Alison W. Loren, MD
The American Cancer Society estimated that in 2015 in the United States, more than 86,000 women younger than age 45 were diagnosed with cancer. Many of them face reproduction and fertility concerns, which could lead to long-term distress and impaired quality of life in survivorship. To shed light on this important subject, The ASCO Post recently spoke with Alison W. Loren, MD, Associate Professor of Medicine at the Perelman School of Medicine of the University of Pennsylvania (UPenn), Philadelphia.
Pathway to Field of Oncofertility
How did you become interested in the field of oncofertility?
I care for patients with blood cancers, and I’m also a bone marrow transplant specialist. As it turns out, because bone marrow transplants are so intensive, infertility is a common late effect of treatment.
When I was a junior faculty member, I was given an opportunity by the Center for International Blood & Marrow Transplant Research to participate in a study looking at the various effects of bone marrow transplant. One of my mentors at UPenn recollected that I was interested in pregnancy and cancer survivorship and recommended me to the Working Committee on Late Effects Fertility Working Group. So that was my pathway into the field of oncofertility.
Along those lines, we are so focused on treating our patients’ cancer that we often overlook the intricacies of their lives outside the clinic, such as the desire to have children. There are ample data demonstrating that we don’t talk about this issue enough. For me, there was this enormous gap in education about this issue to be filled for our patients, and the moment was right.
Are there guidelines to help clinicians deal with the various scenarios that might require ethical discussions?
Most definitely. I’m part of the ASCO committee that organized and developed the fertility guidelines, which were initially published in 2006 and were recently updated this past June. The guidelines recommend that all cancer care providers who have patients of childbearing age should address this issue with them. Many patients who are eligible for fertility-sparing interventions may not be presented with these options, and even when they are, many choose not to proceed with them, which is another interesting phenomenon worth exploring.
Simply having a conversation with patients about threats to their fertility reduces stress, anxiety, and post-treatment regret; again, even those patients who chose not to take steps to preserve their fertility feel better after the conversation. As a rule, oncologists are very good at having difficult conversations. We talk about nausea, hair loss, and other treatment-related issues, and we encourage our colleagues to weave fertility issues into the office conversation when appropriate. It’s important for everyone to understand the risks chemotherapy, radiation therapy, and some surgeries pose to their fertility. We encourage providers to document these conversations.
“We are so focused on treating our patients’ cancer that we often overlook the intricacies of their lives outside the clinic, such as the desire to have children.”— Alison W. Loren, MD
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We also encourage oncologists to forge partnerships with other specialists such as endocrinologists, gynecologists, urologists, and sperm bank personnel to streamline referrals. There is evidence that by making referrals easier, it strongly increases patients’ uptake of services provided by fertility specialists. For instance, a center could have an expedited referral line or brochures in the waiting room or arrange easy access to a specific colleague in gynecology who is an expert in fertility. Several members of our ASCO panel are community oncologists, and they emphasized how important it is to try to develop networks to support this important goal for our patients. Both ASCO and the National Marrow Donor Program (Be The Match) have excellent patient and provider resources on their websites.
There are other great resources for patients and providers—for instance, the Oncofertility Consortium and Livestrong, both of which offer many patient resources.
Guidance for Ethical Issues
Is it ethical to deny fertility preservation to patients in whom treatments might carry a substantial risk of life?
I don’t think it is ethical to deny these services, even if the patient’s prognosis is poor, because we cannot predict which patients will survive their treatments, and you would never want to regret missing this opportunity. It is important, though, to talk about this possibility. There should be an honest conversation between the patient and his or her loved ones about what to do with banked tissues in the event the patient dies.
Risk of Cancer Recurrence
What about women who fear that becoming pregnant after they’ve ended their cancer treatment will increase their risk of recurrence?
That is a common worry among cancer survivors, but there are no data showing that a subsequent pregnancy increases the risk of cancer recurrence. We do recommend that women wait at least 1 year after treatment ends before they consider becoming pregnant. Moreover, there are potential increased risks to the fetus that can occur from the side effects of chemotherapy and radiation. For example, damage to the uterus or heart of the mother can put the pregnancy at risk.
What is the provider’s obligation in discussing the costs of fertility treatments with patients and aiding in obtaining financial resources?
I do think it should be part of the discussion, and providers sometimes cite financial issues as a reason why they don’t bring up fertility treatments. Several states have pushed for legislation that would compel insurance companies to cover fertility treatment. I think it’s outrageous that these services are not uniformly covered. Wigs and breast implants are covered, so why not treatments that help vulnerable men and women have the opportunity to explore their fertility options? It’s simply another side effect of cancer treatment. There may be resources that provide some form of financial assistance to those who can’t afford these services, and we recommend that nurse navigators and social workers familiarize themselves with these resources.
Please share a few closing thoughts about this compelling issue.
Adding discussions about fertility to the many responsibilities of the oncology team may seem overwhelming. But oncologists care so much for their patients’ welfare that in my experience, they don’t view this as a burden but rather an opportunity to advance high-quality care. They don’t have to be experts in this area; they can simply raise the issue, start the conversation, and reach out to myriad specialists in fertility treatment who will take it from there. ■
DISCLOSURE: Dr. Loren reported no conflicts of interest.