Life-preserving treatments once frequently threatened the fertility of patients with cancer.
However, fewer barriers exist today thanks to increasing understanding of fertility preservation options and increased patient access to fertility specialists.
Teresa K. Woodruff
spoke with Teresa K. Woodruff, PhD,
vice chair for research in the department of obstetrics and gynecology at Northwestern University, about the oncologist’s role in discussing fertility preservation with their patients, as well as how clinicians can address concerns such as cost of care.
How important is it for clinicians to raise the subject of fertility preservation
with patients who have cancer?
Answer: It is absolutely critical. As soon as a patient receives a first cancer diagnosis, fertility-sparing options should be considered. Many times clinicians think fertility preservation is something that can be discussed later, but it is really important that the topic is raised at the outset.
What if a clinician is uncomfortable raising the subject?
It is true that clinicians sometimes are not ready for this conversation. Just as an oncologist does not have to be an expert in genetics in order to make a referral for genetic counseling or just as they do not have to be experts in plastics or reconstruction in order to make a referral, all clinicians can make a referral for oncofertility. There are now many oncofertility experts who are ready to receive patient referrals for fertility discussions and integrate the oncology care strategy with the available reproductive interventions. It is important to remember that not all patients will be interested in fertility, but all patients need to understand how their reproductive function will be affected. Questions about their monthly menstrual cycle or questions about contraceptive options — hormonal or barrier — are two that can be addressed. Overall, reproductive health during cancer treatment and immediately thereafter are key messages.
is it so
important to discus
this subject early
A: Both radiation and chemotherapy will damage the female egg and male sperm, so we want to make sure that we protect those cells from the off-target effect of treatment. We often speak to patients about the fact that they will lose their hair, but we do not talk to them about losing their reproductive function. It is imperative to talk to patients about this upfront so interventions can be offered early rather than when it is too late.
How have fertility preservation options for patients with cancer advanced in recent
A: There have been enormous gains. We can preserve eggs, which we could not do 5 years ago. We even have paradigms for preserving fertility for infants, which we did not have 5 years ago. We now have both emerging and existing options that are appropriate for almost all patients with cancer. This is an exciting and important message for oncologists to hear.
Q: Have treatments improved to the point where they now pose less risk to patients’ fertility than they did 5 or 10 years ago?
A: Ten years ago or more, the only intervention for a young woman would have been a hormone cycle that would last 6 to 8 weeks. Now, if the patient undergoes a hormone cycle, it lasts only 8 to 10 days. Ten years ago, many patients were not going through hormone cycles because there were no referral networks between oncologists and reproductive medicine. Everything has changed in terms of the ways in which a patient with cancer can manage their fertility compared with 5 or 10 years ago.
Q: Most major academic institutions have additional resources like a fertility expert or consultant to help patients with this issue. What about smaller centers and community oncologists? What can they be reasonably expected to do in this regard?
This is a very important question. Right now, we are working to try and bring information outside academic centers. The message is that all physicians have referral options. They can use the oncofertility national hotline (http://oncofertility.northwestern.edu) and patients and their families can travel to a larger center where a clinician can take care of their reproductive health. Sometimes all a patient needs is the information about their reproductive health, such as contraception and endocrine support, and they do not need or want a reproductive intervention. We want to make sure that everyone understands the particular threat for each individual patient, and this cuts across all boundaries of geography.
Aside from getting the conversation started, what role should the oncologist and other members of the care team have
to help p
fertility preservation options and address other concerns, such as costs?
A: This is an important issue. Just as the oncology team deals with referrals to a variety of services, fertility is a part of this management of care. There are specialists within reproductive oncofertility who are ready to talk about the cost issue. Patients should be given information on the likely fertility threat and the options, and specialists can talk with them about costs. For example, many insurance companies do have in vitro fertilization benefits. It is important that nurses, allied health professionals and oncologists tell their patients about fertility and not limit the option for this referral because of perceptions about cost.
How can clinicians and patients strike a balance between taking the time to work through fertility preservation options while not
waiting too long to start cancer treatment?
A: A person diagnosed with cancer has to make many rapid-fire decisions. They will typically have people around them helping them to make decisions and to navigate through the questions they are going to have. Often times, there is time between diagnosis and the first sterilizing treatment to consider fertility preservation. The key for us on the oncofertility side is to really create valuable educational materials to help patients, parents and partners to understand and navigate the questions they will have about their reproductive health in the cancer setting. We hope that oncologists help patients find the resources quickly. It does not have to take 30 or 60 days for an intervention, but it can take this long if a patient is searching the Internet for information with terminology that might not be familiar. This is why the message to the oncologist is so strong. It is time to make reproductive reproduction a referral in the same ways as one might refer to genetic counseling.
Q: Is there anything else you would like to
A: The bottom line is that oncofertility is a new field that provides new tools and interventions for physicians and patients to understand the reproductive consequences of cancer treatment and the options that now exist to protect the reproductive potential of young men and women. Cancer is a terrible diagnosis, but with more and more treatment options, patients are surviving longer than ever before. With survivorship comes issues associated with reproductive health. We have more tools available for patients than ever before. Restoring patients to health is the primary job of the oncologists, and providing options for preserving reproductive health is now part of that equation. – by Jennifer Southall
For more information:
, PhD, can be reached at Women’s Health Research Institute, OB/GYN, Feinberg School of Medicine, 303 E. Superior St., Lurie 10-121, Chicago, IL 60611; email: email@example.com.
Woodruff reports no relevant financial disclosures.