The role of radiation oncologists and discussion of fertility preservation in young cancer patients

Perspectives and needs for fertility preservation decision-making in childbearing-age patients with breast cancer: A qualitative study

Objective

To explore the perspectives and needs related to fertility preservation decision-making in patients of childbearing age with breast cancer.

Methods

Semistructured face-to-face interviews were conducted in a tertiary hospital in Baoding, China from July to October 2023. Purposive sampling was used to ensure the diversity of samples. The interview guide is based on the literature review and the discussions within the research team. A traditional content analysis approach was used for data analysis.

Results

A total of 18 participants were interviewed. Three themes emerged from the data: conflicts between subjective desires and concerns, coexistence of objective benefits and challenges, and decision-making support needs. The conflicts between subjective desires and concerns included five sub-themes, the coexistence of objective benefits and challenges also included five sub-themes, and the decision-making support needs included two sub-themes.

Conclusions

Patients faced a difficult trade-off between desires and concerns, benefits, and challenges regarding fertility preservation decisions, with numerous unmet needs. Healthcare professionals should prioritize patients' fertility desires, providing timely fertility preservation information and adequate counseling after a cancer diagnosis. This approach can help alleviate unnecessary concerns, facilitate satisfactory decision-making, and improve patients' quality of life.

Incidence and influencing factors of fertility concerns in breast cancer in young women: a systematic review and meta-analysis

Objective

This systematic review and meta-analysis aimed to evaluate the prevalence and influencing factors of fertility concerns in breast cancer in young women.

Methods

A literature search on PubMed, Embase, Web of Science, and Cochrane Library databases was conducted up to February 2023 and was analyzed (Revman 5.4 software) in this study. The papers were chosen based on inclusion standards, and two researchers independently extracted the data. The included studies' quality was evaluated using criteria set out by the Agency for Healthcare Research and Quality. To identify significant variations among the risk factors, odds ratios (ORs) and the corresponding 95% confidence intervals (CIs) were utilized.

Results

A total of 7 studies that included 1579 breast cancer in young women were enrolled in the study. The results showed that for breast cancer in young women, the incidence of fertility concerns 53%(95%CI [0.45,0.58]). The results showed that education (2.65, 95% CI 1.65-5.63), full-time work (0.12, 95% CI 1.03-1.93), fertility intentions (7.84, 95% CI 1.50-37.4), depression level (1.25, 95% CI 1.03-1.5), and endocrine therapy (1.32, 95% CI 1.08-1.62) were risk factors for fertility concerns in young women with BC. Having a partner (0.41, 95% CI 0.33-0.5), ≥1 child (0.3, 95% CI 0.22-0.4) were identified as protective factors against fertility concerns in young women with BC.

Conclusions

The incidence of fertility concerns in breast cancer in young women is at a moderately high level. We should pay more attention to the risk factors of fertility concerns to help breast cancer in young women cope with their fertility concerns and promote their psychological well-being.

Disparities in Female Pediatric, Adolescent and Young Adult Oncofertility: A Needs Assessment

Advancements in cancer screening and implementation of targeted treatments have significantly improved survival rates to 85% for pediatric and AYA survivors. Greater than 75% of survivors will live to experience the long-term adverse outcomes of cancer therapies, termed late effects (LE), that disrupt quality of life (QoL). Infertility and poor reproductive outcomes are significant disruptors of QoL in survivorship, affecting 12-88% of survivors who receive at-risk therapies. To mitigate risk, fertility preservation (FP) counseling is recommended as standard of care prior to gonadotoxic therapy. However, disparities in FP counseling, implementation of FP interventions, and screening for gynecologic late effects in survivorship persist. Barriers to care include a lack of provider and patient knowledge of the safety and breadth of current FP options, misconceptions about the duration of time required to implement FP therapies, cost, and health care team bias. Developing strategies to address barriers and implement established guidelines are necessary to ensure equity and improve quality of care across populations.

Looking Through the Lens of a Family Planner to Prioritize Reproductive Health Among Women With Cancer

PURPOSE

Prioritization of cancer treatment initiation in women of reproductive age may underscore potential implications on reproductive health. This study describes a family planning quotient (FPQ) and reproductive life index (RepLI) tool designed to help providers to discuss effectively reproductive health with women with cancer.

METHODS

We tailored the FPQ/RepLI tool for patients with cancer after development in the family planning setting and piloted it with 36 oncology patients referred to our family planning clinic. Each patient completed the FPQ/RepLI with a health educator or medical student and then met with a physician to create a reproductive life plan. A subsample evaluated the tool by rating satisfaction using a Likert scale. Summary statistics were calculated overall and by childbearing status.

RESULTS

Of the 36 women, 22 did not desire additional children and received contraception. One third (n = 14) had not completed childbearing, four of whom continued with fertility preservation counseling. Women who desired childbearing were less likely to already have children ( P = .02), and more than one half were using long-term contraception. All agreed that the FPQ/RepLI helped them to talk to their provider about their reproductive goals. Only 44.4% agreed that their oncologist knew how many children they desired, and 88.9% found the tool helpful and would use it for future tracking of their reproductive goals.

CONCLUSION

The FPQ/RepLI is useful for assessing the reproductive health of young women with a new cancer diagnosis, understanding desires of future childbearing, and providing effective contraception. We recommend the incorporation of this tool into practice to better understand patients' reproductive needs.

Attitudes toward fertility and fertility preservation in women with glioma

Background

No studies have examined the fertility priorities of women undergoing treatment for their glioma. Glioma patients frequently undergo chemotherapy as part of their treatment; however, it is unknown whether patients truly are aware of its possible effects on their fertility. Our objective was to assess the fertility priorities of glioma patients and ascertain whether female glioma patients are being effectively counseled on the effects of chemotherapy on their fertility prior to beginning treatment.

Methods

The sample was composed of female patients from the Neuro-oncology clinic of the University of California, San Francisco. Participants completed a cross-sectional survey between October 2010 and December 2013 exploring their attitudes toward fertility and their experience with fertility counseling prior to chemotherapy initiation.

Results

Seventy-two women completed the survey. Analysis of the survey results showed that 30% of women receiving chemotherapy reported having a discussion regarding fertility preservation prior to beginning treatment. Of those who reported having this discussion, 80% were aware that chemotherapy could negatively affect their fertility. Many women reported that while fertility preservation was not important to them at the time of diagnosis, it was a priority for them at the time of survey completion. Although interest in having children tended to decrease after cancer treatment, the majority of respondents reported wanting a child after treatment.

Conclusions

The data obtained in this study suggest a lack of understanding of reproductive priorities, which may be addressed with a more comprehensive fertility discussion prior to beginning treatment.

Pathways: patient-centred decision counselling for women at risk of cancer-related infertility: a protocol for a comparative effectiveness cluster randomised trial

INTRODUCTION

National guidelines recommend that all reproductive-age women with cancer be informed of their fertility risks and offered referral to fertility specialists to discuss fertility preservation options. However, reports indicate that only 5% of patients have consultations, and rates of long-term infertility-related distress remain high. Previous studies report several barriers to fertility preservation; however, initial success has been reported using provider education, patient decision aids and navigation support. This protocol will test effects of a multicomponent intervention compared with usual care on women's fertility preservation knowledge and decision-making outcomes.

METHODS AND ANALYSIS

This cluster-randomised trial will compare the multicomponent intervention (provider education, patient decision aid and navigation support) with usual care (consultation and referral, if requested). One hundred newly diagnosed English-speaking women of reproductive age who are at risk of cancer-related infertility will be recruited from four regional oncology clinics.The Pathways patient decision aid website provides (1) up-to-date evidence and descriptions of fertility preservation and other family-building options, tailored to cancer type; (2) structured guidance to support personalising the information and informed decision-making; and (3) a printable summary to help women prepare for discussions with their oncologist and/or fertility specialist. Four sites will be randomly assigned to intervention or control groups. Participants will be recruited after their oncology consultation and asked to complete online questionnaires at baseline, 1 week and 2 months to assess their demographics, fertility preservation knowledge, and decision-making process and quality. The primary outcome (decisional conflict) will be tested using Fisher's exact test. Secondary outcomes will be assessed using generalised linear mixed models, and sensitivity analyses will be conducted, as appropriate.

ETHICS AND DISSEMINATION

The University of Texas MD Anderson Cancer Center provided approval and ongoing review of this protocol. Results will be presented at relevant scientific meetings and submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03141437; Pre-results.

The Pathways fertility preservation decision aid website for women with cancer: development and field testing

PURPOSE

To improve survivors' awareness and knowledge of fertility preservation counseling and treatment options, this study engaged survivors and providers to design, develop, and field-test Pathways: a fertility preservation patient decision aid website for young women with cancer©.

METHODS

Using an adapted user-centered design process, our stakeholder advisory group and research team designed and optimized the Pathways patient decision aid website through four iterative cycles of review and revision with clinicians (n = 21) and survivors (n = 14). Field-testing (n = 20 survivors) assessed post-decision aid scores on the Fertility Preservation Knowledge Scale, feasibility of assessing women's decision-making values while using the website, and website usability/acceptability ratings.

RESULTS

Iterative stakeholder engagement optimized the Pathways decision aid website to meet survivors' and providers' needs, including providing patient-friendly information and novel features such as interactive value clarification exercises, testimonials that model shared decision making, financial/referral resources, and a printable personal summary. Survivors scored an average of 8.2 out of 13 (SD 1.6) on the Fertility Preservation Knowledge Scale. They rated genetic screening and having a biological child as strong factors in their decision-making, and 71% indicated a preference for egg freezing. Most women (> 85%) rated Pathways favorably, and all women (100%) said they would recommend it to other women.

CONCLUSIONS

The Pathways decision aid is a usable and acceptable tool to help women learn about fertility preservation.

IMPLICATIONS FOR CANCER SURVIVORS

The Pathways decision aid may help women make well-informed values-based decisions and prevent future infertility-related distress.

Fertility and sexual function: a gap in training in pediatric endocrinology

BACKGROUND

Infertility and sexual dysfunction result from many different pediatric conditions and treatments and can profoundly impact quality of life. The American Academy of Pediatrics (AAP) has recommended consulting "fertility specialists" for counseling, but it remains unclear who these specialists are. Our objective was to assess whether pediatric subspecialists who manage hypogonadism and/or genitourinary conditions feel adequately trained to provide fertility and sexual function counseling.

METHODS

An online survey was distributed to members of Pediatric Endocrine Society (PES), Society for Pediatric Urology (SPU), and North American Society for Pediatric and Adolescent Gynecology (NASPAG). Providers' comfort in counseling various age groups about fertility and sexual function was assessed via a five-point Likert scale. Providers reported whether they felt adequately trained in these areas.

RESULTS

Two hundred and eighty-four surveys were completed by endocrinologists, 124 surveys by urologists, and 41 surveys by gynecologists. Respondents (44% male, 86% Caucasian) represented 39 states and Canada. Seventy-nine percent were at academic centers. Thirty-four percent of providers had been practicing for >20 years. Comfort level was variable and lowest in young males. Ninety-one percent of pediatric endocrinologists reported routinely seeing patients at risk for infertility, but only 36% felt adequately trained in fertility, and 25% felt adequately trained in sexual function.

CONCLUSIONS

Infertility and sexual dysfunction are often overlooked in pediatric care. Our results suggest that pediatric endocrinologists, who frequently manage male and female hypogonadism, should also receive formal training in these areas. Optimizing counseling would help prevent missed opportunities for fertility preservation and alleviate distress among patients and families.

Oncofertility program implementation increases access to fertility preservation options and assisted reproductive procedures for breast cancer patients

BACKGROUND AND OBJECTIVES

Breast cancer treatment can cause premature ovarian failure, yet the majority of young cancer patients do not receive adequate education about treatment effects before initiating chemotherapy. We studied the impact of an oncofertility program on access to fertility preservation.

METHODS

An oncofertility program was initiated to foster collaboration between oncologists and reproductive endocrinologists, and to help increase access to fertility preservation. Documented conversations about fertility concerns, specialist referrals, appointments, and fertility preservation procedures were compared between breast cancer patients from 2004 to 2006, before oncofertility program initiation, and 2007-2012, after program initiation. The study included women <45, stages 0-III, diagnosed before (n = 278) and after (n = 515) program initiation.

RESULTS

Demographics for the cohorts were similar. Fertility discussions (P < 0.0001), patients interested in maintaining fertility at diagnosis (P = 0.0041), referrals to reproductive endocrinologists (P < 0.0001), appointments (P < 0.0001), and fertility preservation procedures (P < 0.0183) increased significantly after programmatic implementation.

CONCLUSIONS

An oncofertility program increased discussions about fertility preservation and access to assisted reproductive procedures. This program positively impacted compliance with national guidelines advising reproductive-age cancer patients to be offered fertility preservation counseling as an initial component of the multidisciplinary care plan. J. Surg. Oncol. 2017;115:116-121. © 2016 Wiley Periodicals, Inc.

Fertility preservation in young patients with cancer

Infertility can arise as a consequence of treatment of oncological conditions. The parallel and continued improvement in both the management of oncology and fertility cases in recent times has brought to the forefront the potential for fertility preservation in patients being treated for cancer. Many survivors will maintain their reproductive potential after the successful completion of treatment for cancer. However total body irradiation, radiation to the gonads, and certain high dose chemotherapy regimens can place women at risk for acute ovarian failure or premature menopause and men at risk for temporary or permanent azoospermia. Providing information about risk of infertility and possible interventions to maintain reproductive potential are critical for the adolescent and young adult population at the time of diagnosis. There are established means of preserving fertility before cancer treatment; specifically, sperm cryopreservation for men and in vitro fertilization and embryo cryopreservation for women. Several innovative techniques are being actively investigated, including oocyte and ovarian follicle cryopreservation, ovarian tissue transplantation, and in vitro follicle maturation, which may expand the number of fertility preservation choices for young cancer patients. Fertility preservation may also require some modification of cancer therapy; thus, patients’ wishes regarding future fertility and available fertility preservation alternatives should be discussed before initiation of therapy.

Outcomes of transplantations of cryopreserved ovarian tissue to 41 women in Denmark

STUDY QUESTION

What are the results of transplanting cryopreserved ovarian tissue?

SUMMARY ANSWER

The transplanted ovarian tissue can last up to 10 years, with no relapses following the 53 transplantations, and the chance of a successful pregnancy is currently around one in three for those with a pregnancy-wish.

WHAT IS KNOWN ALREADY

Cryopreservation of ovarian tissue is now gaining ground as a valid method for fertility preservation. More than 36 children worldwide have now been born following this procedure.

STUDY DESIGN, SIZE, DURATION

This is a retrospective cohort study of 41 women who had thawed ovarian tissue transplanted 53 times over a period of 10 years, including 1 patient who was lost to follow-up.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The 41 Danish women, who had in total 53 transplantations, were followed for ovarian function and fertility outcome. Safety was assessed by monitoring relapse in cancer survivors.

MAIN RESULTS, AND THE ROLE OF CHANCE

Among 32 women with a pregnancy-wish, 10 (31%) had a child/children (14 children in total); this included 1 woman with a third trimester on-going pregnancy. In addition, two legal abortions and one second trimester miscarriage occurred. A total of 24 clinical pregnancies were established in the 32 women with a pregnancy-wish. The tissue remained functional for close to 10 years in some cases and lasted only a short period in others. Three relapses occurred but were unlikely to be due to the transplanted tissue.

LIMITATIONS, REASONS FOR CAUTION

Self-report through questionnaires with only in-one hospital formalised follow-up of transplanted patients could result in unreported miscarriages. The longevity of the tissue may vary by few months compared with those reported because some patients simply could not remember the date when the tissue became non-functional.

WIDER IMPLICATIONS OF THE FINDINGS

Cryopreservation of ovarian tissue is likely to become integrated into the treatment of young women, with cancer, who run a risk of losing their fertility. The full functional lifespan of grafts is still being evaluated, because many of the transplanted women have continued to maintain ovarian activity. Some of our first cases have had tissue functioning for ∼ 10 years.

Anal cancer: current standards in care and recent changes in practice

Answer questions and earn CME/CNE The management of squamous cell carcinomas of the anal canal has evolved from surgery as first-line treatment to curative chemoradiation, with surgery reserved for salvage. Significant progress has been made in understanding how to most effectively deliver chemotherapy and reduce toxicity through advancements in radiation delivery. The purpose of this article is to review the multimodality approach to the diagnosis and management of anal cancer based on a review of the published data and in light of available guidelines.

More research, more responsibility: the expansion of duty to warn in cancer patients considering fertility preservation

Reproductive technology is advancing at a steadfast pace. Researchers are successfully refining options for fertility preservation, to the benefit of the cancer community. Research has consistently shown cancer patients and survivors desire to have risks to fertility and preservation options disclosed, and major campaigns have been undertaken to refer these patients to fertility specialists. However, the decision to pursue fertility preservation is not an isolated judgment. A variety of future decisions may arise for the individual or couple, choices that may not have been relayed during the initial decision-making process. Future decisions include the length of time to continue to store frozen gametes, donating banked gametes to infertile couples, and whether embryos created with one partner would be accepted by a new partner. It is important to continue the advancement of fertility preservation not only in the scientific milieu, but also in addressing a patient's preparedness for long-term decision making.