Fertility preservation in pediatric leukemia and lymphoma: A report from the Children's Oncology Group

The mitochondria as an emerging target of self-renewal in T-cell acute lymphoblastic leukemia

Acute lymphocytic leukemia (ALL) is the most common leukemia in children, with the T-cell subtype (T-ALL) accounting for 15% of those cases. Despite advancements in the treatment of T-ALL, patients still face a dismal prognosis following their first relapse. Relapse can be attributed to the inability of chemotherapy agents to eradicate leukemia stem cells (LSC), which possess self-renewal capabilities and are responsible for the long-term maintenance of the disease. Mitochondria have been recognized as a therapeutic vulnerability for cancer stem cells, including LSCs. Mitocans have shown promise in T-ALL both in vitro and in vivo, with some currently in early-phase clinical trials. However, due to challenges in studying LSCs in T-ALL, our understanding of how mitochondrial function influences self-renewal remains limited. This review highlights the emerging literature on targeting mitochondria in diverse T-ALL models, emphasizing specific mitochondrial vulnerabilities linked to LSC self-renewal and their potential to significantly improve T-ALL treatment.

Fertility Preservation in People With Cancer: ASCO Guideline Update

PURPOSE

To provide updated fertility preservation (FP) recommendations for people with cancer.

METHODS

A multidisciplinary Expert Panel convened and updated the systematic review.

RESULTS

One hundred sixty-six studies comprise the evidence base.

RECOMMENDATIONS

People with cancer should be evaluated for and counseled about reproductive risks at diagnosis and during survivorship. Patients interested in or uncertain about FP should be referred to reproductive specialists. FP approaches should be discussed before cancer-directed therapy. Sperm cryopreservation should be offered to males before cancer-directed treatment, with testicular sperm extraction if unable to provide semen samples. Testicular tissue cryopreservation in prepubertal males is experimental and should be offered only in a clinical trial. Males should be advised of potentially higher genetic damage risks in sperm collected soon after cancer-directed therapy initiation and completion. For females, established FP methods should be offered, including embryo, oocyte, and ovarian tissue cryopreservation (OTC), ovarian transposition, and conservative gynecologic surgery. In vitro maturation of oocytes may be offered as an emerging method. Post-treatment FP may be offered to people who did not undergo pretreatment FP or cryopreserve enough oocytes or embryos. Gonadotropin-releasing hormone agonist (GnRHa) should not be used in place of established FP methods but may be offered as an adjunct to females with breast cancer. For patients with oncologic emergencies requiring urgent oncologic therapy, GnRHa may be offered for menstrual suppression. Established FP methods in children who have begun puberty should be offered with patient assent and parent/guardian consent. The only established method for prepubertal females is OTC. Oncology teams should ensure prompt access to a multidisciplinary FP team. Clinicians should advocate for comprehensive FP services coverage and help patients access benefits.Additional information is available at www.asco.org/survivorship-guidelines.

Oncofertility care for children, adolescents, and young adults at risk for treatment-related fertility loss

As therapy for childhood malignancies becomes more sophisticated and survival has improved, long-term therapy-related sequelae have emerged. Loss of reproductive potential among childhood cancer survivors is one such concern that has become increasingly recognized among patients, families, and healthcare providers. The risk status for infertility based upon therapy received, state of current reproductive technology and outcomes, and an emphasis on adequate referral and counseling for fertility preservation options are reviewed. Contributing factors to infertility are discussed, and options for female and male preservation based upon age and pubertal status are summarized. This article highlights the current state of fertility opportunities for children and adolescents undergoing therapy for cancer. Providers caring for these young patients should be familiar with such options and should routinely initiate evaluations for eligibility of fertility preservation.

Oocyte Cryopreservation Outcomes in Women With Hematological Malignancies Undergoing Chemotherapy-A Systematic Review and Meta-Analysis

OBJECTIVE

Hematological cancers are among the leading malignancies affecting women of reproductive age. Oocyte cryopreservation (OC) is routinely recommended before initiating gonadotoxic treatments. We aim to evaluate OC outcomes in women with hematological cancers undergoing chemotherapy.

DATA SOURCES

A comprehensive literature search was conducted in Medline, Embase, and Cochrane Library until January 2024.

STUDY SELECTION

Studies examining fertility outcomes of women undergoing OC before chemotherapy for hematological cancers were included. Comparison groups included healthy controls or patients with other cancers. The primary outcome was the number of mature oocytes frozen per stimulation cycle; secondary outcomes included total cumulus-oocyte complexes, stimulation duration, total gonadotropin dose and fertility outcomes following the utilization of cryopreserved oocytes.

DATA EXTRACTION AND SYNTHESIS

A total of 14 cohort studies, 2 case-control studies, and 6 case reports involving 858 hematological cancer patients undergoing OC and 2676 comparators were included. The mean mature oocyte yield ranged from 7 to 19 in the hematological cancer group, and 6 to 14 in the comparator groups (mean difference [MD] 0.11; 95% CI -0.10 to 0.33). A comparable number of total cumulus-oocyte complexes (MD 0.09; 95% CI -0.07 to 0.25) and total dose of gonadotropins were found (MD 0.33; 95% CI -0.32 to 0.98). The analysis found a marginally longer duration of stimulation in the hematological cancer group (MD 0.21; 95% CI 0.11-0.31). Also, the hematological cancer group was found to be statistically younger, (MD -1.32; 95% CI -1.85 to -0.79), the difference is not clinically meaningful. Results for subgroup analyses concurred with the main analysis. Fertility and utilization of cryopreserved oocyte data were lacking.

CONCLUSION

These findings suggest that women with hematological cancers undergoing OC may expect similar oocyte yield compared to women with other cancers or healthy controls. Oocyte quality and pregnancy outcomes following the utilization of cryopreserved oocytes in hematological cancer patients remain unclear and should be the subject of further study.

Pediatric Lymphomas: Key Concepts and Clinical Approaches for Pediatricians

Lymphomas are the third most prevalent pediatric cancer following leukemia and brain tumors, representing 10% to15% of all childhood cancers. We can divide lymphomas into Hodgkin and non-Hodgkin lymphomas, with marked differences between these 2 groups. Clinical manifestations can be insidious, and clinicians should have a high index of suspicion when treating patients with lymphadenopathies, weight loss, or prolonged fever. Although refinements in chemotherapy regimens have improved survival for pediatric lymphomas, more recent successful incorporation of targeted therapies offers hope for even better outcomes with fewer late effects. Given the excellent prognosis for many of these patients, it is increasingly important for primary care physicians to recognize and manage potential late effects of therapy, both physical and psychological.

Fertility preservation in pediatric central nervous system tumors: A report from the Children's Oncology Group

The Oncofertility Consortium Pediatric Initiative Network has published recommendations about the risks of infertility due to gonadotoxic therapy. We abstracted gonadotoxic therapies from central nervous system (CNS) Children's Oncology Group (COG) protocols between 2000 and 2022. We assigned them as unknown, minimal, significant, or high levels of increased risk for gonadal dysfunction/infertility. Seven of 11 CNS protocols placed patients at a high level of risk in at least one treatment arm. Males (7/11) were most commonly at a high level of risk, followed by pubertal females (6/11) and prepubertal females (5/11), highlighting the importance of pre-treatment counseling regarding fertility preservation interventions in this population.

Clinical Practice Guideline-Inconsistent Management of Fertility Preservation in Pediatric Cancer Patients in Community Settings: A Children's Oncology Group Study

Background: The primary objective was to measure adherence to clinical practice guideline (CPG) recommendations for fertility preservation (FP) in pediatric cancer patients treated in National Cancer Institute Community Oncology Research Program (NCORP) sites. Secondary objectives were to describe factors such as site size associated with CPG-inconsistent care delivery and cryopreservation completion. Methods: This retrospective, multicenter study included patients 15 to 21 years old with a first cancer diagnosis from January 2014 through December 2015 who were previously enrolled to a Children's Oncology Group (COG) study and received care at a participating NCORP site. Patients were randomly selected from a list generated by the COG for chart review by participating sites. Primary outcome was care delivery that was inconsistent with a strong CPG recommendation on FP, namely discussion and offering of FP options before cancer treatment initiation, as adjudicated centrally by a panel. Results: A total of 129 patients from 25 sites were included. Among these, 48% (62/129) received CPG-inconsistent care. Most CPG-inconsistent care was due to lack of FP discussion documentation (93.5%, 58/62). Small site size, treatment at a pediatric (vs mixed adult/pediatric) site, and female sex were associated with higher odds of CPG-inconsistent care delivery. Conclusions: Newly diagnosed pediatric cancer patients often received CPG-inconsistent care for FP, with disproportionate gaps noted for females, and those treated at smaller or pediatric NCORP sites. The primary reason for CPG-inconsistent care is lack of FP discussion from clinicians. Opportunities to improve FP CPG implementation are highlighted.

The Effects of Cancer Immunotherapy on Fertility: Focus on Hematological Malignancies

In recent years, cancer management has benefitted from new effective treatments, including immunotherapy. While these therapies improve cancer survival rates, they can alter immune responses and cause long-term side effects, of which gonadotoxic effects and the potential impact on male and female fertility are growing concerns. Immunotherapies, such as immune checkpoint inhibitors, immunomodulators, monoclonal antibodies, and CAR-T, can lead to elevated levels of proinflammatory cytokines and immune-related adverse events that may exacerbate fertility problems. Immunotherapy-related inflammation, characterized by cytokine imbalances and the activation of pathways such as AMPK/mTOR, has been implicated in the mechanisms of fertility impairment. In men, hypospermatogenesis and aspermatogenesis have been observed after treatment with immune checkpoint inhibitors, by direct effects on the gonads, particularly through the inhibition of cytotoxic T lymphocyte antigen-4. In women, both damage to ovarian reserves, recurrent pregnancy loss, and implantation failure have been documented, secondary to a complex interplay between immune cells, such as T cells and uterine NK cells. In this review, the impact of immunotherapy on fertility in patients with hematological cancers was analyzed. While this area is still underexplored, fertility preservation methods remain crucial. Future studies should investigate immunotherapy's effects on fertility and establish standardized preservation protocols.

Pediatric Cancer Immunotherapy and Potential for Impact on Fertility: A Need for Evidence-Based Guidance

The use of immunotherapies for the treatment of cancer in children, adolescents, and young adults has become common. As the use of immunotherapy has expanded, including in earlier lines of therapy, it has become evident that several aspects of how these immunotherapies impact longer-term outcomes among survivors are understudied. Traditional cancer therapies like alkylating and platin agents carry the greatest risk of infertility, but little is known about the impact of novel immunotherapies on fertility. This topic is of great interest to patients, patient advocates, and clinicians. In this article, we review immunotherapeutic agents used to treat childhood and young adult cancers and discuss potential mechanisms by which they may impact fertility based on the known interplay between the immune system and reproductive organs. We highlight the relative paucity of high-quality literature examining these late effects. We discuss interventions to optimize fertility preservation (FP) for our patients. Conducting longitudinal, collaborative, and prospective research on the fertility outcomes of pediatric and young adult patients with cancer who receive immunotherapy is critical to learn how to effectively counsel our patients on long-term fertility outcomes and indications for FP procedures. Collection of patient-level data will be necessary to draft evidence-based guidelines on which providers can make therapy recommendations.

Fertility preservation in pediatric solid tumors: A report from the Children's Oncology Group

Treatment for childhood solid tumors may lead to an increased risk for gonadal dysfunction/infertility. Discussion of risk should occur at diagnosis, any changes in therapy, and during survivorship. Gonadotoxic therapies were abstracted from 32 Children's Oncology Group (COG) phase III, frontline solid tumor protocols, in use from 2000 to 2022. Risk for gonadal dysfunction/infertility was assessed based on gonadotoxic therapies, sex, and pubertal status and assigned as minimal, significant, and high following the Oncofertility Consortium Pediatric Initiative Network (PIN) risk stratification. Most protocols (65.6%, 21/32) contained at least one therapeutic arm with a high level of increased risk. Solid tumor therapies present challenges in risk stratification due to response-adjusted therapy and the need to account for radiation field in the risk assessment. This guide hopes to serve as a tool to assist in standardizing gonadotoxic risk assessments across disciplines and improve referral for fertility services and reproductive health counseling for patients receiving COG-based solid tumor therapy. Internationally, many solid tumor therapies follow similar paradigms to COG studies, and risk stratifications may be generalizable to similar styles of therapy. In addition, this model may be applied to other international groups with the goal of standardizing fertility assessments.