To coincide with blood cancer awareness month in September, clinical negligence senior associate, Emily Reville, explores the implications on fertility before, during and after treatment for blood cancer.
The overarching term blood cancer actually encompasses a number of different cancer diagnoses. Blood cancer is the UKs third largest cancer in terms of mortality with around 15,000 people dying per year.
Leukaemia is a type of cancer that affects the blood cells in the bone marrow. There are a number of different forms of leukaemia which affect different blood cells at various times in their development. Leukaemia is also the most common cancer in children under the age of 15 with over 650 children and young adults diagnosed every year.
Lymphoma is a type of cancer that affects white blood cells called lymphocytes. These cells are an important part of the immune system. Again, there are a number of different kinds of lymphoma with the most common being Hodgkin and non-Hodgkin lymphoma which are differentiated by a particular type of cell present in the blood.
Myeloma is a type of cancer that affects the plasma cells within the white blood cells.
The terms acute and chronic are often used to describe blood cancers. The former means that the cancer is fast growing and the latter means that it is slower growing.
Firstline treatment is often by way of chemotherapy which is a drug used to destroy the cancer cells. Chemotherapy is not however selective in the cells it targets, leading to both the malignant cells and healthy cells being destroyed. Some chemotherapy drugs are more likely than others to cause infertility and this can depend on the dosage of the drug used.
Infertility after chemotherapy may be temporary, with a womans menstrual cycle becoming irregular or stopping altogether during treatment and then returning to normal subsequently. It can take between 6 and 12 months for the menstrual cycle to return to normal following treatment.
Up to two thirds of women will suffer permanent infertility following chemotherapy as the drugs damage or destroy eggs in the ovaries. If all the eggs are destroyed by chemotherapy, a woman will enter early menopause.
Full body radiotherapy is also used in the treatment of blood cancer. Again, the dose of radiation is important but any radiation to the pelvic region is very likely to cause damage to the ovaries and eggs.
Hematopoietic stem cell transplantation (HSCT) is considered the most effective treatment of numerous severe blood cancers. However, there are also gynaecological implications for patients undergoing HSCT including premature ovarian failure, menstrual cycle cessation as well as genital and sexual symptoms. HSCT nearly always results in irreversible ovarian damage.
Patients with acute leukaemia and some types of lymphoma may require treatment urgently following diagnosis. The typical treatment regimes for these patients do not involve sufficient cytotoxic dosages to induce irreversible ovarian failure. However, patients with non-Hodgkins lymphoma frequently need urgent treatment with cytotoxic therapy.
Patients with acute blood cancer are likely to need immediate treatment and cannot delay the 10 days needed to undergo egg collection. In patients undergoing chemotherapy for acute leukaemia and Hodgkins lymphoma, there may be an opportunity to undergo egg collection after chemotherapy and before HSCT and radiotherapy. Chemotherapy does however cause a number of other side effects, such as infection and clinical instability, which may make preservation of fertility difficult.
Those patients with chronic blood cancers may have the opportunity to undergo egg collection prior to treatment. They may well be treated in a watch and wait programme and not start treatment right away.
Whilst diagnosis with blood cancer is in itself devastating for patients, some life-changing injuries, such as infertility, may only become apparent once they reach remission. This is likely to be an unexpected outcome for some patients. Counselling about the risks of infertility prior to the start of treatment is therefore essential. Unfortunately, oncology and haematology clinicians are often unfamiliar with fertility preservation options and reproductive specialists may not be comfortable with the rare and serious blood cancers.
The 2013 NICE clinical guidelines on the assessment and treatment of fertility problems state that the impact of the cancer and its treatment on future fertility should be discussed between the patient and their medical team at diagnosis. They also recommend that oocyte or embryo cryopreservation is offered to women of reproductive age, including adolescent girls, who are preparing for medical treatment that is likely to make them infertile if they are well enough to undergo ovarian stimulation and egg collection, this will not worsen their condition, and sufficient time is available.
In addition to discussing with patients whether they wish to undergo such procedures at an early stage, clinicians should consider in cases where treatment is urgent whether there might be future opportunities to address fertility to circumvent a potentially shortened fertility window or to take advantage of the hiatus between initial chemotherapy and HSCT and radiotherapy.
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