Today we are discussing fertility care for cancer patients with William J. Gradishar, MD, a medical oncologist at Northwestern University Feinberg School of Medicine in Chicago. Along with his colleagues, Dr. Gradishar recently penned a perspective on the role oncologists play in facilitating cancer patients’ fertility care that was recently published in JAMA Oncology.
— Interviewed by Anna Azvolinsky
Cancer Network: First, what are some of the ways that oncology treatments may affect fertility in women?
Dr. Gradishar: So the issue with treating women with breast cancer is to obviously reduce the risk that their disease will return, and largely, where fertility issues have the greatest potential impact is in patients with early-stage disease where their hoped-for life span will be normal after their diagnosis and treatment, so that other issues in life become all the more important. And it isn’t to minimize those issues with patients with advanced disease, but the reality is that we don’t have curative therapy in that setting and fertility issues are not as much a priority for the vast majority of patients with advanced disease as it is to improve the longevity of their life.
So in women with early-stage disease, we have to make a judgment about what the risk of recurrence is. Additionally we look at the characteristics of the tumor, and in doing so we try to determine whether they will be best served by receiving anti-hormone therapy or chemotherapy or some combination of both. Additionally there may be certain subsets of patients that require at least a year of trastuzumab or so-called targeted anti-HER2 therapy. These treatments all have the potential to affect the patients’ overall fertility status and since many women, particularly those who are in the child-bearing years, may be undergoing treatment for as long as 10 years with anti-hormone therapy, as an example, trying to figure out how to optimally integrate fertility, pregnancy issues becomes important.
So when we see a new patient with breast cancer, particularly one who is young and has aspirations of having a child, we have to think about that piece of their life right from the get-go while we talk about optimally treating their breast cancer. And to that end, we often have a discussion about the implications of breast cancer, but in tandem we also will query them about what their goals are with regards to having a child or fertility and make sure they have the opportunity to see a fertility expert very soon in their treatment, or I should say, soon after they are diagnosed. So one of the first things we do as we’re evaluating them for their breast cancer and how to optimally treat them, is to also make an arrangement for them to be seen by one of our fertility experts.
There are situations where we are willing to wait a period of time. For instance, in some patients they want to undergo egg preservation, and in order to do that we usually have to have them see a fertility specialist who will put them through a variety of hormonal treatments, and then have egg harvesting, so our initial treatments can be put off for a short period of time. And generally, for most patients, we feel comfortable with delaying the start of therapy for several weeks until that can be accomplished. In the unique situation where the disease is rapidly progressive, an example is inflammatory breast cancer, we don’t necessarily have the luxury of a long delay. But for many patients, if that is something they want to get information about, if that is something they want to pursue, we are certainly willing to give them the time and opportunity to do that because downstream, after their therapy is over, those things will become much more important to them again.
Cancer Network: And just briefly, the issue of fertility preservation, how do you think that has changed in the last decade? It seems that it’s much more on the radar for both patients and clinicians.
Dr. Gradishar: I think it is because we have taken into account the patient’s quality of life to a much greater extent. Not that we ignored it, but those things are very prominent in our thinking of how we choose our therapies, how we think about the survivorship years afterwards, and all the different aspects of a person’s life as they get this diagnosis and what that impact will be. To that end, I think now we try to make a concerted effort in most places—and I take care of only breast cancer patients—to have these women be evaluated by fertility experts very early on. And that may lead to a number of strategies—one of which I already mentioned, egg preservation—if they are going to think about pregnancy at a later date.
There are also ways to potentially protect their ovaries during the course of therapy using agents that essentially, to put it simply, put the ovaries in a state of dormancy during chemotherapy and those agents, so-called GNRH [gonadotropin-releasing hormone] agonists, basically interrupt the endocrine signaling pathway to the ovaries, and by making them dormant they are seemingly better protected from the effects of, say, chemotherapy. And when we do that, there is evidence that the women who had that done have a higher success rate of not only resumption of their menstrual periods, but perhaps even have more success with getting pregnant. So that becomes an option for young women as well.
And then the other thing we have come to accept now is that of course, life gets in the way. In patients who get prolonged duration of anti-hormonal therapy using the example of breast cancer again, we know that most young women aren’t going to wait for 5 to 10 years if pregnancy is something that is important to them. In many situations where that becomes something that is important to the patient, we will give them a break in their hormonal therapy, allow them to get pregnant, and then once they deliver, resume the anti-hormonal therapy to completion, and we’ve done that with many patients and it doesn’t seem to have any untoward effects. So I think that each patient has to be discussed individually, each patient’s goals are different, but we try to make sure that they understand what their options are from the beginning.
Cancer Network: Just lastly and you mentioned this a bit, what do you see as the role of the medical oncologist in helping to educate patients to make sure they make the right fertility care decision for themselves?
Dr. Gradishar: I think the most important thing is they have to be aware of what the impact of their cancer therapy may be on, 1) fertility and 2) even if their fertility remains intact, after receiving therapy, many patients will continue on some form of therapy for years (meaning anti-hormonal therapy), so the best opportunity to really understand all of these implications and the options is at the very beginning, because it is at that point that you can really exercise the opportunity to explore things—and as I said, egg harvesting is one option, protecting the ovaries may be another—and just understand what the implications are.
The worst scenario is to get somebody who has already gone through their therapy, they are in their later years of where child-bearing is most likely, statistically, and they receive chemotherapy and their fertility is gone. And that is something that we can’t reverse, so the best opportunity to understand all the implications is right from the get-go, that way a patient has an ability to increase their understanding and awareness and actually the time to see fertility experts if that is what they are interested in.
Cancer Network: Thank you so much for joining us today.
Dr. Gradishar: You’re welcome.