Receiving a diagnosis of cancer during pregnancy, which may occur for AYAs, raises questions about how cancer treatment may affect both the mother and the developing embryo or fetus; about one in 2,000 pregnancies is complicated by cancer according to estimates (600). The risk to mother or offspring from cancer or the treatment of cancer is mixed and is dependent on a multitude of factors such as age, cancer type, stage of cancer, the trimester at diagnosis, and therapy type received (601-603). AYAs also have worse mental health outcomes compared to those without a diagnosis of cancer. AYA cancer survivors had an 80 percent increased risk of hospitalizations for mental health illnesses and were 4.5 times more likely to purchase antidepressants compared to their siblings (605). Furthermore, a subset of AYA survivors is at risk for early death, with those diagnosed with hematologic malignancies facing the highest risk (606). Financial toxicity among AYA cancer survivors is also higher compared to those with no diagnosis of cancer. One study reported that the costs associated with a diagnosis of cancer are substantial, reaching an average of $259,324 per person over their lifetime. One reason is that a cancer diagnosis often affects these individuals when they are just beginning higher levels of education or starting careers, potentially impacting productivity and well-being (54). The Affordable Care Act (ACA) resulted in improved insurance coverage. Evidence is emerging that states which expanded Medicaid under the ACA had improved overall survival among young adults with cancer, specifically among racial or ethnic minorities when compared to states that did not expand Medicaid benefits (608). Fertility Preservation After a Diagnosis of Cancer One of the adverse consequences of cancer treatments is infertility or the inability to conceive a child. This may result from surgery on reproductive organs or effects of cancer medications on reproductive cells, and can affect both male and female patients. Thus, those diagnosed with cancer should consider discussing with their health care providers whether infertility is a risk for them. If so, the discussion should include whether fertility preservation is an option and which of the available options should they consider. BOYS AND MEN: • Sperm banking • Shielding of testes from radiation if receiving radiotherapy GIRLS AND WOMEN: • Banking of ovarian tissue • Banking of eggs • Banking of embryos • Surgically moving ovaries away from areas of radiotherapy • Removing cervix but preserving uterus • Shielding of ovaries from radiation if receiving radiotherapy Unfortunately, fertility preservation rates are lower in survivors who are Black, poor, or live in rural areas. Currently, cancer-focused organizations have guidelines that recommend discussions of fertility preservation and sexual health as an essential part of cancer management, especially in AYA patient populations. Furthermore, as of July 2023, 16 states have mandates, and three have active legislation, requiring insurance coverage of fertility preservation for patients facing infertility due to treatments such as anticancer therapies (599). This is an increase from July 2022, when only 12 states had mandates. SIDEBAR 43 The POSITIVE clinical trial found that women under the age of 43, who are diagnosed with early-stage breast cancer and are receiving hormone therapy, can safely pause their treatment for up to two years without increasing the risk of cancer recurrence or decreasing the likelihood of becoming pregnant (604). In an analysis of AYA survivors, 71 percent indicated that they faced at least one barrier to survivorship care. These barriers were increased in non-Hispanic Black survivors, with 92 percent reporting difficulties in accessing survivorship care (607). Supporting Cancer Patients and Survivors AACR Cancer Progress Report 2023 137
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