ASCO Issues Updated Guidelines on Fertility Preservation

Roxanne Nelson

May 28, 2013

The American Society of Clinical Oncology has updated its guidelines on fertility preservation for adults and children with cancer. The update is based on a review of evidence that has been published since 2006, when the original guidelines were issued.

The updated guidelines were published online May 28 in the Journal of Clinical Oncology.

There have not been very many randomized controlled trials since 2006 that would justify a completely new update, explained Kutluk Oktay, MD, cochair of the panel that updated the guidelines. "It is difficult to design randomized trials in this area and to get the data," he told Medscape Medical News.

As a result, the update panel concluded that new evidence was "not compelling enough to warrant substantive changes" to any of the 2006 recommendations. However, there are "minor but significant changes worthy of attention."

"There have been advances in the field, and we approached the level of a major revision," said Dr. Oktay, who is director of the division of reproductive medicine and the Institute for Fertility Preservation at New York Medical College in New York City. "The guidelines are now tighter."

Of the 222 new publications that met the inclusion criteria, the majority were observational studies, cohort studies, or case series or reports. Only 18 were randomized clinical trials.

The key recommendations of the updated guidelines are that fertility preservation should be discussed with all patients of reproductive age as early as possible, and those discussions should be documented in the medical record. Patients who express an interest in fertility preservation (or who are ambivalent) should be referred to reproductive specialist. If patients experience distress about potential infertility, they should be referred to psychosocial providers. Providers should answer basic questions about fertility preservation and the potential impact on cancer treatment, and should encourage patients to participate in registries and clinical studies.

New Information

One of the important points in the updated guidelines is that oocyte cryopreservation is now standard practice, said panel cochair Allison W. Loren, MD, MS, assistant professor of medicine at the University of Pennsylvania in Philadelphia. "In the previous guidelines, it was considered investigational, but it is no longer necessary to use a fertilized egg."

Another change is the replacement of the word oncologist with healthcare provider. "Everyone on the team can speak to the patient about this," said Dr. Loren. This is meant to include not only medical oncologists, radiation oncologists, surgeons, and other specialists, but also nonphysician providers, such as nurses, social workers, and psychologists.

The risk for infertility associated with therapy should be addressed with all patients of reproductive age, and with the parents and guardians of children and adolescents. "Fertility preservation should be discussed with the patient as soon as possible, before treatment starts," Dr. Loren told Medscape Medical News. "This is the one treatment-related side effect that can be prevented. It needs to be on the forefront of the agenda."

Although patients can be overwhelmed after receiving a cancer diagnosis, "having this discussion as soon as possible can help reduce patient stress and improve quality of life," she noted.

Expanded Information

There are also more flexible options for ovarian-stimulation protocols. This has been an issue in the past, explained Dr. Oktay, because the procedure is tied to the menstrual cycle, which could result in a treatment delay. Conventional ovarian-stimulation protocols can take 2 to 6 weeks to start, and that delay in cancer treatment could be too long.

However, "we now know that stimulation can be started at any time, and timing no longer depends on the menstrual cycle in most cases," he said told Medscape Medical News. "It can be completed in as little as 10 to 14 days."

Of particular concern with ovarian stimulation is the possibility that the intervention will increase the risk for disease recurrence in women with estrogen-sensitive breast and gynecologic malignancies. However, protocols using the aromatase inhibitor letrozole (Femara) have been developed that might ameliorate this concern, Dr. Oktay noted. "We have put more language in the guidelines about this, explaining that this may be a safer option for ovarian stimulation."

There is also more information in the updated guidelines about the relation between the BRCA mutation and fertility. "We know now that BRCA mutation carriers may have a lower egg reserve because of the mutation," said Dr. Oktay. "We don't know yet whether that affects fertility outcomes."

However, he pointed out that women need to be cognizant of this because it might make them less fertile. The mutation can also make women more prone to chemotherapy-related infertility, and "they may also have earlier menopause," he noted.

Another benefit of fertility preservation is that embryos can be screened for the mutation, he added.

The authors have disclosed no relevant financial relationships.

J Clin Oncol. Published online May 28, 2013. Abstract

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