Attitudes, Beliefs, and Trends Regarding Adolescent Oncofertility Discussions: A Systematic Literature Review

Experiences of Family and Partner Support in Fertility Decision-Making Among Adolescents and Young Adults with Cancer: A National Australian Study

Purpose: To understand how adolescents and young adults (AYAs) with cancer experience family and partner involvement in fertility preservation (FP) decision-making. Methods: As part of a nationally representative Australian cross-sectional study of 15-25-year olds with cancer, 196 participants (mean age 19.9 [standard deviation 3.2] years at diagnosis; 51% male) were surveyed regarding FP decision-making. Results: One hundred sixty-one (83%) participants reported discussion of potential effects of cancer and its treatment on fertility, of whom 57 (35%) did not undertake FP (51% of females; 19% of males). Parental involvement (mothers 62%, fathers 45%) in decision-making was considered helpful, including for 73% of 20-25-year olds with partners. Sisters and brothers were involved less often, yet rated helpful in 48% and 41% of cases, respectively. Older participants were more likely than younger ones to have involved partners (47% vs. 22%, p = 0.001) and less likely to have involved mothers (56% vs. 71%, p = 0.04) or fathers (39% vs. 55%, p = 0.04). Conclusion: This is the first quantitative study to explore family and partner involvement in AYA FP decision-making in both females and males in a nationally representative sample. Parents are important resources who commonly assist AYAs with these complex decisions. Although many AYAs will be the main decision-makers when it comes to FP, particularly as AYAs mature, these data suggest that resources and support should be available for and inclusive of parents, partners, and siblings.

Experiences of Oncofertility Decision-Making and Care in a National Sample of Adolescent and Young Adult Cancer Patients and Parents

Purpose: Cancer and its treatments are known to compromise fertility in adolescents and young adults (AYAs). The emotional burden of possible infertility is reduced in those who receive supportive oncofertility care. In legal minors, provision of health care must consider the legal context and desire that AYAs have for autonomous decision-making, together with their competence to make health decisions. This has important implications for how oncofertility discussions may, or may not, involve parents. The aim of this study was to explore oncofertility decision-making and care experiences in a national Australian sample of AYA cancer patients and their parents. Methods: AYAs aged 15-25 years and parents were recruited from 17 cancer care sites and CanTeen Australia as part of a national AYA cancer care study. The cross-sectional survey included open-ended questions regarding oncofertility care experiences. We used reflexive thematic analysis to identify themes. Results: Data were available for 99 AYAs and 111 parents. Four themes were identified: emotional care needs; parent-AYA dynamics including AYA autonomy and agency; decision-making considerations including values and practicalities; and reflections on oncofertility care and follow-up. Both AYAs and parents placed importance on AYA autonomy in fertility decision-making, but many AYAs appreciated the role of parents in providing support and guidance throughout the process. Conclusion: Health care professionals are encouraged to autonomously engage AYAs around fertility decision-making, while concurrently offering opportunities that promote parental support. Better psychological support and follow-up oncofertility care are also needed.

Gaps in Adolescent and Young Adult Cancer Education in Oncology Fellowship Training

Purpose: Adolescents and young adults (AYAs, 15-39 years) with cancer experience disparities in care and outcomes compared with older/younger patients. AYAs receive care from medical and pediatric oncologists, however, little is known about the extent of training fellows receive. This needs assessment evaluating current AYA oncology (AYA-O) education in pediatric and medical oncology fellowship programs to identify knowledge gaps for curricular development. Methods: An anonymous, cross-sectional, web-based survey developed by pediatric and medical oncologists was sent to medical (n = 178) and pediatric (n = 119) hematology/oncology program directors (PDs) at 251 sites in the United States. PDs were asked to participate and distribute the survey to their fellows. Survey questions addressed current AYA curriculum, provider comfort, and priorities for future AYA educational content. Results: Participants from 69/251 programs responded (program response rate = 27%), including 51 PDs (32 pediatric, 19 medical oncology) and 58 fellows (33 pediatric, 25 medical oncology). Eighty-five percent of PDs (44/51) reported lacking formal AYA curricula. Of these, 80% (35/44) offer some topic-specific lectures, while 20% (9/44) provide little/no education for any topics. For nearly all topics, at least 45% of combined respondents reported little/no education. Respondents believe AYA topics are important for inclusion in future curricula. The most important topics for inclusion reported were oncofertility (82%), survivorship (78%), and communication (77%). Conclusions: There are large and actionable gaps in AYA-O education during fellowship training. Efforts are underway to develop AYA-O curriculum to provide both medical and pediatric oncology fellows with the knowledge and skills required to provide optimal AYA care.

Shared Decision-Making About Future Fertility in Childhood Cancer Survivorship: Perspectives of Parents in Uganda

Background: Despite a plethora of literature on barriers to addressing future fertility in childhood cancer survivors, the data are not representative of limited middle-income settings. Unique and context-specific factors may influence addressing future fertility care among childhood cancer survivors in Uganda. This study aimed to explore the experiences, attitudes, and perceptions of parents on their interactions with health providers about future fertility, as part of their child's cancer survivorship. Methods: Using grounded theory, semistructured interviews were conducted with parents of children diagnosed with cancer, <18 years of age, and not in the induction or consolidation phases of treatment. Transcripts were thematically analyzed. Results: A total of 20 participants were interviewed, with the majority identifying as female (n = 18). The global theme that arose was the importance of shared decision-making, and the key themes encompassing this were as follows: (1) importance of accurate information, (2) respect of autonomy, and (3) engagement and psychosocial support. Conclusion: In Uganda, parents of children with cancer value a multifaceted approach to satisfactory decision-making within the context of oncofertility.

Optimizing health literacy to facilitate reproductive health decision-making in adolescent and young adults with cancer

Despite being considered "standard of care" by many organizations, fertility and reproductive health communications and counseling practices remain inconsistent for adolescents and young adults (AYAs) newly diagnosed with cancer and during survivorship. One factor known to affect how information is provided and received in the medical setting is health literacy. Providers should consider health literacy to optimize reproductive health communication with AYAs as they cope with their diagnosis, understand what it means for their future, process information about treatment options, learn about their potential harmful effects on fertility, make quick decisions about fertility preservation, and navigate a future family planning course. Thus, the objectives of this manuscript are to (a) summarize literature on reproductive health literacy; (b) describe health literacy frameworks; (c) examine ways to assess health literacy; and (d) identify ways to enhance clinician-patient communication in the AYA oncofertility setting.

Understanding Fertility Attitudes and Outcomes Among Survivors of Adolescent and Young Adult Cancers in a Low-Resource Setting: A Registry-Based Computer-Assisted Telephone Interview Survey

Purpose: To establish the extent of self-reported reproductive failure associated with cancer treatment, and attitudes toward fertility among adolescent and young adult (AYA) cancer survivors in Uganda. Methods: A registry-based computer-assisted telephone interview survey was conducted in Uganda. The survey population were survivors of childhood, adolescent and early adulthood cancers diagnosed between 2007 and 2018. The survey explored fertility outcomes, experiences of oncofertility and fertility attitudes of AYA cancer survivors. Results: Thirty-four (female = 14 and male = 20) interviews were completed. Survivors were 18-35 years of age. The median age at cancer diagnosis was 23.5 for females and 17.5 for males. Kaposi's sarcoma contributed to 44% of primary cancer diagnoses. All the survivors had received chemotherapy alone or in combination with other modalities and 79% of survivors had not received satisfactory information about future fertility before cancer treatment. Twenty one percent of males and 46% females met the criteria for infertility and 60% of these had met this criterion after their cancer diagnosis. Eighty two percent wanted to raise a biologically related child. Forty seven percent would be dissatisfied with their lives if they were unable to have a child or additional children. Conclusion: AYA cancer survivors in this low-resource setting reported reproductive failure, despite a strong fertility desire. Information and counseling provided on therapy-related problems before cancer treatment was insufficient and reinforces the need to build capacity for oncofertility resources within the region.

Psychometric properties of the Fertility Intention Scale among breast cancer patients of childbearing age in mainland China

Objective

There are no valid assessment instruments assessing fertility intention among breast cancer survivors in mainland China. Therefore, this study aims to examine the psychometric properties of the Taiwanese version of the Fertility Intention Scale (FIS) among female patients with breast cancer of childbearing age in mainland China.

Methods

Two hundred and sixty-four female patients with breast cancer of childbearing age were recruited from two tertiary hospitals in Tianjin and Baoding, of which 32 patients completed the survey twice. Confirmatory factor analysis was adopted to assess construct validity. Correlations between the Reproductive Concerns After Cancer scale and FIS scores were calculated using Spearman correlation for convergent validity. The known-group validity of the FIS was verified using Mann–Whitney U test to compare the FIS scores between patients with or without the intention to conceive. Moreover, reliabilities were examined using Cronbach's alpha and intra-class correlation coefficient.

Results

Confirmatory factor analysis showed a good model fit to previous factor structures (χ²/df = 3.19, root mean square error of approximation = 0.091, comparative fitting index = 0.980, Tucker–Lewis index = 0.975), and no FIS item was dropped. The FIS scores were weak negatively correlated with the Reproductive Concerns After Cancer scale scores (r = –0.172, P < 0.01). The convergent validity of FIS was not satisfactory. Differences were noted between patients with or without the intention to conceive (50.62 ± 6.35 vs. 45.98 ± 7.19, P < 0.01). The FIS showed acceptable known-group validity. The internal consistency (Cronbach’s α = 0.824) and the test-retest reliability (r = 0.863, P < 0.01) of the FIS were also acceptable.

Conclusions

Overall, the FIS provides a comprehensive evaluation of the fertility intention among patients with breast cancer of childbearing age in mainland China. However, the convergent validity was not satisfactory; thus, further revision and validation may be required in the future.

Looking Back to Move Forward: Lessons Learned from a Successful, Sustainable, Replicable Model of Adolescent and Young Adult Program of a Tertiary Cancer Care Center

Background:

The Princess Margaret Cancer Centre (PM) established the adolescent and young adult (AYA) oncology program in 2014 to address the unique needs of AYA by delivering targeted, evidence-based care through a multidisciplinary team.

Methods:

We performed a retrospective analysis of patients who underwent a consultation with the PM AYA program from 2014 to 2020. The association between the health domain concerns reported and age at consultation, cancer diagnoses, and time since diagnosis was analyzed using chi-square test of independence in SPSS.

Results:

In our cohort of 1128 AYA, the median age at assessment was 28.2 years. The most common diagnoses were lymphoma (n = 251, 22.2%), leukemia (n = 207, 18.4%), and breast cancer (n = 162, 14.4%). The most common concerns reported were related to fertility (n = 882, 78.2%) and work/school (n = 472, 41.8%). Fertility concerns were most common in 25–34 age group (443/540, 82.0%) and work-/school-related concerns were highest in 18–24 age group (191/355, 53.8%). Diagnoses significantly affect majority of concerns reported. Fertility concerns were most common in AYA consulted near diagnosis, while body image-, exercise-, and diet-related concerns were more frequently reported, while on active treatments.

Conclusions:

Supporting fertility concerns remains the cornerstone of any successful AYA program. Work-/school-related concerns deserve more elucidation and attention. We identified important patterns in the health-related concerns of AYA, especially as they relate to age, diagnoses, and time since diagnosis. This insight will guide us for improving patient-centered care delivery to AYA.

Patient-Centered Communication to Address Young Adult Breast Cancer Survivors' Reproductive and Sexual Health Concerns

Women faced with a diagnosis of breast cancer as young adults commonly experience negative effects of cancer and cancer treatment on their reproductive and sexual health (RSH) that are inadequately addressed by their healthcare providers (HCPs). The objectives of this study were to 1) identify approaches to improving RSH communication from YA breast cancer survivors' perspectives, 2) identify facilitators and barriers to the approaches identified, and 3) identify specific strategies to improve patient-centered RSH communication. We conducted individual telephone interviews with 29 women who were diagnosed with breast cancer under age 40 years. We used a grounded theory approach to identify themes, and explored how the themes related to the PCC framework to elucidate specific strategies for improving communication. Three main themes emerged: 1) Normalizing and integrating assessment of RSH concerns; 2) HCP conveying genuine caring and investment; and 3) Improving accessibility of comprehensive RSH services after cancer. Results revealed concrete strategies for improving patient-centered RSH communication at the patient-provider and health system levels. These included reminding patients that RSH concerns are common, routinely asking about RSH, using active listening, and connecting patients to HCP who can address their RSH concerns.

How can fertility counseling be implemented for every newly diagnosed pediatric patient facing gonadotoxic treatment?-A single-center experience

Since the survival rates of pediatric patients undergoing cancer treatment or hematopoietic stem cell transplantation (HSCT) have increased rapidly in recent decades, the late effects of treatment are now an important focus of patient care. Access to fertility preservation (FP) procedures as well as their financing differs considerably across Europe. However, some countries in Europe have recently changed the legal basis for financing FP procedures; therefore, the implementation of structures is mandatory to give patients access to FP. In this prospective cohort study, we characterized the process for establishing pediatric fertility counseling, including the development of an in-house standard procedure for recommendations regarding FP with potentially gonadotoxic treatment and valuating data from all FP counseling sessions. All data concerning patient characteristics (pubertal status, disease group) and recommendation of FP measures were prospectively collected and adoption of FP measures analyzed. Prior to the establishment of a structured process for FP in our pediatric oncology and stem cell transplantation center, there was no standardized FP counseling. We demonstrate that with the establishment of an inhouse standard procedure, it is possible to give consistent yet individualized FP counseling to approximately 90% of our patients facing gonadotoxic treatment, counseling over 200 patients between 2017 and 2019. This pilot study could potentially be adapted in other pediatric hematology, oncology, and stem cell transplantation centers to allow a more standardized handling of FP counseling for all patients facing gonadotoxic treatment.

Attitudes and practices about fertility preservation discussions among young adults with cancer treated at a comprehensive cancer center: patient and oncologist perspectives

BACKGROUND

Young adults (YAs, ages 18-39) diagnosed with cancer face multiple challenges that affect their health-related quality of life, including the potential for cancer-related infertility. Providing information about the risk of infertility and options to maintain fertility is critical for YAs who are newly diagnosed. However, barriers to effective communication exist for oncologists and their patients. The purpose of this study was to interview medical oncologists and YAs from the same cancer center to examine attitudes and practices about fertility preservation.

METHODS

Semi-structured interviews were conducted with medical oncologists (N=12) and YAs within 2 years post-treatment (N=24), representing the most common cancers affecting YAs. Interviews were audio-recorded, transcribed, and coded using qualitative methodologies with the analysis software NVivo 10.

RESULTS

Twelve oncologists (50% female, 67% <50 years) and 24 YAs (67% female, M=29 years) completed interviews. Common themes across oncologist and YA interviews were the roles of cancer type or stage and patient interest or parity in influencing the decision. The most important factor for YAs was to receive accurate, in-depth information. Unique themes for oncologists focused on clinical aspects of their patient's disease. For YAs, they shared about the emotional impact of cancer-related infertility and desire for support from trusted others.

CONCLUSIONS

Results provide a better understanding of the attitudes and practices about fertility preservation discussions among YAs. Given the common factors affecting fertility preservation decisions, models of shared decision-making may be ideal for YAs and oncologists. Future interventions should explore tailored applications of this approach for YAs newly diagnosed with cancer.

Talking but not always understanding: couple communication about infertility concerns after cancer

BACKGROUND

Cancer related infertility can have an impact on couple relationships, with evidence that couple communication facilitates coping. However, little is known about the ways in which couples communicate about cancer-related fertility concerns. The aim of this article is to examine couple communication about fertility concerns in the context of cancer, and the perceived quality of such communication from the perspective of cancer survivors and their partners.

METHODS

Eight-hundred and seventy-eight cancer survivors (693 women, 185 men) and 144 partners (82 women, 62 men), across a range of tumour types and age groups, completed a survey which examined cancer related fertility concerns. Seventy-eight survivors (61 women and 17 men), and 26 partners (13 women and 13 men), participated in semi-structured interviews, in order to examine the subjective experience of fertility concerns in-depth. Thematic analysis was used to analyse the interviews and open ended survey questions. Valid percentages for single items from the relationships subscale of the Fertility Preservation Inventory (FPI) related to qualitative themes, identified frequency of responses.

RESULTS

The major theme was 'talking but not always understanding". 89.6% of cancer survivors and partners (95.1%) reported working well together handling fertility questions (FPI), but agreed that communication could be improved (65.9% survivors; 65% partners). Open and honest couple communication was associated with feelings of support, understanding and relationship growth, including perception of partner comfort (79.2% survivors, 81.6% partners). However, 32% survivors and 31.1% partners concealed fertility concerns to avoid upsetting their partner, or reported that their partner doesn't understand their fertility concerns (survivors 25.5%, partners 14.6%), with 14.1% of cancer survivors and 19.4% partners reporting fear of relationship breakdown because of fertility issues. Fear of rejection when forming new relationships, and concerns about how to talk to future partners, was reported by non-partnered individuals.

CONCLUSION

Health-care professionals should include partners of cancer survivors in fertility discussions. Couple interventions developed in general psycho-oncology should be extended to the domain of fertility, in order to facilitate effective couple communication. Communication in future relationships needs to be addressed for single people and adolescents and young adults (AYAs) who have fertility concerns.

The impact of cancer-related fertility concerns on current and future couple relationships: People with cancer and partner perspectives

OBJECTIVE

The purpose of this study was to examine how cancer-related fertility concerns impact on couple relationships from the perspectives of people with cancer (PWC) and partners of people with cancer.

METHODS

A qualitative research design was used, drawing data from open-ended responses to a survey and in-depth individual interviews. Eight hundred and seventy-eight PWC (693 women, 185 men) and 144 partners (82 women, 62 men), across a range of tumour types and age groups, completed a survey, and 78 PWC (61 women and 17 men) and 26 partners (13 women and 13 men), participated in semi-structured interviews.

RESULTS

Thematic analysis identified that many PWC and partners experience a 'double burden', manifested by cancer-related fertility concerns creating relational stress, changes to couple sexual intimacy and feelings of inadequacy when forming new relationships. However, many participants adopted strategies to facilitate coping with infertility or fertility concerns. This included acceptance of infertility and privileging of survival, focusing on relationship growth, optimism and nurturing in other ways.

CONCLUSION

Cancer-related fertility concerns can have a significant impact on couple relationships. Psychological support from clinicians may facilitate couple coping, as well as help to address concerns about future relationships for un-partnered people with cancer.

Fertility education for adolescent cancer patients: Gaps in current clinical practice in Europe

OBJECTIVE

As adolescent cancer patients may suffer from infertility following treatment, fertility counselling is essential. Our aim was to explore the current situation in four European countries in terms of (I) education about the risk for infertility, (II) counselling on fertility preservation, (III) patients' knowledge on fertility, (IV) sufficiency of information and (V) uptake of cryopreservation.

METHODS

In total, 113 patients (13-20 years) at 11 study centres completed a self-report questionnaire three and six months after cancer diagnosis. Multivariate logistic regression was used to estimate odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

As many as 80.2% of participants reported having received education about the risk for infertility prior to treatment, 73.2% recalled counselling on fertility preservation. Only 52.3% stated they felt sufficiently informed to make a decision. Inability to recall counselling on fertility preservation (OR = 0.03, CI: 0.00-0.47) and female gender (OR = 0.11, CI: 0.03-0.48) was associated with lower use of cryopreservation, whereas older age was associated with higher use.

CONCLUSION

Fertility counselling was available to a relatively high proportion of patients, and it did influence the utilisation of cryopreservation. However, many patients did not feel sufficiently informed. Further improvement is needed to enable adolescent cancer patients to make an informed decision on fertility preservation.

Barriers and Facilitators to Fertility-Related Discussions with Teenagers and Young Adults with Cancer: Nurses' Experiences

Introduction: Improvements in cancer survival rates for teenagers and young adults (TYAs) have resulted in quality-of-life issues into survivorship becoming increasingly important. However, infertility is a potential late side effect of cancer treatment, which can negatively impact on quality of life. Advances in assisted reproductive technologies have resulted in increasingly effective fertility preservation (FP) options. Purpose: This study aimed to explore nurses' experiences of undertaking fertility-related discussions with TYAs with cancer aged 13-24 years. Methods: An interpretive phenomenological analysis (IPA) approach was used. Eleven purposively selected nurses working on a specialist TYA cancer unit participated in semistructured interviews. Data were analyzed using IPA. Results: Parents/family were experienced as self-appointed informal gatekeepers who were perceived to hold the power to control nurses' access to communicate with young people about fertility issues. Nurses adopted a supportive role, which was enhanced by the positive nature of their relationship with the TYA. Uncertainty was expressed over whether the TYA had been fully informed of their infertility risk and potential FP options. Conclusions: Nurses should manage parental involvement sensitively if TYAs are to make informed decisions regarding their future reproductive health. There is a need for clear role delineation in fertility discussions to ensure that TYAs are provided with the opportunity to discuss infertility risk and be referred to a specialist before initiating cancer treatment. Nurses should cultivate the primacy of the nurse-TYA relationship to improve fertility care. Further research into the factors that TYAs may consider beneficial within the nurse-patient relationship is required.

Taboo Topics in Adolescent and Young Adult Oncology: Strategies for Managing Challenging but Important Conversations Central to Adolescent and Young Adult Cancer Survivorship

Research on adolescents and young adults (AYAs) with cancer has flourished over the past decade, underscoring the unique medical and psychosocial needs of this vulnerable group. A cancer diagnosis during adolescence and young adulthood intersects with the developmental trajectory of AYAs, derailing critical physical, social, and emotional development. AYAs face these abrupt life changes needing age-appropriate information and resources to offset these challenges. Greater attention is needed to address AYA-specific concerns on reproductive and sexual health, financial security and independence, emotional well-being, social support, and end-of-life care. If these unique needs are unaddressed, this can adversely affect AYAs' health care engagement and overall quality of life, increasing their risk for cancer-related morbidity and early mortality. In particular, health care decisions made during treatment have important implications for AYA patients' future health. Oncology clinicians are well positioned to address AYA patients' concerns by anticipating and addressing the challenges this age group is likely to face. In this paper, we explore several core topics that affect AYAs' quality of life and that can be challenging to address. Starting from the moment of diagnosis, through cancer treatment and post-treatment survivorship, and into end of life, each section highlights critical developmental-centric life domains that are affected by the cancer experience. Specifically, we discuss resources, tools, and strategies to navigate these challenging conversations. Taking a risk-reduction approach that invites two-way communication and facilitates referral to age-appropriate resources would help destigmatize these experiences and, in turn, would support the provision of compassionate and effective age-concordant care to this vulnerable group.

Exploring patient and provider perspectives on the intersection between fertility, genetics, and family building

OBJECTIVE

Adolescent and young adult (AYA) cancer patients have distinct medical and psychosocial needs and fertility is a key concern. Early age of onset is a risk factor for hereditary cancer and AYAs are more likely to experience reduced fertility. This has implications for future family building decisions and fertility preservation (FP) and genetic testing/counseling (GT/GC) education.

METHODS

Patients diagnosed with cancer between the ages of 18 and 39 and health care providers (HCPs) who treat AYA cancer patients were recruited from a single institution. Qualitative interviews explored AYA patients' and HCPs' concerns regarding their experiences discussing genetics and FP.

RESULTS

The majority of patients (n = 17) were female (59%), and the majority of HCPs (n = 18) were male (67%). Overall, participants had differing perceptions of FP and GT/GC-related information provided during the clinical visit. Patients indicated initiating the conversation about FP and did not recall HCPs discussing GT/GC with them. HCPs indicated patients were often overwhelmed with too much information and comprehension of this discussion is limited. HCPs also felt patients' emotions/beliefs determined their information-seeking behavior specific to FP and GT/GC. Participants felt educational materials should be developed and delivered in a video format depicting a patient-provider interaction or patient testimonial.

CONCLUSION

AYA patients are often overwhelmed by a cancer diagnosis; the complexity/volume of information regarding FP and GT/GC may hinder understanding and decision-making about family building. Educational materials that help patients understand what questions to ask HCPs about FP and GT/GC should be developed to improve knowledge, psychosocial well-being, and future family building decisions.

A fertility preservation toolkit for pediatric surgeons caring for children with cancer

Survival for children with cancer has improved significantly in recent decades, prompting an increasing emphasis on minimizing late effects of therapy, including infertility and premature gonadal insufficiency. The time interval after diagnosis and before therapy initiation can be stressful and overwhelming for patients and their families coming to terms with the implications of the diagnosis, but is also the optimal time to address oncofertility options. Pediatric surgeons are often an integral part of the care team for these patients during this vulnerable time period and play a key role in advocating for and performing oncofertility procedures. Children with cancer have both non-experimental and experimental fertility preservation options available depending on their pubertal status and a risk assessment performed based on their anticipated therapy. This review provides an oncofertility toolkit for pediatric surgeons to perform a risk assessment, counsel families on fertility preservation options, and establish an oncofertility program tailored to the resources available at their institutions.

Adolescent and young adult oncology-past, present, and future

There are nearly 70,000 new cancer diagnoses made annually in adolescents and young adults (AYAs) in the United States. Historically, AYA patients with cancer, aged 15 to 39 years, have not shown the same improved survival as older or younger cohorts. This article reviews the contemporary cancer incidence and survival data through 2015 for the AYA patient population based on the National Cancer Institute's Surveillance, Epidemiology, and End Results registry program and the North American Association of Central Cancer Registries. Mortality data through 2016 from the Centers for Disease Control and Prevention's National Center for Health Statistics are also described. Encouragingly, absolute and relative increases in 5-year survival for AYA cancers have paralleled those of childhood cancers since the year 2000. There has been increasing attention to these vulnerable patients and improved partnerships and collaboration between adult and pediatric oncology; however, obstacles to the care of this population still occur at multiple levels. These vulnerabilities fall into 3 significant categories: research efforts and trial enrollment directed toward AYA malignancies, access to care and insurance coverage, and AYA-specific psychosocial support. It is critical for providers and health care delivery systems to recognize that the AYA population remains vulnerable to provider and societal complacency.

Fertility and hormone preservation and restoration for female children and adolescents receiving gonadotoxic cancer treatments: A systematic review

BACKGROUND/PURPOSE

The purpose of this systematic review by the American Pediatric Surgical Cancer Committee was to summarize evidence from the current medical literature regarding fertility restoration and hormone replacement for female children and adolescents treated with gonadotoxic treatments.

METHODS

Using PRISMA guidelines, questions were addressed by searching Medline, Cochrane, Embase Central and National clearing house databases using relevant search terms. Eligible studies included those that addressed ovarian tissue cryopreservation (OTC), oocyte harvest, ovarian transposition, and ovarian tissue auto-transplantation for females under the age of 20. Four reviewers independently screened studies for eligibility, extracted data and assessed the risk of bias. Study outcomes were summarized in a narrative synthesis.

RESULTS

Two thousand two hundred seventy-six studies were identified by database search and manual review and 2185 were eliminated based on defined exclusion criteria. Ninety-one studies served as the basis for the systematic review. There were 1019 patients who underwent OTC with ages ranging from 0.4 to 20.4 years old, with 298 under the age of 13. Twenty patients aged 13-20 years old underwent successful oocyte harvest. Thirty-seven children underwent ovarian transposition as a means of fertility preservation. Eighteen patients underwent auto-transplantation of thawed ovarian cortical tissue that was harvested before the age of 21 years resulting in 10 live births.

CONCLUSIONS

Clinically accepted and experimental fertility preservation options such as OTC, oocyte cryopreservation, and ovarian transposition are available to females aged 20 years and younger who are at risk for premature ovarian insufficiency and infertility due to gonadotoxic treatments. There is a large cohort of pediatric-aged patients, with a wide variety of diagnoses and treatments, who have undergone fertility preservation. Currently, fertility and hormone restoration experience for patients who were 20- years of age or younger at the time of fertility preservation remains limited.

LEVEL OF EVIDENCE

IV.

Challenges and opportunities in the care of survivors of adolescent and young adult cancers

Adolescents and young adults (AYA) with cancer are an understudied group. Much of what is known about long-term outcomes after AYA cancer has been derived from cohorts of childhood cancer survivors, which seldom include patients at the older end of the AYA age spectrum. In general, AYA cancer survivors have a lower risk for premature mortality, subsequent primary neoplasms and chronic health conditions than childhood cancer survivors. However, AYA cancer survivors are vulnerable to psychosocial challenges, concerns about fertility and relationships and financial toxicity. No single model is optimal for the care of these survivors, but it is generally agreed that all survivors require a survivor care plan that promotes their adherence to evidence-based surveillance guidelines. There is a need to create survivor cohorts that include the full range of AYA ages and diagnoses to be able to address the many pressing questions that remain unanswered in this vulnerable population.

Cancer and fertility: optimizing communication between patients and healthcare providers

PURPOSE OF REVIEW

This article reviews the status of guidelines and recommendations for communication between patients with cancer and healthcare providers (HCPs) concerning fertility issues.

RECENT FINDINGS

The timing, the type of information provided, and the openness of HCPs can all affect how patients with cancer perceive discussions regarding fertility concerns and preservation. In addition, whether such discussions occur is associated with intrinsic factors, such as age and sex of the patients as well as HCP's knowledge level. It has also been found that the patients have different needs for information regarding fertility preservation and preferences for types of communication strategies regarding the impact of their disease and treatments on options for family planning.

SUMMARY

Although discussions about fertility concerns in the context of cancer between physicians and patients are occurring more frequently, there are inconsistent findings regarding satisfaction with these discussions. Recent research has found that the timing, type of information given, and level of openness of the HCP can impact how patients perceive communications regarding the risks of cancer treatment on fertility preservation options and future family planning. Age, sex, and HCP's knowledge of fertility risks and fertility preservation services are also notable factors associated with whether and how extensively discussions about fertility take place. More women than men report having a fertility discussion with an HCP. However, men are more likely to report satisfaction with the fertility discussion than women.

What is the Role of the Oncology Nurse in Fertility Preservation Counseling and Education for Young Patients?

Oncology nurses are uniquely positioned to offer fertility preservation counseling and education for cancer patients of reproductive age, yet there is a dearth of research that focuses on current practice and perceptions of nursing role. In 2013, the American Society of Clinical Oncology extended the duties of fertility preservation counseling among patients of reproductive age undergoing cancer treatment to include registered nurses and other allied health professionals as active partners in the counseling and education process. This study used a cross-sectional descriptive survey to assess current practices, role perceptions, and barriers to fertility preservation counseling among registered nurses working in an academic care setting with outpatient and inpatient services. There were significant gaps in current practices and perceptions of roles regarding fertility preservation counseling. Many nurses expressed the perception that fertility preservation counseling was important, but it was outside the scope of their practice to perform this education. This preliminary work defined need for an interdisciplinary fertility preservation team, communication surrounding educational practice norms, and designated oncofertility navigator.

Fertility counseling before cancer treatment and subsequent reproductive concerns among female adolescent and young adult cancer survivors

BACKGROUND

Fertility counseling before cancer treatment has been advocated by clinical guidelines, though little is known about its long-term impact on the unique reproductive concerns of female adolescent and young adult (AYA) cancer survivors. The goal of this study was to measure the association between fertility counseling by fertility specialists before cancer treatment and subsequent reproductive concerns.

METHOD

A cross-sectional analysis was performed among 747 AYA survivors aged 18-40 years who had been recruited from cancer registries and physician and advocacy group referrals between 2015 and 2017. Participants self-reported information on past fertility counseling at cancer diagnosis, cancer type and treatment, and current reproductive concerns, as measured using the multidimensional Reproductive Concerns After Cancer scale. Multivariable log-binomial regression models tested associations between fertility counseling and reproductive concerns.

RESULTS

The mean age of the cohort was 33.0 years (standard deviation, 5.1 years), and the mean period since diagnosis was 7.7 years (standard deviation, 5.0 years). Seventy-three percent of participants were white, and 24% were Hispanic. Fertility counseling was reported by 19% of survivors; moderate to high overall reproductive concerns were reported by 44% of participants. In adjusted analysis, fertility counseling was significantly associated with moderate to high reproductive concerns (risk ratio, 1.22; 95% confidence interval, 1.02-1.45) and not modified by exposure to fertility-threatening treatments (P_interaction = .23).

CONCLUSION

A large proportion of AYA cancer survivors across cancer types and treatment exposures reported moderate to high reproductive concerns, suggesting that there is a need to address these cancer-specific reproductive health concerns after treatment. Higher concerns, even with counseling, suggests the need to improve the quality of fertility counseling throughout the cancer continuum.

"Creating a family after battling cancer is exhausting and maddening": Exploring real-world experiences of young adult cancer survivors seeking financial assistance for family building after treatment

OBJECTIVE

Young adult (YA) cancer survivors who received gonadotoxic therapy are at risk for impaired fertility and/or childbearing difficulties. This study explored the experiences and financial concerns of survivors pursuing family building through assisted reproductive technology (ART) and adoption.

METHODS

Retrospective study of data collected from grant applications for financial assistance with family building. Grounded theory methodology using an inductive data-driven approach guided qualitative data analysis.

RESULTS

Participants (N = 46) averaged 32 years old (SD = 3.4) were primarily female (81%) and married/partnered (83%). Four main themes were identified representing the (1) emotional experiences and (2) financial barriers to family building after cancer, (3) perceived impact on partners, and (4) disrupted life trajectory. Negative emotions were pervasive but were balanced with hope and optimism that parenthood would be achieved. Still, the combination of high ART/adoption costs, the financial impact of cancer, and limited sources for support caused extreme financial stress. Further, in the face of these high costs, many survivors reported worry and guilt about burdening partners, particularly as couples failed to meet personal and societal expectations for parenthood timelines.

CONCLUSION

After cancer, YAs face numerous psychosocial and financial difficulties in their pursuits of family building when ART/adoption is needed to achieve parenthood. Survivors interested in future children may benefit from follow-up fertility counseling post-treatment including discussion of ART options, surrogacy, and adoption, as appropriate, and potential barriers. Planning for the financial cost and burden in particular may help to avoid or mitigate financial stress later on.

Oncofertility Decision Making: Findings from Israeli Adolescents and Parents

PURPOSE

To date, few studies qualitatively investigate adolescent oncofertility decision making. This qualitative study seeks to understand the experiences of adolescents and parents in making oncofertility decisions within the pronatalist context of Israeli society.

METHODS

Semi-structured interviews were conducted in Israel with adolescents between the ages of 12 and 19 years who were in remission for at least 2 months and had been offered fertility preservation (FP) of sperm, ova, or ovary cryopreservation, and their parents, separately. Transcripts were thematically analyzed.

RESULTS

Thirty-five interviews were conducted-16 with adolescents and 19 with parents-representing 20 cases of FP decision making. Adolescents and parents do not necessarily view decision making in the same way. Both parties mention a variety of factors in and justifications for FP decisions. Although most participants imagine the adolescent will use cryopreserved biological materials only if s/he experiences reproductive difficulties, nearly all participants do not recall having discussed what to do with these materials in the case of death. Many adolescents and parents feel comfortable waiting to take further action regarding adolescent fertility until the topic has greater relevance to the adolescent's life. Satisfaction with FP decision making is nearly unanimous, regardless of whether FP was pursued.

CONCLUSION

As in other cultural contexts, Israeli adolescents and parents demonstrate multifaceted decision making with respect to oncofertility. A significant finding from this study suggests that health professionals shy from discussing posthumous planning of cryopreserved materials with adolescent cancer patients and their parents. Further investigation is warranted to determine whether this is a uniquely Israeli phenomenon, the cause for it, and how to overcome it.

Nurses' experiences of undertaking fertility-related discussions with teenagers and young adults with cancer: An interpretive phenomenological analysis

AIMS

The aim of this study was to explore and interpret nurses' experiences, feelings and associated meanings attached to undertaking fertility-related discussions with teenagers and young adults with cancer. The study also aims to advance an understanding of factors which facilitate or hinder such discussions, to progress clinical practice.

BACKGROUND

Improved cancer treatments have increased survival rates for many teenagers and young adults. However, as a side-effect of treatment, infertility may result. International and UK studies suggest this patient population may not be provided with adequate opportunities to discuss this important issue. Little is known about nurses' experiences of undertaking fertility-related discussions.

DESIGN

Qualitative Interpretive Phenomenological Analysis.

METHODS

Eleven semistructured interviews were conducted between February and May 2016 with purposively selected nurses working in a Teenage Cancer Trust Unit in a UK hospital. Interviews were recorded and transcribed verbatim. Data were analysed using Interpretive Phenomenological Analysis.

FINDINGS

Nurses experienced a perceived lack of knowledge resulting in avoidance of raising fertility issues. Nurses expressed a specific need for more knowledge and education which was viewed as an essential prerequisite to their participation in discussions. The limited time frame for female patients to preserve fertility prior to commencement of treatment was felt to inhibit both fertility-related discussion and fertility preservation.

CONCLUSION

Ongoing education and support for nurses may ensure teenage and young adult cancer patients' reproductive needs are met. Nurses need to consider ways to ensure female patients benefit from improved information regarding infertility risks and preservation options to support their reproductive needs.

Knowledge and Beliefs About Oncofertility and Associations with Quality of Life Among Adolescent and Young Adult Survivors of Pediatric Cancer

PURPOSE

Adolescent and young adult (AYA) cancer survivors experience fertility and childrearing challenges in adulthood, but there is limited evidence on awareness, beliefs, and concerns about oncofertility in this population, needs for supportive resources, and associations with quality of life (QoL).

METHODS

Participants were 69 AYAs aged 12-25 who were diagnosed with cancer at age 18 years or younger and ≥1 year cancer free, recruited from childhood cancer clinical records and support organizations. Participants completed self-report assessment of oncofertility knowledge and beliefs, information needs, and measures of QoL. Analyses examined associations between oncofertility-related variables and QoL.

RESULTS

Knowledge and beliefs about oncofertility options were considerably low in the sample, and participants reported unmet oncofertility resource needs. In multivariable analyses, QoL was associated with beliefs valuing the importance of fertility in childhood cancer (β = 0.87, p = 0.01) and lower information needs (β = -1.19, p = 0.022).

CONCLUSIONS

Infertility is a well-documented effect of childhood cancer treatment. Our findings indicate that clinical providers are a preferred source of information for AYA patients, and there is a need to address oncofertility concerns and challenges in this group. Research is needed to examine barriers to addressing fertility issues in childhood cancer treatment and ways to promote dialogue between providers and patients and their families.

Threat of biographical disruption: the gendered construction and experience of infertility following cancer for women and men

BACKGROUND

Infertility is a major concern for people with cancer and their partners. There have been calls for further research on the gendered nature of psychosocial, emotional and identity concomitants of fertility post-cancer across women and men.

METHOD

The gendered construction and experience of infertility following cancer was examined through a survey of 693 women and 185 men, and in-depth one-to-one interviews with a subsample of survey respondents, 61 women and 17 men, purposively selected across cancer types and age groups. Thematic decomposition was used to examine the open ended survey responses and interviews. The chi square test for independence was used to test for group differences between women and men on closed survey items.

RESULTS

In the thematic decomposition, infertility was identified as providing a 'Threat of Biographical Disruption' which impacted on life course and identity, for both women and men. Subthemes identified were: 'Parenthood as central to adulthood'; 'Infertility as a threat to gender identity'; ' Unknown fertility status and delayed parenthood'; 'Feelings of loss and grief'; 'Absence of understanding and support'; 'Benefit finding and renegotiation of identity'. In the closed survey items, the majority of women and men agreed that they had always 'wanted to be a parent' and that 'parenthood was a more important life goal than a satisfying career'. 'It is hard to feel like a true adult until you have a child' and impact upon 'my feelings about myself as a man or a woman' was reported by both women and men, with significantly more women reporting 'I feel empty because of fertility issues'. Many participants agreed they 'could visualise a happy life without a child' and there is 'freedom without children'. Significantly more men than women reported that they had not discussed fertility with a health care professional.

CONCLUSION

The fear of infertility following cancer, or knowledge of compromised fertility, can have negative effects on identity and psychological wellbeing for both women and men, serving to create biographical disruption. Support from family, partners and health care professionals can facilitate renegotiation of identity and coping.

Fertility-Related Perceptions and Impact on Romantic Relationships Among Adult Survivors of Childhood Cancer

PURPOSE

To present an overview of fertility-related perceptions and describe the perceived negative/positive impact of (potential) infertility on romantic relationships among childhood cancer survivors.

METHODS

Male and female long-term childhood cancer survivors (N = 92) aged 22-43 and 7-37 years postdiagnosis, completed an online survey about fertility-related perceptions (i.e., knowledge, beliefs, uncertainty, concern, and attitudes toward testing) and romantic relationships. Potential differences based on sociodemographic/cancer-specific factors were tested.

RESULTS

Most survivors (82.4%, n = 75) knew about infertility risk due to childhood cancer treatment. Seventy percent (n = 65) reported being told they were personally at risk, but less than one-third believed it (29.2%, n = 19/65). Half of survivors (48.9%, n = 45) never underwent fertility testing and were unaware of their fertility status. Fertility-related uncertainty and concerns were more common among survivors without children and those who desired (additional) children (d's > 0.5). Among survivors without biological children (n = 52), partnered survivors felt more uncertain about their fertility than singles (d = 0.8). Ten survivors (10.9%) reported a negative impact of infertility on romantic relationships, 6 (6.5%) reported a positive impact, and 7 (7.6%) reported both (e.g., pressure on relationship, fights, break-ups, being closer, and open partner communication).

CONCLUSIONS

Fertility-related perceptions varied among survivors, but the majority never underwent fertility testing. Uncertainty or concerns differed by current circumstances (e.g., wanting children and relationship status). Providers should routinely discuss potential infertility and offer testing throughout survivorship. A negative impact on romantic relationships may seem small, but should be considered for survivors who desire children and may discover they are infertile in the future.

Need for information, honesty and respect: patient perspectives on health care professionals communication about cancer and fertility

BACKGROUND

Individuals affected by cancer report a need for information about fertility from health care professionals (HCPs), in order to inform decision making and alleviate anxiety. However, there is evidence that many health professionals do not engage in such discussions.

METHOD

A mixed method design was used to examine the construction and subjective experience of communication with health professionals about fertility in the context of cancer, from the perspective of patients. A survey was completed by 693 women and 185 men, across a range of cancer tumour types and age groups, and in-depth one-to-one interviews conducted with a purposively selected subsample of survey respondents, 61 women and 17 men. The chi square test for independence was used to test for group differences between women and men on closed survey items. Thematic analysis was used to examine the open ended survey responses and interviews.

RESULTS

Significantly more women (57%, n = 373) than men (46%, n = 80) (X2(2517) = 6.54, p = .011) reported that they had discussed fertility with a HCP since diagnosis of cancer. Satisfaction with the discussion was reported by 65% (n = 242) of women and 69% (n = 54) (ns) of men. This discussion was reported to have been initiated by the patient or their partner in 44% (n = 165) of women and 47% (n = 37) (ns) of men. In the interviews and open ended surveys three themes were identified: Feeling heard and informed about fertility after cancer: Positive experiences of HCP communication; "I was never given full disclosure": HCP silence or reticence about discussing fertility after cancer, including the sub-theme "Their primary concern is getting me cancer free": Constructions of absence of fertility communication by HCPs; and Confusion and lack of compassion: Unsatisfactory information provision about fertility and cancer.

CONCLUSION

Discussion with a HCP about fertility concerns, and satisfaction with the discussion, was associated with reports of lower patient distress, greater knowledge and understanding of the consequences of cancer on fertility, involvement in the decision making process about fertility preservation, and satisfaction with health care.

Parental influences on sperm banking attempts among adolescent males newly diagnosed with cancer

OBJECTIVE

To investigate the influence of parental sociodemographic, communication, and psychological factors on sperm collection attempts among at-risk adolescent males newly diagnosed with cancer.

DESIGN

Prospective, single group, observational study design.

SETTING

Pediatric oncology centers.

PATIENT(S)

Parents (N = 144) of 122 newly diagnosed adolescent males at increased risk for infertility secondary to cancer therapy.

INTERVENTION(S)

Survey-based assessment of parent factors associated with adolescent collection attempts.

MAIN OUTCOME MEASURE(S)

Attempt of manual collection of sperm.

RESULT(S)

Parental recommendation to bank sperm (odds ratio [OR] 3.72; 95% confidence interval [CI] 1.18-11.76) and perceived self-efficacy to facilitate banking (OR 1.20; 95% CI 1.02-1.41) were associated with an increased likelihood of making a collection attempt.

CONCLUSION(S)

Parental recommendation to bank is a critical influence for sperm banking among adolescent males newly diagnosed with cancer. These findings highlight the importance of effective communication between parents, patients, and health-care teams when discussing preservation options. Parent perceptions of their ability to facilitate sperm banking at the time of diagnosis should also be targeted in future interventions.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01152268.

Ethics and Oncofertility: A Call for Religious Sensitivity

For patients of reproductive age, treating cancer may come at the price of infertility. Literature regarding fertility preservation recommendations in this population has increased significantly, but this literature too often overlooks or insufficiently considers the relevance of religious preferences. Similarly, practice guidelines do not address the role of religion in the oncofertility discussion. The acceptance of oncofertility practices varies significantly among Christianity, Judaism, and Islam. A patient’s faith-based spirituality or secular morality may enhance his or her interpretation of the meaning of illness and should be incorporated into the informed-consent process. In this article, we describe the role of religious sensitivity in oncofertility care and argue for its importance in such care. We briefly summarize the views and moral reasoning about oncofertility in a few religions commonly encountered in many patient populations today. We recommend that clinicians discuss fertility options early in the decision process and, when relevant, incorporate the patient’s moral and religious preferences into the treatment plan. We encourage providers to be prepared to offer resources to patients who desire moral and spiritual guidance about fertility preservation options. Hospital chaplains should be able to provide such resources.

Adolescent oncofertility discussions: Recommendations from a systematic literature review

BACKGROUND

Increasing cancer incidence and survivorship rates have made late-term effects, such as effects on fertility, a salient issue for adolescent cancer patients. While various barriers make it difficult for health care professionals to discuss oncofertility with adolescents and their parents, there are numerous reasons to hold such discussions, based on professional obligations and the ethical principles of respect for autonomy and beneficence. This systematic literature review presents and critically examines recommendations for adolescent oncofertility discussions.

METHODS

Conducted according to PRISMA guidelines, this systematic literature review includes English, French, and German articles published up until December 31, 2014. Articles were sought via a combination of search terms in four databases.

RESULTS

Eighty of 96 articles included in this review address recommendations for improving adolescent oncofertility discussions. These recommendations deal with how, when, what, and with whom professionals ought to have these discussions, as well as various systemic barriers and ways to address them.

CONCLUSIONS

Based upon the principles of beneficence, respect for autonomy, and justice, we endorse several recommendations for oncofertility discussions with adolescents and their parents, including having a specific professional on the health care team initiate these discussions with all newly diagnosed patients; regularly doing so before, during, and after treatment; allowing adolescents to decide for themselves whom they wish to include in such discussions; employing various forms of communication; obtaining both adolescent assent and parental consent for fertility preservation (FP) procedures, especially at each stage (e.g., procurement and use); properly educating and training professionals to discuss oncofertility; promoting interdisciplinary collaboration; creating and implementing guidelines and policies; and ensuring equity of access to FP.

Family-building After Breast Cancer: Considering the Effect on Adherence to Adjuvant Endocrine Therapy

Adherence to endocrine therapy (ET) is a longstanding problem in breast cancer (BC) survivorship care, particularly among younger women. Younger patients have reported lower ET initiation rates and greater rates of early discontinuation and are considered an "at risk" group for nonadherence. For women who hope to have children in the future, concerns about premature menopause and the implications of postponing childbearing for the 5 to 10 years of ET are widespread. Preliminary evidence suggests that prioritizing fertility, along with concerns about side effects, leads to ET noninitiation and early discontinuation. Clinical efforts to improve adherence might need to consider patients' family-building goals during the course of treatment and to appropriately counsel patients according to their priorities and family-building intentions. Educational materials about family building after cancer are still not consistently available or provided. Helping patients to access trusted informational resources and decision support tools, in conjunction with medical counseling, will promote informed decisions regarding ET adherence and pregnancy that are medically appropriate. Such shared patient-provider decision-making about ET adherence and pregnancy could help to maximize patient autonomy by incorporating their values, preferences, and priorities into decisions, using providers' medical expertise.