Unique Aspects of Pediatric Care Delivery Model: Pediatric Oncofertility 2017

Childhood cancer represents less than 1% of the nearly 1.6 million new diagnoses of cancer in the United States every year, which amounts to over 15,000 children diagnosed with cancer annually

Less than 1% of cancer diagnoses amounts to 43 children diagnosed every single day and about 40,000 children in treatment in any given year in the United States

The average age at diagnosis for childhood cancer is 6 years old

Childhood cancer affects all ethnic, gender, and socioeconomic groups with no bias

Most pediatric cancers result from DNA changes that can be found early in life, even if the disease does not manifest for several more years

Unlike adult cancers, pediatric cancers are usually not linked to any environmental factors and not linked to any lifestyle factors

Most pediatric cancer patients are treated at a children's oncology group center, and children are more likely to be treated on a therapeutic trial than in the adult population

In children under 14 years old, leukemia and lymphomas make up the vast majority of diagnoses, followed closely by CNS or brain tumors

In adolescent or young adult patients, leukemia and lymphomas are still common, but lymphomas make up a larger proportion largely due to Hodgkin's lymphoma, and sarcomas and solid tumors take up a greater percentage of diagnoses

Childhood cancers typically grow very quickly and some will also spread very quickly, with minimal time between presentation, diagnostic workup, and start of therapy—sometimes within just a couple of days or just a week or two

Childhood cancer patients respond very well to traditional chemotherapy and can tolerate much higher doses and compressed chemotherapy schedules compared to adult counterparts

Traditional chemotherapy is specific for the cell cycle but not necessarily specific for the cell type, so it will affect non-cancerous cells just as much as cancerous cells, which can lead to late effects

Gonadotoxicity associated with cancer therapy includes delayed puberty, early menopause, azospermia, and loss of fertility

Research has shown that fertility is extremely important to patients and their quality of life post therapy, regardless of their age, diagnosis, and whether or not they've already had children

There is a tendency to try to minimize radiation in the pediatric population as much as possible because of the late effects associated with radiation and the fact that they can accumulate as the years go on

Premature menopause may allow a window of opportunity to do fertility preservation in female survivor patients

Data presented at ASCO in 2016 by Doctor Levine from the CCSS showed that female childhood cancer survivors between ages 20 and 29 did not have any statistically significant difference in pregnancy rate compared to their sibling controls

Most oncology therapies now are risk-adapted therapy, where disease is staged at diagnosis and restaged after one or two cycles to identify rapid early responders who receive less intense therapy and slow early responders who continue more intense therapy

Female childhood cancer survivors between ages 30 and 39 had a significantly decreased rate of pregnancy compared to controls, indicating a window of opportunity but requiring quick action due to risk of early menopause

Risk-adapted therapy allows delivery of therapy appropriate to the patient to achieve optimal cures while minimizing late effects, so patients responding well to therapy do not get extra therapy they don't need

Male patients have been shown to be very interested in knowing their risk status and being offered a review of their risk as well as a semen analysis to know where they stand post therapy

Newer immunotherapies include CAR T cell therapy where the patient's own T cells are harvested and genetically engineered to attack a specific target on cancer cells

All patients benefit from counseling and from reviewing their fertility risks

The ASCO consensus statement says that informed consent about fertility should happen before cancer therapy and as early as possible to allow the greatest number of fertility preservation options

Targeted therapies specific to cancer cells include monoclonal antibodies, bispecific T cell engineered therapy, kinase inhibitors, PDL1 inhibitors, small molecules, and anti-angiogenesis agents, which are more specific for cell type so fewer non-cancerous cells are damaged

If fertility preservation services are not available in your area, they should be offered through a referring center who can provide that service for the patients

It is important to talk to the parents of children and minors as well as patients of consenting age about fertility preservation, and this treatment should continue through survivorship

The current 5-year cancer-free survival rate in pediatrics is over 83%

In 2013 it was estimated that about 420,000 childhood cancer survivors were living in the United States, with an estimation of 500,000 or half a million cancer survivors by the year 2020

Some fertility preservation techniques really don't require a lot of time to complete and don't interfere very much with the timing of therapy—they can be done quickly and efficiently

Patients really embrace fertility preservation discussions and are extremely appreciative of the knowledge and the chance to even just think about having children in the future, as it gives them hope for the future