Survivorship Clinic Visits Hold Answer to Questions About Post-Cancer Pregnancies


According to Ellen Miller, MSN, FNP-BC, the frequency of cancer survivorship visits may vary for individual patients, but with long-term follow-up, it was not seen during active treatment. Their role in cancer treatment remains important, as unique complications are often revealed.

A nurse practitioner at Vanderbilt University Medical Center, Miller conducts routine follow-up and survivorship visits in the Department of Radiation Oncology. These appointments are made approximately 3 months after completion of radiotherapy and include long-term treatment-related toxicities, the need to continue regular screenings (such as PAP and mammograms), and other additional resources. It is included.

However, survivorship visits can be more nuanced as patient needs continue to evolve on an individual basis. These visits typically begin one year after he has been treated, and, according to Miller, “have ranged from discussing the psychosocial impact of cancer diagnosis and treatment to anxiety, fear of recurrence, [or] financial concerns. ”

In one instance, Miller encountered a patient who chose to pursue a pregnancy after choosing not to undergo fertility treatment as a teenager. Intrigued by the case, I decided to take a closer look at how fertility and pregnancy conversations between providers and patients need to take place in a survivorship setting.

in an interview with Oncology Nursing News®, Miller described this unique patient case and key takeaways from the experience, highlighting resources that other nurse practitioners working in survivorship clinics may find helpful.

Personal Experience in Survivorship Treatment

At a survivor visit, Miller met a 26-year-old woman who had been treated at age 19 for stage II natural killer/T-cell lymphoma of the nasal cavity.

Treatment for this patient included the SMILE chemotherapy regimen of dexamethasone, methotrexate, ifosfamide, asparaginase, and etoposide, and adjuvant radiotherapy of 50 Gy in 25 fractions. She completed her treatment in April 2017, but in December 2018 and in August 2020 she was given rituximab (Rituxan) four times a week for rising EBV titers. rice field. Miller explained that the chemotherapy ifosfamide may have affected fertility in this patient.

Although she did not initially treat this patient after treatment, Miller said: I got married in my mid-twenties and changed my mind.”

Currently, the patient remains in survivorship care and was able to conceive without medical intervention. I advised them to consult a humanities or fertility specialist.

The process of fertility preservation

According to the Alliance for Fertility Preservation, the standard fertility preservation method for men is sperm banking. Other options included sperm extraction, electroejaculation, and shielding the testes from radiation, although this is not always possible. methods, including in vitro fertilization, testicular sperm extraction, and sperm freezing for use in testicular shielding during radiation therapy. Women can freeze embryos (fertilized eggs) or oocytes (unfertilized eggs). These are considered standard treatments. In some cases, ovarian tissue may be frozen, and ovarian shielding and ovarian transposition may also be an option. Hormone therapy for women is currently under investigation.1

Treatments that cause infertility

Radiation therapy, chemotherapy with alkylating agents, and surgery can all affect male and female fertility. may give2

Additionally, fertility can be difficult to assess because many treatments can cause temporary infertility, Miller said. Additionally, certain treatments can cause premature menopause in women (mid to late 30s), which is also an important factor to consider. Therefore, if treatment reduces the egg supply, ovarian failure is possible. Chemotherapy can also seriously damage those eggs, and surgeries such as hysterectomies affect fertility by limiting their ability to carry.

“Chemotherapy not only damages existing eggs, it can also lead to premature menopause or premature menopause in patients,” emphasized Miller.

Economic aspects of fertility preservation

Unfortunately, the cost of cancer treatment is high and, combined with fertility preservation, can be difficult to manage as there is no federal law mandating insurance companies to cover fertility preservation. States that have passed legislation requiring insurer coverage as of September 28, 2022 are California, Utah, Colorado, Illinois, New York, Maine, New Hampshire, Connecticut, New Jersey, Delaware, Maryland, and Rhode Island. Outside of these 12 states, the approximate cost of freezing eggs, embryos, and tissues ranges from $10,000 to $15,000, with storage and sperm bank costs ranging from $500 to $1,000, and storage fees. is also included.1,3

“Copayment amount [cost] The average cost of fertility preservation is $10,000 to $15,000.It is difficult [anyone]let alone a young man or woman,” said Miller.

Discussing Pregnancy in Survivorship

Fortunately, this young woman was able to conceive naturally. But the experience prompted Miller to think about what pregnancy conversations should look like in a survivorship setting.

“[The] Her experience trajectory was standard, and we appreciated that.

For example, cardiac monitoring is recommended for patients receiving anthracycline chemotherapy or left-sided thoracic radiation therapy. Both of these treatments can damage the heart, and pregnancy can make the heart work harder.

“Even women have heard of women who have had cardiomyopathy. [in the general population]”Because having a baby makes your heart work harder,” says Miller.

In addition, certain doses of radiation therapy to the pelvis and abdomen can cause scar tissue and reduce the elasticity that allows a woman’s body to stretch during pregnancy, whereas radiation therapy to the brain does not affect follicle follicles. It can also affect hormones such as stimulating hormone and luteinizing hormone. [radiation] It can affect blood flow to the uterus and may cause some of the risk of premature birth or its growth restriction.

Fortunately, however, some research suggests that many women can safely have children after cancer treatment with minimal complications.

“What we found with a little research was a study of thousands of offspring of female and male cancer survivors who had been treated for cancer at a young age,” she said. “There was no increased risk of birth defects.”Four

“Another piece of data that I found encouraging and helpful was that children born to cancer survivors do not have a high incidence of cancer unless the patient’s tumor is inherited. [such as] BRCA, Lynch Syndrome, etc.

According to Miller, the data is very reassuring for survivors and allows nurses and nurse practitioners to reassure patients that there is hope for childbearing after cancer. She recommends letting patients know to involve an OB/GYN or fertility specialist if they wish to conceive.

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References

  1. A quick guide to fertility preservation. cancer triage. 2022. Accessed 11 November 2022. https://bit.ly/3Fh0IlY
  2. infertility facts. Leukemia and Lymphoma Society. November 2014. Accessed November 11, 2022. https://bit.ly/3VK9JuW
  3. State Laws and Legislation. Alliance for Fertility Preservation. Accessed November 11, 2022. https://www.allianceforfertilitypreservation.org/state-legislation/
  4. Signorello LB, Marvigil JJ, Greene DM et al. Birth defects in children of cancer survivors: A report from the Childhood Cancer Survivor Study. J Clin On Call2012;30(3):239-245. doi:10.1200/JCO.2011.37.2938



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