Clinic for early-stage cancer patients at KKH centre helps preserve their fertility

SINGAPORE – Ms Yuana Kamsani’s world came crashing down when she was diagnosed with early-stage endometrial cancer in July 2020.

The private tutor, who was 35 at the time, had by then been married for over seven years and had tried to get pregnant. But with the cancer affecting the inner lining of her womb, she saw her chances of becoming a mother evaporating.

The fertility odds were already stacked against Ms Yuana as she suffered from diabetes and was obese.

She was also afflicted with a pre-cancerous condition called endometrial hyperplasia, which had turned her womb lining abnormally thick, making it difficult for her to get pregnant.

Ms Yuana said: “When I was diagnosed with cancer, I felt the world crashing down on me. I thought, ‘Am I going to die?’

“Even if I was cured of cancer... in the end, can I still have babies?”

But a specialised clinic by KK Women’s and Children’s Hospital (KKH) for early-stage cancer patients wishing to preserve their fertility is offering hope to women like Ms Yuana.

As the global incidence of cancer among people below the age of 50 has risen since 1990, KKH has seen more women under 40 with gynaecological cancers over the past few years.

These include endometrial, ovarian and cervical cancers.

The hospital said it had treated about 80 new patients with gynaecological cancers in 2014, whereas it saw over 100 new patients per year from 2019 to 2023.

Dr Felicia Chin, KKH’s senior consultant at the department of gynaecological oncology, said higher rates of obesity and delayed childbearing are behind this rise, among other reasons.

The gold standard for treating early-stage gynaecological cancers is to remove the reproductive organs, but that would mean many women having to give up hope of having their own children.

Dr Chin pointed out that with advancements in cancer care, survival rates are improving and younger patients may end up living for a long time.

“Invariably, they will have thoughts of having a family.

“So we are trying to minimise a situation where patients realise that they can’t because they had their reproductive organs removed,” she said, adding that that is why conversations around fertility preservation for this group of patients are important.

To meet that need, KKH set up the OncoFertility Clinic in September 2020. Since then, the clinic has seen about 200 patients, with the youngest being a 14-year-old and the oldest being 45.

Over half of the clinic’s patients were diagnosed with endometrial cancer, and 44 per cent had ovarian cancer. Only 4 per cent of patients had cervical cancer.

While fertility treatment strategies differ across the three types of cancer, Dr Chin said that the options are available only to those with early-stage and less aggressive cancers.

“Survival is still the priority,” she said.

To help those with endometrial cancer extend their reproductive lifespan, instead of removing the womb, doctors will use hormonal treatments against the cancer such that the womb lining will become normal.

The treatments can be administered orally or through injections.

Patients may also have an intrauterine system – a small T-shaped device – temporarily implanted in the womb.

It is recommended that overweight patients lose weight as obesity can cause high levels of estrogen, which are linked to endometrial cancer.

The patient’s womb lining has to be reassessed every three months to observe how the cancer is responding to treatment.

“The minute patients choose this route, they have to come back for follow-up quite regularly. If they don’t, it can be quite dangerous because there’s a risk of the cancer progressing,” said Dr Chin.

If patients do not respond to treatment after six months to a year, then womb removal is recommended.

If treatment works and the womb lining is normal, hormone treatments are stopped.

Doctors will then seize the window of opportunity to help the patients conceive, by giving them priority for in-vitro fertilisation (IVF) treatment.

“This is because patients who are not on hormone treatments have about a 40 per cent chance of cancer relapse,” said Dr Chin.

Dr Ee Tat Xin, KKH’s consultant at the department of reproductive medicine, said that the process of egg retrieval for an IVF cycle usually starts on the first day of the menstrual cycle. But there are ways to speed up the process.

After blood tests to determine at which point of the hormonal cycle a woman is in, injections can be given to accelerate egg stimulation and retrieval processes. 

Subsequently, the fertilised eggs, or embryos, are transferred back into the woman’s womb. If the embryos implant in the womb lining, the IVF procedure is a success.

“It’s a race against time,” said Dr Ee, adding that patients have become pregnant as quickly as one month after stopping cancer treatment.

After the child’s birth, and if there are no plans for future pregnancies, the patient’s womb will still have to be removed to complete cancer treatment.

“We are actually buying time so the patient can have a pregnancy,” explained Dr Chin.

In the case of ovarian cancer, as surgery is needed to confirm a diagnosis, oncologists can be judicious with the amount of tissue they remove for testing in the initial operation.

This will allow the patient to preserve as much reproductive potential as possible, as one of the key functions of the ovaries is to produce eggs.

The patient’s eggs can also be safely frozen because there is little worry that they contain any cancer cells, as an egg is a single cell.

In cases where chemotherapy is needed, ovarian tissue can also be frozen to avoid damage, and then reimplanted at a later stage.

“But there is always a very small risk that the tissue is affected, and we are reintroducing cancer cells,” said Dr Ee, adding that the situation and risk will always be thoroughly assessed and discussed by the cancer and fertility doctors at the point of decision. 

“With ovarian tissue reimplantation, the patients may then not need IVF in the future as there may be a restoration of natural fertility.

“They will also have a good chance of delaying menopause because the ovaries regulate hormone production,” he said, noting that the range of options is offered to the patients.

As for cancer of the cervix, doctors will also be careful about the amount of tissue removed.

The organ is often described as a door to the womb, and helps to keep the foetus in place.

When the cervix, or a large part of the cervix, is removed, there is a higher risk of miscarriage and preterm labour.

Hence, stitches may be required around the opening to the womb to support the pregnancy.

For Ms Yuana, to optimise her cancer treatment, she also opted for bariatric surgery in July 2021 to help her lose weight. Four months and 30kg later, her diabetes and cancer were resolved.

After the battle with cancer, she went for IVF treatment in August 2022. A month later, she conceived successfully.

Despite the good news, Ms Yuana was cautious about celebrating as her pregnancy was high risk. She finally gave birth to her daughter on April 29, 2023.

“Throughout my pregnancy, although I could feel her, I kept asking myself if I would ever be a mum. After she was born, I was like ‘Wow, now I have a baby’,” said Ms Yuana. “Being a mother is very fulfilling.”

Correction note: In an earlier version of this story, we said that high levels of estrogen is linked to ovarian cancer. This is incorrect. High levels of estrogen is linked to endometrial cancer. We are sorry for the error.