by Samantha Yee, MSW, PhD(c), Factor-Inwentash Faculty of Social Work, University of Toronto
The latest statistics from the Canadian Cancer Society estimate that in the year 2013, 4,896 males and 4,798 females between 20 and 39 will be newly diagnosed with cancer.1 Medical advances in cancer diagnostic testing and increasingly successful cancer treatments have led to growing numbers of young women surviving cancer and living productive lives following cancer therapy. With the growing number of cancer patients conquering cancer, much attention in cancer care is now directed to improving their quality of life following treatment, with reproductive health being one of the priorities.
For many young adults who survive cancer, quality of life also includes reproductive capacity. Fertility is an important quality of life concern for many young women in cancer survivorship because it involves the experience of pregnancy, child birth and motherhood.2 Research into the experiences of cancer survivors has found that many want to have children. Having a history of cancer does not necessarily reduce their desire to be parents.3 Also, just by knowing that procreation is a possibility provides an affirmation that their post-cancer life has returned to normal, and they can have similar motherhood desires and family building plans like other women who have not experienced cancer.
Unfortunately, many life-saving cancer treatments that are used to kill tumor cells, especially pelvic radiotherapy and the use of alkylating agents in chemotherapy, have a negative impact on females’ reproductive functions, causing premature reproductive aging, such as reduced ovarian functions and early onset of menopause. Most cancer survivors will not regain full fertility potential following cancer treatment, and some may develop infertility issues making natural conception difficult or impossible.4 Infertility is a distressing side effect of cancer treatment for young women who have a strong motherhood desire but have not yet started or completed their family at the time of receiving a cancer diagnosis.
In the past, women undergoing cancer treatment had no option to protect their fertility due to the lack of technology. Rapid advances in assisted reproductive treatments and recent new scientific breakthroughs in egg freezing technique (vitrification) not only allow women to freeze embryos, but also mature (through in-vitro fertilization IVF) and immature eggs (through in-vitro maturation IVM), as well as ovarian tissues. Recent Canadian psychosocial studies with female cancer patients/survivors have found favorable views on receiving pre cancer treatment medical consultation from fertility specialists despite the stress at the time of cancer diagnosis, as well as positive attitudes towards undergoing cryopreservation procedures despite the time pressure of commencing cancer treatment.5,6
Is fertility preservation procedure supported by medical societies?
In 2006, the American Society of Clinical Oncology issued a position paper7 stating that oncologists should routinely inform their reproductive-aged cancer patients about the potential fertility risks when making plans for cancer treatment, and to refer them to fertility centres for cryopreservation procedures if they wish. These guidelines were further updated in 2012,8 emphasizing not only the clinical responsibilities of oncologists, but also oncology health care providers and health care professionals.
The Canadian Fertility and Andrology Society is in the process of publishing Canadian practice guidelines on oncology fertility preservation to standardize care for best practice. It is anticipated that the guidelines will be published in the spring of 2014.
What are the fertility preservation options for female cancer patients?
Fertility preservation options are dependent on several factors, including the type of cancer, age, treatment type and dosages, pretreatment fertility status, presence or absence of a partner, and time availability to complete the procedure. At present, embryo freezing is the most promising fertility preservation option, with higher pregnancy rates compared to egg freezing.
Single women who do not have a male partner could consider egg freezing, or use donor sperm from a sperm bank to create embryos for freezing. Ovarian tissue banking through laparoscopic ovarian biopsy is considered to be experimental and should only be offered at fertility centres with institutional clinical ethics guidelines. In addition, technologies in assisted reproduction are advancing at a fast pace. The scientific breakthrough in pre-implantation genetic diagnosis (PGD) techniques to screen embryos with genetic defects has allowed BRCA1 and BRCA2 breast cancer carriers to select healthy embryos for transfer.
What is the timeframe for female cancer patients to preserve eggs or embryos?
Almost all fertility clinics in Canada give priority to oncology referrals; most can arrange the first appointment within a few days to a week.9 The window to complete the procedure is narrow because of the use of IVF, which is a time-sensitive procedure that must synchronize with the monthly menstrual cycle. The process of harvesting eggs using fertility medications takes approximately 2 weeks from the onset of menstruation to stimulate follicle development in the ovaries. The whole process may take 5-6 weeks depending on the woman’s menstrual cycle at the time of referral. Options for preserving fertility diminish rapidly after the initiation of chemotherapy and/or radiotherapy, and are not recommended in general.4
What are the estimated costs for cryopreservation procedures?
At present, Quebec is the only province that provides coverage for all patients seeking fertility treatments; this includes cryopreservation procedures for cancer patients. The Manitoba government provides a refundable personal income tax credit of up to $8000 per year to cover 40% of eligible expenses for fertility treatments and drugs.10
The fees to see a fertility specialist are covered by universal health care in all provinces. Unfortunately, the unique medical situation of cancer patients in need of fertility preservation is not addressed in public health funding. Many cancer patients are indeed quite surprised to find out the costs are out-of-pocket expenses despite their urgent medical circumstance. Several advocacy groups are now initiating dialogues with various provincial bodies to lobby for changes in health funding to cover oncofertility cryopreservation procedures, which are essential medical services for reproductive-aged cancer patients to preserve their chance of future biologic parenthood. The arguments being made are similar to government-funded breast reconstructive surgery for cancer patients who have had a mastectomy.
Fertility drugs required for the IVF procedure to stimulate controlled follicle production are expensive, but most fertility clinics help cancer patients to apply for compassionate drugs from pharmaceutical companies to cover the costs. The medication and procedure fees to preserve fertility are approximately a few thousand to $10,000, depending on the availability of financial subsidies and clinic fee schedules. Some IVF clinics offer additional discounts or flat rate fee reductions to cancer patients.11,12
Fertile Future, a national non-profit organization, has a cost reduction program called the “Power of Hope” (http://fertilefuture.ca/patients/power-of-hope/) that offers financial subsidies to cancer patients. The list of clinics that are affiliated with Fertile Future’s Power of Hope Program is available at http://fertilefuture.ca/patients/fertility-preservation-centres/. Please contact the clinics directly to check their fee schedules and if additional financial assistance is available.
What is the CKN Oncofertility Referral Network?
Findings from the Canadian surveys suggest that there are significant barriers to the provision of oncofertility services from the perspectives of cancer patients,5,6 oncology health care providers,13 and fertility clinics.11,12 As the window of preserving fertility is time sensitive, more collaborative planning on the regional level between oncology teams and fertility clinics is urgently needed.
The CKN Oncofertility Referral Network is a new initiative developed by Cancer Knowledge Network (CKN), Canada’s leading educational resource in cancer. CKN is a portal that is at the intersection of key target populations in the Canadian cancer community – patients, medical professionals and caregivers. This new Canadian-based interdisciplinary platform aims to link the fields of oncology and reproductive medicine to address the reproductive future of cancer patients who are facing a life-preserving but fertility-threatening cancer diagnosis by:
- building a nation-wide on-line referral system to local facilities providing oncofertility consultation and cryopreservation services;
- establishing the only national database reference of fertility preservation statistics in male and female cancer patients;
- establishing concrete resources for both patients and physicians on fertility preservation;
- creating resources that are both accessible and available provincially and federally;
- building the bridges of communication and resource sharing required to bring translated knowledge together to patients, physicians and fertility clinics.
The CKN Oncofertility Referral Network is developed under the medical and scientific guidance of the Oncofertility Scientific Advisory Board to ensure a system of collaboration between oncology and reproductive medicine communities is maintained to serve the best interests of cancer patients/survivors and their families.
Where to find fertility clinics that provide oncology fertility preservation services
CKN has recently developed a national directory of oncology cryopreservation centres that would enable young adult cancer patients to be referred quickly and efficiently to pre-cancer treatment fertility consultations as part of the first steps of their oncology treatment. The CKN Oncofertility Referral Network is housed on the CKN website at https://cancerkn.com/. A dedicated icon system has been established to allow direct access through mobile devices such as iPhone and iPad. At present, Fertile Future also has a list of fertility centres that provide oncology fertility preservation services that is available at http://fertilefuture.ca/patients/fertility-preservation-centres/.
Where to find resources related to fertility preservation for cancer patients
In addition to the referral services and clinic information, the CKN Oncofertility Referral Network plans to publish educational modules and resources that are easily accessible by the general public. CKN currently has over 3,500 subscribers to their website. Distribution of information, updates and newsletters will be sent through CKN’s growing network of subscribers including patients, caregivers, and health care professionals.
1 Canadian Cancer Society’s Steering Committee on Cancer Statistics. (2013). Canadian Cancer Statistics 2013. Toronto, ON: Canadian Cancer Society. ISSN 0835-2976. Retrieved on 19 October 2013 from www.cancer.ca
2 Peate, M., Meiser, B., Hickey, M., & Friedlander, M. (2009). The fertility-related concerns, needs and preferences of younger women with breast cancer: a systematic review. Breast Cancer Research and Treatment, 116, 215-223.
3 Schover, L.R., Rybicki, L., Martin, B.A., & Bringelsen, K.A. (1999). Having children after cancer: a pilot survey of survivors’ attitudes and experiences. Cancer, 86, 697-709.
4 Lee, S.J., Schover, L.R., Partridge, A.H., Patrizio, P., Wallace, W.H., Hagerty, K., Beck, L.N., Brennan, L.V., & Oktay, K. (2006). American Society of Clinical Oncology recommendations on fertility preservation in cancer patients. Journal of Clinical Oncology, 24(18), 2917-2931.
5 Hill, K.A., Nadler, T., Mandel, R., Burlein-Hall, S., Librach, C., Glass, K., Warner, E. (2012). Experience of young women diagnosed with breast cancer who undergo fertility preservation consultation. Clinical Breast Cancer, 12(2), 127-132.
6 Yee, S., Abrol, K., McDonald, M., Tonelli, M., & Liu, K. (2012). Addressing oncofertility needs: views of female cancer patients in fertility preservation. Journal of Psychosocial Oncology, 30, 1-16.
7 Lee, S.J., Schover, L.R., Partridge, A.H., Patrizio, P., Wallace, W.H., Hagerty, K., Beck, L.N., Brennan, L.V., & Oktay, K. (2006). American Society of Clinical Oncology recommendations on fertility preservation in cancer patients. Journal of Clinical Oncology, 24(18), 2917-2931.
8 Loren, A.W., Mangu, P.B., Beck, L.N., Brennan, L., Magdalinski, A.J., Partridge, A.H., Quinn, G., Wallace, W.H., & Oktay, K. (2013). Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline updates. Journal of Clinical Oncology, 31(19), 2500-2511.
9 Yee, S., Buckett, E., Campbell, S., Yanofsky, R.A., & Barr, R.D. (2012). A national study of the provision of oncofertility services to female patients in Canada. Journal of Obstetrics and Gynaecology Canada, 34(9), 849-858.
10 Manitoba Finance. Personal tax credits: fertility treatment tax credits. Manitoba, Canada: 2010. Retrieved on 19 October 2013 from http://www.gov.mb.ca/finance/tao/fttc_faq.html#question1
11 Yee, S., Buckett, W., Campbell, S., Yanofsky, R., & Barr, R.D. (2013). A national study of the provision of oncology sperm banking services among Canadian fertility clinics. European Journal of Cancer Care, 22(4): 440-449.
12 Yee, S., Buckett, W., Campbell, S., Yanofsky, R., & Barr, R.D. (2012). A national study of the provision of oncofertility services to female cancer patients in Canada. Journal of Obstetrics and Gynaecology Canada, 34(9): 849-858.
13 Yee, S., Fuller-Thomson, E., Lau, A., Greenblatt, E. (2012). Fertility preservation practices among Ontario oncologists. Journal of Cancer Education, 27, 362-268.
Samantha Yee, BSW, MSW, RSW, PhD(c) is a doctoral candidate at the Factor-Inwentash Faculty of Social Work at the University of Toronto. Her doctoral thesis is on exploring the intersections of cancer, fertility and motherhood for young women with a history of cancer.
Samantha is a past Chair of the Counselling Special Interest Group of the Canadian Fertility and Andrology Society (2007-2009). She is currently a member of the Scientific Advisory Board of Cancer Knowledge Network’s (CKN) Oncofertility Referral Network, and a co-editor of the CKN Oncofertility monthly e-newsletter. She is also actively involved in a provincial Oncofertility taskforce established by the Ontario Regional Action Partnership of the National Task Force on Adolescent and Young Adult Cancer.