Dana-Farber’s Young-Onset Colorectal Cancer Center's Gut Instincts series continued on Monday, September 27 with an educational workshop on fertility preservation. This webinar is for healthcare professionals, patients, and supporters.
Welcome everybody. My name is kim Yang. I am a medical oncologist here at Dana Farber and the director of the young onset colorectal cancer center here and this is the next installment of our gut instincts webinar series which serves to educate the health professional community as well as patients and advocates about relevant topics in young onset colorectal cancer. So today we are talking about an extremely important topic among our young population fertility preservation which unfortunately is not always consistently address among our patients but can lead to lifelong physical as well as emotional consequences. So I am really pleased today to be joined by a panel of experts who will be talking about this topic from many different aspects and so we hope that you will get a lot out of it in terms of how to approach your patients in the future about this really important topic. So I to start off would like to have each Panelist just briefly introduce themselves and their role here at Dana Farber and Brigham and women's cancer center. So Ben, we'll start with you and bench lecture one of the medical oncologists that I work with kimmy and um my main area of clinical focuses colorectal cancer and I'm interested in um new ways we can create new treatments for patients. And looking forward to talking today about the impact of chemotherapy on fertility. Thank you for being here. Ben Miranda. Hi my name is Miranda Lam. I'm one of the G. I. Radiation oncologists and I treat colorectal cancer patients here at Dana Farber Brigham. I'll be talking about the impact of public radiation on fertility. Thank you for being here. Patricia hi I'm Tricia Kennedy. I am reproductive endocrinology RN specializing in fertility preservation. So our department works with getting young uh oncology patients through this process of fertility preservation as swiftly as possible to be able to return them back to their oncology care. Thank you for being here and then David. Hi David thou I am a patient at the young onset colorectal cancer center was diagnosed with stage three C. Colon colon cancer in june of 2019 at age 34. So I've lived a lot of what we're gonna be talking about today. Uh and I am about 18 months any d. As of right now. Thank you for being here, David. Alright so let's get started. I think we will start with Ben from the medical oncology perspective they need to advance so we can go to the next slide. So um and we can go to the next slide. Thank you. So the agenda for today. I wanted to first talk about the timing of chemotherapy in particular with regards to admin therapy. Um I think the most common scenario we face this and then dig a little bit deeper on the three main drugs that we use which are five F. You um sally plan as part of the full fox regimen and green tea. Can next slide please. So the timing of initiation of attachment therapy in colorectal cancer actually is a challenging topic. There are no prospective data comparing different timing. So we don't have eight weeks versus 12 weeks prospectively studied in a randomized fashion. Nevertheless, ask O N. C C N. S. Mo all recommend initiating chemotherapy in the advent setting by about eight weeks from surgery whenever possible. And this comes out of a series of meta analyses looking retrospectively at major clinical trials. The first of these was a meta analysis of more than 13,000 subjects across eight prospective trials that looked at the pre and post eight week populations and what was observed was that the hazard of death was higher in the late starters. But what was interesting in this meta analysis is mount analysis is that disease free survival. So cancer specific outcomes were actually the same between the two groups. So it seems like from this initial effort that timing of initiation of chemotherapy retrospectively looking may have been more of a marker of the health of the patient. So fit patients started earlier. Sicker patients started later and so the late starts just did worse and actually didn't affect the cancer outcomes was not a chemotherapy delay issue. We can go to the next slide. So in a more modern review looked at this differently. Rather than having one cut off patients were divided into four week intervals, three or four cutoffs and there was an observation that across 15,000 subjects from 10 more modern prospective clinical trials that actually outcomes for both overall survival. So not just an assessment of health of patients in general but even chemotherapy and cancer related outcomes. Disease specific survival. Disease free survival rather were impacted. So for every four week block of delay there's an increased hazard Uh in terms of the outcomes and beyond 12 weeks that's really where you see a significant difference in outcomes for patients. So a delayed start especially beyond 12 weeks actually did have an impact if we waited on chemotherapy. Another follow up study looking at these same data, same clinical trials. Same 10 prospective trials looked at outcomes overall and actually noted that completion of chemotherapy was more important than timing of chemotherapy. So while we want to start sooner when possible. It's most important that we start when patients are fittest and can handle their therapy to completion. So a full six months of therapy as planned in the state of texas where the pre idea era um Maybe less of a relevant issue in younger patients. But I do think it gives us sort of power to say that we can sometimes delay for for the best possible outcomes for a more holistic approach. We can go to the next side. Um so based on this, as I said, we really do need to start before 12 weeks, ideally close to eight weeks. But this should give us a reasonable time frame to pursue fertility preservation in both women and men. Next slide, please. Looking at the particular chemotherapies. I think we should talk about five F. U. The backbone of everything we do in the oncology. Excellent platon and arena T. Can. And there are differences between men and women and differences between each drug. Next slide please. So five F. You. This is of course our favorite drug. It's an anti metabolite as we know and as a consequence it is very little risk of trinity genesis in in cancer patients. It really only has an impact on dividing cells. Not a non dividing cells other than maybe some effect on R. N. A. Um And as a consequence there's not much more than transit impact on sperm counts and ovarian function. Most patients will recover normal function after this without long term outcomes. With the exception of the highest doses of this drug is not really used in this time frame. You can go to the next slide please Plan is obviously critically important drug especially in stage three cancer. So this is a platinum this is direct cause of me to genesis through DNA adducts and it affects both dividing and non dividing cells. It's a bigger molecule to more polar molecules. So it is somewhat less cns penetration and good penetration than five F. You alone. But it still does have an impact and there is an impact on short term fertility in both men and women in particular in terms of sperm counts in the acute setting And about 16% of women under the age of 50, 50 will develop a memory a from fall Fox chemotherapy. Um but most will eventually recover ovarian function and 34% about a third of women develop early ovarian failure as a consequence of fall Fox chemotherapy. So it's an impact but not a huge impact on the vast majority of people, but still we have to account for it. And then finally Arena T. Can for the next slide. So this is to buy some race one inhibitor. This can cause me to genesis in both dividing and non dividing cells. So an important consideration here. This is really only used in some locally advanced rectal cancers in the modern era and in metastatic disease. Um This causes Significant impact on fertility in both men and women and in fact 70% of patients will develop total failure as a consequence of chicken. So this is one where when we have to consider fertility preservation, it's a drug we need to either delay or think carefully about its use in that setting and then next slide. So ultimately just to sum up the chemotherapy impact and we lack prospective data but it seems clear that you can safely delay to a great degree which is start as early as possible. But up to 12 weeks when necessary. Um admin therapy improves outcomes generally. So we have to always keep that in context and full fox has a short term impact. That's pretty significant and a long term impact. Probably a third of patients and really take it has the most significant impact on fertility. And so that's when we have to address when to use it. How to use it in the rectal cancer setting. In the metastatic disease setting. It doesn't really have a role in early disease. So it's um has less of an impact on this discussion. But in metastatic is certainly important drugs. This was the main the main considerations in chemotherapy. We can go on to radiation I think from here. Great. Thanks. So, moving on to radiation and fertility. The outline of my talk, it's on the next slide. Let's all jump right in to discuss the basics of radiation therapy. So apologies to the radiation oncologist on the line, I know that you've all taken a radiation in physics boards. But for the non radiation colleges, I thought it'd be nice to give a background of how radiation works. So next slide, um So radiation is delivered through different machines, the most common being a linear accelerator or line ac for short short. So our patient lies on the robotic table during treatment and radiation is delivered through the head of the gantry. Um Over time, radiation technology has improved and there are not only more precise ways to target the radiation, but there's also improved methods of ensuring that the patient is lined up properly during treatment every day. So we have X rays for daily um set up verification as well as um low dose cat scans to make sure that we are able to see the target. Um And that every day that there's patients are set up in the same way. So next slide um the type of radiation um used to treat cancers on the right side of the electromagnetic spectrum known as ionizing radiation. So ionizing radiation is called such because they're photons have enough energy to ionized atoms causing a downstream chemical reaction. So in terms of in the clinic um you know we primarily use X rays and gamma rays as indicated here. Um But we also in some cases you'll hear of electrons, protons, neutrons and carbon ions. I think the most relevant for today's talk is X rays and gamma rays or photons. Next slide um So how does radiation kill cancer cells? Ionizing radiation as I mentioned, is delivered through different machines um Such as the Linux MAC. And the ionizing radiation of photons with sufficient energy to detach an electron from an atom of cells will result in the formation of an eye on our free radical. Um And so the way radiation works biologically um correlates best with the induction of DNA damage. Um And most specifically um DNA double stranded breaks um from the ionizing radiation causing this chemical reaction. So with DNA damage the tumor cells um will not be able to replicate. And so that is sort of the foundation of radiation next slide. So as many of you know um standard radiation is delivered over many weeks. Um There are certain cancers in certain areas of the body where we are able to deliver radiation in a shorter time course. But for most pelvic radiation um And especially when we're thinking out um rectal cancer rates, you know occasionally we do use radiation for colon cancer. But for rectal cancer radiation uh Standard li we will consider this long the standard course radiation. So why do we fraction eight? Um So we call these daily treatments fractions. Um You know why do we fraction eight? Why why does radiate radiation have to be given daily over so many days? Um And so you know the thought from radio biologic studies and um prior literature is that you know using smaller doses per day can spare the longer term damage to critical organs. And so this dozing provides a balance of tumor kill but also normal tissue recovery. The standard fraction size that we use is 1.8-2 gray. Um and so radiation is measured in gray which is absorbed dose in jewels per kilogram. The next slide. Um So we'll move on to fertility considerations for patients receiving pelvic radiation. Um So what is the process for a patient who's who's being considered for radiation next side. Um So first there is a consultation with the radiation oncologist. Um Once the decision is made to move forward with radiation, the next step is to undergo radiation mapping or simulation. This is a cat scan that's performed in the radiation treatment position. Um And the radiation fields are designed off of this and it's really important for um radiation treatment and planning purposes. We often hear from patients, you know, um Do they need another cat scan? Because they already had prior cat scans for their staging? But this is separate and goes directly into our software so that we can design the radiation fields. Um Excellent. There's the technical aspect to radiation planning. So um you know, based on the patient's anatomy where the tumor is located, the other areas that were concerned about that may need to be covered with the radiation. All happens during this time. The radiation works with the physicists and the symmetry team to create a safe radiation plan that gets the intended amount of radiation to the area the tur or the area at risk. Um and tries to decrease the dose as much as possible to the normal organs around um the target. Uh There's QA that happens. Um And so the timing, this is something that does come up. The timing between the radiation mapping and the daily radiation is typically around 1.5 to 2 weeks. So um you know, once the radiation is complete um for patients with colorectal cancer, you know often given with chemotherapy will either move on to surgery if that's the case or they'll move into follow up. So in terms of you know when the fertility discussion should occur for our patients, especially our young patients or patients interested in fertility auctions. We really recommend that these discussions happen sort of at the time of consult and that the proper connections are made at that time so that after the consult um you know even if we know that the next step maybe chemo radiation and the mapping has occurred, there's still time between the consult in starting the daily radiation to have these discussions. Um And you know potentially have any of the interventions that are needed done in terms of you know as I mentioned between radiation and mapping and daily radiation, there's about a 1.5 to 2 week turnaround. Um that can be extended if needed to make sure that the intent, you know the fertility treatments that are needed um prior to starting our complete in terms of the the types of options that are open. Um You know I think we'll get into that a little bit more in the next presentation but I did want to briefly talk about ovarian transposition just because um one of our surgeons was not able to join today but this is something that will be done sort of in close communication between the radiation oncologist and the surgeon with respect to trying to actually physically move the ovaries Um Either one or both outside of the radiation field. Um And so you know, I think it's something that can be considered in conjunction with or alone with some of these other options side so um as you may have heard in the news and through Dr AMES efforts, you know, colorectal cancer is rising at an alarming rate. Um in young patients, you know, there is data To show that patients over 65, the diagnosis of colorectal diagnoses are decreasing, but those under 65 um The diagnosis of colorectal cancer is actually rising. So one in 10 people that are diagnosed with colorectal cancer Are actually under the age of 50 and many within the reproductive age. Um And this doctor in sort of mentioned at the beginning, you know, there's some data to show that um Many people actually do not receive pre treatment fertility counseling um for colorectal cancer. And you know, there's some data that show it to be as low as you know, under 20%. Um but nonetheless I think, you know, this is really important. Um and so I you know, I want to jump into kind of the radiation specific side effects and kind of what we think about in terms of sensitivity of the reproductive organs to radiation. So I'm going to go through radiation side effect form that we actually use for our patients here at Brigham. So you know, we'll go through often the short term side effects um fatigue changes to urination changes about movements and maybe some changes to blood counts because when pelvic the pelvis is radiate, there's a lot of phone and also you're getting often concurrent chemotherapy. Um And then when we move on to the long term side effects you can see that you know under common we list um you know problems with fertility. And unfortunately this is fairly common with pelvic radiation given the location of the reproductive organs in relation to the G. I. Tract. And especially um treating for rectal cancer which radiation plays a big role in. So next slide. Um So um you know I'll I know that it's important to talk about both fertility preservation for men and women. But you know just as an example for um for women you know at birth women are you know the ovaries contain about a million non renewable follicles that decline over time. And fertility is directly related to ovarian reserve. And as ovarian reserve goes down so does fertility. Um And you know radiation um You know with or without chemotherapy or even chemotherapy alone can impact um this uh the reserve that ovaries have. And so you can see you know in this slide um the the black line is sort of normal ovarian reserve for women. And then um any type of cancer directed treatment can cause you know acute ovarian failure where there's a rapid um sort of decline in the number of available uh sort of follicles. Or it could be a little bit more gradual with sort of premature menopause as you can see from the more dotted line. But you know I think the important thing is that these you know our treatments do really impact our patients. And so it's really important to think about um having this discussion treatments up front. Um You know from the radiation standpoint, you know we we always talk about lara or just you know as low as dose as possible to normal organs including reproductive organs. Um But when we think about you know radiation dose to the testes, you know the testes are actually very sensitive to radiation. So even if we block them out of our field you shielding um the you know the doses that we worry about. You know the literature can range from 2.5 to you know sixth grade where we try to keep that the max dose under that. But even if we do um there's still you know potential scattered dose of radiation that can happen. So you know, it's that's an important thing to keep in mind. You know in terms of ovaries also similarly very sensitive to radiation, radiation oncologists often will try to You know, decrease the radiation max dose to about 3-6 grade. Um you know if that's not achievable and um you know we can try to move as we talked about before. You know move radiation move the ovaries out of the field. The radiation that may help decrease that dose even more in terms of the Uterus and Cervix. You know oftentimes it's hard to um minimize dose to those or to the cervix and yours because of the relationship of um sort of how close that lies to the G. I. Track and so um you know we typically you know historically have not actually measured dose to the uterus or cervix but there are studies to show that you know if we can try to keep the dose lower in the you know under thirties you know under 25 grade that is ideal. But it's very hard you know in terms of how close it is to especially rectal cancer treatment. Um And so sometimes different technologies of radiation can be used to try to do this but it's um you know just thinking about this it is um it is important to try to think about ways that we as a radiation oncologist and kind of decreased dose as much as possible to these organs. And next slide. Um So finally um just are sort of my final recommendations for patients undergoing pelvic radiation for cancer treatment. Um You know I think it's just really important to make sure that you know we as the oncology team make sure that we um bring it up at an initial consultation and connect make the connections in terms of um you know getting them to an anchor fertility team to talk about what options exist and to pursue these options before starting therapy because you know we know that our treatments can have an impact on long term fertility um Specifically after public radiation. Um I know that myself and other gi oncologists g radiation oncologists will um connect our patients to the Dana Farber survivorship clinic and our sexual health clinic um and specifically in our department for female patients who do undergo pelvic radiation. We do provide them with vaginal dilator and vaginal dilator teaching to help with the side effects of vaginal stenosis which you probably saw on our side effect form. Um In addition to the other sort of fertility considerations that we discussed. Thank you very much. Um Hi so I'm going to speak about the fertility preservation program at Brigham next side next line. So the the objectives here are to review male and female options for fertility preservation. The first being um Next slide. I'm sorry. Mhm. Okay again next slide. Okay so we have a partnership with Dana Farber that um typically our program is set up that we have created a link for Dana Farber physicians to send a referral through our computerized system. Epic which goes directly to the fertility preservation team. Then an RN will reach out to the patient that's been referred within 24-48 hours, explain whatever process seems appropriate for that patient or all options and the case that that might be required. We arranged for a physician consult within another 1- two days from there. The patient is then submitted to insurance for approval on whatever kind of treatment is appropriate. The patient is then brought in for a one on one class with an RN to teach them how to proceed with the cycle. If they choose IVF or if it's sperm banking, they don't need the actual in person consult. They just go directly to the bank after they've been counseled by the R. N. And then uh if they do proceed with IVF, they are then ah again taught in person by an RN. We walk them through how the cycle will function. We communicate with back to their referring oncologist and ultimately they're referred back to Dana Farber once they're complete with us. Excellent. So for females there are three options. The first would be in vitro fertilization or IVF. The second would be ovarian tissue freezing or preservation. And the third would be ovarian suppression. Also as DR land mentioned, there is a possibility for ovarian transposition which is moving the ovaries out of the radiation field. Should that be the required treatment. Next slide, I'll first talk about IVF, we will review all the medications with the patient, review the timeline and the monitoring which is done by trans vaginal ultrasound and correlating blood estradiol and progesterone levels. The process itself takes about two weeks to complete. And the patients will be self injecting medications anywhere from 2 to 4 times per day. And then in that 14 day window they will be coming in Approximately 7-10 times for the monitoring. Which is done here at Brigham early in the morning between 6:37:30 a.m. For trans vaginal ultrasounds. And we're looking for the ovarian response to the medications that the patients have been injecting. We can measure the follicles which as again dr liam mentioned they are little sacks that the grow on the ovaries and inside the follicle is the egg. We cannot see the egg but we can't see and measure the follicle and then we correlate that to their rising estrogen levels until we can get them to mature range. At that point they're scheduled for surgical egg retrieval. At that point the patient will stop the medications, they will undergo a trans vaginal um egg retrieval. They will be under general anesthesia. And the retrieval itself has done via ultrasound with a long thin needle attached to the the wand as a guide and the needle puncture through the back of the vaginal wall over to the ovary and pop all the follicles. Pulling the eggs out by suction. There are two options in IVF you can either freeze eggs or embryos and embryo is a fertilized egg custody issues do apply to embryos. So if a woman chooses egg freeze they are hers and hers alone. If a couple decides to create an embryo meaning the partner's sperm fertilizes the egg, they both share custody, therefore they both have to agree on the disposition of the embryos in the future. Next slide all of the injections are given subcutaneous li which is mhm recommended in the abdomen for our population, our medications, there's a list of meds on the side there. Most patients are not familiar with these drug names. So again, another reason for the in person class to familiarize the patient with how to do the injections as well as what each function of each drug does. Next. This isn't an ultrasound photo of a mature a cluster of mature follicles on an ovary. So you can see the dark black circles are the mature follicles typically at the beginning of a cycle at a baseline ultrasound when the follicles have not grown to the size, the ultrasound would kind of look snowy white all throughout. But this is an ovary that has mature follicles, which for us is about a mean diameter of 18 mm. So it's very evident that they are mature and the physicians can easily target extracting me. It's next. Here's an example of what the actual process looks like. You can see the follicles, they're being extracted by the needle attached to the ultrasound wand. Next again, the egg freeze, it is an unfertilized egg frozen on the day of egg retrieval and the female has sole custody of the egg. She can thaw and freeze those and fertilize them in the future with whomever sperm she chooses. And embryo freeze. In oncology patients. We freeze embryos on day one so you can see the process of how embryos grow. We do freeze on a variety of days in fertility page. Infertility patients. Day three's. Oftentimes embryos are transferred. Day five's even better to transfer. But for an co fertility patients were looking to freeze on day one in case in the future that patient needs to have genetic testing on the embryos. We're able to do that with a day one freeze next. Uh The major insurers in massachusetts such as blue cross Tufts, Harvard pilgrim cover fertility preservation in massachusetts, Mass. Health unfortunately offers no fertility preservation benefit out of state, it's kind of hit or miss where there's only a few states that are mandated for uh fertility preservation. We luckily are one of them. If a patient were to self pay, It's $16,000 approximately depending upon the amount of medications the patient needs. There are some charitable agencies such as the livestrong program that will assist patients that don't have coverage and we do the coordination of that for the patient. There's a small, very small application for the patient to fill out and then the rest is fertility and oncology. Next Okay, option two ovarian tissue freezing. So this is commonly used when the oncology timeline does not allow for that two week window of treatment and again adding the extra couple of days in the beginning to get the insurance approval. This is done via laparoscopy with complete removal of the ovary. The tissue is then planed and frozen for use in the future. Next. The cost associated with this is the laparoscopy is usually covered and sometimes we can piggyback that on to like someone's having a poor placement or something like that. So the actual embryology portion is 1100 to Brigham and $800 to the Cryobank which will store that tissue for a year and then continue to build annually until the patient's ready to use that tissue. Ah We're still using we're still working on um how that tissue will be replaced. Whether it's physically replaced into the person that created the tissue or whether it the tissue itself can be can undergo IVF without being replaced. Next. And then lastly when chemotherapy is not expected to have a long term effect on fertility. Depo Lupron is advised. It kind of puts the ovaries into a menopausal state. Well the patient is being exposed to chemotherapy therefore the ovaries are somewhat protected. This is most effective in breast cancer. However it does give the patient an opportunity to not have to go through either of those two more aggressive treatments and just have the injection. Next. This is covered by most insurances again in massachusetts if the Lupron is ordered through oncology and given through oncology. So during the patient's chemotherapy Experience an RN would just give an inter muscular injection. Either 1 1 injection per month or once every three months. The patient will experience some side effects of this drug which are menopausal symptoms. So mood swings, hot flashes, night sweats, vaginal dryness. We offset that those symptoms with oral medication called a Justin, which is a progesterone to okay relieve some of those symptoms. But that has to be clear through oncology to make sure that it's appropriate and that patients case next for males. We have only one option. Well I guess there's more than one. But sperm banking is by far the most common option. So that is a fairly easy in terms of navigating this. It's not, it doesn't take a lot of time. Typically the oncologist will reach out. We are ends will arrange for appointments for the mail. We would like ideally if time allows Three appointments on a 48 hour schedule, something like a Monday Wednesday Friday schedule. And then after the third banking is completed, which is what we advise the R. N. Is then notified from the bank how much sperm the patient has. And depending upon that patients outcome that will dictate the care and the future whether the patient is anticipating a male partner in the future or a female partner in the future and how much the patient has banked will also vary on the partners treatment next uh again with in massachusetts, we are we do have good coverage for oncology care and mass. So uh for the most part it's covered by um all the major insurers in mass with a cancer diagnosis. Again, there are discounted programs besides the Brigham were very expensive comparatively to say California, cryobank or knowing that cryogenics if a patient does have to self pay, It's at Brigham, the first specimen is about $1,100 and each subsequent specimen is about 8:50. And then the store that covers the first year of storage. And then again, we would refer that patient out at the end of the first year to the programs that offer discounted rates such as vernon's purse, which reduces the storage fee To about $100 a year next. So why we feel of course that it matters so much is because unfortunately, so many patients are um faced with this part of their life that they weren't expecting to have to be dealing with at this time, they are newly diagnosed with cancer, which is a shock in itself and then being told, you have to address your fertility. So they're kind of thrown into our world without anticipating that happening to them or they're thinking, you know, in five years I'll have a child or whatever. So the difficulty for us is we don't want any patient ever to have to feel that they have to choose between their future family and their own physical future. So we're in the process now of working with the legislature to try to create a smoother track for males and females that are young and in reproductive age to make this available to everyone and to make it as happen as quickly as possible while fully supporting the patient while they're dealing with this completely unexpected aspect of their lives. Hi there. Ah my name is Dave chow. I am one of the one in 10 that Dr. Lam mentioned. People who are diagnosed with colon cancer Under the age of 50, as I mentioned at the top, I was diagnosed, diagnosed with stage three c colon cancer in 2019. I was 34 at the time. So certainly uh in the age range where I was considering my wife and I were considering family planning and so obviously a cancer diagnosis at this age uh upends so many of the plans that you have and throws so many things into chaos. Uh and certainly family planning uh fit into that space. Um You know, I was incredibly lucky to be treated at the young onset center where doctors and nurses were thinking about Issues that impact people in their 30s as opposed to just, you know, when most people think of cancer, they think of people who are a little bit older and might not be dealing with these issues. Um, you know, for us, we were definitely told That chemotherapy. I was I did 12 rounds of full Fox that that may impact my ability to have kids naturally. Um And so we kind of looked at it as taking out an insurance policy in a lot of ways. And it was something that we needed to get done before treatment as has been discussed today in which is a period where it is just it's such a whirlwind going from diagnosis. I had surgery. Um basically as I was being diagnosed, came up to boston to have my pork put in. And while I was doing that worked with Tricia and the folks at the Brigham to bank sperm. I did that twice up in boston and also did it down in the D. C. Area where I live at Shady Grove fertility. Um You know, I'll certainly say IVF was not something that was on our radar prior to my diagnosis. Um My experience with it and I'll say it's just another situation where being a man is certainly the easier side. Um You know, it it all went very smoothly. Both my experience with sperm banking and my wife's experience with IVF and the egg retrieval. Um that Tricia mentioned thankfully uh you know, while there's still a little bit of uncertainty as to whether I'll be able to have Children naturally. We do have embryos frozen and set aside so that we'll be able to have kids when we want to. Um you know I think it's the other piece that is so unnerving about this at least for me was you know, this is something that has a real impact on future plans. And when I was going through treatment, basically from the time I received my diagnosis through surgery through chemo, it was really just how do I get through this? How do I get through the next treatment, both physically and mentally. You know, how do I make it through these next few weeks, these next few months? And you're not really thinking or at least I was not really thinking about the future in any real way. Um This is something that impacts what I had viewed as, you know, my kind of life trajectory. And so being able to have people who are looking out for me and flagging this before I actually started treatment. So I had these options um really meant the world to me. Um I'll say, I mean, I think the mental piece of this is just as important as the physical. I feel the same way about actually going through treatment. Honestly, the lowest point of my entire cancer journey was after I had sperm bank for the first time, I received a report on my chart and I made the mistake. It's a mistake I never made again of reading the report without consulting with the doctor first um and saw levels sperm levels that were all below, you know, the average range. Um and so thinking at that point that I was not going to be able to have kids and this was um you know, the possibility that even the sperm that I was banking prior to chemo, that that was somehow not going to be viable. Um was devastating to me thankfully after talking to a doctor who actually knew what she was talking about, I found that that was not the case, but I think that as you go through this, the mental is equally if not as important if not more important as as the physical. Um And I think the last thing that I would say Trisha mentioned the cost. Um you know, I live in D. C. So I don't have access to the amazing healthcare that's offered in boston in massachusetts with regard to coverage for fertility as it relates to oncology patients. Um you know, I was certainly lucky to be able to afford the IVF and the storage of my sperm. Um and you know, hopefully we will be able to start a family soon through that process, but I understand that the cost can be prohibitive to so many. So I think it's important that there are options out there as Tricia mentioned um to help defray some of the costs for those who really need it. So thank you for allowing me to participate and share a patient's story. Thank you so much. And especially you, David, thank you for being willing to share your journey. And some of the difficulties and challenges that you encountered as you went through this, this very tough process. Um As David mentioned, we do have a slide of resources available that you can talk to your patients about and that your patients can take advantage of and that will be included in some of the materials with this webinar. Um At this point we welcome any questions from the attendees. You can, you can type them into the Q. And A box that the chat is disabled. So if you just type it into the Q. And A will be able to see them and hopefully get all your questions answered. Uh So why don't I start off perhaps with the first question to Tricia, what are the best options for women for fertility preservation in regards to success rates? You know, we understand that sometimes the timing may not always work out for women to be able to choose one over another. But if there were ample time and there was flexibility. What are the success rates of each of the various options you mentioned? Oh, I think you're on mute. Okay, so the the most successful option would be if time allows IVF with embryo freeze? If a patient is partnered with a male and IVF with egg freeze? If they're not partnered or they're partnered with a female? Mhm. That's the most viable tissue to then be able to access in the future. And the process of using that frozen embryo and or eggs is much, much easier than IVF itself. It's called a cryo preservation cycle. Mhm. And it's simply a matter of starring the embryo, letting it grow out to a certain degree of maturity either day three or day five, if there's going to be genetic testing and then transferring that product back into the the uterus with sometimes no medication at all. Sometimes only oral medication or sometimes oral medication with vaginal insert after about halfway through the cycle. So it's much less um taxing on the female too. Do a frozen cycle versus a fresh cycle. However, the fresh cycles are, you know, sometimes their only option, I typically do advise especially young women that aren't partnered or committed with their current partner. Uh if they embryos are more stable than eggs. So if they want to create embryo with someone, they're not in a long term relationship with they run the risk of having the partner not allowing them to have access to the embryos in the future. So we typically, in a younger patient would advise at least a split of egg embryo which is all still covered under the same umbrella of the approval. And as time goes on and we're getting better and better at egg freezing. The some of the physicians are leaning towards only advising eggs in young women without a significant other right now because then they can choose to fertilize that with whomever they wind up with. The next best option would be the Lupron injection. If time is of an issue there in terms of oncology treatment, it's not always appropriate for uh your patient population. Maybe not so much in gi because of all of the other factors. But it is a valid option for many cancers. And then lastly would be ovarian tissue where we're still kind of navigating. It's no longer experimental. We just passed that milestone about a year ago. But there's and there have been live births from ovarian tissue. But by far the most successful is IVF with embryo freeze. Thank you. That's very helpful information. Perhaps I can ask the next question to Miranda. Um We've heard about different radiation techniques. You know, there's I. M. R. T. S. B. R. T. There's protons. Do any of them or any of them do they carry advantages over the other in terms of fertility preservation. That's a great question. So um as I sort of alluded to him, the the talk, you know the um some of the reproductive organs, especially the uterus and the cervix can be very close to the area that we treat for rectal cancer. So there are some studies that show using potentially I'm R. T. Can help decrease the dose to the uterus um as well as ovaries, you know. Um And you know usually testes are out of the field. And so there's um considerations of additional shielding that can be used uh when radiation is given. So there are different technologies that can be considered um You know, I think there is you know, interest just in general for younger patients with protons. Um but those are often on a clinical trial and only available at certain areas across the country because there are only a certain number of proton centers. But it's um you know, I think the data isn't there yet to you know, say that people have to, you know, get different types of technology. But I think the most important thing is the communication that occurs upfront knowing that, you know, but this is a patient who is either young or wants to have that option open for them later. And it may be a combination of things where, you know, we do use um you know, I. M. R. T. Um in addition to uh consideration of ovarian transposition over in texas and moving it out of the radiation field. Um And so I think these are also important things to consider. Thank you. And then perhaps the next question for David, you know, I I know that uncertainty about what's happening next is one of the hardest things to deal with when somebody has been diagnosed with cancer. How do you balance that with your plans um for for a future family? And I know this is a really difficult question and it might be very individual for each person, but perhaps you have some tips or advice for other patients who may be listening Now, it's a it's a great and it's a timely question and it's something that I should have brought up earlier. Uh man, if I had the answer on how to deal with the anxiety around scans, uh life would be a lot easier for for me and a lot of other patients. Um but it's absolutely Um you know, something that that we're going through right now, um you know, I'm scanned every six months, as I mentioned about 18 months, any d at this point. But as you think about making long term plans and there isn't really a longer term plan than starting a family and having a child. This is something that always comes up and, you know, are we going to be in the same place in six months that we are right now? And, you know, are we prepared for what might come uh if we've if we take that step and, you know, a scan comes back. That has not been um you know, as as with as good news as what we've had recently, um I'm not sure I have the answer, you know, at this point, we're kind of taking it one at a time and and honestly Liz and I are looking at, you know, getting ready to to to start a family with those embryos that we have uh banked, we're looking for the right time and certainly this last skin that I had in august. So a little over a month ago was incredibly stressful and I think that a really main factor in why it was so stressful is because we're getting so close to taking that plunge. And so again, I wish I had an answer. The best answer I can give at this point I guess is just to let you know my experience. But we're kind of taking them one at a time and you know, the one piece that is always in the back of my mind is that I know that if I ever have a test that comes back in the way that you know, I've dreaded, I do know that I've the amazing team at the young onset center uh to fall back on. So um hopefully we'll you know, maybe another update in six months. We'll let you know. Thank you and best of luck to you and Liz thank you for sharing. And then we did have one question coming through the Q. And A. Maybe we will end with that one. And this one is um does anyone have any thoughts about how best to speak with transgender and non binary patients about fertility preservation? Because um understandably that conversation could be very difficult for them and and different. Um so does anyone maybe Tricia do you want to tackle that? Sure. Happy to address that. So that is another major part of our fertility preservation team population. Um So most of the transgender community that comes through to me are from the gem center over at Children's hospital. Oftentimes they're younger patients. And it's they get the same counseling that any other patient would get depending upon. You know what kind of anatomy they have and who they anticipate their partner to be in the future or if they have a partner or currently it's the same exact process. So the options are if they have ovaries, we talk about IVF with egg or embryo freezing. If they have sperm, then we talk about sperm banking. We talk about gestational carriers if they happen to be a couple that has both, both of them have uteruses, uh or both of them have testicles so we can guide them through all aspects of whatever their lifestyle is. And obviously we have to deal with the with the physically formed reproductive organs they have. But from there, once that tissue is frozen in whatever manner we can assist them in any way that is needed in the future. So important. Thank you very much. So we are at the end of the hour. Thank you everyone for attending. This is has been recorded and will be made available on our website in case anybody wants to pass it along or come back and revisit some aspects of the presentation. Thank you to all the panelists for joining and thank you everybody for attending and listening. We'll see you next time. Thank you. Mhm.
