Apr 11, 2019
Mary Lopresti, DO, is a hematologist oncologist with the Lifespan Cancer Institute, where she treats patients who have breast and gynecologic cancers. Most of her patients are younger than 42 years.
Welcome to the ASCO Daily News podcast. I'm Lauren Davis. And
joining me today is Dr. Mary Lopresti, a hematologist/oncologist
with the Lifespan Cancer Institute, where she treats patients who
have breast and gynecologic cancers. Most of her patients are
younger than 42 years. Dr. Lopresti, welcome to the podcast.
Oh, thank you so much, Lauren, for having me today.
We're glad you're here. Today we're talking about issues around
fertility and how cancer can present challenges to women who want
to be able to get pregnant and grow their families. Because you
treat younger patients, at what point in the diagnosis process do
you mention fertility options such as egg freezing?
Well, we've made it our practice at Lifespan to discuss this at the
first touch point with the patient. So our young women who are
newly diagnosed with breast cancer will come in to a
multidisciplinary clinic, and so they'll need a breast surgeon,
medical oncologist, radiation oncologist. And besides from talking
about their new diagnosis and management, at that point, we'll also
ask them if they plan on growing their family or having another
baby or a baby. And at that point, we'll ask them if they would
desire fertility preservation. And so we really from day 1 of
meeting them will explore that option.
What are some of the struggles in helping patients navigate cancer
care when they also have to decide whether or not they want to
preserve their fertility?
I think this biggest struggle is timing, trying to help this woman
decide on her breast surgical options, discuss genetic testing. And
many of these young women have aggressive breast cancers requiring
chemotherapy, so it's the timing of when we give the chemotherapy.
And then if we are planning to give chemotherapy, how does
fertility fit in?
Many times, I think physicians shy away from mentioning fertility
because there's a delay in chemotherapy, which is so important. And
so we've tried to get that timing down a little bit better by
developing an algorithm to get that woman to a fertility
specialized in a streamlined manner, and that has helped us
navigate these young women a little bit better.
What advice do you have for physicians who ideally would mention
fertility preservation but sometimes leave it out because of the
patient's need to start treatment such as chemotherapy as you
mentioned immediately?
Well, I think that it's very understandable for an oncologist to
feel like they need to leave it out if a young woman has large
tumor burden and they're very worried about starting systemic
therapy. But yet, I think it's really up to us as physicians to
make sure that the patient has informed consent. And ASCO has
published guidelines for preservation so that we can help educate
our patients on what options that they have. And I think we need to
continue to try to do that and put our own worries aside.
Are there patients for whom you do not recommend fertility
preservation? And how do those conversations go?
I'd say in general, no. I think we offer it to anyone who desires
to have a pregnancy in the future. Again, there's always a worry in
a woman who has an estrogen positive breast cancer, a large tumor,
bulky lymph node disease to recommend fertility preservation
because the concern has generally been that you could stimulate
very high levels of circulating estradiol level with preservation.
But now with letrozole, which is an aromatase inhibitor, and
tamoxifen, there are ways to decrease the estradiol level and still
get mature follicles as well. So I think that we do recommend
fertility preservation everyone.
And then just moreover on that point is that there was a recent
study by Rodriguez-Wallberg and colleagues. It was a Swedish match
cohort trial. And so they looked at women undergoing fertility
preservation compared it to age match controls, and there was not
an increase in the risk of recurrence with fertility preservation.
So it's a generally safe and can be done in about a two-week
period.
That's wonderful. What do you see for the future of cancer care in
oncofertility?
I think our knowledge will continue to increase as newer drugs come
on the market. I think we should all be concerned about fertility
because we're not going to know how they affect fertility in the
mechanisms there. So I think as physicians, we have to become more
educated, and I think we're going to see more physicians talking to
their patients. I think we're going to see more patients having
access to educational materials or looking on social media for
decision trees to help them with fertility preservation.
I think we're going to know more about other methods of fertility
preservation like ovarian tissue retrieval, which has been largely
experimental, but there has been more and more done with that. And
then there's pre-implantation genetic testing which is being done.
And we're going to be hearing more about that in the future as
well.
That's exciting. Again, today my guest has been Dr. Mary Lopresti.
Thank you for being on our podcast today.
Thank you.
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