fertility preservation (in young females) · fertility preservation (in young females) fedro...
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Fertility preservation(in young females)
Fedro Peccatori, MD PhDEuropean Istitute of Oncology, European School of Oncology
Milan, Italy
ESMO PRECEPTORSHIP PROGRAMMEADOLESCENT & YOUNG ADULT
MALIGNANCIESLugano, 11-12 May 2018
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Fertility preservation in young males is easy!
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Fertility concerns of cancer patients
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657 patients, median age 32.9 years
57% seriously concerned about sterility
29% did not comply to their treatment because of fertility issues
Fertility concerns of breast cancer patients
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Fertility preservation, doctors’ perspective
• 32% of patients did not recall discussing fertility issues with their doctors
• 37% of doctors never read fertility preservation guidelines
• 49% of doctors were confused about safety of pregnancy after cancer
Ruddy KJ, et al. J Clin Oncol. 2014;32(11):1151-1156. Lambertini M, et al. Submitted to The Breast, 2018 Biglia N, et al. Gynecol Endocrinol. 2015;31(6):458-464.
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Stensheim et al; Int J Cancer 2011
Analysis adjusted foreducation level, previous pregnancyage
0.0 0.5 1.0 1.5
Breast cancer
Epithelial ovarian cancer
Cervical cancer
Acute leukemia
Germ cell tumors
Brain tumors
All cancers
Hodgkin's lymphoma
Non-Hodgkin's lymphoma
Melanoma
Thyroid cancer
Pregnancy rate after cancer: not all alike
Pregnancy rate varies according to tumor type
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Stensheim et al; Int J Cancer 2011
Analysis adjusted foreducation level, previous pregnancyage
0.0 0.5 1.0 1.5
Breast cancer
Epithelial ovarian cancer
Cervical cancer
Acute leukemia
Germ cell tumors
Brain tumors
All cancers
Hodgkin's lymphoma
Non-Hodgkin's lymphoma
Melanoma
Thyroid cancer
Pregnancy rate after cancer: not all alike
Worst rates for breast cancer: only 5-10% of subsequentpregnancies
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Stensheim et al; Int J Cancer 2011
Analysis adjusted foreducation level, previous pregnancyage
0.0 0.5 1.0 1.5
Breast cancer
Epithelial ovarian cancer
Cervical cancer
Acute leukemia
Germ cell tumors
Brain tumors
All cancers
Hodgkin's lymphoma
Non-Hodgkin's lymphoma
Melanoma
Thyroid cancer
Pregnancy rate after cancer: not all alike
Best rates for melanoma: slight impact on subsequentpregnancies
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Breast cancer and impact on fertility
- Most frequent above 35 years
- High impact of adjuvant treatments
- Low awareness of fertility preservation
- High fear of pregnancy
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Safety of pregnancy after breast cancer: meta-analysis
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14 studies7 case control studies
4 population based studies3 hospital based studies
1244 cases e 18145 controlsFollow-up 5-30 years
Data pooling using random effect
Original data from 3 studies
Sensitivity analysis and subgroup analysis
Safety: meta-analysis
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All studies, 41% risk reduction
Safety: meta-analysis
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Safety: multicenter study in ER+
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Retrospective, multicenter cohort study (7 Institutions)
333 cases with pregnancy after breast cancer874 non pregnant controls matched for ER, stage, adjuvant treatment, age, year at diagnosis (+ healthy mother effect)
Primary endpoint: DFS ER+ pts.(Two sided test a= 5% , b=20% , 226 events and 645 pts for HR 0.65)
Secondary endpoints: DFS in ER- pts., OS
Subgroup analysis: DFS according to timing of pregnancyDFS according to breastfeeding
Safety: multicenter study in ER+
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Safety: long term follow-up (7.2 years)
DFS in ER+ patients
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Safety: long term follow-up (7.2 years)
OS in ER+ patients
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Melanoma and impact on fertility
- Most frequent between 25 and 29 years
- Low impact of adjuvant treatments (?)
- Low awareness of fertility preservation
- High fear of subsequent pregnancy
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Safety of pregnancy after melanoma
- 966 women with pregnancy after
- 4567 women without pregnancy
- Slightly thicker melanomas in the group without pregnancy (1.11 vs 0.82 mm vs P=0.003)
- HR of death in women with subsequent pregnancy after melanoma: 0.58 (95% CI=0.32-1.05)
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Safety of pregnancy after melanoma
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What women want to know
What is the risk of treatment-induced infertility?
Is there anything we can do to reduced it?
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Assessing the risk of infertility
CRITICAL FACTORS:
✓ Age at diagnosis (oocyte quantity and quality)
✓ Drugs administered (schedule and dosage)
✓ Age at pregnancy (treatment duration)
http://www.savemyfertility.org/pocket-guides
http://www.fertilehope.org/tool-bar/risk-calculator-women-type.cfm
http://oncofertility.northwestern.edu/about-us
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(Wallace et al, Lancet Oncol 2005; 6:209-18)
Ovarian toxicity: drugs
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Ovarian reserve
Menopause
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Ovarian reserve at chemotherapy
CHEMOTHERAPY
Menopause
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Ovarian reserve at chemotherapy
CHEMOTHERAPY
Menopause
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Ovarian reserve at chemotherapy
CHEMOTHERAPY
Menopause
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Ovarian reserve estimation: AMH
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Ovarian reserve estimation: AMH
Kelsey et al, 2011 PLOS
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Treatment duration and ovarian ageing
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Treatment duration and ovarian ageing
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Is there anything we can do ?
THINK PROACTIVELY !
✓ Inform the patient about the risk of infertility
✓ Refer her to the reproductive endocrinologist asap
✓ Consider egg/embryo freezing before chemotherapy
✓ Consider LHRHa during chemo (if breast cancer)
✓ Consider Ovarian Cortex Cryopreservation
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Egg/embryo freezing before chemo
ISSUES RELATED TO OVARIAN STIMULATION
✓ Safety (high estrogen levels)✓ Efficacy (does it work)✓ Timing (when to start ovarian stimulation)
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Safety: Controlled ovarian stimulation in breast cancer (Letrozole)
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Safety: Controlled ovarian stimulation in breast cancer
Kim J, et al. J Clin Endocrinol Metab. 2016;101(4):1364-1371. Rodriguez-Wallberg KA, et al. Breast Cancer Res Treat. 2018;167(3):761-769.
FP = 120Control = 217
FP = 145Control = 351
SINGLE CENTER STUDY (US)
MULTICENTRICREGISTRY-BASED
COHORT STUDY (SWE)
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Efficacy: Egg/embryo freezing before chemo
PROBABILITY OF REPRODUCTIVE SUCCESS ACCORDING TO AGE AND # FROZEN OOCYTES
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Timing: Random start + double stimulation
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Consider LHRHa during chemo
Lambertini et 2015, Annals of Oncology
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Consider LHRHa during chemo
Fixed effect (I≤ = 47.1%, p = 0.026)
Sun (2011)
Song (2013)
Li Jw (2014)
Munster (2012)
Random effect
Karimi-Zarchi (2014)
Del Mastro (2011)
Badawy (2009)
Elgindy 2 (2013)
Elgindy 1 (2013)
Gerber (2011)
Author
Li M (2008)
Sverrisdottir 2 (2009)
Sverrisdottir 1 (2009)
Moore (2015)
0.34 (0.25, 0.46)
0.38 (0.06, 2.30)
0.50 (0.25, 1.03)
0.44 (0.04, 4.35)
1.09 (0.22, 5.52)
0.36 (0.23, 0.57)
0.05 (0.01, 0.29)
0.27 (0.14, 0.54)
0.06 (0.02, 0.20)
1.00 (0.25, 4.00)
0.76 (0.18, 3.25)
Odds
0.56 (0.19, 1.62)
Ratio (95% CI)
0.31 (0.11, 0.89)
2.03 (0.31, 13.27)
0.19 (0.04, 1.06)
0.30 (0.10, 0.87)
114/616
3/11
15/89
1/54
4/26
2/21
13/148
4/39
5/25
4/25
Events,
9/30
Treated
8/31
27/29
14/22
5/66
206/615
5/10
27/94
3/73
3/21
14/21
35/133
26/39
5/25
5/25
Events,
13/30
Controls
17/32
20/23
18/20
15/69
0.34 (0.25, 0.46)
0.38 (0.06, 2.30)
0.50 (0.25, 1.03)
0.44 (0.04, 4.35)
1.09 (0.22, 5.52)
0.36 (0.23, 0.57)
0.05 (0.01, 0.29)
0.27 (0.14, 0.54)
0.06 (0.02, 0.20)
1.00 (0.25, 4.00)
0.76 (0.18, 3.25)
Odds
0.56 (0.19, 1.62)
Ratio (95% CI)
0.31 (0.11, 0.89)
2.03 (0.31, 13.27)
0.19 (0.04, 1.06)
0.30 (0.10, 0.87)
114/616
3/11
15/89
1/54
4/26
2/21
13/148
4/39
5/25
4/25
Events,
9/30
Treated
8/31
27/29
14/22
5/66
1.01 .1 .5 1 2 8 14
Favors LHRHa / Favors Controls
Lambertini et 2015, Annals of Oncology
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Premature-Ovarian Insufficiency Rate
0%
10%
20%
30%
40%
50%
14.1%
GnRHa Group
n = 363
Control Group
n = 359
30.9%
OR* 0.38 (95% CI 0.26–0.57)
P<.001 Meta-analysis approach
*Odds ratio (OR) adjusted for age, estrogen receptor status, type and duration of chemotherapy administered
Overall (I≤=0%,p=0.73) 51/363 111/359
GBG-37 ZORO
OPTION
Study
UCSF-led trial
POEMS/SWOG S0230
PROMISE-GIM6
6/28
GnRHa
21/95
Events/pts
3/26
5/66
16/148
13/29
Control
41/107
Events/pts
2/21
15/69
40/133
0.37 (0.25, 0.57)
0.54 (0.14, 2.07)
0.41 (0.20, 0.81)
OR (95% CI)
1.17 (0.14, 9.55)
0.33 (0.10, 1.14)
0.29 (0.15, 0.57)
0.37 (0.25, 0.57)
0.54 (0.14, 2.07)
0.41 (0.20, 0.81)
OR (95% CI)
1.17 (0.14, 9.55)
0.33 (0.10, 1.14)
0.29 (0.15, 0.57)
1.0982 1 10.2
GnRHa better Control better
Lambertini M, et al. Cancer Res. 2018;78(4 Suppl): Abstract GS4-01.
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Post-Treatment Pregnancy Rate
GnRHa Group: 37/359 (10.3%)
vs
Control Group: 20/367 (5.5%)
IRR* 1.83 (95% CI 1.06-3.15)
P = .030
Meta-analysis approach
GnRHa
Group
n = 37
Number (%)
Control
Group
n = 20
Number (%)
Age distribution, years
≤40
≥41
37 (100)
0 (0.0)
20 (100)
0 (0.0)
Estrogen receptor status
Positive
Negative
6 (16.2)
31 (83.8)
2 (10.0)
18 (90.0)
IRR, Incidence rate ratio
Overall (I≤=0%,p=0.85) 37/359 20/367
POEMS/SWOG S0230
PROMISE-GIM6
Study
OPTION
22/105
8/148
GnRHa
Events/pts
7/106
12/113
3/133
Control
Events/pts
5/121
1.82 (1.05, 3.14)
1.77 (0.87, 3.57)
2.52 (0.67, 9.50)
IRR (95% CI)
1.54 (0.49, 4.85)
1.82 (1.05, 3.14)
1.77 (0.87, 3.57)
2.52 (0.67, 9.50)
IRR (95% CI)
1.54 (0.49, 4.85)
1.105 1 9.5
Control better GnRHa better
Lambertini M, et al. Cancer Res. 2018;78(4 Suppl): Abstract GS4-01.
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Disease-Free Survival/Overall Survival
Median follow-up = 5.0 years (IQR, 3.0–6.3 years)
*Hazard ratio adjusted for age, estrogen receptor status, type and duration of chemotherapy administered and tumor stageIQR, interquartile range
0
20
40
60
80
100
Dis
ea
se F
ree
Su
rviv
al (%
)
402 356 323 286 240 174GnRHa group
407 352 322 268 232 172Control groupNumber at risk
0 1 2 3 4 5
Time Since Random Assignment (years)
Control group 407 67 80.0
GnRHa group 402 69 79.5
TREATMENT Patients Events DFS
All Patients
HR* 1.01 (95% CI 0.72–1.42)
P = .999
0
20
40
60
80
100
Overa
ll S
urv
iva
l (%
)
404 370 350 313 265 199GnRHa group
408 362 342 291 254 188Control groupNumber at risk
0 1 2 3 4 5
Time Since Random Assignment (years)
Control group 408 44 86.3
GnRHa group 404 33 90.2
TREATMENT Patients Events OS
All Patients
HR* 0.67 (95% CI 0.42–1.06)
P = .083
Dis
ea
se
-Fre
e S
urv
iva
l,
%
Ove
rall
Su
rviv
al,
%
Time Since Random Assignment, Years
Time Since Random Assignment, Years
Lambertini M, et al. Cancer Res. 2018;78(4 Suppl): Abstract GS4-01.
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Consider ovarian cortex cryopreservation
Donnez J et al. NEJM 2017; 377: 1657-1665.
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Conclusions
Woodruff et al, JAMA Onc 2016; 2(2):171