A cancer survivor will always be a cancer survivor and will always harbor the risks of its treatment. So I think cancer survivors should be followed for the rest of their lives. It doesn’t always have to be with an oncologist.
—Monika L. Metzger, MD, MSc
Follow-up care for female patients treated for cancer as children, adolescents, or young adults should include assessment and management of the late effects that therapy may have on reproductive health, as detailed in updated guidelines from the Children’s Oncology Group. “It is important for oncologists to take action, to feel responsible for this aspect of cancer care,” Monika L. Metzger, MD, MSc, the lead author of the guidelines told The ASCO Post.
It is also important, she added, “for the general practitioners who take care of these patients after they have gone through cancer treatment to be familiar with the guidelines regarding reproductive health, as well as all other issues of cancer survivorship.” Dr. Metzger is an Associate Member, Department of Oncology, at St. Jude Children’s Research Hospital in Memphis.
Rapidly Evolving Field
The Children’s Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers are evidence-based recommendations for screening and managing the late effects of cancer treatment. The literature updates for the guidelines occur every 2 years though guideline updates based on these reviews occur every 5 years, with the latest version recently published in the Journal of Clinical Oncology.1
“This is a field that has been rapidly evolving,” Dr. Metzger said. She cited the example of oocyte cryopreservation—removing eggs from a woman’s body and freezing them for later fertilization and reimplantation. “Oocyte cryopreservation is no longer considered experimental by the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology,” Dr. Metzger noted.
Dr. Metzger primarily treats young patients who have lymphomas and whose reproductive health may be affected by chemotherapy or radiotherapy. “Adolescents and young adults have their own fears, questions, and concerns,” she said. Conversely, these young patients can seem “particularly unconcerned, which happens, too,” she said, because they don’t think cancer or treatment side effects could possibly ever affect them.
In an interview with The ASCO Post, Dr. Metzger offered insight into the concerns of young patients and their parents and how oncologists and other health professionals can address those concerns.
What should initial discussions with young patients about cancer treatment include about possible effects on reproductive health?
The most important thing at diagnosis is the location of the cancer and whether that could affect anything about your reproductive potential. Then comes discussion of the therapies—the chemotherapy, the radiotherapy, the surgery—and how do those affect your reproductive health altogether. There needs to be a methodical approach to this.
One of the locations mentioned in the guidelines is the hypothalamus, which patients or parents might not think of in terms of reproductive health. Does this need to be explained?
If the central nervous system needs to be irradiated, then it absolutely needs to be brought up that this may affect reproductive health.
Does treatment of hypogonadism with hormone replacement therapy raise concern from patients and parents about risks of hormone replacement itself?
Yes, but not going through puberty is probably even harder. We don’t know the answer yet, but at this point there is no reason not to give hormone replacement therapy to a young girl who is not going into puberty.
Are your patients mostly concerned about having children?
Yes, they are concerned about whether they are going to be able to have children. Less frequently, some patients who have to go through chemotherapy or radiation therapy will also be concerned about whether their kids are going to be healthy.
The guidelines mention that many cancer survivors have unnecessary anxiety about the risk of birth defects, which are not more frequent among their offspring.
Yes, that is true. But we also don’t want our patients to become pregnant during chemotherapy because we don’t know how that will affect the fetus.
While oocyte preservation is no longer considered experimental by the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology, what are the options for younger prepubertal patients?
Ovarian tissue cryopreservation is still experimental. There has been some success with this technique, but it is still too early to know whether this is a realistic option. It is definitely not something that can be used for every type of cancer. For instance, you wouldn’t use it for leukemia, because leukemia can be harbored in the ovarian tissue, and you would hate to reintroduce the disease into an already cured patient.
Is oophoropexy commonly used? How is it determined where to transpose the ovaries to properly shield them?
Oophoropexy—surgical fixation or suspension of the ovaries to remove them from the field of irradiation—is used mainly for Hodgkin lymphoma patients. It is done laparoscopically. The ovaries are tacked behind the uterus, and there is no need to reposition them in order for the patient to become pregnant or to continue normal regular menses.
How well oophoropexy shields the ovaries will depend on the field of radiation. Sometimes there might also be scattered radiation. The ovaries are extremely sensitive to radiation. The radiation oncologist obviously still needs to be careful when irradiating the iliac inguinal lymph nodes.
Do female patients treated for cancer when they are young need to have follow-up assessments of reproductive health throughout their lives, or is there a cutoff, according to either the age of the patient or years posttreatment?
A cancer survivor will always be a cancer survivor and will always harbor the risks of its treatment. So I think cancer survivors should be followed for the rest of their lives. It doesn’t always have to be with an oncologist. The medical community needs to be educated that more and more of the population are going to be cancer survivors, and they would do better following guidelines that address the risks of previous treatment.
A survey cited in the guidelines found that providers and patients tend to avoid the topic of sexual dysfunction, “although 80% of women report a desire to discuss sexual issues.” The guidelines say, “providers should initiate discussions.” What’s a good way to start those discussions?
Health-care providers just need to be very matter of fact. “We were talking about your vision. We were talking about your hearing. Now we are talking about your sexual function.” If the provider is uncomfortable talking about it, then the patient is going to be uncomfortable. ■
Disclosure: Dr. Metzger reported no potential conflicts of interest.
1. Metzger ML, Meacham LR, Patterson B, et al: Female reproductive health after childhood, adolescent, and young adult cancers: Guidelines for the assessment and management of female reproductive complications. J Clin Oncol 31:1239-1247, 2013.