Measuring ovarian toxicity in clinical trials: an American Society of Clinical Oncology research statement

Impact of pembrolizumab on ovarian function in young triple-negative breast cancer patients treated with chemo-immunotherapy

PURPOSE

Pembrolizumab plus neoadjuvant chemotherapy (P-CT) is the new standard in early-stage triple-negative breast cancers (TNBC). Pembrolizumab impact on ovarian reserve remained unknown. We evaluated the impact of pembrolizumab on ovarian reserve, through plasmatic Anti-Müllerian (AMH) analysis, in young TNBC patients.

METHODS

TNBC patients < 43 years treated by P-CT (carboplatin/paclitaxel/epirubicin/cyclophosphamide plus pembrolizumab) of which plasma samples were available before and after treatment were included retrospectively (P-CT group). AMH, FSH, and estradiol were analyzed before and after treatment, then compared to a retrospective cohort of TNBC patients treated with chemotherapy alone (cyclophosphamide/anthracycline/taxanes) (No-P group).

RESULTS

P-CT patients (N = 17) and No-P patients (N = 62) had comparable median age, BMI, smoking exposure, BRCA status, oral hormonal contraceptive use at diagnosis, and baseline AMH. Drugs used were comparable in both groups, except for carboplatin and pembrolizumab, only used in P-CT group. One year after the start of treatment, AMH fell from 1.08 to 0.01 ng/mL (p = 0.0001) and from 1.39 to 0.018 ng/mL (p < 0.0001), in the P-CT and No-P groups, respectively, without difference according to pembrolizumab exposure (p = 0.25). 9/17 P-CT patients (53%), and 21/62 No-P patients (34%), had undetectable AMH after treatment (p = 0.25). FSH and estradiol were comparable between the two groups, before and after treatment.

CONCLUSION

No additional impact of pembrolizumab versus chemotherapy alone on AMH evolution was observed in TNBC patients < 43 years. Nevertheless, undetectable AMH 1 year after the start of treatment was common in the P-CT group. Larger studies are essential to confirm these preliminary results and assess long-term impact of pembrolizumab on ovarian reserve.

Clinical and biochemical amenorrhea in premenopausal patients with breast cancer treated with chemotherapy - a prospective cohort study

BACKGROUND

Patients with breast cancer receiving chemotherapy frequently experience amenorrhea due to the cytotoxic effects of drugs, resulting in ovarian suppression and impacting reproductive health. This study aimed to prospectively investigate the incidence of clinical amenorrhea defined as the cessation of menstrual bleeding for at least three consecutive months and and biochemical amenorrhea, characterized by serum estradiol levels < 20 pg/mL and FSH levels ≥ 40 mIU/mL, using clinical and biochemical methods to determine their relation and identify the predictive factors for early amenorrhea.

METHODS

This longitudinal study was conducted at a tertiary care hospital with 76 premenopausal patients with breast cancer who received chemotherapy. The patients were followed up for two years with monthly clinical assessments of amenorrhea status for a year and biannual hormonal assessments of serum estradiol and follicle-stimulating hormone (FSH) levels. The incidence of clinical and biochemical amenorrhea was estimated and explored to determine any association between the two factors and the impact of risk factors.

RESULTS

The rates of clinical and biochemical amenorrhea were 84.2% and 78.9%, respectively. The median time for clinical amenorrhea was 8 ( 95% CI, 7.83-8.17) months and 18 (95% CI, 17.90-18.10) months for biochemical amenorrhea. A significant association was observed between clinical and biochemical amenorrhea (P =.0022). The estradiol and FSH levels were initially in the premenopausal range and reached postmenopausal values by the end of the study period. Age, BMI, chemotherapy regimen, hormonal treatment, and biochemical amenorrhea were not predictive of the time to clinical amenorrhea.

CONCLUSIONS

The occurrence of chemotherapy-related amenorrhea in premenopausal patients with breast cancer was high. Clinical amenorrhea is a reliable early indicator of biochemical amenorrhea. Regular menstrual and hormonal assessments are essential in patients with breast cancer undergoing chemotherapy. Future studies with larger cohorts are required to explore predictive factors associated with chemotherapy-related amenorrhea.

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.

Optimizing treatment efficacy and fertility preservation in patients undergoing hematopoietic stem cell transplantation: A narrative review of ovarian shielding with total-body irradiation or treosulfan-based conditioning regimens

Background

Pediatric and adolescent/young adult (AYA) patients with hematologic malignancies often require hematopoietic stem cell transplantation (HSCT) using conditioning regimens that pose high risks for gonadal toxicity. Traditional protocols, including total body irradiation (TBI) and busulfan-based regimens, can impair fertility. This review explores the potential of gonadal shielding during TBI and treosulfan-based conditioning as strategies to optimize treatment efficacy while preserving fertility.

Methods

A PubMed search up to February 2025 was performed for English, peer-reviewed articles on hematologic malignancies, HSCT, shielding, and treosulfan. Studies on oncologic outcomes and fertility in pediatric and AYA patients were included.

Main Findings

Ovarian shielding during myeloablative conditioning with TBI effectively reduces ovarian radiation exposure, resulting in improved menstrual recovery and hormone profiles. A treosulfan-based regimen demonstrated higher antitumor activity than a reduced-intensity busulfan-based regimen in randomized controlled trials. In a retrospective analysis, the treosulfan-based regimen exhibited lower gonadal toxicity than the busulfan-based regimen, although careful attention must be paid to dosing settings of the regimens.

Conclusion

Ovarian shielding during TBI and a treosulfan-based regimen hold the potential to preserve the reproductive capacity of patients undergoing HSCT. Future clinical studies that appropriately assess both oncological outcomes and fertility are needed to validate these findings.

A Glimpse of Research Trends and Frontiers in the Etiology of Premature Ovarian Insufficiency via Bibliometric Analysis

INTRODUCTION

Premature Ovarian Insufficiency (POI) is the most common reproductive aging disorder in women of reproductive age, which is characterized by decreased ovarian function in women before the age of 40. Etiology research of POI has garnered interest and attention from scholars worldwide over the past decades.

METHODS

However, to the best of our knowledge, no comprehensive survey with bibliometric analysis has been conducted yet on the research trends of POI etiology. This article aimed to analyze current scientific findings on the etiology of POI, offering innovative ideas for further research. Research articles on the etiology of POI from 1994 to 2023 were collected from the Web of Science Core Collection. A total of 456 research articles were included, and the total number of publications increased annually. We used VOSviewer and bibliometric.com to analyze the keywords, terms, institution, publication country/region, author name, publication journal, and the sum of times the articles have been cited.

RESULTS

This study has shown that a research hotspot is the genetic etiology of POI; however, there is still a lack of research on the impact of epigenetic alterations, iatrogenic injuries, environmental pollution, social stress, and unhealthy lifestyles on the pathogenesis of POI.

CONCLUSION

The factors illustrated here represent potential future directions for POI etiology research and warrant more attention from researchers.

Reproductive mechanisms, pathologies, and health inclusivity: insights from the 2023 Annual Meeting of the Society for Reproductive Biology

In 2023, the Society for Reproductive Biology met in Brisbane to deliver its largest scientific program to date. Herein, we detail key areas of notable discovery across the reproductive biology and fertility landscapes, as well as pressing areas that require further research. Specifically, we focus on five key themes: the cellular basis of reproduction; environmental impacts on reproduction; inclusivity in reproductive health; reproductive cancers; and evolution of reproduction mechanisms. Highlights included the utility of organism models, such as using fruit flies to model human genetic disease, and the development of new blastocyst models; the impact of elevated temperature and endocrine-disrupting chemicals on the germline, sex organ development, and fertility in mammals; how we can improve the inclusivity of transgender and Pacific Rainbow+ people in reproductive health; novel insights in reproductive cancer pathogenesis and inhibitor treatments; and the evolution of the sex chromosomes and sex determination across animals. The breadth of topics covered underscores the far-reaching impacts of reproduction and its related processes across life, health, and wellbeing, as well as for food production and the economy.

Balancing Fertility Preservation and Treatment Efficacy in (Neo)adjuvant Therapy for Adolescent and Young Adult Breast Cancer Patients: a Narrative Review

PURPOSE OF REVIEW

Adolescent and young adult (AYA) breast cancer survivors face a significant risk of infertility due to the gonadotoxic effects of (neo)adjuvant therapy, which complicates their ability to conceive post-treatment. While (neo)adjuvant therapy primarily aims to improve recurrence-free and overall survival, fertility preservation strategies should also be considered for young patients. This narrative review explores recent advancements in fertility preservation techniques, such as oocyte, embryo, and ovarian tissue cryopreservation, and evaluates the feasibility of modifying breast cancer (neo)adjuvant therapy to preserve fertility without compromising survival outcomes.

RECENT FINDINGS

Our review highlights that clinical trials with co-primary endpoints of oncological safety and fertility preservation are limited, and substituting standard treatment regimens solely for fertility preservation is currently not recommended. Nevertheless, new clinical studies have emerged that either exclude highly ovarian-toxic agents, such as cyclophosphamide, or omit adjuvant therapy altogether, even if fertility preservation is not their primary endpoint. Unfortunately, many of these trials have not evaluated ovarian toxicity. Notably, since 2020, major oncology organizations, including the American Society of Clinical Oncology (ASCO), the European Society of Medical Oncology (ESMO) have advocated for the routine assessment of ovarian toxicity in all clinical trials. The review underscores the importance of incorporating ovarian toxicity as a standard endpoint in future trials involving premenopausal breast cancer patients to identify treatment regimens that can effectively balance fertility preservation with treatment efficacy.

Clinical dilemmas in ovarian tissue cryopreservation

Ovarian tissue cryopreservation (OTC) is increasingly offered globally as a fertility preservation strategy for both postpubertal women and prepubertal girls, with subsequent reimplantation of cryopreserved ovarian cortex resulting in a rapidly growing number of live births. There remains very limited evidence of efficacy from tissue stored when the patient was prepubertal or from conditions affecting the ovary directly, e.g., Turner syndrome. Although OTC is becoming a more established practice, several clinical dilemmas remain from a practical and ethical standpoint. This review discusses the challenges regarding optimal patient selection for the procedure, the use of OTC in patients with a poor prognosis, the potential of reimplantation of tissue contaminated with malignant cells, and the role of OTC in those with an intrinsic ovarian disorder.

Endometriosis: recent advances that could accelerate diagnosis and improve care

Endometriosis is a common disorder associated with pain, gastrointestinal and urinary symptoms, infertility, and fatigue. It is defined by the presence of endometrial-like lesions found predominantly in the pelvis. Mechanisms that contribute to disease aetiology include changes in hormonal, inflammatory, and pain pathways. In this article, we focus on recent developments in imaging technologies, on our improved understanding of mechanisms contributing to infertility, on drug therapies that are in clinical trials, and on insights from studies on the gut that offer potential to support self-management strategies. We postulate that improvements in the quality of life of patients will be accelerated by reframing endometriosis as a multi-system disorder and learning from treatments targeting symptoms shared between endometriosis, neuroinflammatory, and gastrointestinal disorders.

Assessing risks and knowledge gaps on the impact of systemic therapies in early breast cancer on female fertility: A systematic review of the literature

The therapeutic landscape for early breast cancer (eBC) has expanded by introducing novel anticancer agents into clinical practice. During their reproductive years, women with eBC should be informed of the potential risk of premature ovarian insufficiency (POI) and infertility with the proposed systemic therapy. Although the topic of female fertility is becoming increasingly relevant in patients with cancer, limited information is available on the gonadotoxicity of new agents available for eBC treatment. Analyses from clinical trials and prospective data on ovarian function biomarkers are lacking. The purpose of this systematic review is to report the available preclinical and clinical data on female fertility risk with the use of the new agents that are part of clinical practice use or under development for eBC management. This review highlights the clear need to perform additional research efforts to improve our understanding on the gonoadtoxicity of new anticancer agents.

Tackling Non-Small Cell Lung Cancer in Young Adults: From Risk Factors and Genetic Susceptibility to Lung Cancer Profile and Outcomes

Lung cancer has traditionally been associated with advanced age; however, its increasing incidence among young adults raises concerning questions regarding its etiology and unique considerations for this population. In contrast to the older population, the onset of lung cancer at younger age may be attributed to a complex interplay of incompletely understood individual susceptibility and prevalent environmental risk factors beyond tobacco smoke exposure, such as radon gas and air pollution, which are widespread globally. Consequently, this leads to distinct clinical and molecular profiles, requiring a tailored approach. Furthermore, a diagnosis of cancer represents a threatening event during the prime years of a young person's life, prompting concern about career development, social aspects, fertility aspirations, and physical independence. This poses significant additional challenges for health care professionals in a field that remains underexplored. This comprehensive review recognizes lung cancer in young adults as a distinct entity, exploring its clinical and molecular characteristics, diverse predisposing factors, and priorities in terms of quality of life, with the aim of providing practical support to oncologists and enhancing our understanding of this under-researched population.

Fertility and reproductive concerns related to the new generation of cancer drugs and the clinical implication for young individuals undergoing treatments for solid tumors

The treatment landscape of solid tumors has changed markedly in the last years. Molecularly targeted treatments and immunotherapies have been implemented and have, in many cancers, lowered the risk of relapse and prolonged survival. Patients with tumors harboring specific targetable molecular alterations or mutations are often of a younger age, and hence future fertility and family building can be important concerns in this group. However, there are great uncertainties regarding the effect of the new drugs on reproductive functions, including fertility, pregnancy and lactation and how young patients with cancers, both women and men should be advised. The goal with this review is to gather the current knowledge regarding oncofertility and the different novel therapies, including immune checkpoint inhibitors, antibody-drug conjugates, small molecules and monoclonal antibody targeted therapies. The specific circumstances and reproductive concerns in different patient groups where novel treatments have been broadly introduced are also discussed, including those with melanoma, lung, breast, colorectal and gynecological cancers. It is clear, that more awareness is needed regarding potential drug toxicity on reproductive tissues, and it is of essence that individuals are informed based on current expertise and on available fertility preservation methods.

Pregnancy After Breast Cancer in Young BRCA Carriers: An International Hospital-Based Cohort Study

Importance

Young women with breast cancer who have germline pathogenic variants in BRCA1 or BRCA2 face unique challenges regarding fertility. Previous studies demonstrating the feasibility and safety of pregnancy in breast cancer survivors included limited data regarding BRCA carriers.

Objective

To investigate cumulative incidence of pregnancy and disease-free survival in young women who are BRCA carriers.

Design, Setting, and Participants

International, multicenter, hospital-based, retrospective cohort study conducted at 78 participating centers worldwide. The study included female participants diagnosed with invasive breast cancer at age 40 years or younger between January 2000 and December 2020 carrying germline pathogenic variants in BRCA1 and/or BRCA2. Last delivery was October 7, 2022; last follow-up was February 20, 2023.

Exposure

Pregnancy after breast cancer.

Main Outcomes and Measures

Primary end points were cumulative incidence of pregnancy after breast cancer and disease-free survival. Secondary end points were breast cancer-specific survival, overall survival, pregnancy, and fetal and obstetric outcomes.

Results

Of 4732 BRCA carriers included, 659 had at least 1 pregnancy after breast cancer and 4073 did not. Median age at diagnosis in the overall cohort was 35 years (IQR, 31-38 years). Cumulative incidence of pregnancy at 10 years was 22% (95% CI, 21%-24%), with a median time from breast cancer diagnosis to conception of 3.5 years (IQR, 2.2-5.3 years). Among the 659 patients who had a pregnancy, 45 (6.9%) and 63 (9.7%) had an induced abortion or a miscarriage, respectively. Of the 517 patients (79.7%) with a completed pregnancy, 406 (91.0%) delivered at term (≥37 weeks) and 54 (10.4%) had twins. Among the 470 infants born with known information on pregnancy complications, 4 (0.9%) had documented congenital anomalies. Median follow-up was 7.8 years (IQR, 4.5-12.6 years). No significant difference in disease-free survival was observed between patients with or without a pregnancy after breast cancer (adjusted hazard ratio, 0.99; 95% CI, 0.81-1.20). Patients who had a pregnancy had significantly better breast cancer-specific survival and overall survival.

Conclusions and Relevance

In this global study, 1 in 5 young BRCA carriers conceived within 10 years after breast cancer diagnosis. Pregnancy following breast cancer in BRCA carriers was not associated with decreased disease-free survival.

Trial Registration

ClinicalTrials.gov Identifier: NCT03673306.