Today, children, adolescents, and young adults with cancer have a better chance of surviving than ever before; however, an increasing number of individuals face the long-term consequences of their malignancy and its related treatment. Both males and females who have undergone treatment for cancer have reason to be concerned about their reproductive health.
In 2003, the Children’s Oncology Group (COG) released guidelines—the COG Long-term Follow-up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancer (COG-LTFU guidelines)—for follow-up care after pediatric cancer treatment and screening for the late effects of exposure to cancer therapy.1 A recent update2 to the section focusing on reproductive health has just been released, providing comprehensive recommendations to clinicians regarding the risk factors, assessment, and treatment of reproductive and sexual issues in cancer survivors.
Recommendations in the updated guidelines are based on the current literature and the clinical experience of an expert panel that included pediatric oncologists, endocrinologists, oncology nurses, urologists, gynecologic oncologists, and radiation oncologists. Four issues of concern are brought to the forefront in this update, specifically as they relate to female children, adolescents, and young adults who have been treated for cancer: hypogonadism, precocious puberty, reduced fertility, and sexual dysfunction.
Screening recommendations contained in the guidelines are intended for asymptomatic survivors receiving routine exposure-based medical follow-up 2 years or more after the completion of therapy. The individual patient’s clinical condition, the guideline authors say, may warrant more extensive evaluation.
The guidelines emphasize the need to identify patients at risk for disorders of reproduction and sexual function; the risk is based on the treatments the patient was exposed to and on individual patient-related factors such as age at exposure and concomitant medical conditions. For most patients, the guidelines state, assessment should be performed yearly, or more often if clinically indicated, and should be directed toward the conditions for which the patient is at highest risk. Treatment recommendations are based on a review of the medical literature.
Ethical considerations in preserving fertility are among the most complex issues addressed in the guidelines. Discussing fertility may be difficult for patients, their parents, and health care professionals, yet adolescents and their parents have expressed low satisfaction with the quality of information they received. By law, minors may undergo only those procedures that are in their best interests, and parents are not permitted to consent to procedures with more than minimal risk unless a benefit has been proven; therefore, experimental attempts to preserve fertility may not be an option.
The guideline update concludes with general recommendations for the assessment and treatment of reproductive and sexual functioning in female cancer survivors:
- Oncologists should be aware of treatment complications that may affect long-term reproductive and sexual health and discuss them with patients and families before treatment, in a developmentally appropriate manner.
- For prepubertal girls, interventions to preserve fertility are still at an experimental stage and should be offered only within a research study.
- After completion of therapy and during long-term follow-up, ongoing surveillance measures should be planned to monitor risks to sexual and reproductive health. All patients should have regular assessments of pubertal development, sexual health and function, as well as pregnancy attempts and outcomes.
- Cancer survivors who are at risk for reproductive and sexual complications should be offered regular screening and counseling; a referral to a specialist in endocrine, gynecologic, or reproductive medicine may be of benefit.
In the future, the guideline authors state, research on gonadoprotective drugs and improved shielding of reproductive organs may improve reproductive health in childhood cancer survivors and, in turn offer a better chance for maintaining fertility.
1. Landier W, Bhatia S, Eshelman DA, et al: Development of risk-based guidelines for pediatric cancer survivors: The Children’s Oncology Group Long-Term Follow-Up Guidelines from the Children’s Oncology Group Late Effects Committee and Nursing Discipline. J Clin Oncol. 2004;22:4979-4990.
2. Metzger ML, Meacham LR, Patterson B, et al. Female reproductive health after childhood, adolescent, and young adult cancers: guidelines for the assessment and management of Female reproductive complications. J Clin Oncol. 2013;31:1239-47.