Preserving Fertility in Children with Cancer

Podcast Transcript

Scott Steele: Butts & Guts, a Cleveland Clinic podcast, exploring your digestive and surgical health from end to end.

Hi everybody, and welcome again to another episode of Butts & Guts. I'm your host, Scott Steele, the Chairman of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. I'm very pleased to have a topic we haven't covered before, and that's preserving fertility in children with cancer. I'm pleased to welcome our expert, our own Seth Rotz, who is a pediatric oncologist. He's also the Director of the High-Five Cancer Survivors Clinic at Cleveland Clinic Children's. Seth, welcome to Butts & Guts.

Seth Rotz: Yeah, glad to be here. Thank you.

Scott Steele: Just as a little bit of background to set the stage for our audience. Advances in pediatric cancer treatment allow more than 80% of children to survive at least five years and hopefully long-term after their diagnosis. What we're looking for, and what we're going to talk about today is trying to address some of the long-term potentially negative consequences with some of the cancer therapy, is extremely important. One of those is infertility, a very top concern, and we're really looking forward to discussing this with Dr. Rotz today. For those who don't know you as well, can you give us a little bit about your background? Where are you from? Where'd you train them, how to come to the point that you're here at the Cleveland Clinic?

Seth Rotz: Yeah, absolutely. I grew up in Northeast Ohio, myself. I've been in Ohio throughout my training. I actually trained in internal medicine and pediatrics before I became a pediatric oncologist, so I'm familiar taking care of adults. In my clinical practice, I see kids with cancer and kids that are getting bone marrow transplants, but my real passion is taking care of long-term survivors and making sure that, even after they're treated that they're staying healthy for the long-term. That's where some of my background in internal medicine comes in, is people start to get up there in age, to make sure that somebody is looking out for, hey, you got radiation or you got chemotherapy as part of your treatment. What kinds of things do we need to be thinking about as you get older, in terms of keeping you healthy? That's the background in my clinical practice.

Scott Steele: Obviously, these are delicate conversations, especially when it talks about not only with youth, but also with their parents. Can you give us a little bit of some insight into how do you even start that conversation about fertility preservation and how old do you deem that you want to have this in mind? How do you go about that?

Seth Rotz: Yeah, it's a great question. Depending on the patient's age, sometimes the conversation is more with the patient. Sometimes it's more with the parents and sometimes it's a combination of both. We treat kids, infants with cancer and we also treat young adults with cancer, so it really depends on the patient's age in terms of how the conversation goes. But our goal is to have a conversation about fertility and infertility and potential fertility preservation options with all of our new cancer diagnosis patients before we start therapy. Yeah, the conversations can be delicate, but, and they can be awkward frankly, sometimes too. But the bottom line is I think most people are really receptive to hearing this because as patients and families get a new cancer diagnosis, it's incredibly unsettling.

But I think for a lot of folks too, starting to have that conversation about fertility is a little bit of a bright point because all of a sudden you have this diagnosis of cancer, but you're also talking about getting over that cancer and trying to think about life on the other side of things. I think a lot of families, as tough of a conversation as it can be sometimes, appreciate that we're thinking about taking care of these things long-term. Different families have different levels of interest, depending on the age. We try to meet families where they are. We just try to give them all the facts so that they can make the best decision possible, but there are different options available for all different ages of folks. I think we'll talk about that coming up, but yeah, there's no age that's too young. Although, some things are experimental, there's possible options for most age groups.

Scott Steele: What are the fertility-preserving options for males and females?

Seth Rotz: Yeah. There's a spectrum of things, depending on the patient's age and how much time we have before we need to start therapy. Certainly things are a little bit simpler in patients that are post-pubertal. For males, cryo-preserving sperm is fairly easy and straightforward and we can do that pretty quickly, even if we need to start therapy right away. In females, we can actually make a referral to women's health and they can do something called a random start ovarian stimulation. They give a couple of different hormones and within about two weeks or so, a lot of times, they can harvest some eggs and then freeze those for later use.

If it's a married couple or something along those lines, you can actually fertilize those eggs and freeze them as embryos. There's a couple options there, but for females, it takes a little bit more time to do things and sometimes time is of the essence with a new cancer diagnosis, but a lot of times we can actually slow down and do that, if that's what folks wanted to do. For younger females or females that don't have as much time, we can actually do something called ovarian tissue cryopreservation. This consists of actually taking the ovary out of the body and freezing it. Then later on, when the patient is interested in having kids, you actually can re-implant parts of that ovary and they work pretty well. There's been over 100 babies born this way, so that's no longer considered experimental.

That's an option for prepubescent females or females who maybe, you need to get chemotherapy started right away. In males, it's really experimental at this point, but something that folks are working on is called the testicular tissue cryopreservation. This is actually taking a small piece of the testes out, freezing it. The idea being that, somewhere along the lines, we'll have the technology available to re-implant that tissue and eventually produce sperm. In monkeys there's been some offspring produced that way, but never a human baby. Hopefully, in due time, we'll have the technology to be able to do that.

Scott Steele: Let's go a little bit more into those experimental therapies. Any other ones that are out there or anything that you can think of that's on the horizon in terms of this?

Seth Rotz: Well, right now, when we have these conversations with folks, we know technology is changing significantly. A lot of times our goal is to say, "Hey, let's just get stuff in the freezer right now and we'll see where things are at in 10 or 20 years down the line when you're interested in having kids." One of the things right now with the ovarian tissue is, that we have to be cognizant of, is if there's a couple of cancer cells hanging out in that ovary, we absolutely don't want to re-implant that 10 or 20 years down the line, once somebody is cured of cancer. Some of the lab work that's going on, is trying to take that ovarian tissue out and separate some of those really primordial eggs that are in there and be able to basically just fertilize those eggs, as opposed to putting that ovarian tissue back in, so that there's really no chance of reinserting the cancer.

That's something that people are working on in the lab right now. Then in terms of that male testicular tissue cryopreservation, a lot of times when you do that, it would be a prepubescent male, and trying to find ways to take those prepubescent sperm stem cells basically, and mature them outside of the body is an area of active research. Again, when we're having these discussions with patients and families, especially with these really young kids, we don't know exactly how this technology is going to develop over the next couple of years, but my general sense with parents is, "Hey, let's get it in the freezer, so if there is this technology that develops, we got a chance later."

Scott Steele: That's fantastic. Let's go into what I like to call Truth or Myth.

Seth Rotz: Okay.

Scott Steele: Cancer treatment can be modified to preserve fertility. Truth or Myth?

Seth Rotz: I think that's true. Certainly, some types of cancers have a tried and true method. We know treatment regimen A works best and we don't really want to compromise there, or maybe there's only one treatment regimen, but there's certainly other diseases where we have a couple of different, I'd say equivalent treatment options. One diagnosis that comes to mind is Hodgkin's Lymphoma. There's a lot of different ways that you can treat Hodgkin's Lymphoma, all with fairly similar outcomes. Some of those regimens are more toxic, in terms of fertility. Some are more toxic because they require radiation that might affect breast tissue and increase the risk for breast cancer later on.

When we have those diagnoses where there's not one clear standard of care, we like to have those conversations with patients and families and say, "Hey, these are the pros and cons of each regimen here. What can you guys sleep with at night? What feels most comfortable to you?" So, we will, at times modify things. If people feel really strongly about trying to limit one type of side effect, we'll absolutely do that. The other thing that we can do, and I touched on this a little bit before is, in general, try to treat new cancers pretty quickly, but sometimes we have more time than we give ourselves credit for. I think a lot of folks are really anxious to get started, but I think just the, sometimes we're a little bit able to sit back and do some of these fertility preservation techniques, like the egg harvest that we just talked about if we're able to wait two or three weeks before we're starting treatment. In that respect, we can modify treatment. We can wait a little bit, so that we're able to do some things.

Scott Steele: Truth or myth. A patient's gender age at the time of treatment can have an impact on future infertility?

Seth Rotz: Absolutely a truth. More so on the female side. We know, first of all, when we look at the risk of infertility in males and females, the ovaries are generally a little bit more hardy than the testes. The females are a little bit tougher, a little bit more resistant to infertility. But in particular with females, we know prepubescent females are a little bit more able to tolerate radiation and chemotherapy, a little bit more than post pubescent females. There's not necessarily a true age cutoff, but really the pubertal status can affect the risk of infertility at the time of treatment.

Scott Steele: I know I asked you this a little bit earlier, but what's on the horizon as far as the future research in the treatment approaches for this further fertility preservation?

Seth Rotz: Yeah. We touched on some of the lab experiments. There's a couple of drugs out there that people have tried. The term ferto-protective, it's kind of a funny term, but the idea that you can perhaps give some drugs during cancer treatment that can help affect or help prevent infertility. The main group of these drugs is called GnRH agonists. That's mostly for females, drugs like Leuprolide, and the data on that is fairly mixed. There's some more trials getting designed now, so we can get some definitive answers if giving these drugs during treatment can help protect the ovaries.

Then there's some other, preclinical drugs on the horizon, to try to protect fertility. But I think really the main things that we talked about earlier is, particularly in the prepubescent kids, trying to refine those technologies so that, "Hey, you don't need to make a decision right now, but let's, take out an ovary or take out a piece of testes and put it in the freezer and have some confidence that we can use that, down the line, if you're interested in having kids and really refining those techniques, is a lot of where the research is right now.

Scott Steele: Let's, as we close up shop here, can you give our listeners a little bit of an overview about Cleveland Clinic Children's Survivorship Clinic?

Seth Rotz: We have a survivorship clinic. We see folks that were treated for childhood cancer or young adult cancers. We see people up to all ages, so you don't have to be a child to come there. Basically, what we are is, we're a specialist with expertise in cancer survivorship. We're not seeking to do primary care, but we're there to talk about, what was the type of cancer treatment that you received and what are the potential risk factors? We also have partnerships with various specialists throughout the Cleveland Clinic Institution. For example, if you received a type of chemotherapy called anthracyclines, those can affect the heart functioning and in puts you at risk for heart disease, as you get older. Now, we have cardiologists both in pediatrics and adults that have particular interest in this. For example, if you got one of these types of chemotherapies, we might order an ultrasound of your heart to make sure your heart was in good shape.

If we saw something a little bit off, depending on your age, we refer you to somebody in the institution, who's got some expertise in this and this goes across all different areas. We see folks, again, of all ages that were treated for cancer. We have a discussion about what chemotherapy they got and a lot of times we're able to figure it out, even if patients don't know, and then make sure that we're adequately screening and really trying to inform and empower patients to take control of their health so that they're aware of what risks may come up as they get older and, and trying to help them navigate those risks.

Scott Steele: That's fantastic stuff. We like to end each of these with our experts getting a little bit better to know you. We'd like to end up with some quick hitters.

Seth Rotz: Okay.

Scott Steele: First of all, what's your favorite meal?

Seth Rotz: What's my favorite meal? Oh, goodness gracious. During the pandemic, we've been having a ton of takeout. I've been really enjoying Indian takeout more recently, I guess.

Scott Steele: What's your favorite sport?

Seth Rotz: Baseball. I'm a big Fantasy Baseball player. It was an interesting season this year, but really enjoy watching baseball.

Scott Steele: Race to the finish. What is the last non-medical book that you read?

Seth Rotz: The last non-medical book? I just read a book about the Civil War, called the The Killer Angels, which was quite interesting. It's a historical fiction, but it's from the perspective of the generals in the Civil War.

Scott Steele: That was mandatory reading when I went to West Point. Then finally, what is one of the favorite things that you like about living here in Northeast Ohio, in Cleveland?

Seth Rotz: I like the summers more than the winters. Cleveland's a fantastic place to raise a family and for seven or eight months of the year, I think we just have absolutely fantastic weather. Now, I won't comment too much on the wintertime, but I just love the summers here and dealing the pandemic, of course, this year in particular, it was so nice to be able to be outside for a while and not be overwhelmed with the heat, but just enjoy some of the natural treasures, to be able to walk around all the areas of Lake Erie and the Metroparks with my family, and to go running and some of those places to help clear my mind. I love it here.

Scott Steele: That's great stuff. Give us a final take-home message for our listeners, regarding this whole topic of fertility and preserving it in children with cancer.

Seth Rotz: Yeah, I think, if I was to have one take-home point, I think all families dealing with a new cancer diagnosis should be having a conversation with their oncologist at the time of diagnosis about the risk of fertility and potential options. We know, when we talk to cancer survivors that this is number one or two on their mind, when they come to Survivorship Clinic. They are often asking, "Hey Doc, is this cancer coming back?" Number one. Usually, if they're in Survivorship Clinic the basic answer is "No, it's not coming back." Then number two is, "Am I going to be able to have kids?" I think having that conversation early on, setting expectations and when we do have the ability to offer fertility preservation to do so, but I think number one is just having that conversation with folks as early as possible.

Scott Steele: Well, we sure appreciate you taking the time with us here and to learn more about cancer treatment options at Cleveland Clinic Children's, please visit Clevelandclinicchildrens.org/cancer. That's Clevelandclinicchildrens.org/cancer. To make an appointment with Cleveland Clinic Children's, please call 216.444-5517. That's 216.444-5517. In times like these it's important for you and your family to continue to receive medical care and be rest assured that here at the Cleveland Clinic, we're taking all the necessary precautions to sterilize our facilities and protect our patients. Dr. Rotz, thank you so much for joining us on Butts & Guts.

Seth Rotz: Yeah, it was great. Thanks for having me.

Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.