The role of the oncology nurse is undoubtedly unique. One way in which nurses differ from their oncologists is in the conversations they have with their patients and caregivers.

“The nurse has a unique role in communication interactions, [which] is very different from the oncologist and other providers,” Elaine Wittenberg, PhD, FACH, an associate professor at California State University, explained in a presentation during the 47th Annual ONS Congress.

In the lecture, titled, “Tools of the Trade: Communicating Sensitive Topics,” Wittenberg, alongside her colleague, Joy Goldsmith, PhD, a professor of health communication at the University of Memphis, discussed the various ways in which an oncology nurse can engage with their patients on a personal level.

“[Theirs] is an uncontrollable communication environment: there is not a set time that [nurses] go and speak with a patient or family member,” she added. “[They are] the most vulnerable from a communication perspective, [they] get questions in the middle of trying to do a clinical tasks, as [they] witness the suffering of patients and families: [Nurses] don't have control over the communication interaction, it is brought to [them].”

Furthermore, although healthcare professionals usually rely on the voice of medicine compared with the voice of illness—this can lead to lack of understanding for patients. The voice of medicine and the voice of illness differ. Medicine represents the disease, it includes the jargon, and treatment names, while the voice of illness represents the experience, perception, and meaning of symptoms. The personal experience can include questions of financial toxicity or managing to drive kids to soccer practice while also making appointment times.

The COMFORT communication model can help bridge that gap ensure that patients are better able to absorb and maintain information provided to them.

The COMFORT model is based on 7 different principles:

The basic premise behind COMFORT is a relationship-focused approach to communication rather than an information-driven approach. This means that listening to what the patient is expressing (either verbally or non-verbally) should be the focus of an interaction. It also involves identifying signs of tension as potential openings to discuss concerns that might otherwise be overlooked.

By identifying these moments with tension and finding ways to connect to a patient, rather than just merely reciting information to a patient, oncology nurses can increase a patient’s understanding, confidence, and comfort, the speakers agreed.

Being health literate means that one can find, select, understand, communicate about, and make discussions related to health, according to Wittenberg However, being able to communicate about health-related decisions does not always represent understanding, and understanding does not always translate easily to decision-making.

“Health literacy is so much more than just finding information or selecting information. It's also includes the ability to talk to people about it, to talk about the things and the information that we find,” she said.

She explained how understanding and action are sometimes 2 different entities: most women know they should receive a mammogram every year–yet not all women actually receive 1 annually, patients may understand that they are supposed to take their medications twice daily–however, but not all patients adhere. Health literacy, therefore, speaks to an understanding that drives informed action.

“Health literacy is not just about education,” Wittenberg said. “I have seen many providers who have become patients who do not have health literacy. And that is because the medicine becomes personal. And when it is personal, it is really hard to process.”

Certain populations may have an even more difficult time understanding these broad concepts, Goldsmith, emphasized. For example, patients older than 65 years may struggle with health literacy, similar to patients at or below the poverty level, as well as those with a non-native and low level of English literacy.

Oncology nurses can address health literacy barriers by using plain language to bridge the gap between what they know and what they need the patient and family to understand. Ideally, language used with these populations should not be more complicated than a sixth-grade reading level.

“We forget that, for many of our patients and families coming to see us, it is the first time i[they are] dealing with illness, it is their first time to deal[ing] with cancer,” she said. “A lot of words can be very confusing, [and] intimidating.

Furthermore, Goldsmith, recommends using an active voice, rather than a passive one, to communicate. For example, “You may need to take a test to find out what’s wrong,” is preferrable over, “Tests may be needed to find out what’s wrong.” In general, the active voice is clearer and easier to understand.

Use of the “second person” is also recommended. An example of using the person family is using the word “you” or incorporating the patient or family’s members first or last name, as opposed to the third person, which is abstract and involves an unnamed person beyond the scope of the conversation. Use of the second person helps make communication patient-centric and focused.

In addition, limiting the information provided at a time is also useful, she noted. Overall, statements should be limited to 15 words or less at a time. If more information is needed, then nurses should take a meaningful pause to allow the patient to absorb what has been said before continuing to another set of information.

Goldsmith emphasized that this can be particularly challenging- it is even challenging for her as a communication professor. However, it can be helpful to imagine that you presenting patients with nothing more than a single sentence or bullet point at a time.

Finally, limiting jargon or new medical words is best practice for helping patients and caregivers reach a place of understanding; everyday language should be prioritized over health care language. An example of “everyday” words related to respiratory issues include breathing, relating to the nose, breathing tubes, and lungs.

“If it isn’t living room talk, it’s jargon,” Goldsmith explained.

Overall, communication with patients must be flexible and considerate of a patient’s background and needs, the presenters concluded.

Oncology nurses can make a big difference for their patients by being present, looking for openings and cues to ask gentle question, and ensuring that their language is patient focused and relationship driven. 

Bolte S, Goldsmith JV, Wittenberg E. Tools of the trade: communicating sensitive topics. Presented at: 47th Annual Oncology Nursing Society Congress; April 27-May 1, 2022; Anaheim, CA.

Articles

Oncology nurses are in less control of their communication environment compared with other health care providers; however, certain strategies can help them communicate effectively with their patients. 

Nurses Can Build Strategies to Facilitate More Meaningful Discussions With Patients and Caregivers

® spoke with Heidi Donovan, PhD, RN, professor of nursing and medicine, and co-director of the National Center on Family Support, at the University of Pittsburgh. Donovan recently co-led a study evaluating the utility of an online symptom management tool for women with recurrent ovarian cancer.

found that women who used the intervention experienced higher satisfaction with their symptom management.

“[In my opinion] some principles of our intervention are critical and actually overdue in clinical practice for ovarian cancer and other cancers,” she noted, emphasizing the importance of systematic symptom assessment in clinical settings, and enhancing women’s confidence in their ability to manage their symptoms, as well as their confidence communicating these symptoms to their healthcare providers.

“[By systematic] I mean [asking] the same questions repeatedly, over time, in order to pick up on changes that that are affecting patients and on symptoms that are affecting their quality of life, and their ability to function on a day-to-day basis,” she said. “The second principle was really enhancing women's confidence… A lot of what we did in this intervention was try to motivate women to recognize how much [of an] effect their symptoms were [causing] and build their confidence in their ability or their knowledge of things that they could try to get better management.”

Donovan HS, Sereika SM, Wenzel LB, et al. Effects of the WRITE symptoms interventions on symptoms and quality of life among patients with recurrent ovarian cancers: an NRG Oncology/GOG Study (GOG-0259). Published online ahead of print February 7, 2022. 

Podcasts

In this episode of “The Vitals,” Heidi Donovan, PhD, RN, discusses novel symptom management intervention for women with recurrent ovarian cancer.

Bringing a New Approach to Symptom Management in Ovarian Cancer

A combination of resistant exercises (such as lifting weights) and endurance exercises (such as walking or jogging) have been found to help patients with breast cancer combat depression and improve quality of life (QOL) and social functioning by improving cardiorespiratory fitness muscular endurance and muscular strength, according to a systematic review and meta‑analysis recently published in 

Furthermore, the findings demonstrated that combining resistance exercises with endurance exercises also helped patients significantly reduce fatigue. These data are important, the study authors noted, because fatigue affects between 62% and 85% of patients receiving adjuvant therapies—such as chemotherapy, radiotherapy, hormone therapy, and forms of targeted therapy—for breast cancer.

“The findings presented show combined exercise interventions elicit significant enduring benefits to global fatigue during adjuvant therapy in breast cancer patients,” the authors said. “They also suggest a lasting clinical benefit for combined interventions to improving the remaining factors (cardiorespiratory fitness, depression, muscular endurance, muscular strength, QOL, and social functioning) thus improving physical fitness and mental wellbeing.”

Investigators canvassed PubMed, BioMed Central, Scopus, Web of Science Core collection, Cochrane Library, and Ovid for records containing the search terms “endurance” and “resistance exercise” with “breast cancer.” Initially, 9488 records were identified as evaluable. Criteria for eligibility dictated that the studies needed to be a published, randomized, controlled clinical trial with a complete database, contain assessment on endurance/aerobic impact on patients with breast cancer with at least 20 minutes of exercise per session, be written in English, and be published between 2010 and 2020.

After screening and assessing the records for eligibility and qualitative synthesis, investigators had 18 total studies evaluable for the meta-analysis.

Overall, investigators found that the 2 exercises combined elicited a positive effect on muscular strength size (standardized mean difference [SMD], 0.47; 95% CI, −0.46 to 1.40; I2 = 87%; 

 = .235). This analysis also achieved optimal power (91.86%) and prediction intervals anticipate this positive effect to appear again in future studies.

Similarly, the combined intervention was linked to improved QOL among the patient population (SMD, 0.18; 95% CI, −0.27 to 0.63; I2 = 31%; 

 = .295). Prediction models also anticipate this positive effect will appear again in upcoming analyses.In terms of social functioning, a positive effect was observed (SMD, 0.26; 95% CI, − 0.33 to 0.86; 

 = .39), but power analysis and prediction intervals were not able to be carried out.

For depression, the effect of the combined exercise types was inconclusive, but investigators did determine a small negative effect size for resistance exercise alone in female patients undergoing adjuvant therapy (SMD, − 0.02; 95% CI, − 0.28 to 0.24; I2 = 0%; 

 = .895). However, the power analysis was low (5.26%)

Finally, in terms of global fatigue, the combined exercise efforts yielded a significant negative effect size (SMD, −0.26; 95% CI, − 0.46 to − 0.07; I2 = 0%; 

 = .008). Prediction intervals suggested that this effect will be replicated in future studies.

In conclusion, although acknowledging that more research is needed, the authors expressed hope that these findings will “progress literature towards improving the process of adjuvant treatment for breast cancer patients to minimize its detrimental side effects. This will help those undergoing aggressive cancer treatments to return to a functional lifestyle posttreatment.”

Mok J, Brown MJ, Akram EC, Morris MA. The lasting effects of resistance and endurance exercise interventions on breast cancer patient mental wellbeing and physical fitness. 

 2022;12:2504. doi:10.1038/s41598-022-07446-3

Exercise improves physical and mental side effects of breast cancer treatments, new study finds. Loughborough University. News release. March 25, 2022. Accessed March 30, 2022. https://bit.ly/3DqR8eY

New data demonstrate that regular exercise can help patients with breast cancer mitigate the physical and mental treatment–related side effects that might impact their quality of life. 

Resistance and Endurance Exercises Showcase Benefit for Patients With Breast Cancer

Nurses can help patients with cancer understand that nutrition is an important part of their treatment plan, according to Caitlin Benda, MBA, MS, RD, CSO, LDN.

In honor of National Nutrition Month, Benda, a clinical oncology nutritionist supervisor at American Oncology Network, spoke to 

® about dietary strategies to support patients undergoing curative cancer therapies.

According to Benda, patients often need to understand that maintaining weight is important while receiving cancer therapy. Furthermore, because eating can become unappealing during this time, implementing different strategies to change a patients’ approach to food can be very effective.

“Using things like individual portions, or small portion sizes that are pre-packaged or convenience foods, so that it's not adding a barrier in of preparation [is helpful],” said Benda. “Make things easy to grab [and] easy to find, [that can simply mean] setting a bowl of trail mix next to a patient as they are watching TV so that they can munch as they are doing something else: incorporating that ‘mindless eating’ can be really helpful in encouraging that overall intake and chipping away at those nutritional goals.”

Furthermore, applying a positive attitude to eating can help patients overcome emotional barriers with it, explains Benda.

“[I encourage] having a positive celebration over how hard patients are trying and what they are doing and encouraging them frequently throughout the day. Oftentimes, [this entails] trying to encourage intake every hour—or every 2 hours if intake and portion sizes are compromised—and helping a patient to develop what is doable for them,” she explained. “Whether it is a certain food, a certain taste that's working [against them], encourage being liberal with overall intake and getting in what[ever] they can over the course of the day—and, little-by-little, set goals that are achievable.”

Videos

Caitlin Benda, MBA, MS, RD, CSO, LDN, a clinical oncology nutritionist supervisor at American Oncology Network, comments on different ways oncology nurses can assist patients in reaching their overall caloric intake.

Patients With Cancer May Need Help Changing Their Eating Approaches 

Patients with hematologic malignancies identifying as White had a significantly higher uptake of telemedicine use throughout the COVID-19 pandemic compared with those who identified as Black, according to data from a retrospective observational study. These findings, the study authors argued, demonstrate a need for further exploration into these disparities.

Overall, patients with hematologic malignancies were found to reduce their in-person visits and increase their telemedicine use, according to the analysis, which was presented during the 2021 ASH Annual Meeting & Exposition.

However, telemedicine uptake was reportedly disparate between Black patients and White patients. This was found to be consistent across all diseases and combine treatments (t = 9.5; 

 < .01, including acute myeloid leukemia [AML] inpatient treatments (t = 2.4; 

 = .04), multiple myeloma oral treatment (t = 6.0, 

 < .01), and in multiple myeloma inpatient treatments (t = 2.3; 

 = .04). This trend was observed throughout the study duration, which lasted from March 2020 to February 2021.

However, although a statistically significant 18% reduction in in-person visits was observed among patients who identified as White and were receiving oral medication (95% CI, 9.9%-25%) between March 2020 and May 2020 compared with the projected rates, there was no observed reductions in in-person visit rates for patients who identify as Black. For White patients, the projected rate was 2.0 visits per patient per month, and the actual visit rate was 1.61 visits per patient per month (95% CI, 1.8-2.2).

“These patterns in documented visits reflect potential telemedicine use disparities, which requires further study into possible compound causes, including economic and societal factors,” Natalia Neparidze, MD, lead study author and an associate professor of Internal Medicine and Hematology at Yale School of Medicine, said in a poster presentation on the data.

The onset of the COVID-19 pandemic impacted healthcare delivery by reducing the number of in-person visits and pushing telemedicine to the forefront of care. Differences in these trends across racial groups are not clear. The study presented during the meeting was conducted to further explore racial disparities in visit throughout the pandemic for those with documented active treatment for hematologic malignancies.

To do this, investigators leveraged data from the nationwide Flatiron Health electronic health record–derived deidentified database, which included information from approximately 280 cancer clinics and around 800 sites of care across the United States.

The analysis included patients with AML, diffuse large B-cell lymphoma, follicular lymphoma, mantle cell lymphoma, chronic lymphocytic leukemia, or multiple myeloma. Patients needed to be at least 18 years of age and documented receipt of at least 1 systemic therapy that they received between March 1, 2016, and February 28, 2021.

Treatment types within lines of therapy were stratified based on race (White vs Black/African American) and treatment type within lines of therapy (orals vs inpatient). Oral treatments include oral agents plus outpatient infusions with orals. Inpatient treatment could comprise chemotherapy, bone marrow transplant, and CAR T-cell therapy.

To estimate projected counterfactual monthly visit rates between March 2020 and February 2021, fit time-series forecasting models to pre-pandemic monthly visit rate data were leveraged. The differences between projected and actual visits were calculated by using cross-correlation analysis to assess for significant differences in visits between Black and White patient populations.

The analysis included a total of 24,432 patients; this included 2,343 Black patients and 16,218 White patients. Among patients receiving oral treatment in-person, 6.6% were Black and 32.0% were White; 0.9% and 4.7% of patients, respectively received oral treatment via telemedicine. Moreover, 4.8% and 46.0% of patients who received in-person inpatient treatment were Black and White, respectively; 0.5% and 4.7% of patients, respectively, received inpatient treatment via telemedicine.

Neparidze N, Lau KW, Wang X, et al. Racial disparities in telemedicine uptake during the COVID-19 pandemic among patients with hematologic malignancies in the United States. 

. 2021;138(suppl 1):1973. doi:10.1182/blood-2021-153787

This article was originally published on OncLive as “Analysis Reveals Racial Disparities in Telemedicine Use During COVID-19 Pandemic Among Patients With Hematologic Malignancies”

The disparate use in telemedicine between White and Black patients warrants further exploration into compound cases, such as economic and societal factors. 

Telemedicine Use During COVID-19 Disparate Between White and Black Patients With Hematologic Cancers

Female cancer survivors are as likely to give birth to healthy babies as women who were not treated for cancer, according to a study recently published in the 

Journal of the National Cancer Institute.

 However, female cancer survivors are more likely to develop a severe complication during pregnancy or labor than those without a history of cancer, the data caution.

Findings showed that female cancer survivors were just as likely as the general female population to carry a pregnancy past 20 weeks (relative risk [RR] = 1.01; 95% CI, 0.98-1.04) and that there was no difference in birth defects or Agpar scores between babies born in the survivor or control group cohorts.

Among more than 4000 cancer survivors, only 87 women (2%) experienced a serious complication during labor or developed a heart problem during pregnancy. Furthermore, cancer survivors were twice as likely to experience these difficulties compared with non-cancer survivors.

At 30 years old, women who had survived cancer had a cumulative incidence of achieving a recognized pregnancy of 22.3% (95% CI, 20.7%-23.9%) compared with 26.6% (95% CI, 25.6%-27.3%) among the general population (HR, 0.80; 95% CI, 0.75-0.86). Risk factors for a lower likelihood of conception included history of a brain tumor, alkylator chemotherapy, cranial radiation, or hematopoietic stem cell transplantation (HSCT).

“The message here is largely positive,” said study leader Paul Nathan, MD, of the Hospital for Sick Children in Toronto, Canada. “Women who have a history of childhood cancer have a really good chance of getting pregnant, and most of them are quite fine through the pregnancy. But it’s super important for the people caring for them to know about these risks.”

Investigators identified 4062 women who had underwent cancer therapy between 1985 and 2012 while they were under the age of 21 years. All evaluable patients were identified via a single-payer health insurance program covering Ontario, Canada. Each patient with a history of cancer was compared with 5 women with no history of cancer. In total, the survivors were compared against 20,308 comparisons women from the general population, totaling in an assessment of over 24,000 women.

Although women who had received treatment were just as likely to give birth to a healthy baby as women from the general population, they were at an increased risk of severe maternal morbidity (RR, 2.31; 95% CI, 1.59-3.37), cardiac morbidity (RR, 4.18; 95% CI, 1.89-9.24), and preterm birth (RR, 1.57; 95% CI, 1.29-1.92). Furthermore, patients who had received allogenic HSCT were more likely to experience a preterm birth (RR, 8.37; 95% CI, 4.83-14.48) as did those who underwent autologous transplant (RR, 3.72; 95% CI, 1.66-8.35).

These results suggest that female cancer survivors may benefit from high-risk obstetric care, although in the United States, ensuring that survivors know to seek these resources could be improved through better communication between providers, noted experts.

“High-risk obstetric care is widely available in most of the country, but childhood cancer survivors may not be recognized as needing that kind of care,” Emily Tonorezos, MD, director of NCI’s Office of Cancer Survivorship, commented on the study. Tonorezos noted that health care providers may not know that their patient was treated for cancer as a child, particularly if they have relocated between cities or states and transferred to a new medical system.

“The burden of making sure you’re getting good health care is very often on the survivor and their family,” added Tonorezos. “That’s not where the burden should be, but survivors need to [make sure] health care providers have some of that information, because sharing data is not built into our health system,” she added.

Nathan agreed that women who were treated for cancer before the age of 21 would benefit from frank conversations with their providers about a potential need for high-risk obstetric care. This high-risk care could encompass heath monitoring throughout pregnancy, as well as frequent fetal monitoring. The key, according to Nathan, will be ensuring that all the providers caring for a childhood cancer survivor understand their medical history.

“Health care providers’ knowledge of a patient’s cancer history can also spur other important conversations about reproductive health,” he said. “[Figuring out] how to share this information with health care providers is going [to be] one of our key goals.”

Overall, however, these findings are promising for cancer survivors, as they suggest that a healthy pregnancy is possible with a little additional monitoring, concluded experts. “The expectation of a healthy pregnancy and a healthy baby should be the norm, even for childhood cancer survivors,” said Tonorezos.

1. Zgardau A, Ray JG, Baxter NN, et al. Obstetrical and perinatal outcomes in female survivors of childhood and adolescent cancer: a population-based cohort study. Published online ahead of print January 19, 2022. 

2. NCI Staff. Good News and cautions about pregnancy for childhood cancer survivors. National Cancer Institute. March 4, 2022. Accessed March 28, 2022. https://bit.ly/3iJyGoA

Childhood cancer survivors may benefit from high-risk obstetric care despite being able to conceive and give birth safely. 

Childhood Cancer Survivors Likely to Deliver Healthy Babies, But May Require Additional Monitoring During Pregnancy 

Oncology nurses have a unique relationship with their patients that may differ from that of physicians, said Lindsay Kroener, MD. This relationship means that often nurses may be the person a patient turns to with questions and concerns about fertility preservation vs their physicians.

“I think a lot of times, the physicians are coming in [and] they have a million [other] things going on,” she said in an interview with 

 “Sometimes the nurses have a little more time [with the patient].”

Kroener recently presented on the topic during the 

 Miami Breast Cancer Conference®. Her presentation, “Answering Your Patient’s Questions About Fertility,” outlined 

the scope of the fertility preservation in cancer

 and candidate considerations, and conversations surrounding pregnancy following cancer treatment.

Approximately 1 in 48 women younger than 40 years old receive an invasive cancer diagnosis, Kroener explained in her presentation.2 Moreover, as survival rates continue to improve, the question of posttreatment fertility strategies has become more relevant. Many women who survive cancer are unfortunately at an elevated risk of infertility, ovarian insufficiency, and adverse perinatal outcomes.

However, a variety of factors, including age, ovarian reserve, and cancer therapy type or dosage all result in differing degrees of infertility risk.

“It is really important for us, as health care providers, to address the possibility of infertility and discuss options for fertility preservation with reproductive aged patients,” Kroener noted in her presentation. “This is endorsed by many professional societies, including ASCO, National Comprehensive Cancer Network, the American Society for Reproductive Medicine, and the American Academy of Pediatrics. Addressing these issues are really considered to be a measure of quality care in oncologic care.”

However, ensuring the nurses are up-to-speed on fertility preservations is a good place to begin. For this reason, Kroener said she was happy to be included on the nursing track at this year’s conference.

“Even at our own institution, this is something that we really want the nursing staff to be informed [about, especially] because they are in such direct contact with the patient and [represent] a great sort of resource of information,” Kroener told 

 “I was happy to see this on that track.”

As prognoses continue to improve, concerns about treatment-associated fertility risks are becoming more prevalent and are often a topic of discussion between patients and their nurses or nurse practitioners.

Nurses Can Lead Conversations on Fertility Preservation 

In this episode of “The Vitals,” we spoke with Caitlin Benda, MBA, MS, RD, CSO, LDN

 a clinical oncology nutritionist supervisor at American Oncology Network, about dietary strategies to support patients undergoing curative cancer therapies.

Throughout our conversation, Benda discussed how nurses can help change a patient’s approach to diet in order to combat complications brought about by nausea and appetite loss. In addition, she highlights the importance of allowing patients some autonomy in their diet, common gastrointestinal—related side effects with different cancer treatments, and the importance of nutrition screening tools in increasing necessary referrals.

“Oncology nurses, especially infusion nurses, are spending a lot of time around patients, gathering information from these patients that maybe the patient did not have time to communicate in the same amount of detail to the physician or to whoever they were seeing in the office,” notes Benda. “Using that information and sending referrals to dieticians early on in the process [is vital]. We know that malnutrition is a very significant problem among individuals going through cancer treatments, and it is much easier to prevent malnutrition than it is to treat malnutrition.”

In this episode of “The Vitals,” Caitlin Benda, MBA, MS, RD, CSO, LDN, discusses important dietary considerations for patients with cancer.

Food for Thought: Nutrition Considerations for Patients With Cancer

Today, embryo and oocyte cryopreservation are 2 mainstays of fertility preservation in the realm of breast cancer treatment, according to Lindsay Kroener, MD, an assistant clinical professor in the Department of OB/GYN at UCLA David Geffen School of Medicine.

Kroener recently discussed the topic during the 

, “Answering Your Patient’s Questions About Fertility,” outlined the scope of the fertility preservation in cancer, different treatment options and candidate considerations, and conversations surrounding pregnancy following cancer treatment. In an interview with 

Kroener highlighted how egg and embryo cryopreservation have evolved over the years to represent the most reliable options for patients.

“These treatments are not going to be for everyone. But in terms [of oncofertility], egg and embryo cryopreservation are the best options we have,” she said.

Specialists conduct ovarian stimulation by injecting gonadotropins (FSH/HMG) to stimulate growth in multiple ovarian follicles. These injections are delivered across 8 to 12 days and initiation usually begins on the second or third day of the menstrual cycle. During this time, patients are monitored every other day via an ultrasound and blood work.

When the follicles reach an appropriate size, they receive a trigger shot to induce egg maturation. About 35 to 36 hours later, the eggs are retrieved. This procedure typically occurs in the outpatient setting for about 15 to 20 minutes, and while the patient is under a conscience sedation.

In the case of oocyte cryopreservation, the retrieved eggs are examined microscopically, and the mature ones are cryopreserved. For embryo cryopreservation, oocytes are fertilized with partner sperm on the day they are retrieved and then maintained in a culture for 5 to 7 days. When blastocyst stage occurs (100 cells) the specimen is cryopreserved.

“Those eggs can either be cryopreserved right at that time, or they can be grown out into embryos (if there's sperm to fertilize those eggs),” explained Kroener. “One of the key things [to consider] is [that], as of 2012, cryopreservation is actually considered non-experimental and so it really offers a good option for our non-partnered patients [who no longer need] to say, ‘Hey, I [need to] go find donor sperm to make embryos.’”

Lindsay Kroener, MD, offers an overview of current fertility preservation options for patients about to undergo cancer therapy. 

Cyropreservation Continues to Improve Fertility Options for Patients with Breast Cancer

Fertility preservation practices have evolved in recent years, allowing patients with invasive breast cancer to have more options; however, it also potentially creates more questions to address between providers and patients initiating cancer treatment, according to Lindsay Kroener, MD, an assistant clinical professor in the Department of OB/GYN at UCLA Geffen School of Medicine.

Kroener recently presented on the topic during the 

 Miami Breast Cancer Conference. Her presentation, “Answering Your Patient’s Questions About Fertility,” outlined the scope of the fertility preservation in cancer, different treatment options and candidate considerations, and conversations surrounding pregnancy following cancer treatment.

Approximately 1 in 48 women younger than 40 receive an invasive cancer diagnosis, Kroener explained.

 Furthermore, as survival rates continue to improve, the issue of posttreatment fertility has become even more prominent. Unfortunately, women who have survived cancer are often at an increased risk of infertility, ovarian insufficiency, and adverse perinatal outcomes. Varying factors such as age, ovarian reserve, and cancer therapy type or dosage can all impact the degree of infertility risk. However, researchers currently lack the correct tools to accurately guess the timing of infertility.

In addition, patients who lose their fertility have demonstrated higher rates of depression and other signs of worsened quality of life compared with other cancer survivors. Therefore, discussions addressing the possibility of infertility and options for fertility preservation should be initiated by health care providers who care for patients of reproductive age.

“It is really important for us, as health care providers, to address the possibility of infertility and discuss options for fertility preservation with reproductive aged patients,” Kroener said. “This is endorsed by many professional societies, including ASCO, National Comprehensive Cancer Network, the American Society for Reproductive Medicine, and the American Academy of Pediatrics. Addressing these issues are really considered to be a measure of quality care in oncologic care.”

Currently, standard-of-care fertility preservation may include embryo or oocyte cryopreservation following controlled ovarian stimulation, gonadal shielding, ovarian transposition, fertility-sparing surgery, and sperm banking in males. Moving forward, other alternative options may include ovarian tissue banking, ovarian suppression with gonadotropin-releasing hormone agonists (GnRH), and in vitro maturation of oocytes. However, Kroener’s primarily discussed ovarian stimulation and GnRH agonists.

Candidates who should be considered for ovarian stimulation for egg/embryo cryopreservation are women who are both post-pubertal but premenopausal. The urgency for therapy initiation is important to consider, as well as potential complications the patient may be undergoing. For example, patients with thrombocytopenia may experience heightened complications when attempting to preserve their eggs or embryos.

Baseline ovarian reserve is also a relevant factor, she explained. FSH/E2, AMH, and antral follicle counts should be assessed at baseline to determine how many eggs a patient could potentially preserve.

In the case of oocyte cryopreservation, the retrieved eggs are examined microscopically, and the mature ones are cryopreserved. For embryo cryopreservation, oocytes are fertilized with partner sperm on the day they are retrieved and then maintained in a culture for 5 to 7 days. When blastocyst stage occurs (100 cells) the specimen is cryopreserved. Of note, for oocyte cryopreservation, survival rates are currently very high; about 90% of the vitrified oocytes should survive the thaw.

This is considered a mainstay in treatment, particularly for patients who do not have sperm available, said Kroener.

Previously, when cryopreservation technologies were not as good, only about 50% of oocytes would survive freezing, she continued, and patients were often encouraged to use donor sperm to create an embryo, since they had a higher rate of success with the freezing technology. Luckily that is no longer the case.

Patients can now choose between oocyte and embryo cryopreservation—the benefit to embryo cryopreservation is that the patient will know if their egg is suitable to become an embryo (because not all eggs successfully become embryos), and if they have a long-term partner with whom they wish to create an embryo, they receive a lot more information about the embryo up front and before it is preserved. One of the risks associated with embryo cryopreservation is that once an embryo is created, it is communal property between both partners. If either partner changes their mind about having a child with their other partner, the embryo can no longer be used following cancer treatment.

“I always have this conversation with patients,” said Kroener. “There is no forced parenthood. Basically, both people need to consent to use an embryo; a frank discussion here is important. Some patients even opt to freeze some eggs and some embryos, [and] we are certainly capable of doing both now.”

Traditionally, ovarian stimulation began on cycle 2 or of the menstruation cycle. However, initiation can also begin in the middle of a cycle or in the luteal cycle (second half of the cycle) without changing outcomes. This flexibility has been vital because it has permitted more patients to shorten the delays in cancer treatment initiation, Kroener explained.

One important component to consider is that ovarian stimulation elevates estrogen levels. Therefore, patients with hormonally driven cancers, such as estrogen receptor–positive breast cancer, may experience IVF-related complications like bleeding, infection, and ovarian hyperstimulation.

To mitigate these risks, it is common to administer 5mg of letrozole during stimulation in order to suppress estrogen levels.

Many patients may inquire about ovarian suppression with GnRH, noted Kroener noted; however, there are limited data demonstrating that this method is associated with beneficial pregnancy rate outcomes. Furthermore, it may be associated with reduced premature ovarian insufficiency.

Both ASCO and ASRM have expressed that GnRH agonists can be offered to patients with breast cancer, but it should not replace traditional methods for fertility preservation, such as oocyte or embryo cryopreservation.

“Basically, ovarian suppression with GnRH agonist is putting patients into a medical menopause for a short period of time,” she said. “This can be administered at the time or immediately preceding the administration of toxic treatments.”

“One of the benefits here is that it is much less invasive, expensive, and intensive, and it can be given right away without any delay. [However], the biologic mechanism by which this may prevent or decrease the chance of ovarian failure is a little bit unclear,” Kroener said.

Unfortunately, it can often take months or years after the conclusion of cancer therapy for menses to resume. The timeline for resumption is heavily influenced by age and baseline ovarian reserve. Women younger than 30 years typically resume menses within 1 year, while 2 to 3 years is typical for women 35 or older, and many women older than 50 years do not resume menses after completing cancer treatment. 

Finally, when discussing pregnancy after surviving cancer treatment, Kroener advises incorporating timing and safety into the conversation. She therefore recommends preconception counseling with a high-risk obstetrician. Secondly, if a patient is having difficulty conceiving, utilizing the cryopreserved oocytes or embryos is often a good next step.

Whether or not pregnancy increases the risk of breast cancer recurrence risk is still rather controversial, she noted. Current data do not suggest that pregnancy is linked to worse disease-free survival or overall survival outcomes, but available data are still limited.

“The take home on this is that although some of the data we have are reassuring, it is certainly limited and [pregnancy] should be an individualized assessment with the patient and their oncologist,” Kroener summarized.

Kroener L. Answering your patient’s questions about fertility preservation. Presented at: 

 Miami Breast Cancer Conference®; March 3-6, 2022; Miami Beach, FL.

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At a presentation during the 39th Annual Miami Breast Cancer Conference, Lindsay Kroener, MD, highlighted key components related to fertility preservation for patients with breast cancer. 

Supportive Care