A national study of the provision of oncofertility services to female patients in Canada

Development and Validation of an Indicator for Oncofertility Care in Ontario, Canada, for Adolescents and Young Adults with Cancer

Introduction: There is a lack of metrics to monitor and evaluate fertility care in adolescents and young adults with cancer. This study evaluated the indicator "proportion of cases attending a fertility consult visit ≤30 days from diagnosis of cancer" using the National Quality Forum (NQF) criteria. Methods: This was a retrospective cohort study using administrative data available through the Institute of Clinical Evaluative Sciences in Ontario, Canada. Cases were included if they were diagnosed with a cancer between January 2005 and December 2019, and aged 15-39 years. Fertility consultations were identified by Ontario Health Insurance Plan Claims Database (OHIP) diagnostic codes 628 and 606.Validity was assessed by examining expected differences in the proportion of fertility consults within clinical and demographic factors using chi-square tests. Reliability was assessed by comparing fertility consult visits identified using OHIP diagnostic codes with consults identified using visits to physicians in a registered specialty, using Pearson's correlation coefficient. Results: The population was composed of 39,977 cases, with 6524 (16.3%) having attended a fertility consult. For diagnostic years 2016-2019, differences in the proportion of cases receiving their first fertility consult within 30 days of diagnosis were observed for sex, age, cancer type, hospital type, Local Health Integration Unit, and region (p < 0.001). There was no correlation between the time from diagnosis to fertility consult and time from diagnosis to the first visit to a fertility-related specialty (r = 0.11; p = 0.002). Conclusion: The indicator examined in this article adhered to the criteria described by the NQF, providing a possible metric for reporting on oncofertility care.

Polish Female Cancer Survivors' Experiences Related to Fertility Preservation Procedures

Purpose: The aim of the study was to assess the experience of Polish female cancer patients related to fertility preservation (FP) after gonadotoxic treatment. Methods: A cross-sectional study was performed among young women, who were diagnosed with a neoplasm. The questionnaire was distributed via the Internet. Results: The study group consisted of 299 women. Most of them had breast cancer (34%) or Hodgkin lymphoma (20%). The most popular treatment regimen was a combination of surgery, chemotherapy, and radiation (30%). Almost 78% of study participants underwent potentially gonadotoxic treatment. Fifty-seven percent of study participants admitted that oncologist had not informed them about FP methods, while only 19% were encouraged to visit fertility specialists. Seventeen percent of women decided to preserve fertility before malignancy treatment, 11.8% of women cryopreserved oocytes, 16% cryopreserved embryos, 16% cryopreserved ovarian tissue and 55% had ovarian suppression. Conclusion: The access to fertility counseling in Poland is limited. Emphasis should be placed on the coordination between cancer treatment centers and reproductive specialists.

Survey of young women with breast cancer to identify rates of fertility preservation (FP) discussion and barriers to FP care

PURPOSE

To identify the proportion of reproductive age women with breast cancer that engaged in a fertility preservation discussion and reproductive endocrinology and infertility (REI) consultation.

METHODS

This cross-sectional survey recruited women 18-42 years who were diagnosed with breast cancer from 2006 to 2016 by phone or email and asked them to complete an online survey. Demographic characteristics, barriers to FP, utilization of FP consultation, and FP procedures (oocyte and embryo cryopreservation) were analyzed.

RESULTS

A majority of women (64%) did not have FP discussed by any provider. Older women and those who were parents at the time of diagnosis were less likely to engage in a FP discussion. However, there were no significant differences in partner status or cancer stage between women with or without FP discussions. Of the women who desired future children prior to the cancer diagnosis, 93% received chemotherapy; however, only 34% of these women had a consultation with an REI. The most common reasons for declining FP consultation were already having their desired number of children (41%), financial barriers (14%), and concern about delaying cancer treatment and cancer recurrence (12%). Forty percent of women who desired future children and met with an REI pursued FP procedures.

CONCLUSION

Younger women were more likely to receive FP counseling. FP consultations and procedures were low even in women who desired future fertility, with the predominant barriers being cost, fears concerning a delay in cancer treatment, and future cancer recurrence.

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.

Perceptions and attitudes of medical oncologists regarding fertility preservation and pregnancy in high-risk cancer patients: A survey among Canadian medical oncologists

PURPOSE

Infertility is a critical late toxicity that impacts adolescent and young adult (AYA, ages 15-39 years) cancer survivors. International oncology societies recommend discussing fertility preservation (FP) for all AYA patients, regardless of stage or prognosis. We aim to understand Canadian medical oncologists' perceptions, attitudes, and knowledge toward FP and pregnancy in patients with cancer, including advanced stages and high risk for recurrence.

METHODS

An anonymous electronic survey utilizing hypothetical scenarios was sent to medical oncologists in the province of Ontario, Canada. Descriptive statistics were used to summarize all data. Logistic regression models were constructed to identify factors that predicted FP discussions and referrals.

RESULTS

The survey was received by 91 medical oncologists, and the response rate was 44%. Fifty-eight percent of respondents offer FP for all patients. Physicians are more likely to refer patients for FP before curative intent therapy than before palliative chemotherapy (95% vs. 39.5%, p < 0.001). Most respondents (86%) are comfortable discussing FP; however, only 31% self-reported feeling up-to-date on knowledge of current FP methods. Female physicians were more likely to report up-to-date knowledge and confidence discussing FP with patients. Forty percent of respondents identified that concerns about the welfare of the resulting offspring should not be a cause for denying patients assistance in reproduction.

CONCLUSION

There is a significant difference in physician attitude toward offering FP based on the cancer stage. Increased awareness of standard of care guidelines and resources for difficult situations may improve the frequency of discussions about FP in motivated cancer patients.

Understanding the Symptoms and Concerns of Adolescents and Young Adults with Cancer in Alberta: A Comparative Cohort Study Using Patient-Reported Outcomes

Purpose: Adolescents and young adults (AYAs) with cancer are in a unique situation due to their age and developmental stage in life and may have different symptoms and concerns than older patients. Patient-Reported Outcomes (PROs) questionnaires, routinely used in Alberta, can help identify the distinct needs of AYAs. We aimed to compare PROs data for AYAs and older adults (OAs) to better understand how the concerns of AYAs differ, which is key to providing individualized care and creating targeted programming and system-level change. Methods: Retrospective data were collected for two patient cohorts who completed at least one PROs questionnaire between October 1, 2019 and April 1, 2020. The AYA cohort was aged 18-39, and the OA cohort was aged 40 and older. Symptoms were compared using mean scores and multiple linear regression, and concerns were compared using counts and multivariate negative binomial regression. Results: AYAs had significantly higher mean scores on depression and anxiety, compared to OAs, and lower mean scores for most physical symptoms. They indicated significantly more concerns in the Emotional and Social/Family/Spiritual domains, and were over three times more likely to indicate Work/School as a concern. Conclusion: AYAs with cancer have distinct concerns that should be addressed to ensure comprehensive, quality cancer care for this population. PROs data are useful in identifying needs and facilitating evidence-based, data-driven change at all levels of the health care system.

Oncofertility: Knowledge, Attitudes, and Barriers Among Indian Oncologists and Gynecologists

Purpose: Recommendations from the American Society of Clinical Oncology (ASCO) emphasize the critical need to understand current trends in fertility preservation (FP) among the two sets of primary health care providers involved in oncofertility: the oncologists and the gynecologists. This study is aimed at understanding the health care providers' knowledge, attitudes, and barriers in oncofertility across India. Methods: An 18-item oncofertility survey was designed and directed to 77 oncologists and 214 gynecologists across India. The responses were analyzed by using descriptive statistical methods, and the oncofertility trends between the two groups were studied. Results: The total response rate was 34%, with 49 of 214 oncologists (23%) and 49 of 77 gynecologists (64%) participating in the survey. The awareness of ASCO FP guidelines among oncologists and gynecologists was 53% and 59.5%, respectively. About 48% of oncologists felt knowledgeable about sperm banking, whereas 52% knew about oocyte freezing but not about other options. On the other hand, among gynecologists, 38% reported inadequate knowledge of testicular or ovarian tissue cryopreservation. About 85% of oncologists reported routine referral of cancer diagnosed patients for FP, whereas 75% of gynecologists reported routine FP discussion with patients. Health care providers from both groups perceived the major barriers in oncofertility to be, "financial burden on the patient" (73%-86%) and, "lack of patient awareness" (71%-79.5%). Conclusion: Effective collaboration between oncologists and gynecologists is essential to establish a successful FP program. Economic burden on the patient and lack of patient and physician awareness are limiting factors that need to be overcome.

Evolution of adolescent and young adult oncology in Canada

In the context of cancer, adolescents and young adults [...]

Assisting with Decision-Making: How Standardized Information Impacts Breast Cancer Patient Decisions Regarding Fertility Trade-Offs and Chemotherapy

Purpose: Fertility is a concern for young women with breast cancer. We explore patient preferences for chemotherapy and whether women will trade-off survival benefits to maintain fertility following standardized information delivery. Methods: During a standardized interview, outcomes associated with adjuvant chemotherapy and 5 years of tamoxifen (CT) or 5 years of tamoxifen alone (NoCT) were described to participants. A threshold task was performed, in which each participant participated in two scenarios: (1) 10% absolute survival benefit from treatment and (2) 25% absolute survival benefit from treatment. The threshold point represented the reduction in fertility post-treatment that a participant would accept before she would trade-off CT benefit. Descriptive statistics were used to characterize participants. Demographic factors (age, marital status, parity at diagnosis, and education) associated with willingness to trade-off survival benefits were evaluated with logistic regression. Results: Analysis comprised 50 women with a median age of 34.5 years (range 25-39 years). Thirty-nine women (78%) completed university education. Thirty-four (68%) and 45 (90%) women in scenarios 1 and 2, respectively, were willing to trade-off all fertility (i.e., reduce fertility to 0% chance of conceiving naturally) to undertake CT and maintain survival benefits. Eight (16%) and three (6%) women in scenarios 1 and 2, respectively, chose to not pursue CT at all to maintain natural fertility. Regression analysis did not identify any variables that were predictive of participants' preferences. Conclusion: Most women with breast cancer are not willing to trade-off survival benefits of adjuvant therapy to maintain fertility.

Oncofertility Decision Support Resources for Women of Reproductive Age: Systematic Review

BACKGROUND

Cancer treatments have the potential to cause infertility among women of reproductive age. Many cancer patients do not receive sufficient oncofertility information or referrals to reproductive specialists prior to starting cancer treatment. While health care providers cite lack of awareness on the available oncofertility resources, the majority of cancer patients use the internet as a resource to find additional information to supplement discussions with their providers.

OBJECTIVE

Our aim was to identify and characterize Web-based oncofertility decision aids and health education materials accessible for women of reproductive age with a diagnosis of any cancer.

METHODS

We searched five databases and the gray literature for the years 1994-2018. The developer and content information for identified resources was extracted. Each resource underwent a quality assessment.

RESULTS

We identified 31 open access resources including 4 decision aids and 27 health educational materials. The most common fertility preservation options listed in the resources included embryo (31/31, 100%), egg (31, 100%), and ovarian tissue freezing (30, 97%). Notably, approximately one-third (11, 35%) contained references and 5 (16%) had a reading level of grade 8 or below. Resources were of varying quality; two decision aids from Australia and the Netherlands, two booklets from Australia and the United Kingdom, and three websites from Canada and the United States rated as the highest quality.

CONCLUSIONS

This comprehensive review characterizes numerous resources available to support patients and providers with oncofertility information, counseling, and decision making. More focus is required to improve the awareness and the access of existing resources among patients and providers. Providers can address patient information needs by leveraging or adapting existing resources to support clinical discussions and their specific patient population.

The Voices of Young Women with Breast Cancer: Providing Support and Information for Improved Fertility Preservation Discussions

Purpose: Fertility is a concern for young women with breast cancer. We explore patient experiences with fertility discussions at diagnosis to identify barriers and preferences to patient-centered delivery of care. Methods: A qualitative study was conducted on consecutive, female breast cancer survivors, 39 years of age or younger at diagnosis and within 2 years of diagnosis, who attended routine outpatient follow-up at a large academic teaching center. Interviews lasted 30 minutes and were transcribed verbatim. Thematic analysis was conducted to explore experiences around fertility discussions. Strength of the theme was determined by examining the frequency of a response. Data collection and analysis continued until theoretical saturation was reached. Results: Analysis comprised 50 women with a median age of 34.5 years (range 25-39 years). Thirty-nine women (78%) had completed university education. Thirty-three women (66%) recalled having fertility preservation discussions at diagnosis. The most common themes identified include the following: (i) the requirement for more patient support, (ii) improving information, (iii) integration of patient values, (iv) creating options for patients, (v) financial limitations, and (vi) the need to look beyond the immediate impact. Conclusions: In this contemporary cohort of young adult breast cancer survivors, fertility discussion experiences at diagnosis remain suboptimal. Improved information and a focus on individual patient desires can improve experiences.

Fertility-related experiences after breast cancer diagnosis in the Sister and Two Sister Studies

BACKGROUND

Commonly used chemotherapies can be toxic to the ovaries. To the authors' knowledge, the majority of studies evaluating receipt of fertility counseling for women in their reproductive years have been performed in specific settings, thereby limiting generalizability.

METHODS

A nationwide sample of US women diagnosed with breast cancer before age 45 years completed a survey assessing the prevalence of fertility counseling. Age-adjusted log-binomial regression was used to estimate prevalence ratios (PRs) and 95% CIs for fertility counseling.

RESULTS

Among 432 survivors diagnosed between 2004 and 2011, 288 (67%) had not discussed the effects of treatment on fertility with a health care provider before or during treatment. Fertility discussion was associated with younger age (PR, 3.49 [95% CI, 2.66-4.58] for aged <35 years vs ≥40 years) and lower parity (PR, 1.81 [95% CI, 1.29-2.53] for parity 1 vs 2). Approximately 20% of respondents reported that they were interested in future fertility (87 of 432 respondents) at the time of their diagnosis, but not all of these individuals (66 of 87 respondents) received counseling regarding the impact of treatment on their fertility, and few (8 of 87 respondents) used fertility preservation strategies. Among 68 women with a fertility interest who provided reasons for not taking steps to preserve fertility, reasons cited included concern for an adverse impact on cancer treatment (56%), lack of knowledge (26%), decision to not have a child (24%), and cost (18%).

CONCLUSIONS

Across multiple treatment settings, the majority of women of reproductive age who are diagnosed with breast cancer did not discuss fertility with a health care provider or use fertility preservation strategies. Discussing the potential impact of cancer treatment on future fertility is an important aspect of patient education.

How can we improve oncofertility care for patients? A systematic scoping review of current international practice and models of care

BACKGROUND

Fertility preservation (FP) is an important quality of life issue for cancer survivors of reproductive age. Despite the existence of broad international guidelines, the delivery of oncofertility care, particularly amongst paediatric, adolescent and young adult patients, remains a challenge for healthcare professionals (HCPs). The quality of oncofertility care is variable and the uptake and utilization of FP remains low. Available guidelines fall short in providing adequate detail on how oncofertility models of care (MOC) allow for the real-world application of guidelines by HCPs.

OBJECTIVE AND RATIONALE

The aim of this study was to systematically review the literature on the components of oncofertility care as defined by patient and clinician representatives, and identify the barriers, facilitators and challenges, so as to improve the implementation of oncofertility services.

SEARCH METHODS

A systematic scoping review was conducted on oncofertility MOC literature published in English between 2007 and 2016, relating to 10 domains of care identified through consumer research: communication, oncofertility decision aids, age-appropriate care, referral pathways, documentation, training, supportive care during treatment, reproductive care after cancer treatment, psychosocial support and ethical practice of oncofertility care. A wide range of electronic databases (CINAHL, Embase, PsycINFO, PubMed, AEIPT, Education Research Complete, ProQuest and VOCED) were searched in order to synthesize the evidence around delivery of oncofertility care. Related citations and reference lists were searched. The review was undertaken following registration (International prospective register of systematic reviews (PROSPERO) registration number CRD42017055837) and guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

OUTCOMES

A total of 846 potentially relevant studies were identified after the removal of duplicates. All titles and abstracts were screened by a single reviewer and the final 147 papers were screened by two reviewers. Ten papers on established MOC were identified amongst the included papers. Data were extracted from each paper and quality scores were then summarized in the oncofertility MOC summary matrix. The results identified a number of themes for improving MOC in each domain, which included: the importance of patients receiving communication that is of a higher quality and in different formats on their fertility risk and FP options; improving provision of oncofertility care in a timely manner; improving access to age-appropriate care; defining the role and scope of practice of all HCPs; and improving communication between different HCPs. Different forms of decision aids were found useful for assisting patients to understand FP options and weigh up choices.

WIDER IMPLICATIONS

This analysis identifies core components for delivery of oncofertility MOC. The provision of oncofertility services requires planning to ensure services have safe and reliable referral pathways and that they are age-appropriate and include medical and psychological oncofertility care into the survivorship period. In order for this to happen, collaboration needs to occur between clinicians, allied HCPs and executives within paediatric and adult hospitals, as well as fertility clinics across both public and private services. Training of both cancer and non-cancer HCPs is needed to improve the knowledge of HCPs, the quality of care provided and the confidence of HCPs with these consultations.

Patterns of Referral for Fertility Preservation Among Female Adolescents and Young Adults with Breast Cancer: A Population-Based Study

Purpose: To assess the fertility preservation (FP) referral rates and patterns of newly diagnosed breast cancer in female adolescent and young adult (AYA) patients.

Methods: Women aged 15–39 years with newly diagnosed breast cancer in Ontario from 2000 to 2017 were identified using the Ontario Cancer Registry. Exclusion criteria included prior sterilizing procedure, health insurance ineligibility, and prior infertility or cancer diagnosis. Women with a gynecology consult between cancer diagnosis and chemotherapy commencement with the billed infertility diagnostic code (ICD-9 628) were used as a surrogate for FP referral. The effect of age, parity, year of cancer diagnosis, staging, income, region, neighborhood marginalization, and rurality on referral status was investigated.

Results: A total of 4452 patients aged 15–39 with newly diagnosed breast cancer met the inclusion criteria. Of these women, 178 (4.0%) were referred to a gynecologist with a billing code of infertility between cancer diagnosis and initiation of chemotherapy. Older patients, prior parity, and advanced disease were inversely correlated with referrals. Referral rates also varied regionally: patients treated in the south-east and south-west Local Health Integration Networks (LHINs) had the highest probability of referral, and patients covered by north LHINs had the lowest (central LHIN as reference). General surgeons accounted for 36.5% of all referrals, the highest percentage of all specialists. Referral rates significantly increased over time from 0.4% in 2000 to 10.7% in 2016.

Conclusion: FP referral rates remain low and continue to be influenced by patient demographics and prognosis. These findings highlight the need for further interdisciplinary coordination in addressing the fertility concerns of AYA with newly diagnosed breast cancers.

A review of factors affecting patient fertility preservation discussions & decision-making from the perspectives of patients and providers

Women undergoing cancer treatments and their healthcare providers encounter challenges in fertility preservation (FP) discussions and decision-making. A systematic review of qualitative research was conducted to gain in-depth understanding of factors influencing FP discussions and decision-making. Major bibliographic databases and grey literature in English from 1994 to 2016 were searched for qualitative research exploring patient/provider perspectives on barriers and facilitators to FP decision-making. Two researchers screened article titles, abstracts and full-texts. Verbatim data on research questions, study methodology, participants, findings and discussions of findings were extracted. Quality assessment and thematic analysis were conducted. The search yielded 74 studies dating from 2007 onwards; 29 met the inclusion criteria. Analysis revealed three types of barriers: (a) FP knowledge, skills and information deficits contributed to discomfort for providers and discontent for patients; (b) psychosocial factors and clinical issues influenced providers' practices around FP discussions and patients' decision-making; and (c) material, social and structural factors (e.g., lack of resources and accessibility) posed challenges to FP discussions. Potential facilitators to FP discussions and decision-making were also identified. A discussion of ways to improve physician's knowledge and facilitate women's decision-making and access to FP is presented, along with areas for policy development and further research.

Fertility preservation healthcare circuit and networks in cancer patients worldwide: what are the issues?

Background

Fertility preservation (FP) is a major determinant of quality of life after cancer remission for women who may not have achieved their ideal family size. This article describes the FP services and strategy currently available, highlighting issues of oncofertility worldwide.

Main body of the abstract

For these patients in complex situations, health networks are essential to improve coordination of care, and the strengthening of this coordination is a major challenge to improve the performance of the health system. Two international networks have been created in order to foster scientific exchange between countries and to standardize the oncofertility healthcare circuit. However, the paucity of referral nationwide networks lead to a structural gap in health care policies.

Short conclusion

Management strategies of oncofertility in the world are still fragile and uneven. To structure the oncofertility sector, a multidisciplinary project allowing teams to collaborate is of utmost importance particularly in low and middle-income countries.

International evolution in AYA oncology: Current status and future expectations

Adolescents and Young Adults (AYAs) contribute approximately 1 million incident cases globally, but the great majority are underserved. In high-income countries, overall survival exceeds 80%, but the needs of this population during and after their treatment experience are poorly met, though specialized clinical programs are evolving. Engagement of national governments is advantageous and deployment of multidisciplinary teams essential. Collaboration between pediatric and adult healthcare providers is mandatory and AYAs must be given a strong voice in program development. Building and sharing international experience will hasten advances in clinical care, education, and research, while a focus on developing countries is a worthy challenge.

Advanced practice nurses: Improving access to fertility preservation for oncology patients

Cancer therapies such as chemotherapy, radiation therapy and surgery may place the future fertility of both children and young adults at risk. Oncofertility is a rapidly evolving area that involves increasing access to fertility preservation (FP) information and services. This manuscript aims to: a) highlight the fertility risks associated with cancer therapy and its psychosocial impact, b) describe FP options, c) discuss the unique challenges of FP in distinct cancer populations, and d) illustrate the pivotal role of APNs in oncofertility counselling and education.

Desire for children, difficulties achieving a pregnancy, and infertility distress 3 to 7 years after cancer diagnosis

PURPOSE

The aim was to investigate desire for children, difficulties achieving a pregnancy, and infertility distress among survivors 3 to 7 years after cancer treatment in reproductive age.

METHODS

Cancer survivors were identified in national population-based cancer registries. Eligible subjects presented with selected cancer diagnoses between 2003 and 2007 between the ages of 18 to 45. A postal questionnaire including study-specific questions, the Short-Form 36 Health Survey and the Fertility Problem Inventory, was sent to 810 survivors, and 484 participated (60 % response).

RESULTS

Most survivors who had a pretreatment desire for children still wanted children 3-7 years after treatment, and this group was characterized by young age and being childless at diagnosis. In addition, a substantial group of survivors (n = 55, 17 %) that did not have a pretreatment desire for children had changed their mind about wanting children after treatment. About a third of the survivors with a desire to have children had experienced difficulties achieving a pregnancy after the cancer treatment, and an unfulfilled desire to have children was associated with worse mental health. Survivors presently facing difficulties achieving a pregnancy reported moderate levels of infertility distress and expressed low interest in using gamete donation.

CONCLUSIONS

Health professionals in cancer care need to be aware that patients' plans for future children may change, particularly if they are young and childless. All patients of reproductive age should be provided with adequate information about the impact of cancer treatment on future fertility and fertility preservation.

Sexual dysfunction and infertility as late effects of cancer treatment

Sexual dysfunction is a common consequence of cancer treatment, affecting at least half of men and women treated for pelvic malignancies and over a quarter of people with other types of cancer. Problems are usually linked to damage to nerves, blood vessels, and hormones that underlie normal sexual function. Sexual dysfunction also may be associated with depression, anxiety, relationship conflict, and loss of self-esteem. Innovations in cancer treatment such as robotic surgery or more targeted radiation therapy have not had the anticipated result of reducing sexual dysfunction. Some new and effective cancer treatments, including aromatase inhibitors for breast cancer or chemoradiation for anal cancer also have very severe sexual morbidity. Cancer-related infertility is an issue for younger patients, who comprise a much smaller percentage of total cancer survivors. However, the long-term emotional impact of being unable to have a child after cancer can be extremely distressing. Advances in knowledge about how cancer treatments may damage fertility, as well as newer techniques to preserve fertility, offer hope to patients who have not completed their childbearing at cancer diagnosis. Unfortunately, surveys in industrialised nations confirm that many cancer patients are still not informed about potential changes to their sexual function or fertility, and all modalities of fertility preservation remain underutilised. After cancer treatment, many patients continue to have unmet needs for information about restoring sexual function or becoming a parent. Although more research is needed on optimal clinical practice, current studies suggest a multidisciplinary approach, including both medical and psychosocial treatment options.

Oncofertility in Canada: an overview of Canadian practice and suggested action plan

BACKGROUND

Cancer can be a devastating diagnosis. In particular, malignancy and its indicated treatments have profoundly negative effects on the fertility of young cancer patients. Oncofertility has emerged as a new interdisciplinary field to address the issue of gonadotoxicity associated with cancer therapies and to facilitate fertility preservation. In Canada, these fertility issues are often inadequately addressed despite the availability of resources. The goal of this four-part series is to facilitate systemic improvements in fertility preservation for adolescent and young adult Canadians with a new diagnosis of cancer.

METHODS

Here, we describe the services currently available in Canada and the challenges associated with their utilization. Finally, we outline strategies to help maximize and facilitate fertility preservation in the young cancer patient.

RESULTS

Despite an existing infrastructure to the oncofertility system in Canada, the ability of that system's components to function together and to coordinate patient care is a challenge. Areas of weakness include poor access and referral to fertility services, a lack of readily available education for patients and health care providers, and inconsistent interdisciplinary coordination in patient care.

CONCLUSIONS

The implementation of a framework for multidisciplinary resource allocation, education, patient referral, and established lines of communication may facilitate a functional oncofertility system in Canada.

Oncofertility in Canada: the impact of cancer on fertility

BACKGROUND

Cancer can be a devastating diagnosis. In particular, malignancy and its indicated treatments have profoundly negative effects on the fertility of young cancer patients. Oncofertility has emerged as a new interdisciplinary field to address the issue of gonadotoxicity associated with cancer therapies and to facilitate fertility preservation. In Canada, these fertility issues are often inadequately addressed despite the availability of resources. The goal of this four-part series is to facilitate systemic improvements in fertility preservation for adolescent and young adult Canadians with a new diagnosis of cancer.

METHODS

In this article, we review the gonadotoxic effects of cancer treatment on young men and women of reproductive age.

RESULTS

The detrimental effects of cancer on fertility can be severe and may vary depending on the chemotherapy, radiotherapy, or surgical treatments involved.

CONCLUSIONS

Fertility preservation should be addressed in an effort to mitigate the gonadal damage that may come with cancer therapy.

A national study of the provision of oncology sperm banking services among Canadian fertility clinics

The purpose of this study was to survey the current state of oncology sperm banking services provided by fertility clinics across Canada. A total of 78 Canadian fertility facilities were invited to complete a questionnaire related to the availability, accessibility, affordability and utilisation of sperm banking services for cancer patients. The total response rate was 59%, with 20 (69%) in vitro fertilisation clinics and 26 (53%) other fertility centres returning the survey. A total of 24 responding facilities accepted oncology sperm banking referrals. The time frame to book the first banking appointment for 19 (79%) facilities was within 2 days. Inconsistent practice was found regarding the consent process for cancer patients who are of minority age. Eight (33%) facilities did not provide any subsidy and charged a standard banking fee regardless of patients' financial situations. Overall, the utilisation of oncology sperm banking services was low despite its availability and established efficacy, suggesting that Canadian cancer patients are notably underserved. The study has highlighted some important issues for further consideration in improving access to sperm banking services for cancer patients, especially for adolescents. Better collaboration between oncology and reproductive medicine to target healthcare providers would help to improve sperm banking rates.