Preserving fertility for young adult cancer patients

No matter your age, almost everyone's first worry upon hearing a diagnosis of cancer is survival. Is this cancer going to kill me? For young adults, another very powerful worry is fertility preservation. Will I be able to have children?

For men, this is pretty simple and straightforward. Oncologists routinely suggest a visit to a sperm bank where the task is usually quick and fairly inexpensive. For women, this is more nuanced and more difficult. It is also much less frequently discussed at the onset of cancer treatment. A new study from Canada found that almost 50% of young women with cancer are not informed about their options. To quote one participating oncologist:

"The failure of oncologists to engage with fertility is truly a failure, because it is not a lack of available information or knowledge, it's more the physician's lack of interest, lack of accessing available information, lack of acting on it, and a lack of patience to actually take the initiative."

I would add a few more reasons, including the sense of urgency that usually accompanies a cancer diagnosis, the fear that a new patient is experiencing that makes it hard to raise new questions or imagine the future, and the reality that the process is longer and more complicated and much more expensive for women who want to preserve their eggs.

The American Society of Clinical Oncology (ASCO) guidelines published in 2013 state: As part of education and informed consent before cancer therapy, health care providers (including medical oncologists, radiation oncologists, gynecologic oncologists, urologists, hematologists, pediatric oncologists, and surgeons) should address the possibility of infertility with patients treated during their reproductive years (or with parents or guardians of children) and be prepared to discuss fertility preservation options and/or to refer all potential patients to appropriate reproductive specialists.

In Boston, we are fortunate to have a number of options, clinics where fertility is the focus. Although most are intended primarily for couples trying to conceive, the process can be the same. However, not all insurances cover the costs of preservation of eggs for cancer patients, and the fee is high. There are some organizations to help with the expense, and any IVF facility can share that information. There is also the fact that egg retrieval and preservation is a process that cannot be hurried. It takes a minimum of weeks and must be scheduled around a woman's cycle. In the crisis of a new cancer diagnosis, it can be very hard to slow down to deal with this issue before beginning treatment. Sometimes it is dangerous to wait, although often initiating cancer treatment is not an acute medical emergency.

Everyone knows that cancer patients who are parents are sad and worried about the possibility of dying prematurely and leaving their children without a mother or father. People who are not yet parents, or who have not completed their families, may also be grief-stricken about the loss of a dream. This dream does not always need to be vanquished, but young adult patients need to be educated and understand their choices and possibilities about fertility. Sometimes the solution includes surgery (e.g., temporarily moving ovaries to keep them out of a planned radiation field), but, most often, it involves working with an IVF Clinic.

As cancer care increasingly tries to attend to the whole person, considering all of a life and not only the diagnosis and cancer treatment, this is a central concern for many young people. One cannot assume that this is only a worry for people who are already coupled. Single adults, too, may be thinking about children in their futures. Clinicians must take the time and care to discuss this very big issue with their new patients.