1. Pediatric Oncology Perspective
Karen Burns, MD MS
Co-Director, Comprehensive Fertility Care and Preservation Program
Cincinnati Children’s Hospital Medical Center

2. Outline
Epidemiology
Therapy
Survivorship
Consensus statement

3. Childhood Cancer
Childhood cancer represents <1% of new cancers diagnoses in US each year
Childhood cancer is NOT rare
>15,000 children are diagnosed each year
43 children are diagnosed every single day
Over 40,000 children are in treatment every year
Average age at diagnosis is 6
Affects all ethnic, gender, and socio-economic groups

4. Childhood Cancer Result from changes in DNA allowing infinite growth
Early in life
Not linked to environmental or lifestyle factors
Most children with cancer are treated at a Children’s Oncology Group (COG) center
Children are more likely to be treated on a therapeutic study

6. Childhood Cancer Generalizations
Cancers grow fast
Some will spread quickly
Minimal time between presentation, diagnosis and therapy
Respond well to traditional cytotoxic chemotherapy:
Specific for phase of cell cycle, not cell type
Act via different mechanisms altering DNA and/or DNA repair mechanics
Anthracyclines
Alkylating Agents
Antimetabolites
Vinca alkaloids/plant products
Platinum compounds
Miscellaneous
Minimize radiation
Late effects are common

7. Risk-adapted Therapy Stage disease at diagnosis
Begin stage/risk based therapy
Re-evaluate after 2+ cycles to assess response
RER: less intense therapy
SER: more intense therapy

8. *Deliver appropriate therapy
*Minimize late effects

9. New Therapies New era of targeted therapy
Immunotherapy
CAR T cell
Target is specific to cancer cell
Monoclonal antibodies, BiTE therapy
Kinase inhibitors
PD-L1 inhibitors
Small molecules
Anti-angiogenesis
Specific for cell type, fewer non-cancer cells are damaged

10. Source: Surveillance, Epidemiology, and End Results (SEER) Program (seer.cancer.gov) Based on follow-up of patients into 2012

11. Survivors
Survival rates for childhood cancers have increased dramatically
Current 5 year survival >83%
In 2013, estimated 420,000 survivors of childhood cancer in US
reach 500,000 by 2020
Expected to Increased awareness of long term effects
Gonadotoxicity
Delayed Puberty
Early Menopause
Loss of Fertility
Armstrong et al, 2016

12. Survivorship Female patients may have a second window of opportunity
CCSS data: Levine et al, ASCO 2016
Age 20-29: No difference in pregnancy rates between survivors and siblings
Age 30-39: Pregnancy in survivors significantly decreased compared to siblings
Male patients interested in knowing status
Review risk
Semen analysis
All patients benefit from counseling, reviewing risk

13. ASCO Consensus Statement
As part of education and informed consent before cancer therapy, health care providers … should address the possibility of infertility with patients treated during their reproductive years (or with parents or guardians of children) and be prepared to discuss fertility preservation options and/or to refer all potential patients to appropriate reproductive specialists.
Although patients may be focused initially on their cancer diagnosis … encourages providers to advise patients regarding potential threats to fertility as early as possible in the treatment process so as to allow for the widest array of options for fertility preservation.
“As part of education and informed consent before cancer therapy”…physicians should inform cancer patients about options for fertility preservation and future reproduction … “or refer to reproductive specialists…”
“…regardless of the patient’s age, gender, culture, socioeconomic status, or healthcare team bias…”
“…and continue throughout treatment and survivorship in a manner appropriate to the patient’s