Patient Demand Drives Interest in Oncofertility

Nadeem R. Abu-Rustum, MD

Nadeem R. Abu-Rustum, MD, says that better cancer care and improvements in fertility-preserving procedures are helping to increase interest in oncofertility. Ultimately, though, demand from patients is driving the field.

Five-year survival rates for all malignant cancers have improved for patients aged 15 to 39 years since 1975. Preserving fertility has become a greater concern as more young patients are surviving longer.

“There’s much more awareness among patients,” said Abu-Rustum, chief of the Gynecology Service at Memorial Sloan Kettering Cancer Center and vice chair of the National Comprehensive Cancer Network gestational trophoblastic neoplasia committee. “They’re asking, ‘Why do I need to lose my ovaries? Why do I need my uterus removed? Can you just remove the cervix? Is there any opportunity for me to save my eggs?’”

In an interview withTargeted Therapies in Oncology, Abu-Rustum discussed options and treatments that can allow women to maintain their reproductive ability.

TARGETED THERAPIES IN ONCOLOGY:Why is oncofertility becoming a more prominent topic of discussion among physicians and patients?

Abu-Rustum:Over the past 20 years, there’s been a big push to try to save the ovaries and save the uterus whenever possible. Our most common diseases are endometrial cancer, cervix cancer, and ovarian cancer. In very select patients, usually those younger than 43 who have very early disease, you can save the uterus or an ovary. Efforts are made in cervix cancer to remove just the cervix, sparing the uterus and ovaries. Endometrial cancer, in some young patients, can be treated with hormones, preserving the uterus. In very, very early, very specific types of ovarian cancer, you can remove 1 ovary and preserve the other one. In all our more common diseases, there’s complete acceptance of efforts to try to do organ preservation.

TARGETED THERAPIES IN ONCOLOGY:What is driving the growth in oncofertility?

Abu-Rustum:There’s a lot more awareness in patients. Physicians, too, have become more aware that we don’t need 1 prescription for everything. Twenty years ago, if you had a small cervix cancer, you would have removed the whole uterus, including tubes and ovaries. Now many of these patients are treated just with local excision. If you have a very early endometrial cancer that meets very specific criteria and you’re younger than 40, we may be able to preserve the uterus and treat with hormones, and you may still be able to achieve pregnancy.

If you have specific types of very early ovarian cancer, we can remove an ovary and save the uterus and the ovary on the other side. There’s a lot more understanding of how these tumors behave and that it’s safe to do individualized, tailored procedures. Pretty much all the data show that when done carefully in highly select patients, it’s safe.

TARGETED THERAPIES IN ONCOLOGY:Have improvements in technology made these fertility-preserving procedures more available to more patients?

Abu-Rustum:Absolutely. Patients have a lot more options than they did years ago. We can freeze eggs, which was not possible many years ago, or embryos or ovarian tissue. The techniques have gotten better. Our ability to retrieve this tissue, save it, keep it viable, and reintroduce it to the patient has also gotten better. It’s not limited to just 1 center in the country. Many centers can do this well now. The proliferation of this technology and the availability of options are better for the patients.

TARGETED THERAPIES IN ONCOLOGY:How does a patient’s desire to preserve fertility affect her cancer treatment?

Abu-Rustum:If the operation is done as a fertility-sparing procedure, it doesn’t affect very much. Instead of doing a hysterectomy, we can just remove the cervix—you modify the entire surgical approach.

Let’s say the patient needs to be treated with radiation where the ovaries are going to be destroyed. You would refer the patient to a reproductive endocrinologist first, they retrieve and freeze eggs, and the patient goes on to treatment. Most of the time, there’s not much delay.

In the past, one of the arguments was that preserving fertility would delay treatment by months. Most of the time, with the technology the reproductive endocrinologists have, this process can be done in less than 4 weeks.

Reference:

5-year relative survival (percent) for the top 5 cancer sites by age all races, both sexes, 1975-2014. National Cancer Institute website. cancer.gov/csr/1975_2015/browse_csr.php?sectionSEL=32&pageSEL=sect_32_table.20. Accessed September 7, 2018.