Disparities in the use of assisted reproductive technologies after breast cancer: a population-based study

A Retrospective Study of Fertility Counseling and Preservation Rates for Women of Reproductive Age With Breast Care After Integrating a Fertility Specialist Into a Multidisciplinary Tumor Board

INTRODUCTION

Many breast centers have adopted multidisciplinary tumor boards to discuss and develop treatment plans for patients diagnosed with breast cancer. This study aims to determine whether adding a fertility specialist to tumor board will improve fertility counseling and utilization in breast cancer patients METHODS: A retrospective study of reproductive age patients diagnosed with breast cancer between January 1, 2012, and January 31, 2020, before and after integrating a designated fertility specialist into a comprehensive multidisciplinary care (cMDC) tumor board. Rates of fertility counseling and preservation were assessed for patients treated before (pre-cMDC) and after (post-cMDC) tumor board enhancement. Associations of race/ethnicity, age, chemotherapy, hormone receptor status, insurance type, parity, stage, site of treatment, and home county with fertility care rates were assessed in the post-cMDC group.

RESULTS

Of 306 patients diagnosed with breast cancer, 117 (38%) were in the pre-cMDC and 189 (62%) were in the post-cMDC tumor board group. Significantly more patients in the post-cMDC tumor board group were offered fertility counseling than patients in the pre-cMDC tumor board group (23.3% (44) vs. 0.9% (1); P < .001). However, rate of fertility preservation did not differ significantly between groups.

CONCLUSION

Integrating a fertility specialist within a cMDC tumor board may help improve rates of fertility counseling among breast cancer patients but may not improve preservation rates.

Patient Location and Disparities in Access to Fertility Preservation for Women With Gynecologic or Breast Cancer

OBJECTIVE

To assess the effect of geographic factors on fertility-sparing treatment or assisted reproductive technology (ART) utilization among women with gynecologic or breast cancers.

METHODS

We conducted a cohort study of reproductive-aged patients (18-45 years) with early-stage cervical, endometrial, or ovarian cancer or stage I-III breast cancer diagnosed between January 2000 and December 2015 using linked data from the California Cancer Registry, the California Office of Statewide Health Planning and Development, and the Society for Assisted Reproductive Technology. Generalized linear mixed models were used to evaluate associations between distance from fertility and gynecologic oncology clinics, as well as California Healthy Places Index score (a Census-level composite community health score), and ART or fertility-sparing treatment receipt.

RESULTS

We identified 7,612 women with gynecologic cancer and 35,992 women with breast cancer. Among all patients, 257 (0.6%) underwent ART. Among patients with gynecologic cancer, 1,676 (22.0%) underwent fertility-sparing treatment. Stratified by quartiles, residents who lived at increasing distances from gynecologic oncology or fertility clinics had decreased odds of undergoing fertility-sparing treatment (gynecologic oncology clinics: Q2, odds ratio [OR] 0.76, 95% CI, 0.63-0.93, P =.007; Q4, OR 0.72, 95% CI, 0.56-0.94, P =.016) (fertility clinics: Q3, OR 0.79, 95% CI, 0.65-0.97, P =.025; Q4, OR 0.67, 95% CI, 0.52-0.88, P =.004), whereas this relationship was not observed among women who resided within other quartiles (gynecologic oncology clinics: Q3, OR 0.81 95% CI, 0.65-1.01, P =.07; fertility clinics: Q2, OR 0.87 95% CI, 0.73-1.05, P =.15). Individuals who lived in communities with the highest (51 st -100 th percentile) California Healthy Places Index scores had greater odds of undergoing fertility-sparing treatment (OR 1.29, 95% CI, 1.06-1.57, P =.01; OR 1.66, 95% CI, 1.35-2.04, P =.001, respectively). The relationship between California Healthy Places Index scores and ART was even more pronounced (Q2 OR 1.9, 95% CI, 0.99-3.64, P =.05; Q3 OR 2.86, 95% CI, 1.54-5.33, P <.001; Q4 OR 3.41, 95% CI, 1.83-6.35, P <.001).

CONCLUSION

Geographic disparities affect fertility-sparing treatment and ART rates among women with gynecologic or breast cancer. By acknowledging geographic factors, health care systems can ensure equitable access to fertility-preservation services.

Gynecologic Care of Black Breast Cancer Survivors

Purpose of Review

Black patients suffer from breast cancer-related racial health disparities, which could have implications on their gynecologic care. This review explores considerations in the gynecologic care of Black breast cancer survivors.

Recent Findings

Black people have a higher risk of leiomyoma and endometrial cancer, which could confound bleeding patterns such as in the setting of tamoxifen use. As Black people are more likely to have early-onset breast cancer, this may have implications on long-term bone and heart health. Black patients may be more likely to have menopausal symptoms at baseline and as a result of breast cancer treatment. Furthermore, Black patients are less likely to utilize assisted reproductive technology and genetic testing services.

Summary

It is important for healthcare providers to be well-versed in the intersections of breast cancer and gynecologic care. Black breast cancer survivors may have unique considerations for which practitioners should be knowledgeable.

A Public Health Emergency: Breast Cancer Among Black Communities in the United States

While Black people have a similar incidence of breast cancer compared to White people, they have a 40% increased death rate. Black people are more likely to be diagnosed with aggressive subtypes such as triple-negative breast cancer. However, despite biological factors, systemic racism and social determinants of health create delays in care and barriers to treatment. While genetic testing holds incredible promise for Black people, uptake remains low and results may be challenging to interpret. There is a need for more robust, multidisciplinary, and antiracist interventions to reverse breast cancer-related racial disparities.

Disparities in Female Oncofertility Care in the United States: More Questions Than Answers

As cancer therapies continue to improve, the survival rates of adolescent and young adult patients have increased. Consequently, considering patient quality of life after cancer, including family building, has become an essential aspect of establishing a treatment plan. However, the gonadotoxic nature of many chemotherapeutic agents limits the option of using one's own gamete for family building. In recent years, significant advancements have been made in oncofertility, particularly vitrification of oocytes. Unfortunately, as with many areas of medicine, health disparities limit those that can access and utilize fertility preservation prior to cancer treatment. This review aims to shed light on existing disparities in oncofertility for female patients, to offer recommendations to enhance education, access, and advocacy, as well as identify potential areas for future research.