Clinical Cases in Oncofertility

Oncofertility is a multidisciplinary field requiring experts from a variety of different backgrounds including endocrinology, oncology, bioethics, urology, etc., in order to provide fertility options to cancer patients.  In the oncofertility book series, each edition focuses on a specific component of oncofertility, with the 3rd book, Oncofertility Medical Practice: Clinical Issues and Implementation, addressing the clinical aspects of fertility preservation.  The entire book culminates with a 15th chapter, “Clinical Cases in Oncofertility,” by Clarisa Gracia, MD, highlighting the most important concepts covered throughout the book through a series of case studies. Dr. Gracia states, “Because the number of complex fertility preservation cases at any single center may be limited, there is value in providing a series of cases from multiple contributors in this book.” Each oncofertility patient is different, stressing the importance of individualized care to minimize risks and maximize outcomes.

Often when discussing oncofertility, we are talking specifically about cancer patients; however, there are other diseases that may impact fertility. Dr. Gracia sites a specific case where an 8yr old pre-pubertal girl with a history of severe sickle cell disease was advised to pursue stem cell transplantation (SCT). Studies have shown that infertility and premature ovarian failure are potential risks of this procedure. Because of that, she was a good candidate for fertility preservation if her family chose to pursue that option. Due to her age, the only viable option for fertility preservation was ovarian tissue cryopreservation and after lengthy counseling sessions, her parents agreed to allow her to participate in this experimental procedure.

Dr. Gracia highlights 2 very important points this case brings into question about oncofertility. The first being that prepubertal girls have limited options for fertility preservation. Egg and/or embryo banking is not possible before puberty, and in this particular case, because the girl was not receiving pelvic radiation, she was not a good candidate for ovarian transposition. The second issue is that more and more cancer therapies are being used to treat non-malignant diseases. These patients are often very ill and can be at greater risk for fertility preservation complications. According to Dr. Gracia, in this case, “patients with sickle cell disease may be at higher risk of vaso-occlusive crises, thrombosis, and postoperative pain.”

Learn more about this and other unique oncofertility cases in, ”Clinical Cases in Oncofertility,” by Clarisa Gracia, MD, in Oncofertility Medical Practice: Clinical Issues and Implementation.

Fighting over frozen embryos: How to prevent disputes over cryopreserved reproductive materials

I just returned from the annual Oncofertility Consortium Conference and one of the ethical topics that came up was the possibility of disputes over frozen reproductive materials. Before undergoing life-saving cancer treatment, people may opt to freeze gametes, gonadal tissue, or embryos in order to preserve their fertility. If these people die or separate from their partners, a battle over what to do with the frozen reproductive materials can ensue. The best and easiest way to deal with disputes over reproductive material is to try to prevent them before they happen. In this blog, I discuss two ways to prevent such disputes.

One way is to have the individual with cancer write an advance directive that clearly outlines what should be done with the reproductive material should the patient die. If the reproductive materials are gametes or gonadal tissue, then ultimately the decision of what to do with the reproductive material should be made by individual with cancer, as it is her/his genetic material. If the reproductive materials are embryos, then the individuals who contributed the gametes to create the embryos should come to an agreement about how the embryos should be handled under unfortunate circumstances (e.g. death of the genetic parents or separation of the couple). Many infertility clinics require all patients—both individuals and couples—to complete a document outlining how to handle reproductive materials in unfortunate circumstances and I think this should be standard practice for oncofertility patients as well. Read the rest of this article on the blog of the Alden March Bioethics Institute at Albany Medical Center.

Building a Successful Fertility Preservation Program

More and more healthcare organizations, hospitals, and clinics are interested in learning about fertility preservation and how exactly an oncofertility program is developed. The Oncofertility Consortium holds a 1-day course entitled, Clinic 101, to teach health care providers the necessary steps involved in developing their own fertility preservation program or ways to strengthen their existing program. Nonetheless, we understand that not everyone can make it to Chicago for this course so a few of our Consortium members put together a little “how-to” to help you get started.  In “Setting Up an Oncofertility Program,” in Oncofertility Medical Practice: Clinical Issues and Implementation, authors H. Irene Su, Lindsay Ray, and R. Jeffrey Chang, provide a first hand account of what is needed to build an oncofertility program through their experience developing a program at the University of California, San Diego (UCSD).

First, starting an oncofertility team requires engaging a medical team with various clinical backgrounds: oncologist, reproductive endocrinologist, urologist, patient navigator/nurse, anesthesiologist, supportive oncology, etc., to commit to communicating and working together from the onset of diagnosis through survivorship. Often, the oncologist and reproductive endocrinologist are the ones to assemble the oncofertility team, in part because they are the clinicians involved in the immediate diagnosis and aftermath of a cancer diagnosis in a pediatric, adolescent, or young adult cancer patient.   Collective expertise in managing oncofertility patients is crucial to a successful treatment plan.

Another important aspect of building an oncofertility program is to establish a marketing/communications team to help educate health care providers and medical practices’ about fertility preservation.  It is also imperative for the marketing team to reach the local pediatric and young adult cancer community to encourage young cancer patients and their caregivers to be proactive in their cancer care so they can make informed decisions about their course of treatment.  Websites, grand rounds, exhibits, educational materials, and resources all help to facilitate effective outreach efforts.

Finally, after a clinical team has been established and outreach and marketing efforts put in place, an oncofertility program needs a financial counselor to assist patients in locating resources to defray the cost of fertility preservation. At this time, most fertility preservation treatments are not covered by insurance. This can have a strong influence on a cancer patient’s decision to pursue oncofertility services; however, knowledgeable financial counselors can help direct patients to the appropriate financial assistance programs and help negotiate oncofertility packages in their own institutions.

To learn more about building a fertility preservation program, please read, “Setting Up an Oncofertility Program,” in Oncofertility Medical Practice: Clinical Issues and Implementation.

October is Breast Cancer Awareness Month

October is Breast Cancer Awareness Month, which is an annual campaign to increase awareness of the disease. Countries around the globe have started celebrating Breast Cancer Awareness Month, with 31 days spotlighting prevention, education, and finding a cure. While most people are aware of breast cancer, many forget to take the steps to have a plan to detect the disease in its early stages and encourage others to do the same. We have made a lot of progress but still have a long way to go!

As Breast Cancer Awareness Month gets under way, consider how you will make a difference this month in the lives of the one in eight women who will be diagnosed with the disease. Whether it’s donating to charities that directly fund cancer treatment or pressuring government to take real action, make your involvement have the most impact.

Know The Facts:

Each year, approximately 70 thousand men and women age 15 to 39 are diagnosed with cancer in the US. Breast cancer accounts for roughly 15% of all cancers in this age group. Young women with breast cancer struggle with many issues either not present or much less severe in the lives of older women; including, the possibility of early menopause and effects on fertility.

Get Involved with Legislation:

To make meaningful change in the lives of those living with breast cancer, Breast Cancer Action is urging advocates to “move beyond ‘awareness’ and pink ribbons.” The 2012 Breast Cancer Action Mandate urges government officials to push legislation that keeps corporations from polluting the environment and pushes pharmaceutical companies and biotech firms to prioritize patients over profits.

Support Grassroots Organizations:

It’s not just the big name charities that you should be supporting. Consider getting involved with grassroots organizations that are tackling the issues that don’t garner mainstream attention. The Young Survival Coalition for example, focuses exclusively on the unique issues young women with breast cancer face. It provides comprehensive resources, support and education to address every phase of a young woman’s breast cancer experience. The Keep Abreast Foundation also works specifically with young people educating them on how to eradicate breast cancer for future generations.

Tomorrow: Receive Free CME Credits for Zsolt Peter Nagy, PhD– Vitrification: State Of The ART For Oocyte And Embryo Cryopreservation

Tomorrow launches this year’s cadre of Virtual Grand Rounds for the Oncofertility Consortium. For those who are not aware of these special rounds, they are live videoconferences with experts in the fields of reproduction, cancer, and oncofertility. The rounds provide researchers, clinicians, and others the opportunity to hear emerging research findings from anywhere across the globe and participate through a live videochat. This year, the Oncofertility Consortium is also able to offer free CME credits to health care providers through these live virtual events.

We are happy to be hosting Zsolt Peter Nagy, PhD for his presentation tomorrow, October 11, 2012 at 12 PM Central time, for his talk on vitrification, the rapid freezing technique used in assisted reproductive technologies (ART). Dr. Nagy will discuss the current state of vitrification in two fertility preservation options for young female cancer patients, oocyte and embryo cryopreservation.

At Noon, Central time, click here to watch Dr. Nagy present his Virtual Grand Rounds

Or sign up to receive free CME credits while participating in Dr. Nagy’s presentation

APHON Releases Fertility Preservation Position Statement

Yesterday we posted a blog about the 36th annual APHON (Association of Pediatric Hematology/Oncology Nurses) Conference being held right now in Pittsburgh, PA.  It’s an exciting time for us because not only do we have a member of the Oncofertility Consortium presenting on fertility perseveration at the conference (Barbara Lockart, MSN, RN, CPNP, CPON), but also because APHON has recently released a position statement entitled, Fertility Preservation for Pediatric and Adolescent Young Adult (AYA) Cancer Patients. The strides that have been made since the Oncofertility Consortium’s inception in 2007 are truly on display here and we couldn’t be more excited!

Nurses are often the thread connecting young cancer patients and their families to pertinent information that can sometimes be overlooked in the urgency of a cancer diagnosis and subsequent treatment planning process.  As studies have shown, fertility issues and options are often not addressed at diagnosis for several reasons (age of the patient, diagnosis, gaps in provider knowledge, etc.); however, several studies report childhood and AYA cancer patients are interested in learning about fertility preservation options, including those that are experimental.

It is APHON’s position that, “discussions regarding fertility preservation occur with all patients and families as early in the treatment trajectory as possible (prior to treatment whenever possible). These discussions should continue throughout treatment and follow-up care as patients continue to grow and develop.” Currently, many pediatric facilities do not have the resources available to offer fertility preservation in their institutions, but they have the option of partnering with reproductive or adult centers that provide fertility preservation services. Collaboration between centers is vital for a successful treatment experience for patients, families, and their healthcare team. The Oncofertility Consortium provides both patients and health care professionals with resources for locating established fertility preservation centers, as well as providing a national fertility hotline, FERTLINE, answered by a Fertility Preservation Patient Navigator who can provide you with additional information.

In addition to that, pediatric oncology nurses’ expertise may be needed to provide adult healthcare providers with information about the unique psychosocial and developmental needs of childhood and AYA oncology patients and their families. They can also be a great resource for patients and families who may not have enough information independently to inquire about specific issues such as cost, insurance coverage, success rates, and storage concerns.

As evidenced by their position statement, APHON is supporting the Oncofertility Consortium’s quest to ensure that all patients, providers, and caregivers have the ability to make informed decisions regarding fertility preservation in the face of a cancer diagnosis. Please take a moment to read, Fertility Preservation for Pediatric and Adolescent Young Adult (AYA) Cancer Patients, and learn more about fertility preservation resources nationwide.

36th Annual APHON Conference: October 4th-6th

Today marks the start of the 36th annual APHON (Association of Pediatric Hematology/Oncology Nurses) Conference in Pittsburgh, PA. The conference is designed for pediatric and adolescent and young adult (AYA) hematology/oncology nurses and allied healthcare professionals who wish to explore ways to enhance their practice. This year’s expanded hematology offerings aim to provide an in-depth knowledge base and understanding of the principles of caring for patients with hematologic disorders. Educational sessions that focus on research, clinical management, and psychological issues are designed to provide attendees with the knowledge and support to enable them to influence pediatric and AYA hematology/oncology nursing and allied healthcare.

On Friday, Oct 5th from 8-9am EST, Northwestern’s own, Barbara Lockart, MSN, RN, CPNP, CPON, will be presenting, “The Science and Hope of Fertility Preservation.” As the emerging field of oncofertility gains ground, we are thrilled to have a venue to discuss fertility preservation among healthcare providers that serve not only as clinicians, but often as advocates as well. It is imperative for parents and caretakers to understand that cancer treatment, including stem cell transplant, may put children and adolescents at risk for infertility. There is a growing awareness that maintaining fertility is important to families and that infertility is a concern for patients throughout the treatment continuum. Fertility preservation is a rapidly evolving field with lifelong implications for the physical, emotional, and spiritual health of patients. Barbara will examine the state of fertility preservation science, as well as guidelines for determining which patients are appropriate for intervention. She will also discuss the role of the nurse as advocate, educator, and researcher.

Overall, the conference seeks to teach the field about current trends and new information in pediatric and AYA hematology/oncology, as well as learning from shared experiences. It will be an exciting combination of speakers, posters, meetings, and preconference workshops and of course, the issues surrounding social media, technology, and therapeutic boundaries will be a hot topic for discussion. If you would like to attend this exciting conference, please visit the APHON Conference homepage for more information about registration, the agenda, and preconference workshops and education sessions being held.

 

Guest Blog: Building and Evaluating an Interdisciplinary Team in Oncofertility

Members of the Oncofertility team were invited to guest post on the NIH Team Science Toolkit blog and we are happy to announce that the blog was just posted. Read the beginning of the blog below.

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Over the past decade, federal funding has played a key role in encouraging the advancement of interdisciplinary team science.  The 2007 Roadmap for Medical Research Initiative, which was created by the National Institutes of Health, is one such example.  The Initiative was designed to bring diverse experts together to solve extremely challenging public health problems, from obesity to mental illness. The Initiative launched a number of programs, including the Oncofertility Consortium (oncofertility.northwestern.edu). The Consortium is an interdisciplinary team of researchers and clinicians created with the goal to expand the reproductive future of young cancer survivors through advanced research and improved clinical care. Given that 10% of cancer patients are diagnosed during or before their reproductive years and that survivorship rates exceed 80%, fertility is a significant survivorship consideration for the 135,000 patients under age 45 who are diagnosed each year and for their families. The subfield of oncofertility (at the intersection of oncology and reproductive medicine) was launched with federal financial support, and the participation of scientists, clinicians, social scientists, humanities scholars, and others to address this issue…Read the rest of this blog on the Team Science Toolkit blog.

Watch the 2012 Oncofertility Conference LIVE!

For those of you who don’t know, the 2012 Oncofertility Conference: Dialogues in Oncofertility,  is taking place as we speak in Chicago, IL. We understand that not everyone can come to us, so we want to bring the Oncofertility Conference to you. Please visit our conference home page, and watch a live stream of this dynamic event. Even better, we are offering Continuing Medical Education (CME) credit so if you’re interested in adding some to your repertoire, please click on the link for those. We hope you can join us!

Watch the live broadcast now!

Watch AND earn CME credits now!

2012 Oncofertility Conference AGENDA

Killing two birds with one stone? Understanding common genetic features of breast cancers and ovarian tumors

The more we understand about our genes, the more we understand genetic diseases and eventually, how to best treat them.  The recent efforts of a nationwide consortium of researchers suggests that the origins of the type of breast cancer a patient is diagnosed with may inform the most effective course of treatment.

The study, published in Nature on September 23rd, is one of the most comprehensive studies of breast cancer to date.  The study revealed that the gene expression profile for one of the most aggressive forms of breast cancer, basal-like carcinoma, is more similar with ovarian tumors than with other breast cancer subtypes.

The four main breast cancer subtypes: Luminal A, Luminal B, HER2, and basal-like, were confirmed and characterized by leading researchers at several institutions as part of The Cancer Genome Atlas Network.  The study is part of an NIH funded initiative with the Cancer Genome Atlas Network to build maps of genetic changes in common cancers.  While most historical studies of breast cancer have utilized one or two methods to analyze and characterize the gene profiles of breast cancers, six parallel technologies were used for this study to examine mutations and defects in DNA, RNA, and proteins.  Consortium scientists analyzed tumors from 507 women, with nearly 350 tumors being analyzed using all six technologies.

Basal-like breast tumors are also known as “triple negative” tumors.  Triple-negative tumors lack receptors for the hormones estrogen, progesterone, and human epidermal growth factor 2 (HER2), which are the gene targets of a number of approved chemotherapies such as Tamoxifen and Herceptin.  However, no receptor hormones means no drug targets.  Basal-like tumors are a considered high-grade, indicative of an abnormal appearance of the cells under a microscope and a tendency to grow and multiply more rapidly. These tumors have a poor prognosis for treatment and are more prevalent in younger women, women with BRCA1 and BRCA2 mutations, and women of African-American descent.

Currently, basal-like breast tumors are treated like most other breast cancers, using similar chemotherapy strategies.  However, basal-like breast tumors are aggressive and not been shown to respond well to therapies targeting hormone receptors or to standard chemotherapy regimens.  Consortium researchers found that each subtype could be identified by unique genetic markers, and that mutations in only three genes, TP53 (tumor suppressor gene 53), PIK3CA and GATA3, occurred in common with all four subtypes.  These findings suggest that not all breast tumors are alike and therefore, may not respond similarly to the same chemotherapy regimens.

Consortium scientists found that basal-like and HER2 tumor subtypes were characterized by the highest mutation rates.  Basal-like tumors shared common features with ovarian tumors and lung cancers, including high rates of TP53 mutations, BRCA1 inactivation, and a loss of RB1 and cyclin E genes, which are known to promote genome instability.  The study shows that 80% of basal-like tumors had TP53 mutations and approximately 20% also have mutations in the BRCA1 or BRCA2 genes. Mutations in the TP53 gene have been strongly linked to poor treatment outcomes, while BRCA1/2 mutations are known to increase breast and ovarian cancer.

A growing body of research suggests that tumors should be characterized and treated based on the presence of abnormal genes and abnormal gene expression profiles rather than on their location in the body.  Consistent with these findings, consortium researchers found that basal-like tumors are genetically more similar to ovarian tumors based on their genetic profiles.  Ovarian tumors are also characterized by a high frequency of TP53 mutations, widespread genomic instability and share other gene mutations in common with similar frequency.   These results give biologic reasoning to consider the potential benefits to patients with basal-like tumors to be treated with platinum-based chemotherapies currently approved for the treatment of ovarian cancer or PARP inhibitors which target tumors with BRCA1 and 2 defects.

Clinical trials are a lengthy but necessary step to determine if platinum-based compounds, currently used to treat cancers elsewhere in the body, and/or PARP inhibitors hold promise for patients diagnosed with basal-like breast carcinoma.  For now, this study offers much needed insight into the origins of the most aggressive form of breast tumor and promising possibilities for future personalized treatments.

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