The survival rates for childhood cancer are
on rise. This would equate to increase in the number of survivors. It has been
shown that around two thirds of survivors will have some kind of late side
effect and one of them could be effect on reproductive potential. Reproductive
concerns can alter the quality of life in some and can lead to mental health issues.
1
Fertility counseling and offering options for
preserving fertility in this age group depends on whether the child is
pre-pubertal or post-pubertal. In pre-pubertal age group, discussion about
fertility can be a challenging situation not only for patient but also for
treating oncologist and reproductive medicine specialist. The options available
at this age group are limited and are mostly offered at present in research
settings. Preservation of ovarian or testicular tissue is the options mainly
given in this sub-group of patients. In post-pubertal children, the options are
same as given to adults in the form of oocyte cryopreservation, sperm
cryopreservation, ovarian tissue cryopreservation, and medical therapy with
GnRH agonists.
Even if the fertility cannot be preserved,
discussion and educating children and their parents about potential risk for
infertility is important. In this age group, education at diagnosis may not be sufficient2
; re-enforcement of discussion at end of therapy and in late effect survivor
clinic may be needed depending on survivor's needs and developmental stage,
hence conversations about the impact
In this issue, we will be discussing recent
publication from largest childhood cancer survivor study with regards to the pregnancy
outcome in child hood cancer survivors.
Pregnancy after chemotherapy in
male and female survivors of childhood cancer treated between 1970 and 1999:
a
report from the Childhood Cancer Survivor Study cohort- Lancet Oncology, 20163
Eric J Chow, Kayla
L Stratton, Wendy M Leisenring, Kevin C Oeffinger, Charles A Sklar, Sarah S
Donaldson, Jill P Ginsberg, Lisa B Kenney, Jennifer M Levine, Leslie L Robison, Margarett Shnorhavorian,
Marilyn Stovall, Gregory T Armstrong, Daniel M Green
Methods: The data from a subset of the Childhood
Cancer Survivor Study cohort, which followed 5-year survivors of the most
common types of childhood cancer who were diagnosed before age 21 years and
treated at 27 institutions in the USA and Canada between 1970 and 1999, were
studied.
The doses of 14 alkylating and similar DNA
interstrand crosslinking drugs from medical records were analyzed. The
independent effects of each drug and the cumulative cyclophosphamide equivalent
dose of all drugs in relation to pregnancies and live births occurring between
ages 15 years and 44 years were analyzed. The siblings of survivors were used as
a comparison group.
Findings: There were 10,938 survivors and 3949
siblings. After a median follow-up of 8 years from cohort entry or at age 15
years, whichever was later, 4149 (38%) survivors reported having or siring a
pregnancy, of whom 3453 (83%) individuals reported at least one livebirth.
After a median follow-up of 10 years, 2445 (62%) siblings reported having or
siring a pregnancy, of whom 2201 (90%) individuals reported at least one
livebirth. Overall, survivors had a decreased likelihood of siring or having a
pregnancy versus siblings (male survivors: hazard ratio [HR] 0·63, 95% CI
0·58–0·68; p<0·0001; female survivors: 0·87, 0·81–0·94; p<0·0001) or of
having a livebirth (male survivors: 0·63, 0·58–0·69; p<0·0001; female
survivors: 0·82, 0·76–0·89; p<0·0001)
In male survivors, reduced likelihood of
pregnancy was associated with upper tertile doses of cyclophosphamide,
ifosfamide , procarbazine and cisplatin . Cyclophosphamide equivalent dose in
male survivors was significantly associated with a decreased likelihood of
siring a pregnancy as compared to females. In female survivors, only busulfan
and doses of lomustine equal to or greater than 411 mg/m2 were significantly
associated with reduced pregnancy. Results for live birth were similar to those
for pregnancy.
Conclusion: The findings from this study have suggested
that greater doses of contemporary alkylating drugs and cisplatin were
associated with a decreased likelihood of siring a pregnancy in male survivors
of childhood cancer. However, these findings have provided reassurance to most
female survivors treated with chemotherapy without radiotherapy to the pelvis
or brain, given that chemotherapy- specific effects on pregnancy were generally
few. Nevertheless, consideration of fertility preservation before cancer
treatment remains important to maximize the reproductive potential of all
adolescents newly diagnosed with cancer.
References:
1.
Gorman JR, Su HI, Roberts SC, et al: Experiencing reproductive concerns,
as a female cancer survivor is associated with depression. Cancer 121: 935-942,
2015
2.
Cherven BO1, Mertens A2, Wasilewski-Masker K2, Williamson R3, Meacham :Infertility
Education: Experiences and Preferences of Childhood Cancer Survivors. J Pediatr
Oncol Nurs. 2015 Nov 18.
3.
Chow EJ, Stratton KL, Leisenring WM, Oeffinger KC, Sklar CA, Donaldson
SS, Ginsberg JP, Kenney LB, Levine JM, Robison LL, Shnorhavorian M, Stovall M,
Armstrong GT, Green DM. Pregnancy
after chemotherapy in male and female survivors of childhood cancer treated
between 1970 and 1999: a report from the Childhood Cancer Survivor Study
cohort.
Lancet Oncol. 2016 Mar 22. pii: S1470-2045(16)00086-3
