Fertility preservation in cancer survivors: a national survey of oncologists' current knowledge, practice and attitudes

Mapping ethical, legal, and social implications (ELSI) of fertility preservation

RESEARCH QUESTION

The study examines the ethical, legal, and social implications of fertility preservation, highlighting its importance across oncofertility, elective egg freezing, and posthumous assisted reproduction, as well as its impact on transgender individuals undergoing gender-affirming surgeries.

DESIGN

A comprehensive analysis of 600 articles, focusing on a diverse range of disciplines, including bioethics, psychology, and sociology, to explore public and healthcare professionals' knowledge, patient experiences, and regulatory constraints.

RESULTS

The body of literature is growing, indicating increasing recognition of FP's significance. Key themes included the centrality of counseling and informed decision-making, especially in oncofertility and EEF, and ethical debates surrounding informed consent and the autonomy of involved individuals. The analysis underscored a western-centric bias in current research, emphasizing the need for more inclusive and culturally sensitive studies.

CONCLUSIONS

The study calls for a nuanced understanding of FP, advocating for policies that consider ethical, cultural, and social dimensions. It suggests the necessity for interdisciplinary research to address identified gaps, particularly in understanding non-Western perspectives and ensuring equitable access to FP services globally. Moreover, the review emphasizes the importance of integrating patient-centric approaches and ethical frameworks to guide FP practices and policies, ensuring they respect diverse values and meet individuals' needs.

"Management of andrological disorders from childhood and adolescence to transition age: guidelines from the Italian Society of Andrology and Sexual Medicine (SIAMS) in collaboration with the Italian Society for Pediatric Endocrinology and Diabetology (SIEDP)-Part-1"

PURPOSE

Andrological pathologies in the adulthood are often the results of conditions that originate during childhood and adolescence and sometimes even during gestation and neonatal period. Unfortunately, the reports in the literature concerning pediatric andrological diseases are scares and mainly concerning single issues. Furthermore, no shared position statement are so far available.

METHODS

The Italian Society of Andrology and Sexual Medicine (SIAMS) commissioned an expert task force involving the Italian Society of Pediatric Endocrinology and Diabetology (SIEDP) to provide an updated guideline on the diagnosis and management of andrological disorders from childhood and adolescence to transition age. Derived recommendations were based on the grading of recommendations, assessment, development, and evaluation (GRADE) system.

RESULTS

A literature search of articles in English for the term "varicoceles", "gynecomastia", "fertility preservation", "macroorchidism", "precocious puberty" and "pubertal delay" has been performed. Three major aspects for each considered disorder were assessed including diagnosis, clinical management, and treatment. Recommendations and suggestions have been provided for each of the mentioned andrological disorders.

CONCLUSIONS

These are the first guidelines based on a multidisciplinary approach that involves important societies related to the field of andrological medicine from pediatric to transition and adult ages. This fruitful discussion allowed for a general agreement on several recommendations and suggestions to be reached, which can support all stakeholders in improving andrological and general health of the transitional age.

A Cross-Sectional Survey of Healthcare Professionals' Knowledge, Attitude and Current Behaviours towards Female Fertility Preservation Services within the UK

(1) Background: This study aims to establish the knowledge, attitudes and current behaviours towards female fertility preservation (FP) services amongst healthcare professionals (HCPs) in the UK. (2) Methods: An online survey was advertised publicly on the social media platform Instagram between 25 February 2021 and 11 March 2021. (3) Results: In total, 415 participants fulfilled the inclusion criteria and completed the survey. The majority of HCPs discussed FP techniques either never 39.5% (n = 164), once a year 20.7% (n = 86) or once a month 17.8% (n = 74). The majority rated their knowledge of each type of FP method as 'very poor' or 'poor' and strongly disagreed 14.2% (n = 59) or disagreed 42.2% (n = 175) with the statement they 'felt confident to counsel a patient on FP'. The majority either agreed 37.8% (n = 157) or strongly agreed 22.2% (n = 92) that it was their responsibility to discuss FP and 38.1% (n = 158) agreed or strongly agreed 19.5% (n = 81) they considered the desire for future fertility when planning treatment. The majority 87.2% (n = 362) had not experienced formal training on FP. (4) Conclusions: Discrepancies in knowledge remain regarding techniques of FP, referral pathways, awareness of facilities offering services and existing educational resources. Many HCPs recognise the importance of FP and their responsibility to initiate discussions. The knowledge that FP may not delay the treatment of cancer has also improved; however, training in FP is scarce.

When the unimaginable happens: Lung cancer diagnosis during pregnancy

The increasing incidence of lung cancer diagnosis during pregnancy has brought new challenges and opportunities to expand the knowledge gap in this protected patient population. Here, available data and top recommendations for the practicing oncologist are discussed.

Precision Immuno-Oncology in NSCLC through Gender Equity Lenses

Precision immuno-oncology involves the development of personalized cancer treatments that are influenced by the unique nature of an individual's DNA, immune cells, and their tumor's molecular characterization. Biological sex influences immunity; females typically mount stronger innate and adaptive immune responses than males. Though more research is warranted, we continue to observe an enhanced benefit for females with lung cancer when treated with combination chemoimmunotherapy in contrast to the preferred approach of utilizing immunotherapy alone in men. Despite the observed sex differences in response to treatments, women remain underrepresented in oncology clinical trials, largely as a result of gender-biased misconceptions. Such exclusion has resulted in the development of less efficacious treatment guidelines and clinical recommendations and has created a knowledge gap in regard to immunotherapy-related survivorship issues such as fertility. To develop a more precise approach to care and overcome the exclusion of women from clinical trials, flexible trial schedules, multilingual communication strategies, financial, and transportation assistance for participants should be adopted. The impact of intersectionality and other determinants of health that affect the diagnosis, treatment, and outcomes in women must also be considered in order to develop a comprehensive understanding of the unique impact of immunotherapy in all women with lung cancer.

Recovering Spermatogenesis By Protected Cryopreservation Using Metformin and Transplanting Spermatogonial Stem Cells Into Testis in an Azoospermia Mouse Model

Cryopreservation and transplantation of spermatogonial stem cells (SSCs) may serve as a new method to restore male fertility in patients undergoing chemotherapy or radiotherapy. However, SSCs may be damaged during cryopreservation due to the production of reactive oxygen species (ROS). Therefore, different antioxidants have been used as protective agents. Studies have shown that metformin (MET) has antioxidant activity. The aim of this study was to assess the antioxidant and antiapoptotic effects of MET in frozen-thawed SSCs. In addition, the effect of MET on the proliferation and differentiation of SSCs was evaluated. To this end, SSCs were isolated from mouse pups aged 3-6 days old, cultured, identified by flow cytometry (ID4, INTEGRIN β1+), and finally evaluated for survival and ROS rate. SSCs were transplanted after busulfan and cadmium treatment. Cryopreserved SSCs with and without MET were transplanted after 1 month of cryopreservation. Eight weeks after transplantation, the recipient testes were evaluated for the expression of apoptosis (BAX, BCL2), proliferation (PLZF), and differentiation (SCP3, TP1, TP2, PRM1) markers using immunohistochemistry, Western blot, and quantitative real-time polymerase chain reaction. The findings revealed that the survival rate of SSCs was higher in the 500 μm/mL MET group compared to the other groups (50 and 5000 μm/mL). MET significantly decreased the intracellular ROS production. Transplantation of SSCs increased the expression level of proliferation (PLZF) and differentiation (SCP3, TP1, TP2, PRM1) markers compared to azoospermia group, and their levels were significantly higher in the MET group compared to the cryopreservation group containing basic freezing medium (p < 0.05). MET increased the survival rate of SSCs, proliferation, and differentiation and decreased the ROS production and the apoptosis rate. Cryopreservation by MET seems to be effective in treating infertility.

Efficient pathway for men fertility preservation in testicular cancer or lymphoma: a cross-sectional study of national 2018 data

BACKGROUND

In 15-49 years-old men, the main cancers are testicular cancer (TC) and lymphomas (L): freezing of ejaculated sperm is primarily used for male fertility preservation (FP) before cancer treatment. Our objective was to analyze the French FP rate in 15-49 years-old men diagnosed with TC or L in 2018. We designed a national descriptive cross-sectional study of sperm banking rate in men with a diagnosis of TC, Hodgkin L (HL) or non-Hodgkin L (NHL). From the French National Cancer Institute (INCa) 2018 data, we extracted the estimated incidence of TC and L in metropolitan France. From the 2018 activity report of CECOS network (Centers for Study and Banking of Eggs and Sperm), we extracted the number of men with TC or L who banked ejaculated sperm. We estimated the proportion of 15-49 years-old men diagnosed with TC or L who banked sperm.

RESULTS

Among 15-49 years-old men, INCa estimated 38,048 new cancer diagnoses in metropolitan France in 2018: 2,630 TC and 3,913 L (943 HL and 2,970 NHL). The CECOS network provided data from 26/27 metropolitan centers (96% response rate): 1,079 sperm banking for men with TC, 375 for HL and 211 for NHL. We estimated that the 2018 sperm banking rate in France was 41% for TC, 40% for HL, and 7% for NHL.

CONCLUSIONS

To our knowledge, our paper is the first cross-sectional study with multicenter and national data analyzing FP rate in cancer men: it suggests an efficient pathway for men to FP before cancer treatment, compared to previously published studies. Although sperm banking rate in 15-49 years-old men could definitely be improved, further studies should evaluate the information given to patients before gonadotoxic treatments, the factors associated with the absence of sperm banking and whether this lack of referral induces a loss of chance for these men.

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.

Effect of a web-based fertility preservation training program for medical professionals in Japan

BACKGROUND

Our web-based training program called "Educating Medical Professionals about Reproductive Issues in Cancer Healthcare" aims to help healthcare professionals communicate promptly with patients and survivors who are adolescents and young adults, with information pertinent to reproductive health issues such as the risk of infertility and fertility preservation.

METHODS

The study participants were professional healthcare providers, including physicians, nurses, pharmacists, social workers, midwives, psychologists, laboratory technicians, genetic counselors, and dieticians. Pre- and post- and 3-month follow-up tests consisting of 41 questions were administered to measure changes in knowledge and confidence. The participants also received a follow-up survey that covered confidence, communication techniques, and practice habits. A total of 820 healthcare providers participated in this program.

RESULTS

The mean total score from the pre-test to the post-test grew significantly (p < 0.01), and participants' self-confidence increased. In addition, there was a change in the behavior of healthcare providers, who began asking about patients' marital status and parity.

CONCLUSION

Our web-based fertility preservation training program improved knowledge and self-confidence regarding fertility preservation issues among healthcare providers caring for adolescents and young adult cancer patients and survivors.

Reproduction in life and death: should cancer patients with a poor prognosis be offered fertility preservation interventions?

In the context of a cancer diagnosis, fertility preservation interventions are used to mitigate the potential impact of gonadotoxic cancer treatment upon fertility. They provide patients with cancer the option to freeze their reproductive material to have their own biological child following treatment. The evidence suggests some clinicians are less likely to have fertility preservation discussions with patients who have an aggressive or metastatic cancer which has a poor prognosis. Although this is contrary to current policy recommendations, there is a lack of guidance relating to offering fertility preservation in the context of a poor prognosis to support clinicians. Controversy surrounds posthumous reproduction, and whether the wishes of the cancer patient, when living and deceased should take precedence over others' wellbeing. We consider the question of whether cancer patients with a poor prognosis should be offered FP from an ethics perspective. We structure the paper around key arguments to which multiple ethical principles might pertain, first establishing a central argument in favour of offering fertility preservation based on respect for autonomy, before exploring counterarguments. We conclude by proposing that a defeasible assumption should be adopted in favour of offering fertility preservation to all cancer patients who might benefit from it. It is important to recognise that patients could benefit from fertility preservation in many ways, and these are not limited to having a parenting experience. The burden of proof rests on the clinician in collaboration with their multi-disciplinary team, to show that there are good grounds for withholding the offer.

Are There Any Developments in the Attitudes and Practices of Oncologists Regarding Fertility Preservation in Saudi Arabia After 12 Years?

INTRODUCTION

The current practice of offering fertility preservation (FP) counseling and treatment has become one of the focal points in patient care throughout cancer treatment. The turning point was the approval of the Council of Senior Religious Scholars four years ago to freeze tissues from the ovarian membrane, the entire ovary, and the eggs for later use in reproduction to preserve the offspring. Thus, we aimed to assess any development in oncologists' knowledge, attitude, and referral practices regarding FP in Saudi Arabia.

METHODS

This is a cross-sectional survey using a self-administered questionnaire. We assessed oncologists' opinions on the importance of FP, their perception of the patient's preferences, and factors to consider when discussing the subject. Then, we assessed the knowledge and referral practices, including the timing of referral before starting cancer treatment.

RESULTS

Most oncologists showed good knowledge and positive attitudes toward FP; however, their referral practices could be better. Most were familiar with FP options. The most significant factors influencing the oncologist-patient FP discussion were the number of existing children, marital status, cost, and type of cancer (96.6%, 76.7%, 65.7%, and 58.9%, respectively).

CONCLUSIONS

There is a significant improvement in the knowledge and attitude of oncologists toward FP. However, patients' counseling and referral to fertility services still need to be improved. There is a shortfall in the clinical practice guidelines for FP in cancer patients in Saudi Arabia. The implementation of clinical practice guidelines would enhance FP. However, patients' counseling and referral to fertility services still need to be improved. The lack of proper guidelines on FP is affecting oncologists' practice.

For the LOvE of Reproductive Health Communication: Assessment of the LGBT Oncofertility Education (LOvE) Module

Purpose: The lesbian, gay, bisexual, transgender, and queer (LGBTQ) Oncofertility Education (LOvE) module aims to improve knowledge on providing inclusive and affirming care for LGBTQ adolescents and young adults (AYAs) with cancer. The objective of this study is to evaluate the role of the module in improving reproductive health communication for the care of LGBTQ AYAs with cancer. Methods: A 10-item multiple-choice pre-test and post-test assessed learner knowledge, with total knowledge scores ranging from 0 (no correct responses) to 10 (all correct responses). A post-module survey and open-ended questions assessed relevance of the module, quality, and appropriateness to professional practice. Paired t-tests analyzed changes in knowledge before and after the module. Content analysis was applied to qualitative responses. Results: Thirty-seven learners completed both the pre-test and post-test. Around 8.1% correctly answered all pre-test questions; 59.5% correctly answered all posttest questions. The average pre-test score was 8.3, versus posttest score of 9.5 (p < 0.0001). Eighty-nine percent of learners strongly agreed that LOvE Enriching Communication Skills for Health Professionals in Oncofertility was relevant to their work; 95% strongly agreed that it was easy to understand and navigate. Open-ended responses highlighted how the module helped learners strengthen the provider-patient relationship in the context of oncofertility, create a safe space for patients, and understand the relevance of educational materials about fertility to LGBTQ patients. Conclusions: We found significant improvement in knowledge of reproductive health care for LGBTQ AYAs with cancer after completing the module. Improving provider knowledge may improve confidence in providing inclusive and affirming care for LGBTQ AYAs with cancer, resulting in improved whole-person care.

Outcomes of Fertility Preservation for Female Cancer Patients in a Single Tertiary Center

PURPOSE

To report our experience of fertility preservation (FP) in female cancer patients.

MATERIALS AND METHODS

We retrospectively analyzed the medical records of female who underwent elective oocyte or embryo cryopreservation before cancer treatment between January 2015 and December 2020 at Asan Medical Center. We analyzed the type of cancer, the rate of reuse of cryopreserved oocytes or embryos, and fertility outcomes such as the resumption of menstruation or pregnancy.

RESULTS

A total of 174 patients underwent 182 oocyte retrieval cycles after controlled ovarian stimulation for oocyte or embryo cryopreservation. The median age of patients was 33.0 (range 19-46) years, and the patients were most unmarried female (65.52%). The majority of patients were diagnosed with breast cancer (78.16%), and the remaining were diagnosed with gastrointestinal (6.33%) and hematologic malignancies (5.75%). The maturation rate of oocyte cryopreservation was 83.33%, and the fertilization rate of embryo cryopreservation was 72.07%. Of the 57 patients currently not undergoing cancer treatment, 34 resumed menstruating and 19 (33.33%, 19/57) returned to attempt a pregnancy. Among them, five patients succeeded in natural pregnancy. Eleven patients received frozen-thawed embryo transfer, and four patients succeeded in becoming pregnant (36.36%, 4/11). Only 6.3% of patients returned to use their gametes, and 93.7% of gametes are still in storage.

CONCLUSION

FP in cancer patients should be considered before cancer treatment. Through continuous research on oncofertility, it is necessary to consider how to increase the return rate and provide appropriate information to cancer patients of reproductive age.

Reproductive endocrinologist and infertility specialists' knowledge, skills, behaviors, and attitudes regarding the care for transgender and gender-diverse individuals

Objective

To investigate associations between reproductive endocrinology and infertility (REI) providers' prior training and current knowledge, skills, attitudes, and behaviors regarding fertility preservation and family building for transgender and gender-diverse (T/GD) patients.

Design

The survey was distributed to members of the Society for Reproductive Endocrinology and Infertility, the REI-physician-focused professional body within the American Society for Reproductive Medicine, with additional participants recruited through snowball sampling.

Results

Participants (n = 206) reported on training in T/GD care; 51% endorsed prior training. Most participants (93%) believed T/GD individuals were as fit for parenthood as cisgender individuals. Prior training was associated with an increased likelihood of offering T/GD health resources and more frequent consultations with specialist colleagues.Common barriers to providing care indicated by respondents included cost, delays in gender-affirming care, and lack of knowledge of the potential impact of hormonal interventions. Common facilitators included education and training, prior experience, and affordability of services.

Conclusions

Most REI providers believed T/GD individuals are fit for parenthood and agreed that prior training facilitates care for T/GD patients. The lack of provider knowledge emerged as a barrier to care. Although training helped facilitate some components of care, systemic barriers such as the cost and variability of patient population characteristics/experiences are important considerations when serving T/GD individuals.

Oncologists’ Knowledge, Practice and Attitude toward Fertility Preservation: A National Survey

Background: Improved chemotherapy and radiotherapy treatment protocols, fortunately, increased the rates of cancer survivors over the years. However, these treatments may result in infertility or subfertility. Oncologists are considered the gateway for knowledge about cancer and its treatments’ effects. Several studies showed that many oncologists do not discuss fertility preservation with their patients. This study aimed to explore the perspective of oncologists in Oman on fertility preservation. Methods: A cross-sectional study of physicians and surgeons dealing with patients with cancer was conducted from June 2021 to December 2021. A standardized and validated questionnaire was used to collect data. Results: Participants reported that they are knowledgeable about sperm cryopreservation and gonadotropin-releasing hormone agonists use but not other methods of fertility preservation. About 94% of the participants reported that they need more knowledge about fertility preservation. More than half of the participants had never encountered cancer patients who used ovarian cryopreservation, testicular tissue cryopreservation, in vitro fertilization with embryo cryopreservation and oocyte cryopreservation. The majority (78%) agreed that discussing fertility preservation with newly diagnosed cancer patients is a high priority. Conclusions: Oncologists in Oman are supportive of fertility preservation. The lack of knowledge and unavailability of well-structured fertility preservation services in Oman hinders the initiation of fertility preservation discussions.

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.

Perspectives and Knowledge about Fertility Preservation Strategies among Female Cancer Patients in Turkey

OBJECTIVES

To evaluate the knowledge level and perspectives of female cancer patients regarding fertility preservation techniques before gonadotoxic treatment. Material and Methods. This was a prospective observational survey-based study conducted between 2016 and 2020 in Izmir Economy University Medical Park Hospital. A total of 150 female cancer patients aged 18-42 years were included. The participants completed a 17-item questionnaire, developed by the research team to evaluate their knowledge and perspectives on fertility preservation techniques.

RESULTS

The mean age of the patients was 39.5 ± 4.9 years. Only 64.7% of the patients were referred to fertility counseling by a gynecologist, while 72.6% of the patients knew of the risk of infertility after cancer treatment. There was a significant correlation between the health status and cancer stage of the patient (p=0.003). The estimated future chance of becoming pregnant spontaneously or through fertility preservation techniques was significantly higher in patients with a higher education level (p=0.041 or 0.008, respectively). Satisfaction with the counseling process was reported as high or low by 66.7% or 20% of the patients, respectively.

CONCLUSIONS

The rate of referral of reproductive-age cancer patients to fertility preservation counseling is still not satisfactory. Education level was the only variable significantly associated with a motivation to become pregnant after cancer treatment, either spontaneously or through fertility preservation techniques.

Fertility preservation decisions in young women with breast cancer: a qualitative study of health care professionals' views and experiences

Fertility preservation (FP) discussions prior to breast cancer treatment are an important aspect of care and considered routine practice. However, studies show that women diagnosed with breast cancer have unmet needs about FP discussions. To better understand them, a qualitative study was conducted to explore the perceptions of healthcare professionals (HCPs) regarding FP for young women diagnosed with breast cancer. Semi-structured interviews were performed in a University teaching hospital to explore the knowledge, attitudes and reported behaviours of HCPs (oncologists, breast surgeons, breast care specialist nurses and fertility specialists) who offer FP discussions (n = 20). Data were analysed thematically. HCPs in this study were aware of the need to discuss FP with patients but were not confident in their knowledge and were unsure of their role in the discussion. Patient characteristics of younger age, nulliparity and ethnicity appeared to influence if and how HCPs discussed FP, in addition to the personal attitudes and knowledge of HCPs. Specialist nurses were identified as having an important role in FP discussions. Raising awareness of the essential components of FP discussions by a checklist or algorithm may help in addressing ambiguity and promoting consistent FP discussions by HCPs.

Quality of integrated female oncofertility care is suboptimal: A patient-reported measurement

BACKGROUND

Clinical practice guidelines recommend to inform female cancer patients about their infertility risks due to cancer treatment. Unfortunately, it seems that guideline adherence is suboptimal. In order to improve quality of integrated female oncofertility care, a systematic assessment of current practice is necessary.

METHODS

A multicenter cross-sectional survey study in which a set of systematically developed quality indicators was processed, was conducted among female cancer patients (diagnosed in 2016/2017). These indicators represented all domains in oncofertility care; risk communication, referral, counseling, and decision-making. Indicator scores were calculated, and determinants were assessed by multilevel multivariate analyses.

RESULTS

One hundred twenty-one out of 344 female cancer patients participated. Eight out of 11 indicators scored below 90% adherence. Of all patients, 72.7% was informed about their infertility, 51.2% was offered a referral, with 18.8% all aspects were discussed in counseling, and 35.5% received written and/or digital information. Patient's age, strength of wish to conceive, time before cancer treatment, and type of healthcare provider significantly influenced the scores of three indicators.

CONCLUSIONS

Current quality of female oncofertility care is far from optimal. Therefore, improvement is needed. To achieve this, improvement strategies that are tailored to the identified determinants and to guideline-specific barriers should be developed.

Cancer, Fertility and Me: Developing and Testing a Novel Fertility Preservation Patient Decision Aid to Support Women at Risk of Losing Their Fertility Because of Cancer Treatment

Background

Women with a new cancer diagnosis face complex decisions about interventions aiming to preserve their fertility. Decision aids are more effective in supporting decision making than traditional information provision. We describe the development and field testing of a novel patient decision aid designed to support women to make fertility preservation treatment decisions around cancer diagnosis.

Methods

A prospective, mixed-method, three stage study involving: 1) co-development of the resource in collaboration with a multi-disciplinary group of key stakeholders including oncology and fertility healthcare professionals and patient partners (n=24), 2) alpha testing with a group of cancer patients who had faced a fertility preservation treatment decision in the past (n=11), and oncology and fertility healthcare professionals and stakeholders (n=14) and, 3) beta testing with women in routine care who had received a recent diagnosis of cancer and were facing a fertility preservation treatment decision (n=41) and their oncology and fertility healthcare professionals (n=3). Ten service users recruited from a closed Breast Cancer Now Facebook group and the support group Cancer and Fertility UK also provided feedback on CFM via an online survey.

Results

A 60-page paper prototype of the Cancer, Fertility and Me patient decision aid was initially developed. Alpha testing of the resource found that overall, it was acceptable to cancer patients, healthcare professionals and key stakeholders and it was considered a useful resource to support fertility preservation treatment decision-making. However, the healthcare professionals felt that the length of the patient decision aid, and elements of its content may be a barrier to its use. Subsequently, the prototype was reduced to 40 pages. During beta testing of the shortened version in routine care, women who received the resource described its positive impact on their ability to make fertility preservation decisions and support them at a stressful time. However, practical difficulties emerged which impacted upon its wider dissemination in clinical practice and limited some elements of the evaluation planned.

Discussion

Women receiving the decision aid within the cancer treatment pathway found it helped them engage with decisions about fertility preservation, and make better informed, values-based care plans with oncology and fertility teams. More work is needed to address access and implementation of this resource as part of routine oncology care pathways.

Update Knowledge Assessment and Influencing Predictor of Female Fertility Preservation in Oncologists

OBJECTIVE

This study aims to offer an update assessment of the knowledge of Chinese oncologists on female fertility preservation, and identify the determinants that influence the implementation of fertility preservation.

METHODS

A total of 713 Chinese oncologists with different specialties completed the online self-report questionnaire to assess their understanding of fertility risks in cancer treatment, knowledge on female fertility preservation, and perceptions on the barriers in referring patients for fertility preservation.

RESULTS

Although most oncologists were familiar with fertility risk in cancer treatment, half of them lacked the knowledge for reproduction and preservation methods. In the multivariable model, oncologists in a hospital with a specialized reproductive institution, positive precaution for fertility risk, and fertility preservation discussion with patients were significantly correlated with the possibility of fertility preservation referral.

CONCLUSIONS

The intervention targets based on the update evaluation and identified influencing determinants will be helpful for all the oncofertility researchers, oncologists and institutions in future efforts for well-established female fertility preservation services.

White paper: Onco-fertility in pediatric patients with Wilms tumor

The survival of childhood Wilms tumor is currently around 90%, with many survivors reaching reproductive age. Chemotherapy and radiotherapy are established risk factors for gonadal damage and are used in both COG and SIOP Wilms tumor treatment protocols. The risk of infertility in Wilms tumor patients is low but increases with intensification of treatment including the use of alkylating agents, whole abdominal radiation or radiotherapy to the pelvis. Both COG and SIOP protocols aim to limit the use of gonadotoxic treatment, but unfortunately this cannot be avoided in all patients. Infertility is considered one of the most important late effects of childhood cancer treatment by patients and their families. Thus, timely discussion of gonadal damage risk and fertility preservation options is important. Additionally, irrespective of the choice for preservation, consultation with a fertility preservation (FP) team is associated with decreased patient and family regret and better quality of life. Current guidelines recommend early discussion of the impact of therapy on potential fertility. Since most patients with Wilms tumors are prepubertal, potential FP methods for this group are still considered experimental. There are no proven methods for FP for prepubertal males (testicular biopsy for cryopreservation is experimental), and there is just a single option for prepubertal females (ovarian tissue cryopreservation), posing both technical and ethical challenges. Identification of genetic markers of susceptibility to gonadotoxic therapy may help to stratify patient risk of gonadal damage and identify patients most likely to benefit from FP methods.

Sexual and fertility-related adverse effects of medicinal treatment for cancer; a national evaluation among medical oncologists

BACKGROUND

Anti-cancer drugs commonly adversely affect fertility and sexual function. Despite this, patients report a lack of counselling of these potential adverse effects. The aim was to determine Dutch oncologists' knowledge about the adverse effects of various cancer drugs on fertility and sexual function.

METHODS

A cross-sectional survey was sent to members of the Dutch Society for Medical Oncology (n = 433). The survey questions included various cancer drugs' adverse effects on fertility, ovulation, spermatogenesis, and sexual function.

RESULTS

One hundred and five of 392 oncologists responded (26.8%). Oncologists were more aware of the adverse effects on fertility compared to sexual function. Drugs that were mostly believed to negatively affect fertility were cisplatin (n = 81, 80.2%), epirubicin (n = 78, 78.0%) and cyclophosphamide (n = 80, 77.7%). Regarding sexual function, most mentioned drugs were tamoxifen (n = 67, 65.7%), GnRH-agonists (n = 64, 63.4%) and cisplatin (n = 58, 57.4%). Oncologists with expertise in urology possessed more awareness regarding sexuality-related adverse effects (cisplatin p = 0.038, etoposide p = 0.025, ifosfamide p = 0.06, vinblastine p = 0.000).

CONCLUSION

Results revealed that oncologists have different beliefs about possible sexual and fertility-related adverse effects concerning medication resources and literature. Based on our results, oncologists do not possess sufficient knowledge to inform patients about sexual and fertility-related adverse effects.

Knowledge, Practice, and Attitudes of Physicians in Low- and Middle-Income Countries on Fertility and Pregnancy-Related Issues in Young Women With Breast Cancer

Fertility and pregnancy-related issues are highly relevant for young (≤ 40 years) patients with breast cancer. Limited evidence exists on knowledge, practice, and attitudes of physicians from low- and middle-income countries (LMICs) regarding these issues.

Online in @ASCO_pubs #JCOGlobOncol large survey by @matteolambe et al. showing suboptimal practice and attitudes of physicians in #LMICs on #fertility and #pregnancy issues in young #BreastCancer patients: increased awareness and education in #oncofertility are needed@OncoAlert

Factors Associated With the Discussion of Fertility Preservation in a Cohort of 1,357 Young Breast Cancer Patients Receiving Chemotherapy

PURPOSE

Female breast cancer (BC) patients exposed to gonadotoxic chemotherapy are at risk of future infertility. There is evidence of disparities in the discussion of fertility preservation for these patients. The aim of the study was to identify factors influencing the discussion of fertility preservation (FP).

MATERIAL AND METHODS

We analyzed consecutive BC patients treated by chemotherapy at Institut Curie from 2011-2017 and aged 18-43 years at BC diagnosis. The discussion of FP was classified in a binary manner (discussion/no discussion), based on mentions present in the patient's electronic health record (EHR) before the initiation of chemotherapy. The associations between FP discussion and the characteristics of patients/tumors and healthcare practitioners were investigated by logistic regression analysis.

RESULTS

The median age of the 1357 patients included in the cohort was 38.7 years, and median tumor size was 30.3 mm. The distribution of BC subtypes was as follows: 702 luminal BCs (58%), 241 triple-negative breast cancers (TNBCs) (20%), 193 HER2+/HR+ (16%) and 81 HER2+/HR- (6%). All patients received chemotherapy in a neoadjuvant (n=611, 45%) or adjuvant (n= 744, 55%) setting. A discussion of FP was mentioned for 447 patients (33%). Earlier age at diagnosis (discussion: 34.4 years versus no discussion: 40.5 years), nulliparity (discussion: 62% versus no discussion: 38%), and year of BC diagnosis were the patient characteristics significantly associated with the mention of FP discussion. Surgeons and female physicians were the most likely to mention FP during the consultation before the initiation of chemotherapy (discussion: 22% and 21%, respectively). The likelihood of FP discussion increased significantly over time, from 15% in 2011 to 45% in 2017. After multivariate analysis, FP discussion was significantly associated with younger age, number of children before BC diagnosis, physicians' gender and physicians' specialty.

CONCLUSION

FP discussion rates are low and are influenced by patient and physician characteristics. There is therefore room for improvement in the promotion and systematization of FP discussion.

Adult cancer patients and parents of younger cancer patients have little information about fertility preservation: a survey of knowledge and attitude

Background

Impaired fertility is one of the side effects of effective cancer therapy. Saving the potential or storing the material to enable people to have biological children after cancer treatment can be of high importance to many cancer survivors. Therefore, we designed a study to determine knowledge and attitudes to fertility preservation (FP) in adult cancer patients and the parents of patients with cancer. Participants who completed this survey were a convenience sample of 384 parents of cancer patients < 18 years and cancer patients ≥ 18 years from two large referral hospitals. A 25-item self-administered questionnaire measured knowledge and attitudes to FP. Responses were yes/no, or on a 4-point Likert scale (greatly, usually, rarely, never) scored from 1 for never to 4 for greatly.

Results

Most parents and most cancer patients were unaware of the FP methods of embryo cryopreservation (96.3% and 88.4%, respectively) and sperm cryopreservation (97.5% and 89.0%, respectively). Attitudes among cancer patients and parents to use of FP options, based on a 4-point Likert scale, were determined by financial cost, lack of access and information on FP options.

Conclusion

Of concern in this sample of Iranian adult cancer patients and their parents is that knowledge of the fertility risk associated with cancer therapy and knowledge of FP treatment options was generally poor, particularly among the parents. To enable cancer patients or their parents to make the best decisions about using FP services, oncologists and fertility specialists should discuss FP options during their consultation.

The Educational Program for Healthcare Providers Regarding Fertility Preservation for Cancer Patients: a Systematic Review

The emerging discipline of oncofertility advocates for the timely provision of fertility preservation (FP) to all cancer patients of childbearing age by healthcare providers. A lack of practice due to limited FP-related knowledge was found among healthcare providers. A systematic review was undertaken on the educational programs on FP for healthcare providers. An initial search was performed in MEDLINE, PsycINFO, CINAHL, Web of Science, PubMed, and Scopus databases in October 2019. This review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Among the 160 articles that were identified, five relevant articles published between 2009 and 2019 were reviewed. Of the five studies, three were quantitative nonrandomized studies, one was a randomized controlled trial, and one was a qualitative study. Three programs were relevant to oncology nurses, one was relevant to social workers as well as nurses, and one was relevant to oncology fellows and residents. The four programs significantly increased healthcare providers' knowledge about FP, but clinical practice was only improved in the Educating Nurses about Reproductive Issues in Cancer Healthcare program (P < 0.01). Nevertheless, most of the studies used a self-made questionnaire or tool to assess the effects of the training programs. The educational programs improved the FP-related knowledge of healthcare providers but lacked the high-quality randomized controlled trials needed to provide robust evidence on the effectiveness of training programs using standard tools. More training projects should be developed based on learning theories or models to improve oncofertility care in clinical practice.

How Do Young Women with Cancer Experience Oncofertility Counselling during Cancer Treatment? A Qualitative, Single Centre Study at a Danish Tertiary Hospital

BACKGROUND

Adolescents and young adults (AYAs) with cancer are at risk of therapy-induced infertility. The importance of initial and specialized fertility counselling to this patient group is undisputed. Despite international guidelines, oncofertility counselling is still inadequate. The purpose of this study was to examine how female AYA cancer patients and survivors experienced initial and specialized oncofertility counselling, and to present their specific suggestions on how to improve the oncofertility counselling.

METHODS

Twelve individual semi-structured interviews were performed with AYAs aged 20-35 with cancer or who were survivors. Participants were recruited via a youth support centre and social organization for AYAs with cancer. Data was analysed using thematic analysis.

RESULTS

Three main themes were found: Support is needed for navigating the fertility information jungle; The doctor's approach determines the content of the patient consultation; Inadequate and worrying information causes mistrust and frustration.

CONCLUSION

Results indicate a continuing problem regarding insufficient oncofertility counselling to AYAs with cancer. To ensure adequate and uniform information, especially in the initial oncofertility counselling, national guidelines for oncology specialists are suggested including multidisciplinary effort and collaboration between oncology and fertility specialists in mind. In addition, participants suggest focus on communication skills.

Beyond Teenage and Young Adult Cancer Care: Care Experiences of Patients Aged 25-39 Years Old in the UK National Health Service

AIMS

Adolescents and young adults aged 15-39 years with cancer face unique medical, practical and psychosocial issues. In the UK, principal treatment centres and programmes have been designed to care for teenage and young adult patients aged 13-24 years in an age-appropriate manner. However, for young adults (YAs) aged 25-39 years with cancer, little access to age-specific support is available. The aim of this study was to examine this possible gap by qualitatively exploring YA care experiences, involving patients as research partners in the analysis to ensure robust results.

MATERIALS AND METHODS

We conducted a phenomenological qualitative study with YAs diagnosed with any cancer type between ages 25 and 39 years old in the last 5 years. Participants took part in interviews or focus groups and data were analysed using inductive thematic analysis. Results were shaped in an iterative process with the initial coders and four YA patients who did not participate in the study to improve the rigor of the results.

RESULTS

Sixty-five YAs with a range of tumour types participated. We identified seven themes and 13 subthemes. YAs found navigating the healthcare system difficult and commonly experienced prolonged diagnostic pathways. Participants felt under-informed about clinical details and the long-term implications of side-effects on daily life. YAs found online resources overwhelming but also a source of information and treatment support. Some patients regretted not discussing fertility before cancer treatment or felt uninformed or rushed when making fertility preservation decisions. A lack of age-tailored content or age-specific groups deterred YAs from accessing psychological support and rehabilitation services.

CONCLUSIONS

YAs with cancer may miss some benefits provided to teenagers and young adults in age-tailored cancer services. Improving services for YAs in adult settings should focus on provision of age-specific information and access to existing relevant support.

Survey of professionals on breast cancer, fertility preservation and pregnancy in Argentina

Introduction

Medical knowledge regarding preservation of fertility and pregnancy in patients with breast cancer (BC) is of interest. We, therefore, decided to conduct a survey on this issue among professionals involved in the treatment of BC in Argentina.

Materials and methods

A survey was conducted and sent by email to 3,412 contacts in the Argentine Mastology Society (Sociedad Argentina de Mastología, or SAM) database, with responses from 396 physicians. The survey design was based on the Lambertini 2017 survey. To the author's knowledge, it is the first Argentine survey to address this issue.

Results

The frequency with which the impact of cancer treatment on the fertility of young patients was addressed by the respondent and referred to a fertility specialist was 'always' and 'almost always' in 86.8% and 78.5% of cases, respectively.

Conclusions

The level of knowledge is comparable to the data presented by other surveys. Membership in a Mastology Unit was associated with more current treatment. Continued work on the training of professionals is necessary to facilitate communication, information and guidance of patients of childbearing age who are going to have cancer treatment in order to advise them on fertility preservation, as well as the possibility of pregnancy after diagnosis of BC, and to be able to provide better care to those with BC associated with pregnancy.

Current Awareness and Attitude toward Fertility Preservation in Indonesia: A Nationwide Survey Among Health-care Providers

CONTEXT

Fertility preservation (FP) is necessary for cancer patients who develop infertility due to chemotherapy and radiotherapy. In Indonesia, many systematic steps and long-term continued actions must be taken to establish FP units since there has been an increasing incidence of cancer among people under 45 years old.

AIMS

This study aimed at a comprehensive evaluation on the awareness and practices of health-care providers (HCPs) toward FP.

SETTINGS AND DESIGN

This was a descriptive cross-sectional study.

SUBJECTS AND METHODS

A validated nationwide online survey was completed by 160 HCPs as a representative sample from 11 provinces in 2017 that provide medical care to cancer patients at hospitals or clinics.

STATISTICAL ANALYSIS USED

Descriptive statistics, analysis of variance, logistic regression, and Pearson correlation tests were used for the statistical analysis.

RESULTS

Respondents were specialists (59.4%) and other HCPs (40.6%). Around 60% of the HCPs who performed cancer therapies already discussed the fertility issues with their patients. Meanwhile, the HCPs (60.7%) also tended not to consult and refer their patients to fertility experts (P < 0.05). However, those who discussed the risk of infertility with patients tended to consult with and refer them to a fertility consultant for further FP procedure as the follow-up for their discussions (odds ratio = 8.98, confidence interval 95%, P < 0.05).

CONCLUSIONS

In Indonesia, FP awareness of the HCPs who performed cancer therapy was high. Nevertheless, attitudes to refer patients to fertility experts for possible FP management still need to be improved.

The Knowledge, Attitude, and Self-Reported Behaviors of Oncology Physicians Regarding Fertility Preservation in Adult Cancer Patients

There is a growing concern about the fertility preservation for adult cancer patients of reproductive age. Very little literature exists about fertility preservation of cancer survivors in Chinese text. This study is first to describe the knowledge level, attitude, and practice behaviors among physicians concerning fertility preservation in adult cancer patients in China. A cross-sectional survey with 30-item was conducted to assess Chinese oncology physicians' knowledge, attitude, and behaviors regarding fertility issues. Of 360 oncology physicians, 206 (57.2%) submitted valid questionnaires. With possible overall scores for knowledge and attitude of 9 and 15, respectively, physicians' responses to the questionnaires were 3.91 ± 1.67 and 12.29 ± 1.23. Only 49.5% of physicians routinely informed their cancer patients of childbearing age about the risk of infertility with cancer treatment. The knowledge score of the men physicians was 2-fold that of the women. Physicians aged 20-29 years were significantly more likely than other age groups to prioritize cancer treatment over fertility concerns. Men physicians were significantly more comfortable than the women discussing fertility preservation issues and cooperating with fertility specialists. The oncology physicians in China had limited knowledge of fertility preservation and rarely discussed these issues with their patients, although their attitude was positive. Results suggest that oncology physicians would welcome an in-house fertility-related training program. KEY MESSAGES: This is the first study to address the topic of fertility preservation as it relates to the care that oncologists provide to cancer patients in China. These results revealed the importance of providing fertility-related training program to oncology physicians. Moreover, this study should provide useful information for other Asian countries, and highlight both the similarities and differences between China and Western countries concerning the reproductive rights of patients. This study should encourage international cooperation with institutions of scientific research and education.

A Survey Study Reveals the Positive Impact of Oncofertility Knowledge and Attitude on Oncofertility Practice Among Oncologists in China

Purpose: The advances of early cancer diagnoses and treatment methods allow many adolescent and young adult-aged cancer patients to live long lives after having cancer. There is a rising concern regarding cancer treatment-induced reproductive toxicities and infertility. Oncologists are the first line of medical professionals interacting with cancer patients and playing essential roles in oncofertility practice. This study aimed to assess the oncofertility knowledge, attitude, and practice of oncologists in China. Methods: We created an online questionnaire survey to examine 927 Chinese oncologists' demographics, knowledge, attitude, experience, and practice regarding young female cancer patients' infertility risk and fertility preservation. Results: Results showed that there is an inadequate oncofertility knowledge among surveyed oncologists, which was affected by oncologists' demographic background of education level, clinical title, and working experience. The majority of surveyed oncologists (84.8%-88.7%) held a positive attitude on young female cancer patients' infertility risk and their fertility preservation demand, but their attitude was impacted by marriage status and patients risk of cancer recurrence. Only 11.8% of surveyed oncologists often referred their patients for fertility preservation, while 66.3% and 21.9% of them have referred once or never, respectively. The oncologists' oncofertility practice was not correlated with their demographic background but was significantly influenced by their oncofertility knowledge and attitude. Conclusion: Our study demonstrates that there is an urgent unmet need to improve oncologists' oncofertility knowledge, attitude, and practice in China as well as remove the communication barrier between oncologists and fertility specialists.

A survey of French gynecologists' knowledge and attitudes toward conservative treatment for fertility preservation in young patients with endometrial cancer

OBJECTIVE

To describe knowledge and attitudes toward fertility preservation (FP) in patients with endometrial atypical hyperplasia or adenocarcinoma (EC/AH) among French gynecologists MATERIALS AND METHODS: A national survey among French gynaecologists: one questionnaire with one common part and two specific parts for gynecological surgeon (GS) or for specialists in reproductive medicine (SRM) was sent from April 2017 to April 2018. Knowledge and attitudes toward FP in EC/AH were evaluated with a "knowledge score" and an "attitudes score" using a four- or five-point Likert scale.

RESULTS

One hundred forty physicians completed the survey (87 GS, 53 SRM). The knowledge score was low (59.3% medium/low), but it was significantly higher for GS compared to SRM. The better-known treatments were oral progestins and hysteroscopic resection. Among the participants treating EC/AH, 52.6% found it "difficult" to manage patients and 61.8% regretted the lack of official recommendations. Most physicians seemed to be uncomfortable/unsupportive with FP in EC/AH (57.2% "attitude score' below 11/20). There was a positive correlation between knowledge and attitude scores. GS "usually/always" give advice to patients about FP before EC/AH treatment. After maximum 3-6 months, 56.6% of SRM chose In Vitro Fecundation (IVF) to reduce time-to-pregnancy, with GnRH antagonist protocols (28%) or mild-stimulation (15.1%) to avoid hyperoestrogenism.

CONCLUSIONS

Despite reassuring results in the literature, French gynecologists are uncomfortable with FP using EC/AH conservative management, which may be because of a lack of confidence in their knowledge. Specific guidelines are needed to help physicians manage these young patients and their fertility.

Knowledge and awareness about fertility preservation among female patients with cancer : a cross-sectional study

OBJECTIVE

The incidence of women in the reproductive age group diagnosed with cancer has recently increased. However, very few patients opt for or are offered fertility preservation (FP) strategies because of a significant lack in awareness. The present study was conducted to evaluate the knowledge of the effect of cancer treatment on fertility and available options for FP.

METHODS

This was a cross-sectional study conducted at a tertiary care center from March 2019 through August 2019. One hundred female patients with gynecological or nongynecological cancer and 18-40 years of age were interviewed. The participants were categorized on the basis of the modified Kuppuswamy socioeconomic status (SES) scale and the responses of the patients in the different categories were compared.

RESULTS

More than half the patients (63%) were in the 20-35-year age group. Most of the patients (71%) were married, and of them, 28 (39.4%) desired to have children. Only 32% of the patients were aware of the detrimental effect of cancer and its treatment on future fertility, and of them, only 28% could specify the gonadotoxic effect of chemotherapy. Knowledge was significantly higher in the upper and middle SES levels than it was in the lower SES level (P<0.001). More than half of the patients (68%) were not aware of the existing FP options, whereas one-third of the patients (32%) were given information about FP by their physicians.

CONCLUSION

The overall awareness of the gonadotoxic effect of cancer therapy and available FP options in the present study was poor. Awareness of FP among both patients and clinicians needs to be increased.

Can the provision of sexual healthcare for oncology patients be improved? A literature review of educational interventions for healthcare professionals

Purpose

Sexual health is an important quality-of-life concern for cancer patients and survivors, but a difficult discussion topic for patients and healthcare professionals. The most important barriers causing healthcare professionals to avoid the topic are lack of education and lack of knowledge. How effective education about sexual health is for oncology healthcare professionals is not clear. The aim of this review is to examine the effectiveness of interventions in improving the provision of sexual healthcare for cancer patients.

Methods

A systematic literature review was conducted according to PRISMA guidelines using the following data sources: PubMed, PsychInfo, Embase and Emcare. Quantitative research was included which contained pre-intervention and post-intervention outcomes. The assessment of the studies was conducted independently by two reviewers. A third reviewer was involved if there was no consensus.

Results

Seven studies were included. In total, 572 oncology healthcare professionals participated, including physicians, nurses and allied healthcare professionals. Interventions consisted of 6 face-to-face sessions and one online program. Primary objectives of the studies were the assessment of improvement in knowledge about sexual health, improvement of practice, frequency of discussing sexual health and comfort level and the decline of perceived barriers to discussing sexual health. Studies showed that interventions resulted in improved realization of the objectives.

Conclusions

Although improvement in the knowledge of healthcare professionals was achieved, it was not possible to give an overall recommendation for the development of interventions due to the limited number of studies and heterogeneity of the data.

Implications for Cancer Survivors

Sexual health is an important area of survivorship that is often neglected. Many oncology healthcare professionals lack training and knowledge to provide such care. More evidence-based practices are needed to improve sexual healthcare for cancer survivors.

Electronic supplementary material

The online version of this article (10.1007/s11764-020-00898-4) contains supplementary material, which is available to authorized users.

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.

Impact of legislation and public funding on oncofertility: a survey of Canadian, French and Moroccan pediatric hematologists/oncologists

BACKGROUND

Chemotherapy and/or radiotherapy treatments may cause premature ovarian failure and irreversible loss of fertility. In the context of childhood cancers, it is now acknowledged that possible negative effects of therapies on future reproductive autonomy are a major concern. While a few options are open to post-pubertal patients, the only immediate option currently open to pre-pubertal girls is cryopreservation of ovarian tissue and subsequent transplantation. The aim of the study was to address a current gap in knowledge regarding the offer of fertility preservation by Ovarian Tissue Cryopreservation (OTC) for prepubescent girls with cancer, and to explore current practices and attitudes of Canadian, French and Moroccan pediatric heme oncologists. The comparative perspective is relevant since legal frameworks surrounding fertility preservation and funding offered by the healthcare system vary greatly.

METHODS

An online survey was sent to the 45 pediatric oncology centers in Canada, France and Morocco.

RESULTS

A total of 39 centers responded (86.6%). OTC is offered by almost all pediatric heme oncologists in France (98%), very few in Canada (5%), and none in Morocco (0%). For pediatric hematologists/oncologists who do not propose fertility preservation in Canada, the reasons are: the technique is still experimental (54%), it is not available locally (26%) and cost of the technique for the family (14%). 97% of Canadian and 100% of Moroccan pediatric hematologists/oncologists think OTC should be funded by the healthcare system as it is in France and in the province of Quebec in Canada.

CONCLUSIONS

The results of this study show tremendous diversity in the provision of OTC across countries, whereby its offer is correlated with legislation and funding. We argue that the current reality, in which this technology is often not offered to families, raises ethical issues related to justice and equity of access, as well as informed consent and future reproductive autonomy.

Level of Knowledge and Needs on Fertility Preservation in Reproductive-Aged Male Patients with Cancer

There is a growing concern about the fertility preservation (FP) for cancer patients of childbearing age. This study is the first in China to survey men with cancer, of reproductive age, regarding their knowledge of FP and their related needs. A 12-item cross-sectional survey was conducted of 332 male patients. The score for knowledge of FP was 3.5 ± 0.67, of a possible score of 8. Only 10.6% of the subjects had chosen to preserve fertility before treatments, but during therapy 68.7% wanted more information about FP. Younger patients were more likely have more knowledge concerning FP than older patients (odds ratio [OR] 0.86). The decision to make arrangements for FP before treatments was heavily influenced by being young and without children (OR, 0.78; OR, 0.11). Male cancer patients of reproductive age had limited knowledge of FP, and the majority was disinclined to make FP arrangements before therapy in China. Therefore, male cancer survivors should be well informed about FP soon after diagnosis and programs should be considered to improve the FP-related knowledge of male cancer survivors. We suggest that an assessment of patients' understanding of FP issues, before treatment, should be standard in clinical work.

Preservation of Childbearing Potential in Cancer Survivors: a Survey of Gynecologists' and Embryologists' Current Knowledge, Attitude, and Practice

Cancer is one of the life-threatening diseases, and cancer therapy may produce severe side effects such as impaired fertility. Saving childbearing potential after cancer treatment is of high importance to cancer survivors. This study assessed gynecologists' and embryologists' current practice, knowledge, and attitude concerning fertility preservation (FP) in cancer survivors. This current survey was performed on a convenience sample of 277 gynecologists and embryologists who attended large international congresses held across Iran. A 23-item self-administered questionnaire that included questions on knowledge, attitudes, and practice was used. Questions had either yes/no responses, or were answered based on a 4-point (1 to 4) Likert scored scale. Total mean score for knowledge of all FP options was 2.97 ± 0.62. Total mean scores for knowledge of all FP options in gynecologists and embryologists were 3.03 ± 0.65 and 2.95 ± 0.61, respectively (p = 0.33). These scores were above the median value of 2.5 obtained using the 4-point Likert scale. Participants regarded the patient age as the most important reason for discussing FP with patients (mean scores 3.74 ± 0.71 and 3.73 ± 0.52 for gynecologists and embryologists, respectively; p = 0.93). The majority of the participants (i.e., 95.2% (79 gynecologists) and 92.2% (166 embryologists)) referred cancer patients to centers providing FP services (p = 0.15). This sample of Iranian gynecologists and embryologists had considerable information on FP methods to develop appropriate attitudes and practices in relation to FP for cancer patients in order to prevent loss of fertility.

Fertility preservation and fulfillment of parenthood after treatment of hematological malignancies: results from the 'Aftercare in Blood Cancer Survivors' (ABC) study

Purpose

Treatment of hematological malignancies carries the risk of lasting sterility. We aimed to identify fertility-related unmet needs.

Methods

The ‘Aftercare in Blood Cancer Survivors’ study is a cohort study of hematological patients who were in treatment-free remission for ≥ 3 years or stable under continuous oral medication. Female patients age 18–45 years and male patients age 18–65 years without a history of pre-treatment infertility were asked to answer a structured questionnaire including questions addressing fertility issues. Multivariable analyses were performed to detect risk factors.

Results

Of 1562 study participants, 1031 met the inclusion criteria for the fertility sub-study. A high proportion of patients (72.4%) received information about the risk of losing fertility, but only a minority (15%) took steps to preserve it. Female and older patients were less likely to be informed. A post-treatment wish for parenthood was expressed by 19.3% of patients. It was strongly associated with childlessness at time of diagnosis and could be fulfilled by 29.4%. Fulfillment of desired parenthood increased with increasing time from diagnosis and was low after allogeneic transplantation.

Conclusions

Female and older hematological patients are less likely to be informed about fertility-related issues than other patients. With societal changes towards first parenthood at higher age, the proportion of patients desiring a child after treatment is likely to increase. Fulfillment of desired parenthood remains challenging, especially after allogeneic transplantation.

Implications for cancer survivors

In patients likely to express a wish for post-treatment parenthood, fertility-related issues should routinely be addressed before gonadotoxic treatment is started.

Electronic supplementary material

The online version of this article (10.1007/s10147-020-01639-4) contains supplementary material, which is available to authorized users.

Does a web-based decision aid improve informed choice for fertility preservation in women with breast cancer (DECISIF)? Study protocol for a randomised controlled trial

INTRODUCTION

Chemotherapy may cause infertility in young survivors of breast cancer. Various fertility preservation techniques increase the likelihood of survivors becoming genetic mothers. Disclosure of cancer diagnosis may impact decision making about fertility preservation. This protocol will develop and test the effectiveness of a web-based decision aid for helping women with breast cancer to make well-informed choices about fertility preservation.

METHODS AND ANALYSIS

This study will be conducted in three phases using mixed methods. In phase I, the aim is to develop a web-based patient decision aid (PDA) in French with a steering committee and using a focus group of five women already treated for breast cancer. In phase II, the face validity of the decision aid will be assessed using questionnaires. In phase III, the PDA will be assessed by a two-arm randomised controlled trial. This will involve a quantitative evaluation of the PDA in clinical practice comparing the quality of the decision-making process between usual care and the PDA. The primary outcome will be informed choice and its components. The secondary outcomes will be decisional conflict and anxiety. Data will be collected during and after an oncofertility consultation. Phase III is underway. Since September 2018, 52 participants have been enrolled in the study and have completed the survey. We expect to have results by February 2020 for a total of 186 patients.

ETHICS AND DISSEMINATION

This study protocol was approved by the Ouest V Research Ethics Board. Results will be spread through peer-reviewed publications, and reported at suitable meetings.

TRIAL REGISTRATION NUMBER

The ClinicalTrials.gov registry .(NCT03591848).

Knowledge, attitude, intention, and religion aspect toward fertility preservation among obstetrics and gynecology residents in Indonesia: A cross-sectional study

Background

The lack of knowledge from healthcare providers regarding fertility preservation will certainly affect the patient's knowledge, attitude, behavior, and also perspective. Obstetrics and Gynecology (OB/GYN) residents may most likely be the first line professionals to integrate fertility preservation technologies into their practice which plays an important task in giving an understanding of the relationship between age and fertility for patients.

Objective

This study aims to assess OB/GYN resident knowledge and beliefs regarding age-related fertility decline, intentions, and religion aspect toward fertility preservation.

Materials and Methods

A cross-sectional study was conducted on 92 Indonesian OB/GYN residents at the Cipto Mangunkusomo Hospital between November and December 2017. Data were collected using a questionnaire which had four sections, knowledge, attitude, intention, and religion aspect toward fertility preservation.

Results

The majority of participants believed that an OB/GYN should encourage discussions about potential childbearing desires (96.74%) and age-related fertility decline (94.57%) with patients, of which 79.34% believed that these discussions should be part of a woman's annual health examination. Cancer patients are likely to undergo oocyte cryopreservation than people who choose career as priority. From the religion aspect, fertility preservation options such as sperm, oocyte, embryo, and ovarian cortex cryopreservation were accepted by most residents with varied religions, while oocyte and sperm donor methods were unacceptable (48% and 57%, respectively) because of the belief that oocyte/sperm should only be given to legitimate partners, but many still do not know that oocyte and sperm donor were prohibited by all religions.

Conclusion

Age-related fertility decline and frozen egg storage should be discussed during annual woman wellness examinations by OB/GYN specialists.

Testicular sperm extraction and intracytoplasmic sperm injection outcome in cancer survivors with no available cryopreserved sperm

OBJECTIVE

To assess rates of successful testicular sperm retrieval and intracytoplasmic sperm injection (ICSI) outcome in cancer survivors affected by non-obstructive azoospermia (NOA) or retrograde ejaculation (RE)/failure of emission (FOE).

METHODS

A retrospective analysis of cancer survivors who did not cryopreserve sperm prior to treatment undergoing testicular sperm extraction (TESE). Non-cancer NOA patients and neurologic RE/FOE were the control group.

RESULTS

A total of 97 cancer survivors were offered TESE and 88 (91%) accepted. Sperm was retrieved and cryopreserved in 34/67 patients with NOA (50.7%) and in 21/21 patients affected by RE/FOE (100%). Sperm retrieval rates were similar in the control group (44.9% in NOA and 100% in RE/FOE). The ICSI cumulative pregnancy rate (60%) and live birth rate (40%) per couple in 30 NOA men did not differ from controls (50.0 and 46.5%, respectively; p = 0.399/0.670). The cumulative pregnancy rate (66.7%) and live birth rate (55.6%) in 18 RE/FOE men did not differ from the control group (38.9 and 33.3%, respectively; p = 0.181/0.315). The cancer type and the resulting infertility disorder (NOA or RE/FOE) were not associated with ICSI outcomes. Female partner age was inversely related to the cumulative live birth rate, being fourfold lower (11.5%) in women ≥ 40 years and 48.8% in younger women (p = 0.0037).

CONCLUSIONS

The rate of successful TESE and the ICSI outcome in cancer survivors with NOA and RE/FOE is the same as non-cancer azoospermic patients. Female partner age (older than 40 years) was associated with a significant reduction in live birth rates after TESE-ICSI procedures.

Fertility preservation in oncology patients: A literature review examining current fertility preservation techniques and access to oncofertility services in Australia

BACKGROUND

In Australia, between the years 2010 and 2014, over 4500 adolescents and young adults (15-25 years old) were diagnosed with cancer. Treatment regimens are often gonadotoxic and are well known to induce ovarian and testicular failure. Oncofertility is an emerging discipline in obstetrics and gynaecology which seeks to preserve and restore the reproductive future of cancer patients.

AIM

To perform a systematic literature review to assess the current fertility preservation techniques available to patients and examine access and uptake of fertility preservation in Australia.

MATERIALS AND METHODS

Electronic databases, including Medline, Cochrane Review, SCOPUS and CINHAL, were searched for peer-reviewed publications and national guidelines examining oncofertility practices from 2008 to July 2018. Three hundred and seventy-five articles were initially screened, with 158 articles for full text review and an additional five clinical guidelines were identified.

RESULTS

There is a paucity of Australian data on oncofertility with <50% of data included for analysis reflecting the Australian experience. The majority of primary research included retrospective papers with small cohort numbers. Key areas addressed included live birth outcomes, uptake of services and patient and physician perspectives on fertility preservation. Few articles sought to examine the positive and negative side effects of fertility preservation in oncology, social challenges of oncofertility and access to services worldwide.

CONCLUSION

Oncofertility is an emerging discipline which seeks to provide safe, efficient and effective fertility preservation options for young adults and adolescents diagnosed with cancer. A multi-disciplinary approach with collaborative communication with oncologists is key to providing this service within Australia.

Satisfaction, disappointment and regret surrounding fertility preservation decisions in the paediatric and adolescent cancer population

PURPOSE

With over 80% of paediatric and adolescent cancer patients surviving into adulthood, quality-of-life issues such as future fertility are increasingly important. However, little is known about regret around decisions to pursue or forgo fertility preservation (FP). We investigated the risk of decision regret in families involved in making a FP decision and explored contributive factors.

METHODS

Parents and patients ≥ 15 years were invited to participate. Participants completed a 10-item survey, including a validated Decision Regret Scale. Scores ≥ 30 indicated high regret. Free-text response items allowed participants to provide reasons for satisfaction or regret.

RESULTS

A total of 108 parents and 30 patients participated. Most (81.4%) reported low regret (mean score 13.7). On multivariate analysis, predictors of low regret included having a FP procedure and a fertility discussion pre-treatment. Most participants believed that FP offers hope for future fertility. Some reported dissatisfaction with the process of decision-making.

CONCLUSION

Overall levels of regret in the study population were low, with factors associated with quality, timely discussion and belief in the success of FP technology being predictors of low regret. However, dissatisfaction with the decision-making process itself revealed that refinements to the programme are required to meet families' needs.

Elective and Onco-fertility preservation: factors related to IVF outcomes

STUDY QUESTION

Is the indication for fertility preservation (FP) related to success in IVF cycles after elective-FP (EFP) for age-related fertility decline and FP before cancer treatment (Onco-FP)?

SUMMARY ANSWER

Although success rates were lower in cancer patients, there was no statistically significant association between malignant disease and reproductive outcome after correction for age and controlled-ovarian stimulation (COS) regime.

WHAT IS KNOWN ALREADY

FP is increasingly applied in assisted reproduction, but little is known about the outcome of IVF cycles with vitrified oocytes in FP patients.

STUDY DESIGN, SIZE, DURATION

Retrospective, observational multicenter study of vitrification cycles for FP and of the warming cycles of women who returned to attempt pregnancy from January 2007 to May 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In all, 6362 women (EFP = 5289 patients; 7044 cycles + Onco-FP = 1073 patients; 1172 cycles) had their oocytes vitrified for FP. A logistic regression analysis was performed to examine the impact of indication for FP corrected for age at vitrification. The protocol used for COS was also included as a possible confounder. The main outcome measures were oocyte survival and live birth. A detailed description of the baseline and clinical data is provided, with comparisons between EFP and Onco-FP. The cumulative live birth rate (CLBR) per utilized oocyte according to age at vitrification was analyzed in those patients returning to use their oocytes.

MAIN RESULTS AND ROLE OF CHANCE

Age at vitrification was significantly older in EFP patients (37.2 ± 4.9 vs. 32.3 ± 3.5 year; P < 0.0001). Fewer oocytes were retrieved and vitrified per cycle in EFP (9.6 ± 8.4 vs. 11.4 ± 3.5 and 7.3 ± 11.3 vs. 8.7 ± 2.1, respectively; P < 0.05), but numbers became comparable when analyzed per patient (12.8 ± 7.4 vs. 12.5 ± 3.2 and 9.8 ± 6.4 vs. 9.5 ± 2.6). Storage time was shorter in EFP (2.1 ± 1.6 vs. 4.1 ± 0.9 years; P < 0.0001). In all, 641 (12.1%) EFP and 80 (7.4%) Onco-FP patients returned to attempt pregnancy (P < 0.05). Overall oocyte survival was comparable (83.9% vs. 81.8%; NS), but lower for onco-FP patients among younger (≤35 year) subjects (81.2% vs. 91.4%; P > 0.05). Fewer EFP cycles finished in embryo transfer (50.2% vs. 72.5%) (P < 0.05). The implantation rate was 42.6% and 32.5% in EFP versus Onco-FP (P < 0.05). Ongoing pregnancy (57.7% vs. 35.7%) and live birth rates (68.8% vs. 41.1%) were higher in EFP patients aged ≤35 than the Onco-FP matching age patients (P < 0.05). The reason for FP per se had no effect on oocyte survival (OR = 1.484 [95%CI = 0.876-2.252]; P = 0.202) or the CLBR (OR = 1.275 [95%CI = 0.711-2.284]; P = 0.414). Conversely, age (<36 vs. ≥36 y) impacted oocyte survival (adj.OR = 1.922 [95%CI = 1.274-2.900]; P = 0.025) and the CLBR (adj.OR= 3.106 [95%CI = 2.039-4.733]; P < 0.0001). The Kaplan-Meier analysis showed a significantly higher cumulative probability of live birth in patients <36 versus >36 in EFP (P < 0.0001), with improved outcomes when more oocytes were available for IVF.

LIMITATIONS, REASONS FOR CAUTION

Statistical power to compare IVF outcomes is limited by the few women who came to use their oocytes in the Onco-FP group. The patients' ages and the COS protocols used were significantly different between the EFP and ONCO-PP groups.

WIDER IMPLICATIONS OF THE FINDINGS

Although the implantation rate was significantly lower in the Onco-FP patients the impact of cancer disease per se was not proven'. EFP patients should be counseled according to their age and number of available oocytes.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used for this study. The authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.