treatments. Obviously, a lot of kids are gonna get chemotherapy and some may get radiation. Let's start with chemotherapy. What are the effects on fertility of chemotherapy and either one of you can answer.
Dr. Anna Franklin: So it's different in boys and girls and males and females. And it also depends on whether or not the patient has gone through puberty yet as to what the effects are. With chemotherapy, if patients have not gone through puberty yet there seems to be a sort of protective effect and they're at a lower risk of developing infertility from chemotherapy. If they have gone through puberty, it's a higher risk and then for chemotherapy the other thing is the type of chemotherapy and then the total doses of chemotherapy. So we know that drugs in the class called alkylating agent like Cyclophosphamide and Ifosfamide and even the platinum drugs like Cisplatin and Carboplatin. Those are some of the drugs that have the highest risks of causing infertility. For some drugs have minimal risks of causing infertility.
Lisa Garvin: And what's the action there? Obviously, chemotherapies are going after fast dividing cells like cancer cells so is that what's affecting the egg and the sperm because they're fast dividing as well so that's the risk?
Dr. Anna Franklin: Sperm are fast dividing, eggs are not. But it's damaging the DNA within the cells that causes the problems inside the sperm and the eggs.
Lisa Garvin: And let's talk about shall we go to females and kinda talk about obviously, they only have a set number of eggs in a--in a defined, you know, period of fertility what sort of options are available to them Donna? What do you talk to them about?
Donna Bell: So it really--once again depends on where they are in developments so prepubescent girls as Dr. Franklin talked about earlier really have a protection just for not going through puberty yet from chemotherapy. And so we really--it's risk assessment and so we assign them to a lower risk of infertility with chemotherapy depending on what their total doses are. A chemotherapy want the chemotherapy regimen is that the receiving and then once girls have gone to puberty and that's really the girls that are at higher risk of the girls that have--are perceived treatment during that time after they've gone through puberty. And so once again, it's whether the drugs that they've received and what are the total doses of the drugs that they've received.
Lisa Garvin: And for men, chemotherapy obvious--I mean, I don't know when--I guess sperm production starts even before puberty does it not?
Dr. Anna Franklin: It starts a little bit before puberty and everything is in place but in order for boys to sperm bank they need to be able to have an erection and ejaculate to provide specimen. And that can't happen unless they've gone through puberty.
Lisa Garvin: So chemotherapy has affects on sperm or a little bit more intense than they are on eggs. It sounds like.
Dr. Anna Franklin: It's hard to compare because you're talking about apples and oranges. The same kinds of drugs that are toxic to eggs, are toxic to sperm. But sometimes men will have a period where their sperm counts are very low but as time goes on it may recover. Whereas other men may never recover sperm counts.
Lisa Garvin: And what are the risks of radiation treatment? Are they kind of similar or, you know, what are the effects there of radiation treatment?
Donna Bell: I think for women who receive radiation to their reproductive organs and so that kind of is two fold. One is the exposure of the ovaries to radiation and what that does to their ovarian reserve and then the second is radiation to their uterus 'cause that can really compromise their ability to carry a pregnancy in the future 'cause there can be some scarring that happens in the uterus and that it would be enable in the future to carry a pregnancy and to enlarge to accommodate a fetus. And so that is a concern for women who've received radiation to their pelvis.
Dr. Anna Franklin: But one of the things we know we can do now is something called ovarian transposition where the surgeons can actually move the ovary out of the radiation field and then they'll suture them place with a temporary suture that dissolves over time so once the radiation is complete, the suture will dissolve and the ovary will go back to the normal place. So that if they are still fertile after their treatment, they can still potentially get pregnant.
Lisa Garvin: Can you do the same with testicles? I would think it would be easier.
Dr. Anna Franklin: You can. You can.
Dr. Anna Franklin: So if they're going to get testicular radiation you can move. If they only get to one testicle, you can move it. The other testicle that's not going to be radiated and also with some men they may have a tumor near the testicle and you may need to move it. And you can either move it back up in the abdomen which is where the testis start during development as fetuses or you can even move it down into the leg temporarily again. But typically, you need to put the testis back where they were.
Lisa Garvin: So these are the some of the things you can do to preserve fertility during treatment. What about banking? When--when is it--when is the decision made for sperm banking?
Lisa Garvin: I mean do you know looking at the treatment you say "Well you know you might be impotent after this." How do you decide who to counsel about sperm banking?
Dr. Anna Franklin: And so really we ask that patients who are referred to us so that we can help assess the risk so we look at what type of cancer they have. What the treatment is, the plan treatment is if their gonna receive and so does that include surgery, does that include radiation, does that--what are the chemotherapy drugs and what are the total doses said that we kind of assess the risk for them. And where they are prepubescent or they've gone through puberty. And then really the time to bank sperm is before beginning treatment. And so we--you know, we sit down, we share this information with them, we share the--the risk so what we talk about is your at a high risk for featuring fertility and at that time we make it very clear that its not sexual function that were talking about. And so many young men are very relieved to hear that. And truly a question about in the future you may not be able to father biologic children and so this--this is what's available to you now to be able to help bank and preserve your fertility for the future and then we go on to describe what that all entails.
Lisa Garvin: Now for women who are post pubertal and--can you--harvesting eggs is obviously more difficult situation but do you do that in some patients?
Dr. Anna Franklin: We do and we go through the same procedure where we provide a risk assessment and say, "You're at high risk or low risk." And then we explain the procedure what goes through harvesting eggs. They typically need to go through a two week period of ovarian stimulation through this of hormone drugs which can be quite expensive and then the eggs are retrieved and then the standard of care is to freeze embryos because they have the greatest success rates of creating pregnancies and having live births from frozen embryos. Technology today freezing eggs is approaching the same success rate of frozen embryos but that is still considered an investigational method by the American Society of Reproductive Medicine.
Lisa Garvin: So what sort of resources are available to patients who want to preserve their fertility in the future?
Dr. Anna Franklin: I think one of the first things that's important for patients is just information and education and two resources that we commonly gives are Fertile Hope which is a program of LIVESTRONG and then also the Oncofertility Consortium and they both have websites and booklets that can be very helpful and Fertile Hope also list different providers at that you can search by a geography. One of the nice things about the Fertile Hopes side is they have a risk calculator where you can put in your age of diagnosis, the diagnosis you have and what your plan treatment in and it will do the risk assessment. Obviously its not exactly the same as getting that information from your own physician but it can give patient some idea. I think it's also helpful for families and friends to be able to go through these websites so that they can help understand what the patients going through.
Lisa Garvin: And cost is obviously an issue. This is, you know, something that people elect to do and probably I'm assuming is not covered by insurance, is that correct?
Dr. Anna Franklin: Correct. So the cost of fertility preservation is not currently covered in the State of Texas by Insurance Cares, private insurance or public insurance. But there are resources out there as Dr. Franklin mentioned there are scholarships through fertile--the fertile hope Organization through the LIVESTRONG Foundation. There's also a great organization that we use often is Heroes for Children and they will actually provide a credit card upfront and with the cost of--we use that very commonly for our young men who are gonna sperm bank. And so that's one--there are resources available for patients and, you know, one other thing that we really strive for is for that not to be the--the thing that makes the decision on whether they decide to sperm--to bank--to preserve their fertility or not because there are resources available for patients and even if they don't qualify for financial assistance sometimes some of the groups that work with us will even do payment plans. And so there's always kind of some method for them to be able to preserve their fertility.
Lisa Garvin: Oh, that must be good to know because, you know, in some cases I would think that sperm might be banked for ten years or more. You know, so that would run into an expensive proposition.
Dr. Anna Franklin: Correct.
Lisa Garvin: So, what would you say to young patients and or their parents because obviously if they don't make the decision at the right time then they don't have the chance to take it back. So what do you advice parents and their young patients to ask or do?
Dr. Anna Franklin: We ask them just to ask their oncologist or their health care provider to have a discussion about fertility. Many oncologists don't receive any specific training about the risk of infertility so they may need to speak to a reproductive specialist. But I think one of the most important things is just getting information so you understand what's going on. And I think that it lays a lot of the anxiety that patients may have later on and that just to--we do provide a risk assessment but those aren't perfect. And every patient is different and we don't know a lot about a lot of the new drugs that were now using so there is still a lot of unanswered questions for us as practitioners.
Lisa Garvin:Any final words from you Donna?
Donna Bell: And this is an issue for survivors so currently there--the number of children's surviving childhood cancer is increasing and that's a good thing. And this is one of the topics that comes up and so really parents and patients have described to us that once they come into young adulthood and they know they have had cancer treatment and they've gone through this cancer experience they figure, "Is this really something that I should ask about? Is this something that I should be concern about? Shouldn't I just be grateful that I survived my diagnosis?" And so really voicing that and working with your oncologist that you're following up with as a survivor to say, "You know, I have these questions about my future fertility." And having that discussion and the good thing is that there's great resources out there now to help answer those questions.
Lisa Garvin: Great thank you ladies. If you have questions about anything you heard today on Cancer Newsline contact askMDAnderson at 1877MDA6789 [background music] or online at www.mdanderson.org/ask. Thank you for listening to this episode of Cancer Newsline. Tune in for the next podcast in our series.
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