DOI: 10.12809/hkmj175072
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
EDITORIAL
Fertility preservation in young cancer patients as a
springboard to address the needs of this unique population
Herbert HF Loong, FHKCP, FHKAM (Medicine)
Department of Clinical Oncology, The Chinese
University of Hong Kong; Adult Sarcoma Multidisciplinary Tumour Board,
Prince of Wales Hospital; Shatin, Hong Kong
Corresponding author: Dr Herbert HF Loong (h_loong@clo.cuhk.edu.hk)
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Treatment outcomes for patients with cancer have
improved greatly, in part due to more aggressive forms of systemic
treatments. Such treatments, however, can compromise fertility and this
has precipitated a growing focus on fertility issues within the oncology
community. International guidelines on fertility preservation in cancer
patients recommend that physicians discuss, as early as possible, with all
patients of reproductive age their risk of infertility from the disease
and/or treatment and their interest in having children after cancer, and
help with informed decisions about fertility preservation.1 2 A local study
performed in a major teaching hospital reported that up to 32% of male
cancer patients encountered deterioration of semen parameters after
gonadotoxic treatments.3 The
thought of the possibility or actual prior experience of treatment-related
infertility can lead to psychological stress.4
5 Patients prefer maintaining their
fertility and future reproductive function at the time of cancer
diagnosis.6 Fertility concerns may
also affect the decision to pursue treatment.7
8 9
As recommended by the American Society of Clinical Oncology2 and the European Society for Medical Oncology,1 sperm cryopreservation and embryo/oocyte
cryopreservation are standard strategies for fertility preservation in
male and female patients, respectively. Other strategies, which include
pharmacological protection of the gonads and gonadal tissue
cryopreservation, are currently considered experimental. Whilst these
guidelines and recommendations are readily accessible, the ‘bottom-line’
of whether a suitable patient is referred for fertility preservation is
entirely dependent on the treating physicians’ awareness and understanding
as well as the local availability of fertility-preservation techniques.
In the article that accompanies this editorial,
Chung et al10 present the results
of a cross-sectional paper-based survey that assessed the awareness of,
attitude towards, and knowledge about fertility preservation among 167
clinicians of various clinical specialties in Hong Kong. Specialists in
General Surgery, Paediatrics, Clinical and Medical Oncology, and
Haematology and Haematological Oncology were included. This is the first
such study ever reported from the territory. Obstetrics and Gynaecology
(O&G) specialists were also included in the survey and accounted for
the largest proportion of respondents by specialty (40.7%). A limitation
of this study, however, was that all respondents were specialists working
in the public sector, as the communications directory of the Hospital
Authority was used to identify potential subjects. The prior referral
experiences of the respondents might be different to all O&G
specialists in our locality, as there is currently no publicly funded
fertility centre in Hong Kong.
Results of this study10
were surprising, to say the least. Without going into the specifics of
different types of fertility preservation and their respective
indications, less than half of the respondents (45.6%) reported being
‘aware of fertility preservation’. Specialists in O&G fared no better
in this regard with only half (50.7%) of the respondents reporting
themselves as being aware. As expected, O&G specialists were more
aware of fertility-preservation techniques in females such as oocyte- and
embryo-freezing as well as ovarian tissue freezing, than their non-O&G
counterparts. Interestingly, when respondents were further asked about
individual fertility-preservation procedures, an increased awareness was
found. In fact, a higher percentage of the same O&G specialists in
this study reported to be familiar with “all of the above”
fertility-preservation techniques previously itemised, compared with being
‘aware of’ fertility preservation per se (63.6% vs 50.7%). These findings
highlight a possible diversity of understanding within our medical
community of what constitutes fertility preservation. Moreover, even if
knowledge is indeed improved, suitable patients may still not be able to
receive appropriate counselling and care, as only a little more than half
(55%) of all respondents were aware that there are dedicated clinics and
specialists who would be willing to accept referrals for fertility
preservation. On a more encouraging note, an overwhelming majority of
respondents (97%) felt that at least a dedicated clinic or fertility
preservation centre is necessary in Hong Kong, and over half felt at least
two centres are required to cater for both private and public patients.
This study highlighted a gap in understanding among the medical community
and a lack of currently available resources for fertility preservation
that must be overcome if we are to truly provide this service effectively.
In general, risks of treatment-related infertility
have been described previously by various groups. A recently published
modified consensus4 11 divided systemic anti-cancer therapies and radiation
therapy of specific doses to gonadal sites into five different risk
categories, namely: (i) high risk, corresponding to >80% risk of
permanent amenorrhoea in women and prolonged azoospermia in men; (ii)
intermediate risk (40%-60% risk of permanent amenorrhoea in women and
likelihood of azoospermia in men when given with other sterilising
agents); (iii) low risk (<20% risk of permanent amenorrhoea in women
and only temporary reduction in sperm counts in men); (iv) very low or no
risk of permanent amenorrhoea in women and temporary reduction in sperm
count in men; and (v) unknown risk of permanent amenorrhoea in women and
effect on sperm production in men. It is important to note that the
gonadotoxic effects of newer targeted therapies such as tyrosine-kinase
inhibitors and monoclonal antibodies have not been studied in detail. The
impact of these agents on a patient’s subsequent fertility has also not
been well described. Whilst data are now gradually emerging, there is a
need for the oncology community to study the impact of these newer agents
on fertility, especially since they have now become the cornerstone of
effective anti-cancer treatment. A possible approach may be to analyse
large population-based health and cancer registries, and cross-reference
individuals who may have received these agents with subsequent successful
child-bearing or birth, either through natural or assisted means.
Moving forward, from a societal perspective, it is
impractical to educate all clinicians of various specialties about the
latest advancements and techniques of fertility preservation. This is also
not necessary. What may be a more reasonable approach is for physicians,
especially oncologists and haematologists who administer gonadotoxic
chemotherapies, to become more diligent in recognising the
fertility-preservation needs and concerns of ‘younger’ oncology patients,
and to have ready access to referrals and consultative services that
fertility specialists can provide. Fertility specialists should also be
made more aware of both the improved treatment outcomes as well as their
potential toxicities. This should not only be limited to toxicities
associated with fertility, but with other physical side-effects as well as
potential socio-economic burdens that newer anti-cancer treatments entail.
Physical, psychosocial, and economic impacts of
cancer care, as well as the natural history of the disease, will likely
affect a patient’s decision about whether to pursue fertility
preservation. Younger patients who are often in the prime of their life
when struck with the devastating diagnosis of cancer may have different
priorities to older adults. The establishment of a dedicated
multidisciplinary adolescent and young adults oncology team that consists
of physicians and allied health professionals with training and experience
in addressing the needs of this unique set of patients, and incorporating
fertility preservation as one of its pillars, is the way forward.
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