Fertility preservation in malignant melanoma
Malignant melanoma is the fifth most common malignancy among women at reproductive age and is among the most common cancers during pregnancy. If you've just found out your diagnosis, DONT’T PANIC! We are here to help and answer all of your questions.
Over the past decade, the new options for drug treatment in malignant melanoma have radically transformed the prognosis of this disease, where recovery from even the very advanced cases is now being discussed
Now target therapy is routine standard of treatment using drugs such as BRAF and MEK inhibitors (dabrafenib/trametinib and vemurafenib/cobimetinib) as well as immunotherapeutics such as checkpoint inhibitors (pembrolizumab, nivolumab, ipilimumab). These drugs have been used successfully in metastatic disease, and in the earlier stages of the disease after successful surgical treatment to ensure the patient's cure.
In short, there is more hope than ever for a SUCCESSFUL CURE!
How does this therapy affect fertility?
Although these drugs have different mechanism of action, what is common for both groups of drugs is the fact that very little is known about the effect they would have on fertility. Unfortunately there are no detailed studies in humans yet due to the fact that these classes of medicines are still fairly new. Most publications in this aspect have been made regarding a study in animals subjected to the same therapy; they demonstrated a reduction in anti-Müllerian hormone and ovarian reserve in general, as well as a deterioration of the spermogram.
As already mentioned, melanoma is also one of the most common malignancies to be diagnosed during pregnancy. However, the most commonly used drugs are potentially teratogenic (may lead to malformations in the fetus), or may increase the risk of miscarriage.
For this reason, the treatment of melanoma detected during pregnancy is very specific and requires a comprehensive approach by a well-trained team, that we have available.
Advice to all girls starting therapy, whether or not they have frozen eggs/embryos, is to start taking contraceptives along with another barrier method, such as a condom, during their therapy to avoid pregnancy.
For all of these reasons, worldwide recommendations are unanimous: every woman of reproductive age, regardless of the type and stage of her cancer, should consult a reproductive specialist.
Should fertility preservation actions be taken at time of diagnosis?
The answer is a resounding YES. Below you will find a table from the approved international medical standards. What it makes clear straight away is that once you have a diagnosis, you should seek our oncology/reproductive consultation immediately; together we can discuss the options available to you, and the most appropriate time to undergo them.
How is this done? You call our number and tell us about your diagnosis and your wish to learn about fertility sparing options. You can have an appointment with us within 24 hours.
We encourage you to contact us not only if you have not given birth yet , but also if you have already had a child. The presence of a partner if you have one, or a parent if you are around 18 years of age, is recommended. During the consultation we will discuss all options, we will evaluate not only the cancer diagnosis together with your doctors and our consultant, but also your ovarian reserve, and all the possible ways to preserve and conserve it.
Frequently asked questions and common situations you may run into
Once I have the diagnosis, when can I find you?
You can contact us as soon as the diagnosis has been determined and the necessary surgical and staging interventions have been performed, e.g. "sentinel biopsy". Bring all documentation relative to the oncological diagnosis with you during your visit.
When could I try to get pregnant after treatment?
To answer this question, it is very important to have a good collaboration in place between your reproductive specialist and your oncologist. We can also help you, with the advice of our consultants. What is of top importance is whether postoperative therapy (target therapy or immunotherapy) will be done. If your disease is stage III, you will most likely be offered postoperative therapy within 1 year after surgery. As mentioned before, pregnancy during active treatment is definitely not recommended. You should wait at least 4-5 months after completion of therapy, depending on the specific medication applied to you. In disease is in earlier stage (I-II), then treatment is entirely surgical and at this point medicinal therapy is not planned. In this case, potential pregnancy must be balanced against the risk of disease recurrence, which is the highest in the first 2 years after surgery. Often medicinal treatment will also be required in case of recurrence, which, as discussed above, is contraindicated during pregnancy. For this reason, waiting at least 2 years after surgery before a potential pregnancy is often recommended.
The oncologist told me that I would not be provided with post-operative treatment. Should I freeze eggs/embryos?
In these cases, it is best to consult a reproductive specialist (visit our facility). Often, after surgical treatment of malignant melanoma, patients are advised to wait at least 2 years before potential pregnancy due to the increased risk of recurrence during this period. Depending on your age, these 2 years may significantly reduce your ovarian reserve and make it difficult to have the desired pregnancy. During your oncology/reproductive consultation with us, we will assess your ovarian function, consider your age, and we will be able to give you the best advice.
If I have already started therapy, can I preserve eggs/embryos?
Yes, you can, and it will not adversely impact your therapy if we can work well together with your treating oncologist. However, this is not a routine practice, and you should focus on your main treatment. Our advice is – don't wait, make the decision in advance, and come in for a consultation with us.
What contraceptive should I use during therapy?
This will be discussed during the consultation, considering the individual characteristics and preferences of each patient. If postoperative therapy is planned for you, we advise you to use at least 2 different methods of contraception.
You should seek advice NOW!
Every woman with cancer at reproductive age should consult a reproductive specialist, regardless of the stage of her disease, and whether she has given birth or not. This is also the official recommendation of the most well recognized medical oncology and reproductive medicine organizations, such as ESMO, ASCO and ESHRE.
This will not delay your therapy in any way.
Your consultation with our reproductive specialists will be done within 24 hours of your call, no matter where you are residing in the country. If you choose to preserve your fertility, we can begin immediately, where the day of your menstrual cycle is of no consequence, and process will be completed within 10 days. At our hospital, there is an exceptional coordination between the reproductive specialists and medical oncologists, this makes it possible for the planned treatment to start immediately after successful egg retrieval.
The procedure is proven to be safe and in no way worsens the prognosis of the cancer or subsequent pregnancy when discussed and coordinated with the treating medical oncologist.
Fertility preservation options
In current best practices, the following procedures are used to preserve reproductive ability in cases with malignant melanoma – egg/embryo freezing or ovarian tissue freezing.
|Fertility preservation options|| |
Frequency of application and success rate of the approach
|Egg/ embryo freezing||★★★|
|Ovarian tissue freezing||★|
★★★ - most commonly used approach, highest success rate ★★ - less frequently used approach, lower success rate ★ - rarely used approach