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New ACOG opinions address gynecologic concerns in young cancer patients

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A useful resource

Cancer in young female patients is rare, and the literature to guide the management of gynecologic issues related to treatment is limited. Thus, these two new ACOG committee opinions provide a useful resource for gynecologists who encounter young cancer patients and cancer survivors in their practice or who are consulted on the management of a bleeding emergency in a young cancer patient, Dr. Frances Ginsburg said in an interview.

Importantly, the opinions stress the need for collaboration and involvement of gynecologic care early in the course of treatment or prior to treatment initiation, she said.

"My feeling about a young woman or child who is facing this kind of situation is that the younger they are the more likely that everybody is focusing on a million other things. ... A lot of times I will get a call after the fact about a patient who had chemotherapy at 18 and at 20 is not getting her period. It’s a little late at that point," she said.

However, the committee opinion on gynecologic concerns is not forceful enough in its statement on the use of gonadotropin-releasing agonists to induce ovarian quiescence in an effort to preserve ovarian function and fertility after cytotoxic treatment in those who have reached sexual development, she said, explaining that the opinion states that results have been mixed, that a meta-analysis showed only a slight increase in ovarian function, and that evidence is currently not strong enough to recommend their use for this purpose.

In fact, compelling randomized trial data showing a benefit with these agents were presented at a recent conference.

"The results were really very dramatic. I think the results were dramatic enough that probably all women undergoing chemotherapy who desire future fertility ought to be offered it as one of their options," she said.

Dr. Ginsburg is director of reproductive endocrinology and infertility in the department of obstetrics and gynecology at Stamford (Conn.) Hospital and assistant professor of clinical obstetrics and gynecology at Columbia University, New York. She had no relevant financial disclosures and is not a member of the ACOG committee.


 

FROM OBSTETRICS & GYNECOLOGY

References

Cancer treatments in children and adolescents can adversely affect reproductive health and future pregnancy outcomes, so gynecologists should be aware of these effects and be involved in patient care, according to a new committee opinion from the American College of Obstetricians and Gynecologists.

The opinion, entitled "Gynecologic Concerns in Children and Adolescents with Cancer," is one of two released July 22 regarding the preservation of reproductive health among young cancer patients. The other opinion specifically addresses prevention and management of heavy menstrual bleeding that can result from cancer and cancer treatments.

Both opinions were developed by the ACOG Committee on Adolescent Health Care and are published in the August 2014 issue of Obstetrics & Gynecology.

Advancements in radiation therapy, chemotherapy, surgery, and multimodal treatment have dramatically improved childhood cancer survival; 5-year survival rates have reached nearly 80%, but the treatments – and the cancer itself – can have immediate or delayed adverse effect on reproductive health, the authors wrote in the first opinion (Obstet. Gynecol. 2014;124:403-8).

Gynecologists should be aware of the potential effects that can occur both during and after each type of therapy, they said.

For example, primary ovarian insufficiency can occur following pelvic radiation therapy and can lead to future adverse pregnancy outcomes. Chemotherapy also can affect ovarian function, and the risk of toxicity is directly proportional to the age and pubertal status of the patient at the time of exposure, with older patients having higher risk.

Surgery, such as resection of the vagina, uterus, ovaries, or fallopian tubes, can lead to adhesions and infertility, and can also lead to pelvic pain, sexual dysfunction, and fistula formation, they said.

Cancer treatments also can lead to precocious or delayed puberty.

Gynecologists should be prepared to manage gynecologic concerns in young patients and survivors, as they may be consulted regarding pubertal concerns, heavy menstrual bleeding and anemia, sexuality, contraception, ovarian function, and breast and cervical cancer screening, the authors noted.

The committee opinion provides information and guidance on managing each of these circumstances. With respect to fertility preservation, the opinion states that anti-Müllerian hormone level is the optimal screening tool for assessing ovarian reserve in survivors and stresses that potential options for fertility preservation should be discussed prior to treatment in those at risk for infertility. Options may include oophoropexy to move the gonads away from the radiation field in those to be treated with pelvic irradiation, and ovarian stimulation and cryopreservation of either oocytes or embryos.

"The science of fertility preservation is a rapidly evolving field; therefore, a referral to a reproductive endocrinologist is recommended to explore the full range of available options," the authors said, adding that for young women who have completed sexual development, gonadotropin-releasing hormone agonists have been used to induce ovarian quiescence in an effort to preserve ovarian function and fertility. Results of this approach have been mixed, and the evidence is not currently strong enough to recommend this therapy, although randomized trials are underway, they said.

In the second opinion, "Options for Prevention and Management of Heavy Menstrual Bleeding in Adolescent Patients Undergoing Cancer Treatment", the authors note that even normal menstrual blood loss can pose a threat to adolescents who are already anemic because of hematologic malignancies or cancer treatment (Obstet. Gynecol. 2014;124:397-402).

"Disruption of the hypothalamic-pituitary-gonadal axis during cancer treatment also may cause anovulatory uterine bleeding," they wrote, adding that gynecologists may, therefore, be consulted regarding strategies for suppressing menstruation prior to treatment or during an episode of severe heavy bleeding to stop the bleeding emergency.

Therapy in both situations should be tailored to the patient and her desires for contraception and fertility.

"Because of the complex nature of cancer care, collaboration with the adolescent’s oncologist is highly recommended," according to the opinion, which outlines options for prophylactic menstrual suppression (combined hormonal contraceptives, progestin-only therapy, and gonadotropin-releasing hormone agonists) and emergent treatment of acute uterine bleeding (hormonal therapy, antifibrinolytics, and surgical options for patients who fail medical therapy).

Surgical options may include dilation and curettage, uterine packing, tamponade with a Foley balloon, or uterine artery embolization, but "evidence for these treatments in adolescents is lacking, and their consideration is based on extrapolation from the literature on adult patients. Also, uterine artery embolization is not suitable as a first-line therapy given its effect on fertility, but may be considered as an alternative to hysterectomy in an acutely ill patient," the authors said.

A treatment algorithm for patients without contraindications to estrogen therapy is included in the opinion, with surgical options listed as a last resort.

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