Applying behavioral theory to understand fertility consultation uptake after cancer

From Storage to Survivorship: A Scoping Review of Young Adult Cancer Survivors' Experiences and Preferences in Reproductive Survivorship Care after Fertility Tissue Preservation

BACKGROUND

Childhood cancer treatment can lead to subfertility in adulthood. Fertility tissue preservation offers a way to safeguard future fertility, especially for prepubescent children, whose preservation options are limited. While this is a significant technological advance, it also presents unique challenges compared to other methods of fertility preservation. Clinical consensus is that all childhood cancer patients should receive high-quality, personalised survivorship care and that healthcare policy and practice must address the expectations and priorities of care recipients. We report the available information on the experiences of cancer survivors who preserved tissue for future fertility, to support the development of survivorship care informed by recipients' perspectives and experiences to identify future research priorities.

METHODS

We conducted a scoping review following the recommendations of the Joanna Briggs Institute and the Systematic Reviews and Meta-Analyses Extension for Scoping Review (PRISMA-ScR). We searched for research that included patient reported outcomes from patients who underwent fertility tissue preservation (FTP) in childhood and early adulthood, following a cancer diagnosis, including outcomes reported by parents. Our search terms aimed to identify literature reporting on both ovarian and testicular tissue preservation. We searched Embase, Cinahl, PsycInfo, Medline, Scopus and Cochrane Database of Systematic Reviews alongside sources of grey literature, for relevant articles including all time-frames between 1980-2023, with support from an independent information specialist at the University of Leeds. Descriptive statistics were used to analyze the data and we present the results in tabular form to summarise the key information.

RESULTS

From 1956 unique records, 5 met our inclusion criteria. No literature was found reporting on the experiences of people who stored testicular tissue. The available literature only included reports from people who had stored ovarian tissue. We found that young women who had stored ovarian tissue faced complex emotional and ethical dilemmas in reproductive decisions post cancer and strongly desired their own biological children.

CONCLUSIONS

This scoping review is the first to report beyond clinical outcomes by focusing specifically on the self-reported outcomes of patients who preserved ovarian tissue in early life after a cancer diagnosis. It provides valuable insights into their experiences and highlights that ovarian tissue cryopreservation (OTC) presents distinct challenges compared to other forms of fertility preservation. We recommend separate consideration of the needs of patients with stored fertility tissue and call for further research to enable personalized survivorship care. To develop tailored care pathways for long-term well-being, patient-reported outcomes are also needed from individuals with stored testicular tissue, parents who consented to their child's tissue storage, and the healthcare professionals involved in their care. This review underscores a significant evidence gap between rapid FTP advancements and the availability of comprehensive care addressing these advancements. As FTP science evolves, patients need detailed information for informed decisions and ongoing support for their unique reproductive and endocrine health concerns throughout their survivorship journey.

The use of fertility treatments among reproductive-aged women after cancer

OBJECTIVE

To examine whether female cancer survivors are more likely to pursue care for infertility after cancer than women without cancer.

DESIGN

Population-based cohort study involving detailed interviews regarding reproductive history.

SETTING

Not applicable.

PATIENTS

Female cancer survivors aged 22-45 years, who were at least 2 years after a cancer diagnosis between the ages of 20 and 35 years (n = 1,036), and age-matched comparison women with no cancer history (n = 1,026).

EXPOSURE

History of cancer vs. no history of cancer.

MAIN OUTCOME MEASURE(S)

Each cancer survivor was randomly matched to a comparison woman, who was assigned an artificial age at cancer diagnosis equal to that of her match. Matching was repeated 1,000 times. Outcomes of visiting a doctor for help becoming pregnant or undergoing fertility treatment were modeled using Cox proportional hazards regression, comparing survivors after a cancer diagnosis to age-matched comparison women, adjusted for race, income, residence, education, and parity.

RESULTS

Only 25.5% of cancer survivors reported meeting their desired family size before a cancer diagnosis. The median time from diagnosis to interview among survivors was 7 (interquartile range 5-11) years. Cancer survivors were more likely to report having no children (32.6%) at the interview compared with women with no cancer history (19.5%). Survivors were not more likely to visit a doctor for help becoming pregnant compared with women without a cancer history, matched on birth year and followed by the age at which cancer survivors received their diagnosis (hazard ratio [HR] 1.16, 95% simulation interval [SI] 0.78-1.74). Compared with cancer-free women, cancer survivors had similar probabilities of pursuing any treatment (adjusted HR [aHR] 0.88, 95% SI 0.46-1.56), using hormones or medications (aHR 0.86, 95% SI 0.46-1.63), or undergoing intrauterine insemination (aHR 1.26, 95% SI 0.40-5.88) to conceive. Cancer survivors were slightly more likely to pursue surgical interventions to become pregnant (HR 1.55, 95% SI 0.67-3.71). Of those who visited a doctor but declined to pursue fertility treatment, one-quarter of women reported declining treatment due to cost.

CONCLUSION

Cancer survivors did not use fertility treatments at higher rates than the general population. Further counseling and education surrounding fertility options are recommended for young adult female cancer patients after treatment is completed.

Examining decisional needs and contextual factors influencing fertility status assessment among young female survivors of childhood cancer: A sequential mixed methods study protocol

INTRODUCTION

Female cancer survivors who received gonadotoxic cancer treatment are at risk for profound diminished ovarian reserve and/or primary ovarian insufficiency with resulting infertility, which can be associated with distress and decreased quality of life.. Despite prioritizing future parenthood, many survivors are unsure of the impact of their treatment on their future fertility, and little is known about the perceived reproductive health needs and factors associated with receipt of a fertility status assessment (FSA). There is a lack of developmentally appropriate reproductive health decisional support interventions available for emerging adult cancer survivors. This study will explore the perceived reproductive health needs of emerging adult female survivors of childhood cancer and to identify decisional and contextual factors that influence pursuit of FSA using an explanatory sequential quantitative to qualitative mixed methods design.

METHODS AND ANALYSIS

This study will enroll 325 female survivors (aged 18 to 29 years and >1-year post treatment; diagnosed with cancer < age 21 years) from four cancer centers in the United States. Sociodemographic and developmental factors, reproductive knowledge and values, decisional needs, and receipt of an FSA will be assessed through a web-based survey. Informed by survey findings, a subset of participants will be recruited for qualitative interviews to explore decisional factors associated with uptake of an FSA. Clinical data will be abstracted from the medical records. Multivariable logistic regression models will be developed to identify factors associated with FSA and qualitative descriptive analysis will be used to develop themes from the interviews. Quantitative and qualitative findings will be merged using a joint display to develop integrated study conclusions and direct future interventional research.