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Fertility preservation for people with cancer

Ovarian suppression with GnRH analogues

Clinical Question

Does ovarian suppression with gonadotropin releasing hormone (GnRH) analogues or antagonists during chemotherapy in women with cancer reduce the risk of primary ovarian insufficiency?

Primary ovarian insufficiency (POI) is a serious, irreversible adverse effect of chemotherapy for pre-menopausal women. POI results in infertility, and increases the risk of osteoporosis, cardiovascular disease and cognitive dysfunction.[1][2] Prevention of POI is therefore very important to preserve the fertility of young Australian women after cancer.

Randomised studies, predominantly in pre-menopausal women with breast cancer, have shown that concurrent administration of gonadotropin releasing hormone agonists (GnRHa) with chemotherapy reduces the risk of POI compared to no GnRHa. As a result, use of GnRHa in this setting is recommended in the European St Gallen and U.S. National Comprehensive Cancer Network guidelines for premenopausal women with breast cancer.[3][4] However, studies in other malignancies, such as lymphoma, comparing chemotherapy with or without concurrent GnRHa have shown mixed results.[5][6][7]

In 2017 the GnRHa goserelin, was listed on the Australian Pharmaceutical Benefits Scheme (PBS) for premenopausal women receiving treatment with an alkylating agent for any malignancy or autoimmune disorders (Australian Government Department of Health 2017).

Breast cancer

The majority of evidence for the efficacy of GnRHa in prevention of POI comes from studies of premenopausal breast cancer patients. Recent meta-analysis assessing the efficacy of GnRHa in prevention of POI in premenopausal patients with early breast cancer concluded that concurrent GnRHa (goserelin, triptorelin or leuprolide) administration resulted in lower rates of chemotherapy induced POI.[8][9][10] The most recent of these meta-analyses, by Lambertini and colleagues, included five randomised controlled studies (RCT) using individual patient data. The primary endpoint was study defined chemotherapy-induced POI. POI rates were lower in those who received concurrent GnRHa compared to those who did not (14.1% versus 30.9%, adjusted OR 0.38; 95% CI, 0.26 to 0.57; P<0.001).[8]

With regards to the potential impact of GnRHa given during chemotherapy on breast cancer outcomes, Lambertini et al concluded that the five-year overall survival (OS) was similar between those who received GnRH agonist and those who did not.[8] An exploratory analysis of patients with estrogen receptor negative breast cancer in the POEMS trial showed better four-year estimated disease free survival (DFS) and overall survival in the goserelin arm (HR 0.49, 95% CI 0.24 – 0.97, p = 0.04 and HR 0.43, 95% CI 0.18 – 1.0, p = 0.05 respectively).[11] The PROMISE trial, which included patients with both oestrogen receptor negative and oestrogen receptor positive breast cancer showed no difference in 5-year DFS between the GnRHa and control arms (HR 1.17, 95% CI: 0.72-1.92, p=0.52).[12] These results are reassuring regarding the safety of GnRHa use in both oestrogen-receptor positive and negative breast cancer.

Other malignancies

Studies exploring the efficacy of GnRHa in haematological and solid malignancies other than breast cancer are mostly limited to lymphoma patients. These studies show mixed results. A recent 2018 meta-analysis by Senra and colleagues, which included three studies of 109 patients with lymphoma and 10 studies of 1099 patients with breast cancer, demonstrated a lower rate of POI in women receiving GnRHa compared to chemotherapy alone overall (RR, 0.60; 95% CI, 0.45–0.79). However, subgroup analysis showed the benefit was only seen in patients with breast cancer (RR, 0.57; 95% CI, 0.43–0.77) but not patients with lymphoma (RR, 0.70; 95% CI, 0.20–2.47).[13]

Similarly, the rate of spontaneous pregnancy after completion of treatment was higher in women receiving GnRHa compared to chemotherapy alone (RR, 1.43; 95% CI, 1.01–2.02). However this benefit was again only seen for breast cancer patients (RR, 1.78; 95% CI, 1.09–2.90) and not lymphoma patients. (RR, 1.13; 95% CI, 0.66–1.93).[13] This difference in outcomes between breast cancer and lymphoma studies may be due to the heterogeneous chemotherapy regimens prescribed, the lower median age and the smaller sample sizes in the lymphoma trials compared to breast cancer trials.

The largest randomised control trial in patients with lymphoma included in this study was performed by Demeestrere and colleagues in 129 women with Hodgkin and non-Hodgkin lymphoma.[5] In 63 evaluable women, the POI rate, defined as an elevated FSH level, was 19% in the GnRHa group versus 25% in the control group (P = 0.763) (Demeestere 2016).[5] Pregnancy occurred in 53% of the GnRHa group compared to 43% of the control cohort (P = 0.467), with five pregnancies occurring in those with protocol defined POI, suggesting that defining POI by elevated FSH alone is not adequate.[5]


Evidence Summary

Evidence summaryLevelReferences
In premenopausal women with early breast cancer, concurrent GnRHa administration with chemotherapy resulted in lower rates of chemotherapy-induced primary ovarian insufficiency.I[8], [9], [10]

Recommendation

Evidence-based recommendationGrade
Pre-menopausal women with breast cancer should be offered GnRHa before commencement of chemotherapy (given at least one week prior to chemotherapy) to reduce the risk of primary ovarian insufficiency.A

References

  1. Logan S, Perz J, Ussher JM, Peate M, Anazodo A. Systematic review of fertility-related psychological distress in cancer patients: Informing on an improved model of care. Psychooncology 2018 Nov 20 Available from: http://www.ncbi.nlm.nih.gov/pubmed/30460732.
  2. Howard-Anderson J, Ganz PA, Bower JE, Stanton AL. Quality of life, fertility concerns, and behavioral health outcomes in younger breast cancer survivors: a systematic review. J Natl Cancer Inst 2012 Mar 7;104(5):386-405 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22271773.
  3. Jackisch C, Harbeck N, Huober J, von Minckwitz G, Gerber B, Kreipe HH, et al. 14th St. Gallen International Breast Cancer Conference 2015: Evidence, Controversies, Consensus - Primary Therapy of Early Breast Cancer: Opinions Expressed by German Experts. Breast Care (Basel) 2015 Jul;10(3):211-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/26557827.
  4. NCCN. National Comprehensive Cancer Network Guidelines. Version 2. Fort Washington, PA, USA: National Comprehensive Cancer Network (NCCN); 2016.
  5. Demeestere I, Brice P, Peccatori FA, Kentos A, Dupuis J, Zachee P, et al. No Evidence for the Benefit of Gonadotropin-Releasing Hormone Agonist in Preserving Ovarian Function and Fertility in Lymphoma Survivors Treated With Chemotherapy: Final Long-Term Report of a Prospective Randomized Trial. J Clin Oncol 2016 Aug 1;34(22):2568-74 Available from: http://www.ncbi.nlm.nih.gov/pubmed/27217453.
  6. Giuseppe L, Attilio G, Edoardo DN, Loredana G, Cristina L, Vincenzo L. Ovarian function after cancer treatment in young women affected by Hodgkin disease (HD). Hematology 2007 Apr;12(2):141-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17454195.
  7. Waxman JH, Ahmed R, Smith D, Wrigley PF, Gregory W, Shalet S, et al. Failure to preserve fertility in patients with Hodgkin's disease. Cancer Chemother Pharmacol 1987;19(2):159-62 Available from: http://www.ncbi.nlm.nih.gov/pubmed/3105906.
  8. Lambertini M, Moore HCF, Leonard RCF, Loibl S, Munster P, Bruzzone M, et al. Gonadotropin-Releasing Hormone Agonists During Chemotherapy for Preservation of Ovarian Function and Fertility in Premenopausal Patients With Early Breast Cancer: A Systematic Review and Meta-Analysis of Individual Patient-Level Data. J Clin Oncol 2018 Jul 1;36(19):1981-1990 Available from: http://www.ncbi.nlm.nih.gov/pubmed/29718793.
  9. Munhoz RR, Pereira AA, Sasse AD, Hoff PM, Traina TA, Hudis CA, et al. Gonadotropin-Releasing Hormone Agonists for Ovarian Function Preservation in Premenopausal Women Undergoing Chemotherapy for Early-Stage Breast Cancer: A Systematic Review and Meta-analysis. JAMA Oncol 2016 Jan;2(1):65-73 Available from: http://www.ncbi.nlm.nih.gov/pubmed/26426573.
  10. Shen YW, Zhang XM, Lv M, Chen L, Qin TJ, Wang F, et al. Utility of gonadotropin-releasing hormone agonists for prevention of chemotherapy-induced ovarian damage in premenopausal women with breast cancer: a systematic review and meta-analysis. Onco Targets Ther 2015;8:3349-59 Available from: http://www.ncbi.nlm.nih.gov/pubmed/26622183.
  11. Moore HC, Unger JM, Phillips KA, Boyle F, Hitre E, Porter D, et al. Goserelin for ovarian protection during breast-cancer adjuvant chemotherapy. N Engl J Med 2015 Mar 5;372(10):923-32 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25738668.
  12. Lambertini M, Boni L, Michelotti A, Gamucci T, Scotto T, Gori S, et al. Ovarian Suppression With Triptorelin During Adjuvant Breast Cancer Chemotherapy and Long-term Ovarian Function, Pregnancies, and Disease-Free Survival: A Randomized Clinical Trial. JAMA 2015 Dec;314(24):2632-40 Available from: http://www.ncbi.nlm.nih.gov/pubmed/26720025.
  13. Senra JC, Roque M, Talim MCT, Reis FM, Tavares RLC. Gonadotropin-releasing hormone agonists for ovarian protection during cancer chemotherapy: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2018 Jan;51(1):77-86 Available from: http://www.ncbi.nlm.nih.gov/pubmed/29055060.

Body of evidence

In female cancer patients does ovarian suppression with gonadotropin releasing hormone (GnRH) analogues or antagonists during chemotherapy reduce the risk of primary ovarian insufficiency?

CitationLevel of EvidenceQuality of EvidenceSize of EffectNumber of PatientsRelevance of Evidence
Del Mastro L, Ceppi M, Poggio F, Bighin C, Peccatori F, Demeestere I, et al. Gonadotropin-releasing hormone analogues for the prevention of chemotherapy-induced premature ovarian failure in cancer women: systematic review and meta-analysis of randomized trials. Cancer Treat Rev 2014 Jun;40(5):675-83 Available from:http://www.ncbi.nlm.nih.gov/pubmed/24360817 IMedium17652
Elgindy E, Sibai H, Abdelghani A, Mostafa M. Protecting Ovaries During Chemotherapy Through Gonad Suppression: A Systematic Review and Meta-analysis. Obstet Gynecol 2015 Jul;126(1):187-95 Available from:http://www.ncbi.nlm.nih.gov/pubmed/26241272 IMedium29071
Hickman LC, Llarena NC, Valentine LN, Liu X, Falcone T. Preservation of gonadal function in women undergoing chemotherapy: a systematic review and meta-analysis of the potential role for gonadotropin-releasing hormone agonists. J Assist Reprod Genet 2018 Apr;35(4):571-581 Available from:http://www.ncbi.nlm.nih.gov/pubmed/29470701 IMedium11,1531
Lambertini M, Ceppi M, Poggio F, Peccatori FA, Azim HA Jr, Ugolini D, et al. Ovarian suppression using luteinizing hormone-releasing hormone agonists during chemotherapy to preserve ovarian function and fertility of breast cancer patients: a meta-analysis of randomized studies. Ann Oncol 2015 Dec;26(12):2408-19 Available from:http://www.ncbi.nlm.nih.gov/pubmed/26347105 IMedium11,2312
Lambertini M, Moore HCF, Leonard RCF, Loibl S, Munster P, Bruzzone M, et al. Gonadotropin-Releasing Hormone Agonists During Chemotherapy for Preservation of Ovarian Function and Fertility in Premenopausal Patients With Early Breast Cancer: A Systematic Review and Meta-Analysis of Individual Patient-Level Data. J Clin Oncol 2018 Jul 1;36(19):1981-1990 Available from:http://www.ncbi.nlm.nih.gov/pubmed/29718793 IHigh18732
Munhoz RR, Pereira AA, Sasse AD, Hoff PM, Traina TA, Hudis CA, et al. Gonadotropin-Releasing Hormone Agonists for Ovarian Function Preservation in Premenopausal Women Undergoing Chemotherapy for Early-Stage Breast Cancer: A Systematic Review and Meta-analysis. JAMA Oncol 2016 Jan;2(1):65-73 Available from:http://www.ncbi.nlm.nih.gov/pubmed/26426573 IMedium11,0472
Senra JC, Roque M, Talim MCT, Reis FM, Tavares RLC. Gonadotropin-releasing hormone agonists for ovarian protection during cancer chemotherapy: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2018 Jan;51(1):77-86 Available from:http://www.ncbi.nlm.nih.gov/pubmed/29055060  IHigh11,2082
Shen YW, Zhang XM, Lv M, Chen L, Qin TJ, Wang F, et al. Utility of gonadotropin-releasing hormone agonists for prevention of chemotherapy-induced ovarian damage in premenopausal women with breast cancer: a systematic review and meta-analysis. Onco Targets Ther 2015;8:3349-59 Available from:http://www.ncbi.nlm.nih.gov/pubmed/26622183 IHigh11,0622
Sofiyeva N, Siepmann T, Barlinn K, Seli E, Ata B. Gonadotropin-Releasing Hormone Analogs for Gonadal Protection During Gonadotoxic Chemotherapy: A Systematic Review and Meta-Analysis. Reprod Sci 2018 Oct 1;:1933719118799203 Available from:http://www.ncbi.nlm.nih.gov/pubmed/30270741 IMedium11,0432
Sun X, Dongol S, Jiang J, Kong B. Protection of ovarian function by GnRH agonists during chemotherapy: a meta-analysis. Int J Oncol 2014 Apr;44(4):1335-40 Available from:http://www.ncbi.nlm.nih.gov/pubmed/24535045 IMedium16212
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Cancer Council Australia