Parental knowledge of fertility in male childhood cancer survivors

Family planning preferences in transgender youth in an urban multi-disciplinary gender clinic

Background

Known barriers to family planning in the transgender population include low utilization of cryopreservation and decisional regret. There is growing data on the risk of infertility with GAHT, and on to what degree transgender adolescents feel informed about fertility and family planning options.

Objective

Assess preferences regarding options for family planning and fertility preservation in transgender adolescents treated with GAHT in a pediatric endocrinology gender clinic. The goal is to enhance patient education about potential effects of GAHT on fertility and options for family planning.

Methods

Forty one adolescents aged 10 years and older treated with GAHT in an urban outpatient pediatric endocrinology clinic were surveyed over a 6-month period from January to June 2022. Survey questions were multiple choice, Likert scale, and open-ended. Participants were at least 10 years of age, actively followed in the clinic, and receiving GAHT at time of enrollment.

Results

Forty one participants completed the survey. Four (10 %) expressed interest in discussing family planning with their provider. Eighteen (45 %) were open to discussion in the future; 16 (39 %) were not interested at all. 12 (30 %) participants were planning for future parenthood, and 16 (40 %) participants were undecided. Of those interested in parenthood 7 (53.8 %) planned to adopt or foster. Barriers to family planning expressed included financial concerns, potential need to pause GAHT, and social stigma of transgender parenthood. Twenty (50 %) participants recalled prior family planning discussion with their endocrinologist.

Conclusion

Family planning discussions may not be optimally impactful given that 50 % of participants did not recall the conversations. Family planning is a lower priority in this population as most desired to postpone discussion with their provider despite choosing treatment that could influence fertility. It is essential to identify methods to engage transgender youth in discussions related to family planning during GAHT.

Infertility and Identity: A Closer Look Into Experiences of Emerging Young Adult Childhood Cancer Survivors

Objective: While medical advances are enabling more children with cancer to live into adulthood, a large majority of them suffer from the late effects of treatment and about 30% experience infertility. Infertility impacts both male and female survivors complicating typical development for emerging young adults (EYAs) who typically spend this developmental period actively constructing their identities related to family and gender roles, attaining professional skills, and establishing social views. As literature is limited on identity formation and coping with infertility in young survivors, this study aimed to understand the experiences of childhood cancer survivors who are faced with infertility as a late treatment effect while reconstructing their identity. Method: A qualitative descriptive approach was used to explore the experiences and effects of childhood cancer complications on the identity development of six emerging adults (ages 18-29). Guided by the theoretical framework of identity development data were collected using semistructured interviews. Results: Four distinct themes emerged after the data analyses: restricted exploration and uncertain future, challenges to intimacy and communication, restructuring identity through redefining roles, and coping through familial support. Conclusions: Findings indicate that developmental processes of identity formation are complicated by the challenges stemming from infertility and require specific efforts to reconstruct core identity and redefine desired parental roles. Experimentation and self-discovery may be restricted for EYA cancer survivors as they reevaluate their views on intimate relationships, communication, potential professional roles, and family composition. Practical recommendations for multidisciplinary team members to support this growing population are discussed.

Fertility discussions and concerns in childhood cancer survivors, a systematic review for updated practice

PURPOSE

To provide ways to improve the clinical practice of fertility preservation (FP) for children, adolescents, and young adults (AYA) with cancer.

DESIGN

A systematic research of online databases was undertaken in March 2020 following the PRISMA criteria, including Medline and Web of Science.

RESULTS

Fifty-nine articles were included. Surveys, interviews, and focus groups were used to collect data from patients, parents, and health care providers (HCPs). Four themes worth exploring emerged: (a) what do patients and professionals think of and know about FP? (b) what makes the fertility discussion happen or not? (c) what, retrospectively, led to FP being pursued or not? and (d) how do patients and HCPs feel about fertility issues?

CONCLUSION

A minority of AYAs preserve their fertility (banking assay for 45% of boys and 23% of girls). Yet fertility concerns have a significant impact on the quality of life of young cancer survivors. Although recommendations and guidelines regarding FP are available internationally, there are no specific guidelines as to how to conduct fertility counseling for children and adolescents. Some barriers are not removable, such as a poor prognosis of an obvious severe disease, time constraints for starting treatment, and cultural and religious beliefs. In response to aspects hindering patients and families to be receptive to any discussion at the time of diagnosis, psychological support could reduce the level of emotional distress and help restore a degree of open-mindedness to open a window for discussion. Moreover, as the lack of knowledge of professionals about fertility is frequently pointed out as a limiting factor for fertility discussion, reinforcing professional training regarding FP could be proposed to promote fertility discussion and eventually referral for FP.

The impact of hiring a full-time fertility navigator on fertility-related care and fertility preservation at a pediatric institution

Fertility navigators (FNs) are important in communicating infertility risk and fertility preservation (FP) options to patients receiving gonadotoxic therapies. This retrospective study examined electronic medical records of patients with fertility consults at a large pediatric institution (2017-2019), before and after hiring a full-time FN. Of 738 patient encounters, 173 consults were performed pre-navigator and 565 post-navigator. Fertility consults for long-term follow-up cancer survivors increased most substantially: pre-navigator (n = 7) and post-navigator (n = 387). Across diagnoses, females had a larger increase in consults compared to males (χ² [3, N = 738] = 8.17, p < .05). Findings highlight FNs' impact on counseling rates, particularly in survivorship.

Oncofertility care for newly diagnosed girls with cancer in a national pediatric oncology setting, the first full year experience from the Princess Máxima Center, the PEARL study

Background

Childhood cancer patients often remain uninformed regarding their potential risk of gonadal damage. In our hospital we introduced a five step standard oncofertility care plan for all newly diagnosed female patients aiming to identify, inform and triage 100% of patients and counsel 100% of patients at high risk (HR) of gonadal damage. This observational retrospective study (PEARL study) evaluated the use of this standard oncofertility care plan in the first full year in a national cohort.

Methods

The steps consist of 1)timely (preferably before start of gonadotoxic treatment) identification of all new patients, 2)triage of gonadal damage risk using a standardized gonadal damage risk stratification tool, 3)informing all patients and families, 4)counseling of a selected subset of girls, and 5) fertility preservation including ovarian tissue cryopreservation (OTC) in HR patients using amended Edinburgh criteria. A survey of the medical records of all girls newly diagnosed with cancer the first year (1-1-2019 until 31-12-2019) was conducted.

Results

Of 261 girls, 228 (87.4%) were timely identified and triaged. Triage resulted in 151 (66%) low(LR), 32 (14%) intermediate(IR) and 45 (20%) high risk(HR) patients. Ninety-nine families were documented to be timely informed regarding gonadal damage risk. In total, 35 girls (5 LR, 5 IR, 25 HR) were counseled by an oncofertility expert. 16/25 HR patients underwent fertility preservation (1 ovariopexy + OTC, oocyte cryopreservation (1 with and 1 without OTC) and 13 OTC). Fertility preservation did not lead to complications or delay of cancer treatment in any patient.

Conclusion

We timely identified and triaged most girls (88%) with cancer with a high risk of gonadal damage to be counseled for fertility preservation. We aim to optimize the oncofertility care plan and the standardized gonadal damage risk stratification tool based on this experience and these may be of value to other pediatric oncology centers.

Consult and procedure incidence outcomes following establishment of a fertility preservation program for children with cancer

PURPOSE

Fertility is a quality of life outcome adversely affected by cancer therapy. Many childhood cancer patients, however, are not offered options to preserve their fertility. Providers acknowledge difficulty discussing impaired fertility to patients due to lack of knowledge of available options. Our objective was to review the impact of a pediatric multidisciplinary fertility preservation program on providers' fertility preservation counseling and discussion of options.

METHODS

A retrospective medical chart review was conducted for pediatric cancer patients prior to and following program establishment. Fertility preservation discussions, consults, and incidence were noted. Following filtering and stratification, 198 and 237 patients were seen prior to and following program establishment, respectively.

RESULTS

Following program establishment, provider-patient discussions of impaired fertility (p = 0.007), fertility preservation consults (p = 0.01), and incidence of fertility preservation procedures (p < 0.001) increased among patients. Furthermore, the number of patients who received fertility preservation consults after receiving gonadotoxic treatment decreased (p < 0.001). This trend was particularly noted in pre-pubertal and female patients, for whom fertility preservation options are limited without an established program.

CONCLUSION

The establishment of a formal program greatly improved access to fertility preservation consults and procedures in children with cancer.

Fertility Preservation for Pediatric and Adolescent Patients With Cancer: Medical and Ethical Considerations

Many cancers presenting in children and adolescents are curable with surgery, chemotherapy, and/or radiotherapy. Potential adverse consequences of treatment include sterility, infertility, or subfertility as a result of gonad removal, damage to germ cells as a result of adjuvant therapy, or damage to the pituitary and hypothalamus or uterus as a result of irradiation. In recent years, treatment of solid tumors and hematologic malignancies has been modified in an attempt to reduce damage to the gonadal axis. Simultaneously, advances in assisted reproductive technology have led to new possibilities for the prevention and treatment of infertility. This clinical report reviews the medical aspects and ethical considerations that arise when considering fertility preservation in pediatric and adolescent patients with cancer.

Physicians' self-reported practice behaviour regarding fertility-related discussions in paediatric oncology in Sweden

OBJECTIVE

The aim of this study was to investigate practice behaviours of Swedish physicians with regard to discussing the impact of cancer treatment on fertility with paediatric oncology patients and their parents, and to identify factors associated with such discussions.

METHODS

A cross-sectional survey study was conducted targeting all physicians in Sweden working in paediatric oncology care settings. Participants responded to a questionnaire measuring practice behaviour, attitudes, barriers, and confidence in knowledge. Multivariable logistic regression was used to determine factors associated with seldom discussing fertility.

RESULTS

More than half of the physicians routinely talked with their patients/parents about the treatment's potential impact on fertility (male patients: 62%; female patients: 57%; P = 0.570). Factors associated with less frequently discussing fertility with patients/parents were working at a non-university hospital (male patients: OR 11.49, CI 1.98-66.67; female patients: OR 33.18, CI 4.06-271.07), concerns that the topic would cause worry (male patients: OR 8.23, CI 1.48-45.89; female patients: OR 12.38, CI 1.90-80.70), and perceiving the parents as anxious (male patients: OR 7.18, CI 1.20-42.85; female patients: OR 11.65, CI 1.32-103.17).

CONCLUSIONS

Based on our findings, we recommend structured training in how to communicate about fertility issues in stressful situations, which in turn might increase fertility-related discussions in paediatric oncology.

Adolescent oncofertility discussions: Recommendations from a systematic literature review

BACKGROUND

Increasing cancer incidence and survivorship rates have made late-term effects, such as effects on fertility, a salient issue for adolescent cancer patients. While various barriers make it difficult for health care professionals to discuss oncofertility with adolescents and their parents, there are numerous reasons to hold such discussions, based on professional obligations and the ethical principles of respect for autonomy and beneficence. This systematic literature review presents and critically examines recommendations for adolescent oncofertility discussions.

METHODS

Conducted according to PRISMA guidelines, this systematic literature review includes English, French, and German articles published up until December 31, 2014. Articles were sought via a combination of search terms in four databases.

RESULTS

Eighty of 96 articles included in this review address recommendations for improving adolescent oncofertility discussions. These recommendations deal with how, when, what, and with whom professionals ought to have these discussions, as well as various systemic barriers and ways to address them.

CONCLUSIONS

Based upon the principles of beneficence, respect for autonomy, and justice, we endorse several recommendations for oncofertility discussions with adolescents and their parents, including having a specific professional on the health care team initiate these discussions with all newly diagnosed patients; regularly doing so before, during, and after treatment; allowing adolescents to decide for themselves whom they wish to include in such discussions; employing various forms of communication; obtaining both adolescent assent and parental consent for fertility preservation (FP) procedures, especially at each stage (e.g., procurement and use); properly educating and training professionals to discuss oncofertility; promoting interdisciplinary collaboration; creating and implementing guidelines and policies; and ensuring equity of access to FP.

Gonadal function, fertility, and reproductive medicine in childhood and adolescent cancer patients: a national survey of Japanese pediatric endocrinologists

An increasing number of pediatric cancer patients survive, and treatment-related infertility represents one of the most important issues for these patients. While official guidelines in Japan recommend long-term follow-up of childhood cancer survivors (CCSs), their gonadal function and fertility have not been clarified. To address this issue, we organized a working panel to compile evidence from long-term survivors who received treatments for cancer during childhood or adolescence. In collaboration with members of the CCS Committee of the Japanese Society for Pediatric Endocrinology (JSPE), we conducted a questionnaire survey regarding reproductive function in pediatric cancer patients. A cross-sectional survey was sent to 178 JSPE-certified councilors who were asked to self-evaluate the medical examinations they had performed. A total of 151 responses were obtained, revealing that 143 endocrinologists were involved in the care of CCSs. A quarter of the respondents reported having experienced issues during gonadal or reproductive examinations. Several survivors did not remember or fully understand the explanation regarding gonadal damage, and faced physical and psychological distress when discussing the risk of becoming infertile. Pediatric endocrinologists had anxieties regarding their patients’ infertility and the risk of miscarriage, premature birth, and delivery problems. Only a limited number of endocrinologists had experience with managing childbirth and fertility preservation. Many councilors mentioned the necessity for inter-disciplinary communication among healthcare providers. Both endocrinologists and oncologists should set and follow a uniform clinical guideline that includes management of fertility of CCSs.

Discussing fertility preservation at the time of cancer diagnosis: dissatisfaction of young females

BACKGROUND

Sperm banking is widely available for post-pubertal male cancer patients but options for females remain limited. Anecdotal evidence suggests that fertility issues may be inadequately discussed with females. To understand the experience of both sexes in the UK, surveys of young cancer survivors were performed 7 years apart.

PROCEDURE

Data were collected from young cancer survivors aged over 13 years at diagnosis, attending support group conferences held in 2004 and 2011. Data were collected anonymously using remote handsets in response to questions projected on the screen during plenary sessions.

RESULTS

A total of 81 female and 69 males responded in 2004, and 69 females and 71 males in 2011. In both years, most males reported fertility discussions taking place before treatment started and they were generally satisfied with it. However in both years, fewer females recall a discussion about fertility and they were generally less satisfied. Although in 2011 more females reported a fertility discussion prior to the beginning of treatment, they were no more satisfied than the females in 2004 whose fertility discussion were more likely to take place after treatment had started.

CONCLUSIONS

Whilst male cancer survivors in the UK are generally satisfied about the frequency and timing of discussions about fertility, females are not. Although in 2011 fertility discussions with females more often took place before treatment began, they were no more satisfied than females in 2004. This may reflect the approach by professionals or the absence of effective fertility preservation strategies for them.

Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update

PURPOSE

To update guidance for health care providers about fertility preservation for adults and children with cancer.

METHODS

A systematic review of the literature published from March 2006 through January 2013 was completed using MEDLINE and the Cochrane Collaboration Library. An Update Panel reviewed the evidence and updated the recommendation language.

RESULTS

There were 222 new publications that met inclusion criteria. A majority were observational studies, cohort studies, and case series or reports, with few randomized clinical trials. After review of the new evidence, the Update Panel concluded that no major, substantive revisions to the 2006 American Society of Clinical Oncology recommendations were warranted, but clarifications were added.

RECOMMENDATIONS

As part of education and informed consent before cancer therapy, health care providers (including medical oncologists, radiation oncologists, gynecologic oncologists, urologists, hematologists, pediatric oncologists, and surgeons) should address the possibility of infertility with patients treated during their reproductive years (or with parents or guardians of children) and be prepared to discuss fertility preservation options and/or to refer all potential patients to appropriate reproductive specialists. Although patients may be focused initially on their cancer diagnosis, the Update Panel encourages providers to advise patients regarding potential threats to fertility as early as possible in the treatment process so as to allow for the widest array of options for fertility preservation. The discussion should be documented. Sperm and embryo cryopreservation as well as oocyte cryopreservation are considered standard practice and are widely available. Other fertility preservation methods should be considered investigational and should be performed by providers with the necessary expertise.

Parental attitudes toward fertility preservation in boys with cancer: context of different risk levels of infertility and success rates of fertility restoration

OBJECTIVE

To measure the parental attitudes toward fertility preservation in boys with cancer.

DESIGN

Retrospective cohort study.

SETTING

Questionnaire survey via regular mail.

PATIENT(S)

A total of 465 families whose sons were already treated for cancer.

INTERVENTION(S)

The questionnaire was designed for two groups based on child's age at the time of cancer diagnosis: <12 and ≥12 years old.

MAIN OUTCOME MEASURE(S)

Descriptive statistics regarding a positive or negative attitude of parents toward fertility preservation options in the context of different risk levels of infertility and success rates of fertility restoration.

RESULT(S)

The response rate was 78%. Sixty-four percent of parents of boys ≥12 years old would agree to store sperm obtained by masturbation and/or electroejaculation, and 54% of parents of boys <12 years old would agree to store a testicular biopsy. If the risk of infertility or the success rate of fertility restoration were ≤20%, more than one-fourth of parents would still opt for fertility preservation.

CONCLUSION(S)

All parents should be counseled about the risks of infertility due to cancer treatment, because many parents want to preserve their son's fertility even if the risk of becoming infertile or the chances on fertility restoration are low.

Family information needs at childhood cancer treatment completion

BACKGROUND

Despite the recognized importance of information provision across the cancer trajectory, little research has investigated family information needs recently after childhood cancer. This mixed-methods, multiperspective, study explored the information needs of families of childhood cancer survivors in the first year post-treatment.

PROCEDURE

In total, 112 semi-structured telephone interviews were conducted with 19 survivors (mean age 16.2 years, off treatment for ≤36 months), 44 mothers, 34 fathers, and 15 siblings. Interviews were analyzed inductively, line-by-line, using the framework of Miles and Huberman. Emergent themes were cross-tabulated by sample characteristics using QSR NVivo8.

RESULTS

Participant views were mixed regarding the need for a "finishing treatment review" with their oncologist (the primary information source for most families); however, many mothers (29/44) and fathers (17/34) and most siblings (14/15) reported receiving insufficient information post-treatment. Information regarding fertility and how to prepare for likely post-treatment challenges were the most cited unmet needs. Online support was ranked highest by survivors (mean score: 7/2/10) and siblings (7.4/10), whilst parents preferred an information booklet (often due to concerns about accessing accurate and relevant information from the Internet). While many participants reported feelings of isolation/loneliness, many were reluctant to attend face-to-face support groups/seminars.

CONCLUSIONS

Family members of survivors may experience the most acute unmet needs for information about fertility and in preparation for post-treatment challenges. However, provision of the correct amount of information at the right time for each family member during a highly stressful period remains clinically challenging.

Results from the survey for preservation of adolescent reproduction (SPARE) study: gender disparity in delivery of fertility preservation message to adolescents with cancer

PURPOSE

Diminished reproductive capacity is a devastating consequence of life-sparing therapies for childhood malignancy. In 2006, the American Society of Clinical Oncology (ASCO) published fertility preservation recommendations (ASCOR) emphasizing the importance of early discussion and intervention for fertility preservation strategies. Using the Survey for Preservation of Adolescent REproduction (SPARE), we sought to determine fertility preservation attitudes and practice patterns post-ASCOR from pediatric oncology specialists nationwide.

MATERIALS AND METHODS

The SPARE survey consists of 22 questions assessing pediatric oncology specialists' attitudes and practice patterns toward fertility preservation. Broad perspectives on fertility preservation, including a willingness to discuss fertility, knowledge of current fertility preservation methods and awareness of ASCOR, were assessed.

RESULTS

The majority of respondents acknowledged that fertility threats are a major concern for them and agreed that all pubertal cancer patients should be offered a fertility consultation, but only 46% reported they refer male pubertal cancer patients to a fertility specialist prior to cancer treatment >50% of the time, and only 12% reported they refer female pubertal cancer patients to a fertility specialist prior to cancer treatment > 50% of the time. While 44% of respondents were familiar with the 2006 ASCOR, only 39% of those utilized them to guide decision-making in greater than half of their patients.

CONCLUSION

Our study demonstrates pediatric oncologists' motivation to preserve fertility in pediatric cancer patients; however, barriers to both gamete cryopreservation and referral to fertility specialists persist. Female pubertal patients are referred to fertility preservation specialists with much less frequency than are male pubertal patients, highlighting a disparity.

Attitudes of physicians and parents towards discussing infertility risks and semen cryopreservation with male adolescents diagnosed with cancer

BACKGROUND

In paediatric oncology, the risk of infertility due to treatment constitutes an important problem. For sexually mature male adolescents, sperm cryopreservation is an option, but discussing the topic is complex because of the sensitive nature and the limited time frame. In this article, we determined attitudes and preferred roles of physicians and parents towards discussing sperm banking with male adolescents.

METHODS

Qualitative multi-centre study, using in-depth semi-structured interviews with 14 physicians and 15 parents of male adolescents undergoing cancer treatment.

RESULTS

Although physicians and parents agreed that infertility would have a major impact on the future quality of life, they sometimes disagreed on whether the topic should be discussed with adolescents. Physicians always wanted a separate discussion with adolescents because of the sensitive nature and the experience that parents sometimes misjudged the stage of maturity of their son. Parents, however, wanted control over whether physicians discussed the topic with their child and what was said. Physicians did not accept this control and, when necessary, were willing to bypass the parents and discuss the topic with the adolescent even when parents refused consent.

CONCLUSIONS

Physicians face the difficult task of balancing between their ideas of what is in the (future) interest of the adolescent and accommodating parental wishes. We argue that, because of the private character of sexuality and the potentially inadequate maturity assessment by parents, semen cryopreservation should be discussed separately with adolescent and parents. In addition, there should be an open communication with parents to address potential discomforts.

Psychological aspects of fertility preservation in men and women affected by cancer and other life-threatening diseases

BACKGROUND

With advances in treatment, the number of young cancer survivors who may benefit from fertility preservation is growing. The aim of this study was to review the literature investigating psychological aspects of fertility issues and fertility preservation in patients undergoing fertility-compromising therapy for cancer or other life-threatening diseases, previous to or during their reproductive lifespan.

METHODS

Articles were identified in PubMed, Embase and PsycLIT as well as manually retrieved from literature citations for the time period from 1999 to 2008. Inclusion criteria were (i) qualitative or quantitative design, (ii) focus on patients previous to or during their reproductive lifespan and (iii) dealing with aspects such as (1) impact of fertility issues in cancer patients or (2) health professionals' and/or patients' attitudes towards fertility preservation or (3) counselling.

RESULTS

Twenty-four studies were identified. According to the studies on aspect (1), fertility is an important issue for cancer patients. Health professionals as well as patients and parents consider fertility preservation as an important option for young cancer patients; all parties involved, however, were noted to have knowledge and information deficits. Patients recalling counselling about the impact of cancer treatment on fertility ranged from 34% to 72%. Counselling is far from being offered globally to all patients at risk, and providing information seems to be selective.

CONCLUSIONS

The existing literature demonstrates the need for and the limits of current counselling. Future research should target the means to facilitate the decision-making process for patients and health professionals.