Courtney Collen (Host): Hello, welcome to our podcast series ‘Beyond the Diagnosis’, focusing on embracing life after cancer, through Sanford Health survivorship programs. I’m your host, Courtney Collen with Sanford Health News. We’re so glad you’re here. Once a patient hears those words, “you have cancer”, that patient becomes a survivor. Through my conversations with health providers on topics related to survivorship, we’re learning more about how Sanford continues its commitment to help people live their best life beyond the diagnosis.
Our topic today is Oncofertility. I’m pleased to have not just one but two experts on this topic. Dr. Shelby Terstriep is a medical oncologist at the Sanford Roger Maris Cancer Center in Fargo, North Dakota, specializing in breast cancer and survivorship care. Dr. Keith Hanson is a specialist in obstetrics, fertility and reproductive medicine in Sioux Falls, South Dakota. Thank you both so much for being here. Welcome.
Dr. Keith Hansen: Thank you for having us.
Dr. Shelby Terstriep: Thank you so much.
Host: Dr. Terstriep, as the medical director of the Sanford cancer survivorship program, you have really led these efforts from the very beginning. Give us an overview of what the program is all about.
Dr. Shelby Terstriep: What I found out in training was that the cancer treatment is just such a very minute part of a person’s life. All the other things that go along with the diagnosis, we can really help improve those things along the way as well. What survivorship is, is really focusing on wellbeing. It’s, you know, the physical, the mental, emotional the social and financial wellbeing. So, really taking a look at the other things beyond the cancer treatment. Now the cancer survivorship program, what we really focus on is listening to the cancer survivors and having them tell us what they think they’re missing along their journey and then we really focus on our efforts on creating programs to help address those issues. One of those issues has been oncofertility. And so I’m really pleased to be able to talk about some of the things that we are doing to help improve that process for our patients.
Host: What is oncofertility?
Dr. Terstriep: The intersection between oncology treatment and a person’s fertility and their desire to have children. We know that cancer treatment can affect fertility in some cases, so our goal with oncofertility is really to think about those cases and try to address that before those treatments happen so that we, we can make sure that those patients can accomplish their family planning desires.
Host: Dr. Hanson, how does cancer affect somebody’s fertility?
Dr. Keith Hansen: Well, thanks for asking. It’s not really the per se that affects the fertility, but at the treatments, Many of the treatments are directed at rapidly dividing cells and that’s why they work so well because cancers are kind of uncontrolled division. So, these cancer therapies like radiation and chemotherapy usually are directed towards rapidly dividing cells. And one of the areas in the body that has cells that are dividing include the ovary and the testicle. Besides getting rid of treating the cancer itself, they also have side effects where they can damage other organs like the testicle and the ovary. The other thing is for certain cancers like GYN cancers, the surgery itself can be damaging to the ovaries. Let’s say it’s ovarian cancer and they have to remove an ovary and take samples out of the other ovary that reduces the amount of ovary that the woman has and can actually impact her fertility, too.
Host: What options do patients have for preserving their fertility before beginning a cancer treatment?
Dr. Hansen: Well, that’s a great question and there’s a lot of different options available depending on the type of cancer and also the type of treatment that is planned and what’s going on. One example is in many of our young girls that have a big ovarian tumor. A lot of times the GYN oncologist will try to do is go in and try to do an ovarian preserving surgery so that they can hopefully save the ovary, the part of the ovary that has the eggs in it, or at least save the other ovary so that we can have future fertility possibly. And then if they’re planning to do radiation, especially if they’re planning to do pelvic radiation or low back radiation, one of the things we can do is we can actually move the ovaries up out of the, out of the radiation field.
Most of the patients who come in are planning to do either chemotherapy or radiation therapy. For chemotherapy, there’s a couple of different options available. First of all, you know, the chemotherapy has adverse effects upon the ovary and those adverse effects depend on a number of factors – one of them being the age. A young pre pubertal girls ovaries are a lot more resistant to chemotherapy than a post pubertal girl. And then a 19 year-old woman’s ovaries are much better, more resistant to chemotherapy than a 20 year-old, 29 year-old girl who’s are much more resistant than a 39 year-old girls. So as the ovaries have reduced number of eggs with the natural process of aging, they become more sensitive to the effects of chemotherapy.
So what can we do? Well, one of the options available is, and probably one of the ones that’s most accepted, is to do in vitro fertilization and go in and retrieve eggs, and then either freeze eggs or if they have a husband or want to use donor sperm, we can fertilize the eggs and then freeze embryos. The nice thing about freezing embryos is they’re a lot more resistant to the freezing thawing process than eggs are. So it takes a lot more eggs to achieve a pregnancy than it does embryos. So one of the processes is to do in vitro fertilization, retrieve eggs, and then either freeze them or fertilize them and freeze the embryos. The only problem with that is we need time. You know, we need at least probably 8-to-10 days to stimulate the ovary and take the eggs out. We’ve made a lot of advances in that we’ve done. We now are able to stimulate the ovaries at pretty much any time in the menstrual cycle to try to speed that process up. That’s one option. Another option is to use a drug like Lupron or Lupron glide acetate, which is what’s called a GnRH agonist. What it does is induces a pre-pubertal state. Now, what that is trying to do is reduce the number of cells that are dividing actively in the ovary. And by doing that, then we can hopefully they’ll become more resistant to the chemotherapy as long as they don’t get a huge dose of chemotherapy. And hopefully they’ll survive the process of the therapy. One of the problems that can happen in young girls who get chemotherapy is their white counts can drop their platelet counts, can drop. They can have very heavy periods. And so the Lupron or the loop light acetate, the GnRH agonist actually can stop their periods during this process of chemotherapy and actually stabilize them. So they don’t get into trouble with very, very heavy periods. So we kind of liked that drug, and we can even combine that within vitro if we need to. Another process that’s available is to actually freeze the ovary. But you have to go to surgery to do that. You do a laparoscopy, you know, where we put the incision in the belly button, put the scope in, we take out an ovary. You only just remove one in case the other ovary will survive the chemotherapy. And by doing that, then we can freeze the ovary, which we usually have to mince it up into small pieces, and then we can freeze it. Later, when the person is done with our chemo, you can throw out the pieces and put them back into the pelvis. The only problem with that is you better be absolutely sure that there’s no metastatic disease or any cancer cells in that ovary before you put it back in. We don’t have good ways to test that now we’re working on it, but we don’t have good ways. The other thing they’re working on is trying to make it so they can stimulate the eggs out of the ovary without in vitro, without having to put them back in our body, just do it outside the body. And so those are really kind of the big areas for a woman, a guy, you know, a male who’s getting ready to do chemotherapy. We can do you know, have him give us a semen sample. And then we can, cryopreserve it.
Dr. Terstriep: I think the bottom line for us as an oncologist is to really think about it right away and make the referrals right away so that we can not waste any time. Most of the time, we have eight days to before we really need to start treatment. It’s really a change in our pattern of, of thought processes to think fertility first and then treatment second, which is great. I mean, when you think about it is we’ve come that far with cancer treatment that we’re really concerned about them having kids afterwards. I mean, I think that’s a Testament to oncology advancement.
Host: If a newly diagnosed cancer patient has concerns or questions about fertility, when is the best time to have that conversation?
Dr. Terstriep: The moment they’re diagnosed.
Host: …and who should it be with?
Dr. Terstriep: Our navigators are one of the first people that will be discussing who they’re all going to be seeing. I think it’s appropriate to start addressing it with the navigator and their oncologists right away.
Host: Let’s talk about after cancer treatment. When is it appropriate for a cancer survivor to have children?
Dr. Hansen: We usually work in concert with the hematologist oncologist and find out from them how long they think the patient needs to wait with no evidence of disease before they try to conceive. We also chat and have the patient meet with a maternal fetal medicine doctors who are our high risk OB/GYN doctors. And we of course meet with the patient and all of us together sort of help the patient decide when they should start to try to get pregnant. And we discuss, especially with breast cancer patients, when can we safely start them on estrogen because pregnancy has a lot of estrogen in it. So, you know, so we do communicate a lot with people.
Dr. Terstriep: I think it’s very different depending on cancer and depending on the age of the person. We think of cancers, really as thousands of different diseases. And so each of those diseases have a different likelihood of recurrence and difference in how fertility could impact that.
Host: If we’re talking about considering fertility preservation, is there any financial assistance available? How might somebody go about looking into that?
Dr. Hansen: That’s a great question. We’ve actually, you know, one of the problems is that, you know, a lot of these procedures are expensive and they’re a lot of times the insurance companies won’t cover them. The American Society of Reproductive Medicine, and a number of other groups, are in the process of trying to get states to mandate insurance coverage for oncofertility because a lot of the insurance companies will come back and say, ‘Well, we don’t cover infertility’. Well, this is not infertility. This is preserving fertility. They’ve already got a number of states to mandate coverage. But right now, when in our area and in a lot of places, it’s not covered by insurance. So we work with a lot of groups. We work with Fertile Hope, you know, and they help to sometimes fund part of it. We’ve talked with Sanford and they’re willing to give us a write-off or ready to reduce the cost of the procedures that we do, but they are really willing to work with us to try to help these people, you know, to be able to achieve this process because it really does help them improve their mood, improve their ability. When I meet with a lot of these gals and you know – Dr. Terstriep might be better at answering this – after we talked to him and he say, you know, they just go from crying to happy that there’s a possibility that they might build a preserve their fertility in the future. So we do a lot of things to try to help them to get help with covering it. If they decide to do Lupron, to shut everything off, a lot of AbbVie who makes it as willing to help cover it for us and stuff. So we, we do a lot of work with those groups.
Dr. Terstriep: We make every effort to try to make it as affordable as possible for our cancer survivors. But it’s a problem. And we’ve been really strongly advocating in the in the states to try to get this funded. But in the meantime, until that happens, one of the easiest and quickest things that we have been successful with is really using GoFundMe’s for these patients. These patients will you know, people want to know how they can help. And that is a peer-to-peer fundraising has been really effective for this it’s, you know, not what we want to have to do. We’d rather have insurance cover it. But when, when it’s a matter of somebody getting this treatment before or not getting it because of financial reasons, it’s, it’s pretty effective.
Host: If a patient undergoing cancer treatment does not wish to pursue fertility preservation, what other family planning options might be available?
Dr. Hansen: Well, first of all, you know, some people will go through chemotherapy and they will still maintain perfect fertility. So, it’s not always sterilizing. Now it depends, once again, you can get doses that are always sterilizing, both of chemo and radiation therapy, but some of the chemotherapies are a lot less sterilizing. There are a lot of different options. One option, if it’s the male, a donor sperm is, is always an option for them to use. The other, if it’s the female, is use donor eggs. There’s two, major ways you can do donor eggs. One is if you have a known donor, like a sister who wants to donate her eggs, we can go in and stimulate her ovaries, take the eggs out, fertilize them with her husband’s sperm and then put the embryo backup in and that has a very, very good fertility rate.
There’s actually now what are called donor egg groups where they actually have you know, cohorts of eggs that have been cryo-preserved from young, usually college age women who go through the process and will freeze their eggs. So it’s kind of like a egg bank as compared to a sperm bank and you can actually purchase them and they can send them up to us. We can thaw them out, fertilize them, and then put them up inside and inside the uterus and the gal can have a baby that way. There’s donor embryos where couples that have went through in vitro fertilization, and let’s say have triplets, and ‘I have leftover embryos, you know, we’re done’ and they decide they can give them to other couples and it’s, they can have a baby that way there’s adoption. And then finally, there’s some very interesting studies going on. A guy at Magee Women’s Hospital is doing with trying to reconstitute the gonads, either the testicle or the ovary. He’s been successful in reconstituting the male rats’ gonad, which is kind of science, amazingly science fiction from basically from the skin STEM cells. So who knows what will happen in the future. There are other options that are available and things that can be done.
Host: Thank you. Let’s talk the oncofertility navigation program at Sanford. Dr. Terstriep, tell me about this navigation program, what it is, and how did it start?
Dr. Terstriep: As a solution to what our cancer survivors were telling us that were holes in their care. And what they felt was there was, we needed to have a bridge between the reproductive endocrinology department and the oncologist. What this navigator will do is really help to assist with education and help with some of the financial issues so that is not a barrier for them having to even be referred to reproductive endocrinology. We know a lot of times they won’t even go to that appointment because they’re worried about the financial issues. The other thing is really collaborating between the two departments, a facility facilitating that collaboration. Finally, you know, one of the things that we heard loud and clear from the cancer survivors were that it’s very hard for them to bring up when should they use their embryos or their frozen sperm, or when should they think about having more kids, because they really felt when they were with the oncologist, if the oncologist wasn’t bringing it up, they should just be thankful that their cancer wasn’t back and that it probably wasn’t the right time to be thinking about that because their oncologist wasn’t talking about that. When reality, you know, often as oncologists, we think, ‘well, they’ll bring it up if it’s important’. And so it was just a little, you know, a, one of those kind of miscommunication type of moments that can happen. What that navigator will do to really help keep the family planning front and center until those cancer survivors feel that their family is complete. So, we’re really excited about this program and really think that that will help bridge that gap that our survivors we’re seeing. And this is really something that is, you know, innovative and not being done everywhere. As we start to really listen to the cancer survivors, that we really can come up with these innovative programs to meet needs, you know, before anyone else can.
Host: At what point does a patient get involved in the fertility navigation program and talk about what that looks like.
Dr. Terstriep: I can give you an example. Yesterday, I had a patient who was going to be starting breast cancer treatment and I wanted to get her in to see reproductive endocrinology. I had a navigator come down and help to educate them about that process and about some of the financial issues and how can they help to alleviate some of those issues. After they were seen by reproductive endocrinology, they worked with their team there to make sure that I knew when the eggs were going to be harvested, when I could be starting chemotherapy, and how would that go. She will be starting treatment after the eggs are harvested, and then our navigator will keep in touch with her and we will make a plan for when it will be appropriate for this person to start having to start thinking about having kids and implanting those embryos. Then, the navigator will touch base with her at those times to start that process and, make sure that I’m thinking about that as well.
Host: And Dr. Hanson, we were talking earlier about pediatric oncofertility. We’re not just talking about adults who are cancer survivors and looking at potentially having children in the future. Talk about what you’re seeing in the pediatric space.
Dr. Hansen: Well, very similar to adults, you know, there’ve been a lot of, of progression in the treatment of cancer in children. Now, upwards of 80-85% of those kids survive. When you have that many children that are surviving chemotherapy radiation therapy, it does increase her risk of having infertility or sterility. And that of course is really important when they get older. So, the issue with the children is the pre-pubertal, it’s a little more difficult because of course they’re not making actually gametes at that point. So the ovaries are totally quiet. They’re not making eggs. The testicle is quiet. They’re not making sperm. So, people are looking into potential ways to help in those kids, especially those that have to have very high levels of dose of chemotherapy or radiation therapy. What’s being investigated now is either taking a biopsy, or an entire ovary out of the young girl, and possibly taking a biopsy, or an entire test account of the young guy, and then hopefully be able to use the cells that are within the testicle or within the ovary to reconstitute the testicle or ovary after they’ve gone through other chemotherapy and help them to be able to reverse their sterility and help them to be able to go through a natural puberty. It’s still considered experimental. Once they go through puberty though, then they have the other options that we’ve already talked about for a post pubertal person. It’s a little bit different though, because of all the stuff, you know, it’s a lot to go through for a young woman anyway.
Dr. Terstriep: I think these are situations where the navigation is going is so critical because these kids are so young and they have many years before they’re even thinking about starting to have families. So to even know where their tissue may be stored sometimes can be forgotten. I think that navigation program will really help to alleviate some of that stress for these young kids.
Host: Yeah. Dr. Torres, drip, what is it like for you to see cancer and reproductive endocrinology teams working together to address these concerns and really give patients even more specialized fertility care?
Dr. Terstriep: Oh, I mean, it is absolutely awesome. When you see a cancer survivor bringing their new baby into the clinic with you, it’s one of those days that you cry happy tears. I mean, it is absolutely some of my favorite days that I work in, in the cancer clinic.
Host: Love that. So if somebody has questions or might be looking for resources, where should they begin?
Dr. Terstriep: I think the cancer survivorship program in each region has cancer survivorship navigators who they can be put into contact with. Then we can take it from there and help to facilitate those referrals and conversations.
Dr. Hansen: We’ve had a navigator that’s started to work with us, and she’s wonderful to have. I mean, it’s really nice to have somebody to bridge the large gap between or the gap. I don’t know that large is true, but the gap between the oncologists and us, and then allow for better communication because, you know, to find out, well, what treatment are they planning? And then tell them what, you know. And so it really is a very, very nice program. And I think it, I think it’ll really help our patients by letting them know what’s available and somebody to just kind of keep track of everything. ‘Cause man, it’s really complicated.
Dr. Terstriep: We have our reproductive endocrinologist practice state-of-the-art care that, and they are so incredibly responsive to our cancer patients. I would say they would drop it, you know, they would drop everything, you know, extend their hours to get, to get these patients in. And I think we are so lucky to have that type of expertise, but also that care and compassion that they bring.
Host: Yeah. So important. And what other areas of support would you recommend for cancer survivors?
Dr. Terstriep: An additional area of support that cancer survivors can utilize is our Facebook Sanford Health Cancer Survivorship page on that is an area that we really drive all of our events, information, our educational efforts and our cancer survivorship retreats. It’s a one-stop shop for you to be able to get information. So we’d love for you to connect with us so that we can keep you informed of new and exciting programs and educational series.
Host: I learned a lot today! Dr. Terstriep, Dr. Hansen, thank you both so much for your expertise and for teaching us more about oncofertility navigation program at Sanford Health. This has been another episode of our cancer survivorship podcast series Beyond the Diagnosis. I’m Courtney Collen. Thanks for being here. Have a great day.