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Bill Klaproth (Host):   So there seems to be some questions about any potential links between cancer and fertility medication. Well, let’s clear that up with Dr. Mary Deraismes Hinkley, a physician at Reproductive Science Center of the San Francisco Bay Area. This is Fertile Edge, a podcast by the Reproductive Science Center of the San Francisco Bay Area. I'm Bill Klaproth. Dr. Hinckley, always great to talk with you. So let’s jump right into it. Are there any links between cancer and fertility medications?

Mary Hinckley, M.D., REI (Guest):   Hi Bill. It is good to be back and talking with you. This is a topic that always comes up. I try to actually bring it up if a patient herself or himself doesn’t bring it up at each visit so that I can really review this because I think there are a lot of misconceptions about cancer and fertility drugs or fertility treatments. So it’s important to know that the most up to date publications have shown that there is no link between fertility treatment, fertility medications, and invasive cancer. So the Oncofertility Consortium released a statement saying first of all, most of the data is somewhat limited. There are retrospective studies. The dosing is not always clear. The treatment timelines are not clear. Some patients have difficulty remembering what they did when they do retrospective studies, but there is no compelling data to suggest that fertility medications increase the risk of invasive cancer.

Now, there is a type of cancer out there called a borderline ovarian cancer. There have been a couple of studies that have suggested that fertility treatment could increase this risk. Now, there’s insufficient data on this, but if it did increase the risk, this type of cancer is very treatable and curable. It is not the same type of ovarian cancer that most people have heard about that is a very deadly ovarian cancer that is picked up at very late stages. So I think that’s really encouraging to us. The practice committee reports from the American Society of Reproductive Medicine also support this opinion that we do not see a link between fertility medications and invasive cancer. So I think that can be reassuring to patients. We still want to judiciously use those medicines. No one wants to be on medicine that doesn’t have to be. So I think choosing treatment and optimizing treatment’s important, but I think most people when they know that the bodies out there that are most concerned about cancer—the Oncofertility people and the oncologists—are really agreeing with the fertility doctors that it does not appear that this medication increases risk.

Host:   So that is really interesting. So let me ask you this then. Does being infertile put you at a higher risk of cancer?

Dr. Hinckley:   Well, you know, it really does. That’s what, I think, gets confusing for patients is that the fact that they are infertile tells me that they already have a slightly higher risk of having certain cancers. Now, these are very specific cancers. They depend on what causes your infertility, but we do know that being infertile, never having had a child—even if you didn’t try—and late menopause are all associated with an increased risk of cancer. Some of the reasons and the mechanisms by which we think this increases cancer have to do with hormones. So for example, we see a higher evidence of breast cancer in women who have never had a child. The reason might be because they’ve used birth control pills for longer. That has been shown to have a higher chance of being associated with breast cancer. We see a higher risk of breast cancer for people who have higher estrogen levels floating around in their blood stream day after day. If they're taking hormones for another reason or if they have polycystic ovarian syndrome. We see obesity associated with infertility and obesity associated with cancer. So these are links that are either causative or at least associated with an increased risk of cancer.

There also are a few others if you are someone who has polycystic ovarian syndrome or does not ovulate very frequently. We know that the fact that you don’t have a period at least four times a year can be associated with an increased risk of uterine cancer or endometrial cancer. That is why many patients with PCOS will be put on medicine to have at least four periods a year to reduce their risk of uterine cancer. Then we also know that there’s a higher risk of ovarian cancer for women who have never conceived. There are different theories about why this may be the case. We know that endometriosis is associated with a slightly higher risk of transformation of those cells into cancerous cells. We used to think that women who just ovulated month after month after month—and we called this incessant ovulation—would be at higher risk. More recent studies on ovarian cancer have shown that the type of ovarian cancer, which is called serous cancer, is actually probably from the fallopian tube that then gets pushed out of the tube and lands on the ovary causing ovarian cancer. So now we don’t believe this theory of incessant ovulation being associated with cancer, but we think it is actually the tube. So there are clearly increased risks of cancer for women who also have infertility.

Interestingly, some of the treatments for infertility can lower their risk of cancer. For example, if I'm able to help a woman get pregnant and she has a full term pregnancy, and especially if she breastfeeds, she’s going to lower her chance of breast cancer. So there are things that we can do with fertility medications and treatment that may actually lower their baseline risk of cancer.

Host:   So having a full understanding of the playing field, if you will, is really valuable information.

Dr. Hinckley:   It’s a little bit about knowing what your baseline risk is. If you have infertility, you have a risk. So now you need to know how to mitigate that risk. Is it through fertility treatment or not? You need to talk to a specialist to try to figure that out.

Host:   Right. So then what about someone who has a family history of cancer? What are the risks? What should she do?

Dr. Hinckley:   Well, that’s a good question. We do see patients who come in who will tell me, “Oh, my sister had breast cancer at a young age. My mom had breast cancer.” Or they have a family history of prostate cancer or pancreatic cancer. Of course when you’ve lived through this, you are very concerned about it not only for yourself but for your loved ones. So it’s very good to seek treatment and help for trying to diagnose whether you have a higher risk because of your family of having some genetically linked type of cancer or increased risk for a type of cancer. So the first thing to do is know your family history. You need to ask those people, even the aunts and uncles that maybe you don’t talk to so often or at least get your mother and father to ask their siblings. You need to write it down so that you know it. Then you may want to consider seeing a genetics counselor who specializes in cancer screening. So if you have enough history in your family of specific cancers, that will tip off some genetics counsellors to knowing whether they should do screening on you. That screening is usually done through a blood test. They're able to look at certain mutations that you might carry which would predispose you to a higher chance of developing cancer.

This field is really blossoming these days. We’re starting to find more and more mutations that we know expose patients to a greater risk. Once you know that, you're then able to do something about it. That can be really helpful. Your fertility doctor can be someone who can point you in the right direction to those genetic counselors. There’s even online counselors now. There’s a company that’s able to do that assessment and ask your family history and find out if you need to do specific blood tests and order them, and they can be delivered to your house through the mail. So it doesn’t always mean that it’s going to be hard and laborious. Many times it’s covered by insurance if your doctor has ordered these tests. So that can be a great way to figure out how your family’s history might affect you.

Then you can do some things to proactively reduce your risk. Now, if you have a strong family history of breast cancer, especially at a young age, there are screening protocols that we go through now. Whether that’s getting a mammogram at an earlier age or using the MRI or ultrasound. One of the other things I always think of is just taking care of your lifestyle. Obesity, alcohol intake over four drinks a week for women, not exercising, exposing yourself to carcinogens either in your plastic water bottles and the water you drink and the things that are in your house. These are all ways to reduce risk of cancer. Many of us feel that our bodies, since our cells are constantly dividing, they sometimes make a mistake. They have a mutation and a cell line that could become cancerous. If we have healthy systems then we have the ability to shut those cells down and kill them off so that the good cells can continue to propagate. If we’re not really paying attention to our lifestyle, we may be allowing some of these unhealthy cells to grow out of control. That may be the genesis of cancer, especially if you have some predisposing risk factors in your genetic line from your family. So I think being proactive to reduce your risk is going to be critical in this next generation as we’re living longer and being healthier, but I do think it's important for patients to understand that fertility medications in and of themselves do not appear to be the enemy. They are not evil. They can be used for good. They just have to be used in the right way at the right time. So talking to a fertility specialist can be really essential.

Host:   Absolutely. So know your family history, see a genetic counselor if necessary, and then make sure you live a healthy lifestyle. We want to shut those bad cells off as you say. Any final thoughts Dr. Hinckley as we wrap up?

Dr. Hinckley:   Well, you know I think the other one is to always be open with your history and follow up with your doctors. So we are continuing to learn new things. IVF has only been around for 42 years as of the recording of this podcast. It’s important to always keep your record up to date with your doctor, to let them know you did fertility treatment, what you did, when you did it. That way if new things develop about risks for cancer or for anything else that may come down the line or if just your infertility puts you at risk. Your doctor will know that and will be able to think about that moving forward to help you manage those risks.

Host:   Well, Dr. Hinckley, as always very, very informative. Thank you so much for your time. We appreciate it.

Dr. Hinckley: Oh you're welcome. Always happy to share what I know. Take care.  

Host:   That’s Dr. Mary Deraismes Hinckley. To get connected with Dr. Hinckley or another physician, please visit rscbayarea.com. That’s rscbararea.com. If you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Fertile Edge by the Reproductive Science Center of the San Francisco Bay Area. I'm Bill Klaproth.