Receiving the diagnosis of cancer for a young woman can be a devastating experience. Immediately, a deluge of urgent decisions arise for both the patient and her treating physicians. Is surgery necessary? How about chemotherapy or radiation? With all of the immediate decisions that need to be made, all of the office visits, imaging studies and blood tests that are routinely performed, essential questions about the potential impact of cancer therapy on the future health and quality of life of the young woman are unfortunately frequently overlooked.
Hopefully, the woman receiving the diagnosis finds her way into the care of an oncologist (cancer specialist) and that oncologist is prepared to discuss all of the options regarding treatment as well as potential side effects of that treatment- including the impact it may have on a woman's future fertility. In order of decreasing frequency, the most common cancer diagnoses for women under the age of 40 include: breast cancer, melanoma, cervical cancer, leukemia, Non-Hodgkin's lymphoma, and uterine cancer. Particularly if discovered in their early stages, these cancers are associated with good treatment response and survival statistics. However, the necessary treatment options required to cure many of these malignancies involve therapies that have a significant impact on fertility.
Surgery that removes the ovaries, uterus or cervix obviously leads to fertility challenges. However, it is essential that the treating surgeon discuss options for fertility-sparing surgical procedures. A woman should be appropriately counseled as to whether or not her particular cancer might be treated with one of these fertility-sparing options, and how (if at all) this might impact her chance of relapse or recurrence. True informed consent means that all of the options have been presented, risks and benefits have been thoroughly reviewed, and all of a woman's questions have been addressed. The impact of systemic chemotherapy for the treatment of cancer is often under appreciated. Many of the most commonly used chemotherapy agents can lead to a condition called chemotherapy-related ovarian failure. The risk of ovarian failure after chemo depends on the patient's age (older women have a higher risk of failure), the specific agents used (alkylating agents can be particularly adverse), and the total dose administered (more cycles lead to a higher risk of long-term impact).
Radiation can also affect future fertility, again varying dependent on the patient's age, the location of the irradiated field, and the total dose received. Simple surgical procedures such as lifting the ovaries out of the field of radiation (known as oophoropexy), can have significantly beneficial impact on the rate of radiation-induced ovarian failure. Even if the cancer itself cannot be treated surgically, women should be informed of the option of oophoropexy and referred to a gynecologic oncologist who can perform this procedure.
Embryo, oocyte and ovarian tissue cryopreservation as well as the use on GnRH-analogue treatment concurrent with chemotherapy or radiation are options for young women undergoing treatment for cancer. A referral should be made to a reproductive endocrinologist who will be able to fully address their respective risks, benefits, outcome measures, and appropriateness for each woman considering future fertility.
An interdisciplinary and often integrative approach, with excellent communication between a woman and her various subspecialists is essential to successfully address all of these questions and concerns. As frightening as a cancer diagnosis may be, young women deserve the careful and thorough review of all of the options available to them, with special consideration made to their ability to retain fertility if they so desire. There can and must be hope on the horizon for young women with cancer.
Southern California Reproductive Center was first established in 1988. In that time it has completed over 7 dozen research studies with results reported in peer-reviewed venues. It has 11 more research studies currently in process. SCRC does approximately 900 invitro fertilization cases each year. For the past three years SCRC has remained the best fertility clinic in the Los Angeles Metro area. SCRC has an affiliated surgery center as well as assisted reproduction laboratory on site. The infertility experts at SCRC also train other fertility specialists. For example, young physicians who pursue a fellowship in Reproductive Endocrinology rotate through the practice and are trained by the SCRC physicians, who are also affiliated with Cedars-Sinai Medical Center and are on the faculty of UCLA Medical School.