ONCOLOGY. Vol. 21 No. 5

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REVIEW ARTICLE

Reproductive Issues in the Gynecologic Cancer Patient

By Jeanne Carter, PhD¹, Sharyn Lewin, MD², Nadeem Abu-Rustum, MD³, Yukio Sonoda, MD⁴ | April 30, 2007

¹Assistant Attending Psychologist, Department of Psychiatry and Behavioral Sciences, Department of Surgery, Gynecology Service ²Fellow, Department of Surgery, Gynecology Service ³Director, Minimally Invasive Surgery, Department of Surgery, Gynecology Service ⁴Assistant Attending Surgeon, Department of Surgery, Gynecology Service, Memorial Sloan-Kettering Cancer Center, New York, New York

The American Society of Clinical Oncology formally released guidelines on fertility preservation[1] and called attention to issues of reproductive knowledge and access. Some researchers suggest that the period of diagnosis and treatment tends to focus on the cure and symptom management, and, as a result, quality-of-life issues may be ignored.[95] Wenzel and colleagues evaluated the relationship of infertility and long-term quality of life in female cancer survivors and found reproductive concerns are of great importance and centrally linked to psychosocial outcomes.[14]

•Informational Needs—The informational needs of young cancer survivors demonstrated that while fertility issues may not have been paramount at the time of diagnosis, they became increasingly important over time.[96] Many women reported insufficient or unavailable information about fertility and expressed a desire for more information either prior to or during treatment. Literature drawn from other populations (eg, breast cancer patients) indicates that most women feel that the information received on fertility and the sequelae of treatment (ie, menopause, sexuality, and mood) prior to treatment was either insufficient or unavailable.[97,98] Research conducted in young female breast cancer survivors found that 72% discussed fertility concerns with their doctor, but only 51% felt that their concerns were adequately addressed.[97]

Zebrack and colleagues examined a cohort of young adult survivors of childhood cancer and found that nearly 60% reported uncertainty about their fertility status, and only half recalled a health-care provider discussing potential reproductive problems associated with treatment.[98] The need for more information about reproductive issues and options prior to or following treatment has been identified as an issue for cancer survivors.[15,96,99,100] When cancer directly affects the reproductive organs, discussions about treatment options become more complex, especially with the limited information available about the consequences of conservative management.

The lack of adequate information on fertility issues has received attention in the President's Cancer Panel, which states: "All people of reproductive age who are diagnosed with cancer should be given complete culture- and literacy-sensitive information, both verbally and in writing, about options for preserving fertility and on possible effects of treatment on pregnancy and offspring before cancer therapy is selected or initiated."[101] There are, however, several barriers that may interfere with addressing the reproductive informational needs of younger cancer survivors, such as the urgency of treatment, insufficient doctor-patient communication, a lack of information regarding reproductive options, as well as geographic and economic constraints limiting access to a specialist or services. Even for women who are aware of reproductive options, research suggests that women undergoing infertility treatments may not be aware of the rates of successful pregnancy or the risks and benefits associated with treatment.[102]

Education and support are clearly an essential component of cancer survivorship, and research suggests that individuals who receive information have increased satisfaction with treatment choice[99] and decreased levels of anxiety and distress.[103] Furthermore, provision of information has been shown to successfully address late effects of cancer treatment.[104-107] Many nonprofit organizations can provide excellent information to help cancer survivors learn more about family-building options (Fertile Hope: www.fertilehope.org), cancer and intimacy (American Cancer Society: www.cancer.gov), and survivorship (Lance Armstrong Foundation: www.laf.org), to name just a few.

•Family-Building Options—Advances in reproductive technologies have allowed for alternative family-building opportunities with the assistance of others (third-party parenting). Cancer survivors experiencing ovarian failure, the loss of their uterus, or both now have the ability to build a family through mechanisms other than adoption. Remarkably, very little is known as to whether cancer survivors have knowledge about such family-building options or even view themselves as appropriate candidates. Research is needed to investigate the extent to which this population pursues alternative forms of reproduction and parenting, such as assisted reproduction or adoption. Questions as to the level of knowledge regarding treatment options for assisted reproduction and desire to utilize services as well as to identify potential barriers to and facilitators of care, such as socioeconomic status, insurance coverage, and access to a specialist, should be addressed in order to understand the survivorship needs of this young cohort who have an excellent prognosis and outlook for long-term survival.

Conclusions

The President's Cancer Panel reported that nearly 10 million American cancer survivors were living beyond their initial diagnoses andcoping with the side effects of treatment.[101] Many of these individuals were diagnosed in their childbearing years. However, the psychological and psychosexual morbidity of reproductive issues is not well documented. Often, at the time of treatment planning, the threat to life is such that reproductive concerns are not the priority,[15] but conservative surgical management may be appropriate for some women diagnosed with gynecologic cancer. For those women medically unable to have fertility-preserving treatment, the meaning becomes apparent upon treatment completion, and the accompanying psychological toll may become part of the long-term sequelae to be resolved in cancer survivorship.

Despite the availability of reproductive assistance, more research is needed to determine if knowledge and access to reproductive assistance, allowing for genetic offspring, the experience of pregnancy, and/or alternative family-building options are being discussed and utilized in the cancer setting. Additionally, more studies are necessary to document the rates of success of assisted reproduction among cancer survivors.

Health-care providers and researchers have started to focus on a number of related questions requiring further investigation. For example, does the lack of reproductive knowledge increase the risk of depression and distress? Does the experience of infertile women with no history of cancer awaiting third-party parenting techniques mirror the psychological response of cancer survivors eligible for these techniques? In addition, mechanisms to facilitate adjustment and adaptation in cancer survivorship need to be identified.

Wenzel and colleagues[14] evaluated the relationship of infertility and long-term quality of life in female cancer survivors and found that reproductive concerns are of great importance and centrally linked to psychosocial outcomes. However, much more research is imperative to understand the unique needs experienced by cancer survivors of reproductive age.

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This article reviewed

Fertility Preservation in the Gynecologic Cancer Patient

Gynecologic Cancer Survivors: A Comprehensive Approach

CARLA P. ROBERTS, MD, PhD and IRA R. HOROWITZ, MD, SM
DIANE C. BODURKA, MD; CHARLOTTE C. SUN, DrPH; and DAVID M. GERSHENSON, MD

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Reproductive Issues in the Gynecologic Cancer Patient

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