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An Ounce of Prevention

KarenMandelby Dr. Karen Mandel


Finding a partner and having a family is an important aspiration in people’s lives. Nevertheless, for many cancer survivors, this goal is unattainable due to the impact on their fertility from their cancer therapy. Others may be worried that their cancer history may have an impact on the health of their future children. In my 10 years working with survivors of pediatric cancer, the inability to have children is the most devastating of all late effects of treatment. Very few of my survivors worry about the long term effects on their heart or kidneys, even when they are already experiencing organ dysfunction. But most of them worry about their ability to have children, even those who did not have any therapy that would impair their fertility.

The survival rate for paediatric cancer is currently greater than 80% in the developed world. In adults, it is over 60%. Approximately 10-15% of adult cancer patients are young adults still of reproductive age. Thus the impact of lost or impaired fertility affects a large number of people. Given the significant impact on their psychosocial health and quality of life, the impact of cancer treatment on a patient’s ability to have children must be addressed before it’s too late.


Fortunately, for many patients who are about to undergo cancer treatment, there are things that can be done in order to preserve fertility. However, the subject must be broached BEFORE cancer therapy is initiated and the damage is done. Discussions about potential impaired fertility and timely referral to a reproductive specialist must be part of every oncologist’s “new diagnosis” talk with patients and their families. The American Society of Clinical Oncology (ASCO) published clinical practice guidelines in 2006 outlining the responsibility of oncologists to discuss the impact of treatment on fertility. Despite this, only about half of oncologists do so.


There is often little we can do to prevent the impact that a cancer diagnosis has on the people we care for. Fortunately, preserving future fertility is possible in most cases. At the Children’s Hospital of Eastern Ontario, we have instituted a protocol for fertility preservation in all post pubertal males and a pilot program ovarian tissue preservation in females will be starting shortly. Unfortunately, there are still no good options for pre-pubertal males.


A fertility preservation protocol at all cancer centres is key to the wellbeing of our survivors. There are far too many young women suffering from the devastating news that they cannot have children. There are too many young women panicking as they try to figure out how to have children in their early 20s before they hit premature menopause when they haven’t met the right partner yet. There are too many men trying to figure out how to inform the woman that they want to spend their life with that they can’t father a child. All of these scenarios happen frequently. Yet, with a few minutes to make a referral, they needn’t have happened at all.




Dr. Karen Mandel did her undergraduate medical training at the University of Western Ontario. She then completed a Pediatrics residency at the University of Chicago followed by a fellowship in Pediatric Hematology/Oncology at the Hospital for Sick Children in Toronto. She holds Royal College certification in both Pediatrics and Hematology/Oncology. During fellowship, Dr. Mandel had the opportunity to work at a summer camp for children with cancer. It was there that she became aware of the effects that cancer therapy can have on the growing and developing bodies of children. That inspired Dr. Mandel to pursue a special interest in the aftercare of childhood cancer survivors.
Dr. Mandel was the Programme Leader for the Childhood Cancer Survivor Programme at the University of Ottawa until her recent move back to her hometown of Toronto. She is currently enjoying being a mother for a while before commencing a new career in Toronto. She continues to do research and program development in fertility preservation for childhood cancer patients.


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