Infections with certain viruses, bacteria, and parasites have been identified as strong risk factors for specific cancers. To examine the link between infections and cancer, researchers performed a systematic analysis of the proportion of cancer cases attributable to infection in 2008. They used data on cancer incidence from the GLOBOCAN project along with epidemiological data regarding the causal effects of infection on cancer. The data included information on 27 types of cancer from 182 countries.

They found that of the 12.7 million new cancer cases that occurred worldwide in 2008, 16 percent—or roughly two million—were attributable to infections. The rate of infection-related cancer was about three times higher in developing countries. For example, 3.3 percent of cancers in Australia and New Zealand were infection related, whereas 32.7 percent of cancers in sub-Saharan Africa were attributable to infections. The four main infections associated with cancer were human papillomavirus, hepatitis C, hepatitis B, and Helicobacter pylori. These infections were responsible for approximately 1.9 million cancer cases in 2008, mainly gastric, liver, and cervical cancers.

Cervical cancer accounted for about half of the infection-related cancers in women. Liver and gastric cancers accounted for more than 80 percent of the infection-related cancers in men.  About 30 percent of infection-related cancers occurred in people younger than 50 years. It’s important to note that it takes decades of chronic infection before an infection progresses to cancer.

Based on the statistics, the researchers noted that approximately two million cancer cases each year might be preventable with better public health methods for preventing infection. In an accompanying editorial, Dr. Goodarz Danaei, an assistant professor of global health at Harvard School of Public Medicine in Boston, noted that vaccines for HPV and hepatitis B are effective and that increasing their availability should be a priority for higher risk countries.[2] He suggests that increasing vaccine coverage could reduce the global burden of cancer.

References:

Prostate cancer is the most commonly diagnosed type of cancer (other than skin cancer) in U.S. men. Although many prostate cancers are diagnosed at an early, curable stage, treatment of prostate cancer can cause urinary, sexual, and bowel problems that have a substantial impact on quality of life. Prevention of prostate cancer, therefore, continues to be an important research priority.

There is a great deal of interest in the relationship between diet and cancer, and some previous studies suggested that selenium and vitamin E may reduce the risk of certain types of cancer, including prostate cancer.

To further explore the relationship between selenium and vitamin E supplementation and risk of prostate cancer, researchers conducted SELECT, which was a randomized trial that enrolled more than 35,000 men from 400 study sites across the United States, Canada, and Puerto Rico. At the start of the study, all men had normal prostate-specific antigen (PSA) levels and a normal digital rectal examination. Study participants were assigned to one of four groups: selenium supplementation; vitamin E supplementation; selenium and vitamin E supplementation; or placebo.

In 2008, after approximately 5.5 years of follow-up, preliminary results indicated no benefit from supplementation and participants were instructed to stop taking the supplements. Researchers, however, continued to collect information from the men in order to continue to evaluate the long-term effects

After 7 years of follow-up (5.5 years of supplementation), researchers found that vitamin E supplementation was associated with a statistically significant increased risk of prostate cancer, whereas supplementation with selenium was not. Men in the vitamin E group were 17% more likely than men in the placebo group to be diagnosed with prostate cancer.

These results suggest that daily supplementation with vitamin E may increase the risk of prostate cancer among healthy men. It is always important to communicate with your physician about any supplements you may be taking so that you can discuss the risks and benefits.

References:

How does cancer treatment affect fertility in men?

Chemotherapy: Chemotherapy can temporarily—and in some cases, permanently—stop sperm production by the testes.[1] The extent to which chemotherapy affects sperm production depends on several factors, including the type and dose of chemotherapy.

Radiation: Radiation to the abdomen or pelvis can also reduce or eliminate sperm production by the testes.

Surgery: Surgery that involves the removal of both testicles (an option for some men with prostate cancer) eliminates sperm production, but other types of surgery can also affect a man’s fertility. Some types of pelvic surgery, for example, can change or eliminate ejaculation.

Options for preserving fertility in men

Although many men are able to conceive naturally after cancer treatment, others are not.

If possible, men should talk with their doctor about their future fertility before beginning cancer treatment. Some options for preserving fertility require that steps be taken before cancer treatment begins.

Sperm banking is the most well-established method of preserving fertility in men.[2] It involves the collection and storage of sperm, ideally before cancer treatment begins. The samples are kept frozen at a lab or sperm bank until they are needed. Sperm can be stored in this way for many years. After being thawed, the sperm can be used for intrauterine insemination (IUI) or in vitro fertilization (IVF). During IUI, sperm are placed directly into a woman’s uterus. During IVF, mature eggs are removed from a woman’s ovary and mixed with the sperm in the lab. Embryos that result from IVF can then be placed in a woman’s uterus or frozen for later use.

If a sample contains very few viable sperm (or if a man has already undergone cancer treatment and has a low sperm count), another approach may be used to fertilize an egg. Intracytoplasmic sperm injection (ICSI) requires only a small number of healthy sperm, along with mature eggs that have been collected from a woman’s ovary. A single sperm is injected directly into each egg. The embryos that develop can then be placed in a woman’s uterus or frozen for later use.

If it is not possible to collect sperm from ejaculate, it may in some cases be possible to collect sperm directly from the testicles. This approach is still investigational.

Finally, it may also be possible to modify some cancer treatments to minimize their effects on subsequent fertility. During radiation therapy, for example, it may be possible to shield the testes in order to preserve sperm production.

Pregnancy after cancer

In the event that your fertility is not affected by cancer treatment (or recovers quickly or unexpectedly), you and your partner should use birth control if you do not wish to have a child. If you are trying to conceive a child naturally, your doctor may advise you to wait for several months after treatment; this allows for the elimination of sperm that may have been damaged during treatment.

In general, the risk of birth defects in children born to cancer survivors appears to be similar to the risk in the general population.[3] If your cancer was due to a hereditary cancer syndrome, such as Lynch syndrome (hereditary nonpolyposis colorectal cancer), your children may inherit the gene mutation responsible for your family’s increased risk of cancer. Talking with a genetic counselor may be helpful.

Other options for parenthood

Not all men have the luxury of being able to explore their reproductive options before beginning cancer treatment, and not all men will find a fertility preservation option that meets their needs. But there are still ways to become a parent. Discussion of other routes to parenthood may be a painful topic for men who want to father a child but cannot. But as cancer survivors consider how best to build their families, methods such as adoption are important options.

Adoption: Couples and individuals who wish to adopt have a range of options, including different types of domestic and international adoptions. You may wish to start by learning about the adoption laws in your state and by talking with other adoptive parents about the professionals and agencies they worked with. Before selecting an adoption agency, you may wish to talk with them about their attitudes toward placing a child with a cancer survivor. Many agencies will be receptive toward this, but it’s important to know before making a final decision.

Donor Sperm: Donor sperm is readily available from sperm banks and can be used for either intrauterine insemination or in vitro fertilization.

Individual decisions within a larger community

The decisions that you make about building a family (or about coming to terms with not building a family) will be intensely personal, but know that you are part of a larger community of patients and healthcare providers who are grappling with these issues.  To think about future parenthood is to think about life after cancer. For many people with cancer, planning for the future may provide the motivation needed to get through treatment.

More information?

Discuss with others…. http://cancerconnect.com/groups/young-adults/topics/fertility-after-cancer-treatment

Fertile Hope (www.fertilehope.org) provides a range of fertility resources for people with cancer.

References:

How does cancer treatment affect fertility in women?

Chemotherapy: Many chemotherapy drugs are toxic to the egg cells (oocytes) in the ovaries. If the number of remaining oocytes in the ovaries reaches a critically low point during treatment, women experience “acute ovarian failure.” This means that the ovaries stop functioning during or shortly after cancer treatment. If oocytes are lost during treatment but do not reach this critically low point, women are at risk for early menopause but may still be able to get pregnant for some time after treatment.

Radiation: Radiation to the pelvis can also destroy oocytes. Radiation to the pelvis can also affect uterine growth and blood flow, particularly if received before puberty.[1] A poorly developed uterus may make a woman more likely to have a miscarriage, or more likely to have a preterm or low-birthweight infant.

Surgery: Some cancers require surgical removal of the uterus, the ovaries, or both.

The effects of cancer treatment on fertility can vary substantially by age. Younger women, who have a larger pool of oocytes when they start cancer treatment, are more likely than older women to be able to get pregnant after treatment.[2]

Options for preserving fertility in women

If possible, women should talk with their doctor about their future fertility before beginning cancer treatment. Some options for preserving fertility require that steps be taken before cancer treatment begins.

One of the most established approaches for preserving fertility among female cancer patients is embryo freezing.[3] Before starting cancer treatment, a woman would be given hormones to stimulate the development of eggs in her ovaries. Mature eggs would be removed and fertilized with the sperm of her husband, partner or a sperm donor. The embryos that result from these fertilized eggs would be frozen for later use.

Although embryo freezing is an established approach to helping women become pregnant after cancer, there are downsides. A woman may not currently have a male partner and may be unwilling to use an anonymous sperm donor. It’s also important to be aware that embryo freezing takes approximately two weeks after the start of a woman’s period. If a woman needs to begin cancer treatment immediately, she may not be able to go through this process. Finally, this approach is only an option for women of childbearing age; stimulating the ovaries to produce mature eggs is not an option for girls who develop cancer during childhood.

Several other options are still in the experimental phase. One approach being explored is the freezing of unfertilized eggs.3 Once again, the ovaries would be stimulated to produce mature eggs before cancer treatment begins. The eggs would then be frozen without being fertilized by sperm. Currently, freezing unfertilized eggs is less likely to result in pregnancy than freezing embryos, largely because unfertilized eggs are less likely than embryos to survive the process of freezing and thawing. Nevertheless, it may be an option for women who do not have a male partner at the time of their cancer diagnosis, and it avoids the difficult issue of what to do with unused embryos.

Another promising but still experimental approach is to freeze all or a part of an ovary before cancer treatment.[4] After treatment, the ovarian tissue is implanted either back in the woman’s pelvis or in another location (such as under her skin). If this process is successful, the ovarian tissue will begin producing eggs. A safety concern with this approach is the possibility of reintroducing cancer cells along with the ovarian tissue, and the tissue will need to be carefully screened for cancer before it is transplanted.4

Finally, it may also be possible to modify some cancer treatments to minimize their effects on subsequent fertility. For example, shielding the ovaries during radiation, or moving the ovaries out of the radiation field, may protect them from the effects of radiation. Scientists are also exploring whether using drugs to suppress the activity of the ovaries during chemotherapy will make the ovaries less susceptible to damage by chemotherapy.[5] For women with certain types of cervical or ovarian cancer, fertility-preserving surgery may also be an option.[6] It’s important to understand that only specific subsets of patients will be candidates for these approaches, and that some of the methods are still in the early stages of evaluation.

Pregnancy after cancer

In addition to having concerns about their ability to get pregnant, women may have concerns about whether pregnancy after cancer treatment will be safe for themselves and their children. While there is a limited amount of information about these topics, the news is generally good.

The risk of cancer recurrence during or after pregnancy has been most studied in women with breast cancer, and these studies generally have reported that pregnancy does not increase the risk of breast cancer recurrence. [7] Many doctors, however, suggest waiting for a period of time after treatment before becoming pregnant. [8]

If chemotherapy or radiation therapy has damaged her heart or lungs, a woman may also have concerns about the strain that pregnancy will put on her body. Studies of breast cancer survivors suggest that long-term heart problems are uncommon after chemotherapy or radiation therapy, [9] but a woman may wish to talk with her doctor about her current health status and the likely effects of pregnancy.

Children born after their mother’s cancer treatment do not appear to be more likely than other children to have birth defects or cancer.[10] If a woman’s cancer was due to a hereditary cancer syndrome, such as Lynch syndrome (hereditary nonpolyposis colorectal cancer), her child may inherit the gene mutation responsible for her family’s increased risk of cancer. Talking with a genetic counselor may help clarify the child’s risk.

When planning for pregnancy, be aware that some cancer treatments may cause you to have an early menopause even if your periods resume after treatment. Also be aware that you may be capable of conceiving even if your periods do not resume; continue to use birth control if you do not wish to become pregnant.

Other Options for Parenthood

Not all women have the luxury of being able to explore their reproductive options before beginning cancer treatment, and not all women will find a fertility preservation option that meets their needs. But there are still ways to become a parent. Discussion of other routes to parenthood may be a painful topic for women who want to become pregnant and cannot. But as cancer survivors consider how best to build their families, methods such as adoption are important options.

Adoption: Couples and individuals who wish to adopt have a range of options, including different types of domestic and international adoptions. You may wish to start by learning about the adoption laws in your state and by talking with other adoptive parents about the professionals and agencies they worked with. Before selecting an adoption agency, women may wish to talk with them about their attitudes toward placing a child with a cancer survivor. Many agencies will be receptive toward this, but it’s important to know before making a final decision.

Egg Donation: Women who still have a uterus may be able to become pregnant using an egg donated by another woman. Through in vitro fertilization, the donated egg would be fertilized by the cancer survivor’s male partner or a sperm donor, and implanted in her uterus. Alternatively, another couple may donate a frozen embryo that could be implanted in her uterus.

Gestational Carrier or Surrogate: Women who do not have a uterus, or who are otherwise unable to sustain a pregnancy, may be able to have another woman carry a pregnancy for them. If the cancer survivor has functioning ovaries, her own egg can be fertilized by her male partner’s sperm and transferred to the uterus of another woman. In this case, the woman who carries the pregnancy is known as a gestational carrier. If the cancer survivor does not have functioning ovaries, another woman can both donate an egg and carry the pregnancy. This is the arrangement traditionally known as surrogacy.

Individual Decisions Within a Larger Community

The decisions that you make about building a family (or about coming to terms with not building a family) will be intensely personal, but know that you are part of a larger community of patients and healthcare providers who are grappling with these issues.

To think about future parenthood is to think about life after cancer. For many people with cancer, planning for the future may provide the motivation needed to get through treatment.

More Information?

Discuss with others….. http://cancerconnect.com/groups/young-adults/topics/fertility-after-cancer-treatment

Fertile Hope (www.fertilehope.org) provides a range of fertility resources for people with cancer.

References:

Prostate cancer is the most commonly diagnosed cancer (other than skin cancer) in U.S. men. Each year, more than 240,000 men are diagnosed with the disease. When the cancer is diagnosed at an early stage, treatment options include surgery, radiation therapy, and active surveillance (close monitoring but no treatment unless the cancer shows signs of worsening).

Radiation therapy uses beams of radiation to slow or stop cancer cell growth, which shrinks or eliminates the tumor. Men with early stage prostate cancer have multiple radiation options, including conformal radiation therapy, IMRT, and proton therapy. In the past, conformal radiation therapy was the standard of care; however, the use of IMRT has become more commonplace in the past decade—with nearly 96% of men receiving IMRT in 2008. IMRT is a type of high-dose, targeted radiation meant to limit damage to surrounding organs. Proton therapy is another type of targeted radiation therapy; it is a high-tech, costly method that requires specialized equipment and facilities.

The population-based study used data from a nationwide cancer registry and included nearly 13,000 Medicare patients age 66 or older. The patients received one of three types of radiation treatment for localized prostate cancer between 2000 and 2009.

The researchers found that, compared with conformal radiation, men treated with IMRT were 10-20% less likely to experience hip fractures and gastrointestinal adverse effects (such as rectal bleeding or diarrhea), but 12% more likely to experience erectile dysfunction. Notably, IMRT patients were 20% less likely to receive additional cancer therapy.

In comparing IMRT and proton therapy, the researchers found that patients treated with the proton therapy did not have much better or worse results than those treated with IMRT—however, they did have more stomach-related side effects. In fact, IMRT patients had a 34% lower risk of gastrointestinal adverse effects than those treated with proton therapy.

The researchers concluded that there was no data to support a clinical benefit of proton therapy over IMRT. IMRT appears to be the safer choice among radiation options for men with localized prostate cancer. While recent advances in technology have led to more refined radiation techniques, the researchers caution that more expensive radiation is not necessarily better. Proton therapy costs twice as much as IMRT, but does not necessarily produce better outcomes.

Reference:

Radical prostatectomy refers to the surgical removal of the entire prostate and some surrounding tissue. Prostatectomy may be performed using traditional open surgery, in which the surgeon makes a single, long incision, or through a laparoscopic procedure (sometimes called minimally invasive surgery), in which several small incisions are made. During laparoscopy, the surgeon inserts a small video camera through one of the incisions in order to see inside the abdomen. In a variant of laparoscopic surgery known as robotic-assisted laparoscopic surgery, the surgeon sits at a console near the operating table and performs the surgery by controlling robotic arms that hold the surgical instruments.

This study evaluated data from 78,232 men over age 65 who underwent prostate removal between 2003 and 2007. What makes this study unique, however, is that it included the data from 100% of Medicare patients in the United States—resulting in a comprehensive body of data that reflects results from both large and small communities from every region of the country. The large sample size enabled researchers to detect statistically significant differences in outcomes between the two methods that smaller studies might not have captured.

During the study period, 19,594 men underwent MIRP with either laparoscopy or robotic technology and 58,638 men underwent traditional open surgery (retropubic radical prostatectomy, or RRP). The use of MIRP increased during the study period—at the beginning, it was used in fewer than 5% of cases, but by the end of the study period, it was used 44.5% of the time. In contrast, the use of RRP decreased from 89.4% in 2003 to 52.9% in 2007.

The researchers found that MIRP was associated with fewer post-surgical complications, fewer blood transfusions, and shorter hospital stays. What’s more—they discovered that post-surgical complications decreased over time in the MIRP group and increased over time in the RRP group. Complication risks in the RRP group increased from 27.4% to 32% and included a significant increase in post-surgical death from 0.5% to 0.8%. Men in the MIRP group had a 0.2% risk of post-surgical death compared to 0.6% for men in the RRP group. The risk of death was small in both groups; however, this was a statistically and potentially clinically significant difference between the two groups.

The researchers concluded that between 2003 and 2007, men who underwent MIRP had fewer blood transfusions, fewer genitourinary complications, and fewer surgical complications compared to their counterparts who underwent RRP. Furthermore, RRP was associated with more post-operative mortality and complications.

Men with prostate cancer are encouraged to speak with their physician to safely evaluate the risks and benefits of the different surgical procedures.

Reference:

A growing body of evidence suggests that aspirin may reduce the risk of several types of cancer, with particularly strong evidence for colorectal cancer. Not all studies have found a benefit, however, and any potential benefits of aspirin must be weighed against risks such as bleeding.

To further explore the relationships between daily aspirin and cancer, researchers conducted a combined analysis of 51 previous randomized trials.[1] The trials were originally designed to evaluate the effect of daily aspirin on outcomes such as heart disease, but information about cancer was also available.

• Daily aspirin reduced cancer deaths. After five years, aspirin users had a 37 percent reduction in risk of cancer death.
• Aspirin also reduced the likelihood of developing cancer. From three years onward, aspirin users had a 24 percent reduction in the risk of being diagnosed with cancer.
• As expected, aspirin carried a risk of major bleeding, but this risk appeared to diminish over time.

Another study published in the same issue of The Lancet evaluated the effect of daily aspirin on cancer metastasis (the spread of cancer from its original site to other parts of the body). The study focused on 987 people who were diagnosed with cancer while participating in one of five trials of aspirin use. Those who were taking aspirin were less likely to have metastatic cancer than those who were not taking aspirin.[2]

These results suggest that regular aspirin use may reduce cancer incidence and mortality, but concerns remain about the risks of regular aspirin use in healthy individuals. People who are considering using aspirin on a regular basis are advised to discuss the risks and benefits with their physician.

References:

Prostate cancer is the most commonly diagnosed cancer (other than skin cancer) in US men. In 2012, roughly 240,000 men are expected to be diagnosed with the condition.

The management of early prostate cancer may involve surgery, radiation therapy, or active surveillance (close observation and testing but no treatment until the cancer shows signs of worsening). Because not all prostate cancers are life-threatening, active surveillance allows some men to avoid (or at least delay) the side effects that accompany surgery and radiation therapy.

Studies have suggested that for men with low-risk prostate cancer, survival with active surveillance is comparable to survival with immediate cancer treatment. Low-risk prostate cancers are those that are small, have a low Gleason Score, and occur in a man with fairly low prostate-specific antigen (PSA) levels. Many men may be reluctant, however, to defer cancer treatment.

To provide some guidance about active surveillance, the National Institutes of Health convened a State-of-the-Science Conference. The conference brought together an independent panel of experts to review, discuss, and summarize the available information on the topic.

In a draft statement, the panel concluded “Because of the very favorable prognosis of low-risk prostate cancer, strong consideration should be given to removing the anxiety-provoking term “cancer” for this condition. Treatment of low-risk prostate cancer patients with radical prostatectomy or radiation therapy leads to side effects such as impotence and incontinence in a substantial number. Active surveillance has emerged as a viable option that should be offered to patients with low-risk prostate cancer.”

The panel also outlined additional research that is necessary in this area. Topics included the identification of candidates for active surveillance, the optimal protocol for active surveillance, and how best to communicate the option of active surveillance to patients. Additional information about short- and long-term outcomes with active surveillance is also needed.

Reference: National Institutes of Health State-of-the-Science Conference: Role of active surveillance in the management of men with localized prostate cancer. Draft statement, December 7, 2011.

Metastatic cancer refers to cancer that has spread to distant sites in the body. Several types of cancer—including prostate cancer—have a tendency to spread to the bone. Bone metastases can lead to serious problems such as fracture and spinal cord compression, and may require treatment with surgery or radiation therapy.

Radium-223 chloride is an investigational drug that delivers very targeted doses of radiation to areas of cancer in the bone.
To assess whether radium-223 chloride improves outcomes among prostate cancer patients with bone metastases, researchers conducted a Phase III clinical trial among 922 men with hormone-refractory cancer. Patients were treated with best standard treatment plus either radium-223 or a placebo.

• Median overall survival was 14 months in the radium-223 group and 11.2 months in the placebo group.
• In addition to prolonging overall survival, radium-223 also delayed the development of bone complications such as fracture. Time to first bone complication was 13.6 months in the radium-223 group and 8.4 months in the placebo group.

The results of this study suggest that radium-223 improves outcomes among prostate cancer patients with bone metastases. Plans are underway to evaluate radium-223 in combination with other cancer treatments, and for patients with other types of cancer.

Reference: Sartor AO, Heinrich D, Helle SI et al. Radium-223 chloride impact on skeletal-related events in patients with castration-resistant prostate cancer (CRPC) with bone metastases: A phase III randomized trial (ALSYMPCA). Presented at the 2012 Genitourinary Cancers Symposium. February 2-4, 2012.San Francisco,CA. Abstract 9.

Prostate cancer is a hormonally sensitive disease that can be controlled for long periods with androgen deprivation therapy (ADT). When prostate cancer stops responding to this treatment, it is referred to as hormone-refractory prostate cancer. Advances have been made in the treatment of hormone-refractory cancer, but challenges remain and new drugs continue to be developed.

MDV3100 is an investigational drug with a new approach to hormonal therapy. The drug interferes with the ability of male hormones to bind to their receptors within a cell, and also reduces the ability of the receptors to enter the nucleus and stimulate cell growth.

To evaluate the safety and efficacy of MDV3100 in the treatment hormone-refractory prostate cancer, researchers conducted a Phase III clinical trial known as AFFIRM. The study enrolled 1,199 men with metastatic, hormone-refractory prostate cancer. All of the men had experienced a worsening of their cancer in spite of previous treatment with hormonal therapy and the chemotherapy drug Taxotere® (docetaxel). Study participants were treated with either MDV3100 or a placebo (sugar pill).

• At the time of an initial analysis part way through the study, researchers found that MDV3100 had significantly improved overall survival: median overall survival was 18.4 months among men treated with MDV3100 and 13.6 months among men treated with placebo. As a result of this benefit, the study was stopped early, and men in the placebo group were offered MDV3100.
• MDV3100 was also found to delay cancer progression: survival without cancer progression was roughly 8 months among men in the MDV3100 group and 3 months among men in the placebo group.
• MDV3100 was generally well tolerated. The most common side effects were fatigue, diarrhea, and hot flushes.

This study suggests that MDV3100 improves outcomes among men with metastatic, hormone-refractory prostate cancer. MDV3100 is also being evaluated for the treatment of earlier stages of prostate cancer.

Reference: Scher HI, Fizazi K, Saad F et al. Effect of MDV3100, an androgen receptor signaling inhibitor (ARSI), on overall survival in patients with prostate cancer postdocetaxel: Results from the phase III AFFIRM study. Presented at the 2012 Genitourinary Cancers Symposium. February 2-4, 2012.San Francisco,CA. Abstract LBA1.