CancerNetwork: Well I do have one more! I know that fertility preservation is becoming a bigger issue across the cancers, after treatment. Can you talk a little about how lymphoma survivors fare in terms of preservation of fertility?
Dr. Evens: At least in the context of this study, that was a very tricky issue because they were all actively pregnant. But with more of a 30,000-foot view, it definitely is an issue in cancer survivors, both men and women. Especially for anyone who is at a child-bearing age, we absolutely want to have that discussion.
The risk of infertility is based on a couple of things; first, the age of the patients and especially women. Obviously, the greater the age of a woman, the greater the risk of infertility even without chemotherapy. The other variable for determining risk of infertility is the type of chemotherapy used. There are certain chemotherapy regimens, for example the one I mentioned for HL, ABVD, where the resulting risk of infertility in women younger than age 30 or 35 is in the single digits—probably in the range of 1% to 3%. But there might be a more aggressive chemotherapy regimen, say hyperCVAD [cyclophosphamide, vincristine, doxorubicin(Drug information on doxorubicin), dexamethasone(Drug information on dexamethasone) in course A; methotrexate, cytarabine(Drug information on cytarabine) in course B], or the MCGRATH chemotherapy, or a regimen called BEACOPP [bleomycin, etoposide, doxorubicin, cyclophosphamide(Drug information on cyclophosphamide), vincristine, procarbazine(Drug information on procarbazine), prednisone(Drug information on prednisone)], and these are the more aggressive chemotherapies where the risk of infertility—both in men and women—might be anywhere from 30% to 80%.
So there are some lymphomas where there's really a “grade A” standard therapy regimen, and we know that if we vary from that regimen, the survival will drop. So we usually don't vary, and instead we say “what can we do to preserve fertility?” For men, there's obviously sperm banking, and for women there certainly is ovarian harvest, but that usually has to be in the context of in vitro fertilization. In other words, they need to have a partner to immediately fertilize the egg. Outside of that context, unfortunately ova cannot be frozen alone, like sperm can. However, there are experimental protocols, clinical trials that are looking at how to preserve them—there are active fertility programs that are analyzing breakthrough techniques to try to make this possible.
So as you can see, fertility preservation is dependent on both patient and disease type, but it's definitely an important discussion to have.