In 2010, approx­i­mately 10,500 boys and girls in the US and 160,000 world­wide are expected to be diag­nosed with can­cer before the age of 15. In addi­tion hun­dreds of thou­sands of ado­les­cents are treated for can­cer yearly between the ages of 15 to 19.

Get­ting beyond can­cer treat­ment involves a focus on well­ness and ways to improve qual­ity of life. Dis­cover ways to main­tain a healthy lifestyle, signs to look for, poten­tial risks and ways to cel­e­brate the life of a child with cancer.

The spe­cific type of can­cer varies with age and geo­graph­i­cal dis­tri­b­u­tion.  In the US the most com­mon (Amer­i­can Can­cer Soci­ety)  are                  Leukemias (31%)
Brain and ner­vous sys­tem (21.3%)
Neu­rob­las­toma (7.1%)
Wilm’s tumor (5.2%)
Non-Hodgkin Lym­phoma (4.3%)
Rhab­domyosar­coma (3.3%)
Retinoblas­toma (2.6%)
Osteosar­coma (2.5%)
Ewing sar­coma (1.6%)
Oth­ers e.g ovar­ian germ cell tumors, Hodgkin lym­phoma, liver cancer

With improve­ment in sur­vival (80% in the US), Cur­rent pri­or­i­ties for child­hood can­cer man­age­ment aim at improve­ment of qual­ity of life of the grow­ing num­ber of child­hood can­cer sur­vivors. Spe­cific to repro­duc­tion, preser­va­tion of fer­til­ity aims at enabling chil­dren and ado­les­cents to make repro­duc­tive choices that can­not be delayed till they reach matu­rity.

Effect of treat­ment of child­hood can­cer on fer­til­ity. It is very impor­tant for chil­dren and their fam­i­lies are informed about the effects of can­cer treat­ment before shortly after diag­no­sis and cer­tainly before they start treat­ment.

Chil­dren treated for child­hood can­cer are at risk for delay or fail­ure of puberty. They are less likely to be bio­log­i­cal par­ents in adult­hood. Two large stud­ies (The Child­hood Sur­vival Study in the US and The Nor­we­gian Radium Hos­pi­tal study) indi­cated that chil­dren treated for can­cer are 50% less likely to become par­ents when com­pared to those not exposed to can­cer treat­ment. Mod­ern can­cer treat­ment include surgery, multi-drug chemother­apy, radi­a­tion, bio­log­i­cal agents and some­times hematopoi­etic stem cell trans­plan­ta­tion (bone mar­row trans­plan­ta­tion). Some can­cers espe­cially in boys can impair fer­til­ity inde­pen­dent of treat­ment e.g Hodgkin lym­phoma and tes­tic­u­lar cancer.

Chemother­apy espe­cially alky­lat­ing agents cause accel­er­ated loss of germ cells (oocytes or sperm pro­duc­ing cells).

Radi­a­tion of the ovary or testes can lead to par­tial or com­plete loss of germ cells depend­ing on the total dose and frac­tion used. Also radi­a­tion of the head can affect hor­mone pro­duc­tion from the mas­ter gland in the brain and impair ovu­la­tion or sperm production.

Bone mar­row trans­plan­ta­tion requires pre-treatment with high dose chemother­apy and total body radi­a­tion and is asso­ci­ated with loss of fer­til­ity in the vast major­ity of boys and girls.

Surgery to remove the ovary or testes is some­times required  for can­cer treat­ment e.g. germ cell tumors of the ovary or testes.

Meth­ods of fer­til­ity preser­va­tion in girls. Mod­i­fi­ca­tion of treat­ment plan is some­times pos­si­ble to pre­vent dam­age to repro­duc­tive tis­sue. For exam­ple, girls diag­nosed with germ cell tumors of the ovary, its pos­si­ble to pre­serve one ovary and the uterus. Freez­ing of ovar­ian tis­sue or eggs are avail­able options for preser­va­tion of fer­til­ity in girls. After puberty, ovar­ian stim­u­la­tion is pos­si­ble, fol­lowed by egg retrieval and freez­ing. This require about 2 to 3 weeks to accom­plish. This method require ovar­ian stim­u­la­tion.  Estro­gen pro­duced dur­ing stim­u­la­tion may lead to advance­ment of sec­ondary sex char­ac­ters e.g. breast devel­op­ment. Ovar­ian tis­sue freez­ing is pos­si­ble for girls before and after puberty. It can be per­formed in one day and does not delay can­cer treat­ment. It is con­sid­ered when can­cer treat­ment is expected to be asso­ci­ated with very high risk for ovar­ian fail­ure. One ovary is har­vested using min­i­mally access surgery. Vis­i­ble fol­li­cles in the ovary are aspi­rated using a nee­dle and any eggs obtained are frozen. The ovary is the cut into thin slices and frozen. The ovary can be trans­planted later for the pur­pose of ini­ti­a­tion of puberty and repro­duc­tion. Unfor­tu­nately, trans­plan­ta­tion is not suit­able for cer­tain can­cers that carry high risk for con­t­a­m­i­nat­ing the graft e.g. leukemias.

Meth­ods of fer­til­ity preser­va­tion in boys. The stan­dard for fer­til­ity preser­va­tion in men is sperm freez­ing. In boys, eth­i­cal and phys­i­cal con­sid­er­a­tion issues may inter­fere with sperm col­lec­tion from young boys. In stud­ies done two decades ago, most boys start to emit sperms at ages 9 to 11 years, even in the absence of pubic hair. Prac­ti­cally this can be assisted by a vibra­tory stim­u­la­tion device. Some­times, for social or reli­gious rea­sons its dif­fi­cult to ask young boys to pro­duce sperm sam­ples. The other avail­able option is a sim­ple sur­gi­cal pro­ce­dure to retrieve sperm from the testes, tes­tic­u­lar sperm aspi­ra­tion or extrac­tion (TESE). Tis­sue from the testes is then frozen for later use at matu­rity, using ICSI (direct injec­tion of sperm into an egg). There are options for young boys e.g. tes­tic­u­lar stem cell freez­ing, but they are exper­i­men­tal and not ready for gen­eral use.

Genetic issues and preser­va­tion of fer­til­ity in chil­dren. Some chil­dren develop can­cer because they carry a faulty gene e.g. retinoblas­toma. Chil­dren can be tested for this gene. If the abnor­mal gene is detected, embryos or eggs pro­duced by these chil­dren can also be tested — preim­plan­ta­tion genetic diag­no­sis (PGD) and only healthy ones are used. This will pre­vent the gene from being trans­ferred to their future children.

Eth­i­cal con­sid­er­a­tions. Fer­til­ity preser­va­tion in chil­dren is a com­pli­cated issue for par­ents and chil­dren alike. Ethi­cist advised that fer­til­ity preser­va­tion pro­ce­dures should be offered to chil­dren when there is high risk for loss of fer­til­ity. If the pro­posed method entails delay in can­cer treat­ment, this delay should not affect treat­ment out­come. Informed con­sent should be obtained from par­ents and ASSENT should be obtained from the child. Minors who are suf­fi­ciently mature to achieve a devel­op­men­tally appro­pri­ate aware­ness of their con­di­tion and the risks and ben­e­fits of the avail­able treat­ment alter­na­tives should give their approval to the use of such treat­ment. Every mea­sure should be taken to assure that the child will con­trol the fate of sperm, eggs or repro­duc­tive tis­sue when they reach matu­rity. Nobody will have cus­tody over repro­duc­tive cells or tis­sue except the per­son who pro­duced them.

Recent psy­cho­log­i­cal research from UK indi­cated that (Craw­shaw & Sloper 2010)

For some young men and women treated for child­hood can­cer, fer­til­ity con­cerns dom­i­nates can­cer legacy. Pro­fes­sional and social net­works pro­vided few oppor­tu­ni­ties to ask ques­tions, receive infor­ma­tion, process feel­ings or develop han­dling strate­gies. Beliefs about the extent of fer­til­ity dam­age did not nec­es­sar­ily relate to infor­ma­tion received. For some, fer­til­ity mat­ters affected iden­tity, well-being and life plan­ning as well as repro­duc­tive func­tion. This was not restricted to par­tic­u­lar ages, life stages, gen­der or time since treat­ment ended and was height­ened by asso­ci­ated stigma and silence. Oppor­tu­ni­ties for dia­logue should be offered reg­u­larly across health and social work dis­ci­plines given fertility’s psy­cho­log­i­cal and social as well as med­ical significance.