Jun 19, 2015
Dr. Jay Andersen and his patient Lisa Bailey were featured in a U.S. News & World Report article about preserving fertility when facing a cancer diagnosis.
Preparing for a Baby After Cancer
An early window of opportunity can let patients preserve their fertility.
By Lisa Esposito
When you learn you have cancer, having children might be the last thing on your mind. But with cancer, time is of the essence. The fertility discussion is necessary to safeguard your fertility before you undergo chemotherapy, radiation or surgery.
Lisa Bailey, 38, of Portland, Oregon, had always dreamed of having children while she built her career as a physician assistant. But in February 2010, she learned she had a malignant, rapidly growing tumor in her left breast. The news felt like it shattered all her plans. Overwhelmed as she was, Bailey didn't realize she could take steps to help preserve her fertility.
Cancer and cancer treatments can threaten patients' ability to have children. Many factors affect that risk, including the patient's age, type of cancer, chemo type and dosage, surgery to the reproductive system and radiation therapy, depending on dose and location.
Some patients may need to start chemo or radiation right away. Others can afford to wait a few weeks, long enough to harvest eggs with women – or for men, a day or so to collect sperm – to freeze and store for possible future use, known as fertility cryopreservation before the patient is exposed to radiation or chemo.
Fortunately, Bailey's sister, whom she considers her best advocate, also happens to be a physician. She recognized that fertility could be an issue. Within two days of the cancer diagnosis, the sisters independently sought fertility treatment.
The first clinic they called told Bailey they could see her in three weeks. A second program was more accommodating – the fast-track fertility-preservation program at Oregon Reproductive Medicine. Within 48 hours, Bailey was in for a consult, and during the next several weeks, the team guided her throughout the fertility preservation process – including connecting her with resources to help with costs.
Bailey chose to undergo egg cryopreservation. Meanwhile, through her oncology team, she had genetic testing, which revealed the BRCA1 genetic mutation, increasing her risk both of breast cancer recurrence and ovarian cancer. After undergoing egg harvesting, with 26 eggs frozen and stored, Bailey had a double mastectomy, followed by chemo and radiation. Eventually, she had her ovaries removed.
Surveys show a disconnect between the proportion of cancer patients interested in having kids someday and those who actually seek and pursue fertility preservation, says Dr. Jay Andersen, a medical oncologist and co-director of Breast Specialists-Compass Oncology, a Portland, Oregon, practice in The US Oncology Network.
The fertility topic can get lost in the shuffle for several reasons. "Patients are already inundated with decision-making," he says. "They're struggling with a cancer diagnosis at a young age. Many of these women are professional women. They may already have children. They're in the prime of their life." Women are dealing with complex issues in an already overcrowded schedule – meeting with the plastic surgeon, medical oncologist, radiation oncologist and others. Psychologically, women may feel an urgency to get cancer treatment underway.
From a medical standpoint, Andersen says, it's usually safe to delay the cancer treatment a bit. "If it takes an average of two weeks to navigate the fertility preservation pathway, we're OK with that in the vast majority of breast cancer cases," he says. "It's not going to have a negative impact on clinical outcomes."
The oncology team has a responsibility to bring up infertility risk and treatment options with all cancer patients (and parents of children with cancer). Andersen points to guidelines from both the National Comprehensive Cancer Network and the American Society of Clinical Oncology stating that patients should be offered a referral with a reproductive specialist as an essential part of their planning. ASCO provides a helpful cancer-fertility guide for people in this situation.
Some patients "are very well aware that they're planning to start a family, in the future, maybe even the near future and are asking questions readily when they're seen," says Dr. Nicole Longo, an internal medicine physician at Cancer Treatment Centers of America at Eastern Regional Medical Center in Philadelphia.
For other patients, discussing fertility can be daunting, but provide an aspect of hope, Longo says. More and more, cancer is transitioning into a chronic disease, with patients living longer and having options for building a family, she says. "To have that normal quality of life, which includes having a family, brings hope to the table for a lot of our patients."
With men, sperm banking can usually be done in a single afternoon if all goes well. However, if analysis shows a low sperm count or poor sperm movement, they may have to return for a second specimen. In some cases, sperm banking doesn't work. "Cancer can affect your hormones and anatomic structure," Longo says. "If you happen to have cancer in the testicle that may be affecting your sperm production. Having cancer anywhere in your body can affect hormone production."
For women with cancer who opt for cryopreservation, one issue is whether to freeze and store unfertilized eggs, called oocytes, or fertilized eggs – embryos created with their partner.
Until 2012, Longo says, embryo cryopreservation was the standard of care, but now egg cryopreservation is equally acceptable. She says that makes it easier for single women, who might not have a partner they're sure of as a future father. It also may avoid possible religious or cultural implications that can come with storing embryos. For women, the process can take up to four to six weeks.
Longo serves as director of the CTCA OncoPrez fertility preservation program for the nationwide hospital system, which partners with dedicated fertilization centers. The emphasis is on expediting the preservation process, she says. "Getting a patient in right away, sometimes we can cut extraction and the egg harvesting down and getting back to two to four weeks, as opposed to four to six."
It's possible to advance cancer and infertility treatment simultaneously, in a narrow window of time. For instance, Longo says, a woman who has a mastectomy for breast cancer needs several weeks to heal from the surgery before starting chemo. "We can attempt to complete preservation during that window so there's no time lost getting back to treatment."
Four Years Later
Andersen emphasizes that the "vast majority" of early-stage breast cancer cases can be cured with proper treatment. So it's important to plan and prioritize fertility treatment, too, he says. "We don't women to ever look back and regret not having pursued that option when they're a breast cancer survivor – which is great – but they lost out on a potential option to be a mom."
Longo says patients can turn to a spectrum of family-building options to meet their unique needs – including donor eggs, donor sperm, surrogacy, fostering and adoption.
Last year, Bailey and her husband suffered a setback. They found out her preserved eggs, recently defrosted and fertilized, had ultimately failed to survive. "That was a hard day," she recalls. "But we just regrouped, my husband and I, and said, 'OK, we can do this.'"
They consulted with their fertility specialist and looked into using an egg donor, and after going through a donor site and reading women's stories, they made their choice and decided to move forward. On Bailey's 37th birthday, the couple learned her pregnancy test was positive. In October 2014, they became parents to twins – a daughter and son.