Discussions regarding reproductive health for young women with breast cancer undergoing chemotherapy

Fertility concerns and treatment decision-making among national sample of young women with breast cancer

BACKGROUND

Diagnosis of breast cancer in young women has been shown to affect their decision-making with regard to fertility and family planning. Limited data are available from populations across the U.S. regarding this issue; thus, we sought to describe fertility concerns and efforts to preserve fertility in a national clinical trial population of young breast cancer patients.

METHODS

The young and strong study was a cluster-randomized controlled trial testing an intervention program for young women with breast cancer. Patients were surveyed within 3 months after diagnosis and at 3, 6, and 12 months after. Surveys asked about sociodemographics, psychosocial domains, fertility concerns, and fertility preservation strategies. Univariable and multivariable models were used to investigate sociodemographic, clinical, and psychosocial predictors of fertility concerns.

RESULTS

Of 467 women from 54 clinical sites across the U.S. (14 academic, 40 community), 419 were evaluable regarding fertility concerns. Median age was 40 years (range 22-45), 11% were Black, 6% Hispanic, and 75% had children. Tumor stage was I (35%), II (51%), or III (14%); 82% received chemotherapy. At time of the treatment decision, 133 (32%) participants had fertility concerns, among whom 47% indicated this affected their treatment decisions. Sixty percent of participants reported having discussed fertility with their physician. Twenty percent of those with fertility concerns used fertility preservation strategies. History of difficulty becoming pregnant and younger age were associated with higher odds of fertility concerns in multivariable modeling.

CONCLUSION

Many young women with newly diagnosed breast cancer are concerned about fertility in a way that impacts their treatment decisions. Concerns were discussed, but few used fertility preservation strategies. These findings have implications for counseling young patients.

Fertility concerns in cancer patients: a bibliometric analysis via CiteSpace: A review

Fertility concerns are a pervasive issue but very subtle in patients with cancer. Though various studies have focused on fertility concerns, limited research endeavor has been dedicated to bibliometric analysis. Given this, to visually analyze the hot frontier trends of research related to fertility concerns of patients with cancer using CiteSpace and provide new insights for future research in this field using the bibliometric method. We used CiteSpace software to retrieve the literature related to fertility concerns of patients with cancer in the Web of Science core collection database from the year of establishment to 2022 and conducted visual analysis in terms of authors, countries and regions, research institutions, and keywords. The search resulted in 201 valid articles, and the annual publication volume of literature related to fertility concerns in patients with cancer was generally on the rise; the country with the most publications was the United States, which also had the highest influence; the main research institution was Sloan Kettleson Cancer Research Center; the core research scholar was Jessica R. Gorman; the research hotspots mainly centered on quality of survival, women, survivorship, preservation, breast cancer, adolescence, and infertility. The results of this bibliometric study provide the current status and trends in the fertility concerns of patients with cancer and may help researchers identify the hotspots and frontier trends in this field.

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

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

Fertility preservation provision in the NHS: a national assessment of care policies

Fertility preservation has gained momentum in recent years. As cancer survival rates improve, late effects of loss of gonadal function have increased the need to consider fertility preservation. NICE recommends offering cryopreservation of gametes or embryos to patients undergoing gonadotoxic therapy, highlighting that this should be extrapolated to those with non-malignant conditions that pose a risk to fertility. We investigated whether variation in fertility preservation provision exists across the United Kingdom, with a view to identifying equitable models of provision. In England, cryopreservation of gametes and embryos is funded for all patients undergoing treatment for cancer, but eligibility criteria and duration of storage funding vary widely. In Scotland, a national policy is applied, with health boards equitably providing funding for cryopreservation of gametes, embryos, and ovarian and testicular tissue for those undergoing treatment for benign and malignant conditions which impair fertility, including gender incongruence. In Wales and Northern Ireland, cryopreservation of gametes and embryos is funded for those undergoing treatment likely to make them infertile, but ovarian tissue cryopreservation is not funded. Funding criteria for fertility preservation in England, Wales, and Northern Ireland deviates from NICE guidance. Standardization of fertility preservation policies is needed to provide equity of access for patients.

Disparity in Breast Cancer Care: Current State of Access to Screening, Genetic Testing, Oncofertility, and Reconstruction

Breast cancer is the most common cancer diagnosed in women, accounting for an estimated 30% of all new cancer diagnoses in women in 2022. Advances in breast cancer treatment have reduced the mortality rate over the past 25 years by up to 34% but not all groups have benefitted equally from these improvements. These disparities span the continuum of care from screening to the receipt of guideline-concordant therapy and survivorship. At the 2022 American College of Surgeons Clinical Congress, a panel session was dedicated to educating and discussing methods of addressing these disparities in a coordinated manner. While there are multilevel solutions to address these disparities, this article focuses on screening, genetic testing, reconstruction, and oncofertility.

Sexuality, fertility, family planning, family life, and partnership in young breast cancer patients: a longitudinal study

Objectives

Adolescent and young adult (AYA) breast cancer patients are often faced with sexuality-related problems. Since healthcare providers are often unfamiliar with problems specific to AYA cancer this topic is too little integrated into routine oncological care. The objective of this study was to analyze sexuality, fertility, family planning, family life, and partnership regarding satisfaction and supportive care needs in AYA breast cancer patients.

Methods

A total of 139 AYA breast cancer patients were examined twice, 1 year apart. The patients were asked to complete several questionnaires and to answer multiple questions about satisfaction with sexuality, fertility, family planning, family life, and corresponding supportive care needs in these domains.

Results

While the patients were largely satisfied with their family life and partnerships, they were less satisfied with their sexuality and family planning. Only small mean score changes were observed in these variables over the course of a year. Being a parent already and having the possibility of further completing family planning were strongly associated with higher satisfaction and lower supportive care needs in these domains. Satisfaction was generally negatively associated with supportive care needs. Older age was predictive of lower satisfaction with sexuality at follow-up.

Conclusion

AYA cancer patients deserve special consultations concerning the impact of cancer and treatment on their sexuality and fertility, and it is especially important that women who have yet to complete their family planning be actively offered information and support concerning sexuality and fertility protection before beginning treatment.

Fertility preservation in uro-oncology

PURPOSE OF REVIEW

The purpose of this review is to highlight the demand for fertility preservation among cancer survivors and to draw attention to areas where healthcare workers need to improve. As technology advances, maximizing cryopreservation rates will be paramount to increase the ability individuals to conceive after cancer treatment.

RECENT FINDINGS

Guidelines recommending discussion of fertility for those diagnosed with cancer have been shown to increase patient satisfaction and overall quality of life. Our review demonstrated that increasing counseling rates remains an ongoing challenge and should remain an area of improvement for all healthcare professionals working in the oncology field. Formal programs to improve patient and provider education and access to fertility preservation increase uptake of fertility preservation. For men, many options exist to cryopreserve sperm; a slight delay to achieve fertility preservation has not been shown to lead to worse outcomes. Cryopreservation strategies differ based on puberty status and remain an active area of clinical research.

SUMMARY

Improving fertility outcomes for cancer survivors is possible with appropriate counseling techniques at the time of cancer diagnosis. Clinicians should challenge current barriers for patient access to fertility preservation surrounding cancer treatments.

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.

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.

Real-world anticancer medications for reproductive-age women with breast cancer by using a claims database in Japan

Aim: To describe real-world breast cancer medications among reproductive-age women. Patients & methods: Using data from a Japanese claims database, anticancer prescriptions were classified into seven categories of amenorrhea risk based on fertility preservation guidelines. Results: We identified 2999 women with records of breast cancer and anticancer prescription from 2005 to 2018. The proportions of prescriptions were as follows: high, 4.1-12.9%; intermediate: 6.0-16.3%; low: 0.4-2.3%; very low/no: 0.3-12.2%; unknown: 33.9-45.5%; unlisted combination: 12.2-23.4%; and unlisted drug: 12.5-26.7%. The common drugs in the unknown category were trastuzumab (n = 1527), docetaxel (n = 1014), and paclitaxel (n = 995). For medications unlisted in the guidelines, various drugs and drug combinations were observed. Conclusion: Numerous anticancer drugs are currently being prescribed with insufficient evidence regarding amenorrhea risk.

Pregnancy in Breast Cancer Survivors

Safety of pregnancy occurring after breast cancer treatment has been studied largely, but it is still debatable. These studies have generally showed that overall and disease-free survival in breast cancer survivors with subsequent pregnancy is not less than those without future pregnancy . Also, breast cancer survivors treated with chemotherapy , radiation therapy, or both had no increased risk of congenital anomalies, single gene disorders, or chromosomal syndromes in their offspring. However, it appears that the incidence of preterm labor, low birth weight, and fetal anomalies is higher in these cases.These issues as well as safe time interval from breast cancer treatment to pregnancy , safe contraceptive method after breast cancer, counseling about pregnancy in survivors, and how to follow up the patient for breast cancer recurrence during pregnancy are discussed in this chapter.

Does Use of Neoadjuvant Chemotherapy Affect the Decision to Pursue Fertility Preservation Options in Young Women with Breast Cancer?

BACKGROUND

The American Society of Clinical Oncology guidelines recommend early referral to reproductive endocrinology and infertility (REI) specialists for young women diagnosed with breast cancer. Current practice patterns demonstrate an increased utilization of neoadjuvant chemotherapy (NAC). We evaluated premenopausal women with breast cancer after consultation with a Fertility Nurse Specialist (FNS) and determine factors associated with referral to REI specialists.

METHODS

This retrospective review included all premenopausal women diagnosed at our institution with stage 0-III unilateral breast cancers between 2009 and 2015 who completed an FNS consultation. Clinicopathologic features and factors associated with referral to REI after FNS consultation were analyzed.

RESULTS

A total of 334 women were identified. Median age was 35 years (interquartile range 32-38). The majority of women were single (n = 198, 59.3%) and nulliparous (n = 239, 71.6%). REI referrals were common (n = 237, 71.0%). The Breast Surgery service was the most frequent referring service (n = 194, 58.1%), with significantly more REI referrals compared to Breast Medicine and Genetics services (p = 0.002). Nulliparity was associated with REI referral (p < 0.0001). Adjuvant chemotherapy (p = 0.003) was associated with pursuing REI referral, whereas NAC (p < 0.001) was associated with declining REI referral.

CONCLUSIONS

Most women elected to consult with an REI specialist, confirming strong interest in fertility preservation among premenopausal women with breast cancer. However, women receiving NAC more frequently declined referral to REI, suggesting that the need to start NAC may influence decisions regarding fertility preservation. With increasing utilization of NAC, our study supports the need for further counseling and education regarding fertility preservation for women undergoing NAC.

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.

Exploring the facilitators and barriers to using an online infertility risk prediction tool (FoRECAsT) for young women with breast cancer: a qualitative study protocol

INTRODUCTION

As cancer treatments may impact on fertility, a high priority for young patients with breast cancer is access to evidence-based, personalised information for them and their healthcare providers to guide treatment and fertility-related decisions prior to cancer treatment. Current tools to predict fertility outcomes after breast cancer treatments are imprecise and do not offer individualised prediction. To address the gap, we are developing a novel personalised infertility risk prediction tool (FoRECAsT) for premenopausal patients with breast cancer that considers current reproductive status, planned chemotherapy and adjuvant endocrine therapy to determine likely post-treatment infertility. The aim of this study is to explore the feasibility of implementing this FoRECAsT tool into clinical practice by exploring the barriers and facilitators of its use among patients and healthcare providers.

METHODS AND ANALYSIS

A cross-sectional exploratory study is being conducted using semistructured in-depth telephone interviews with 15-20 participants each from the following groups: (1) premenopausal patients with breast cancer younger than 40, diagnosed within last 5 years, (2) breast surgeons, (3) breast medical oncologists, (4) breast care nurses (5) fertility specialists and (6) fertility preservation nurses. Patients with breast cancer are being recruited from the joint Breast Service of three affiliated institutions of Victorian Comprehensive Cancer Centre in Melbourne, Australia-Peter MacCallum Cancer Centre, Royal Melbourne Hospital and Royal Women's Hospital, and clinicians are being recruited from across Australia. Interviews are being audio recorded, transcribed verbatim and imported into qualitative data analysis software to facilitate data management and analyses.

ETHICS AND DISSEMINATION

The study protocol has been approved by Melbourne Health Human Research Ethics Committee, Australia (HREC number: 2017.163). Confidentiality and privacy are maintained at every stage of the study. Findings will be disseminated through peer-reviewed scholarly and scientific journals, national and international conference presentations, social media, broadcast media, print media, internet and various community/stakeholder engagement activities.

Use of fertility preservation services in female reproductive-aged cancer patients

OBJECTIVE

The objective of the study was to determine the rates and predictors of fertility preservation services among reproductive-aged women with common cancers in the United States.

STUDY DESIGN

We used the MarketScan database to identify women 18-45 years of age with lung, breast, colorectal, or cervical cancer who underwent surgery and chemotherapy from 2009 through 2016. Services from 3 months before to 3 months after chemotherapy for evaluation for fertility preservation, laboratory testing for fertility evaluation, and fertility-preserving procedures were captured. Multivariable models were used to assess the factors associated with the use of fertility-preservation services.

RESULTS

A total of 18,781 women, including 386 cervical, 1372 colorectal, 246 lung, and 16,777 with breast cancer, were identified. In women 18-35 years old, 11.7% underwent evaluation for fertility preservation, 13.7% underwent laboratory testing, and 6.3% pursued fertility-preserving procedures. The rates of office evaluation, laboratory testing, and performance of procedure were 3.3%, 7.5%, and 1.9 % in women aged 36-40 years and 0.5%, 7.2%, and 0.3% in those aged 41-45 years, respectively. The rate of fertility preservation evaluation rose from 1.0% in 2009 to 5.5% in 2016 (risk ratio, 4.66, 95% confidence interval, 2.38-9.11) while use of fertility-preserving procedures increased from 1.0% to 4.6% (risk ratio, 3.84, 95% confidence interval, 1.94-7.59) during the same time period. In a multivariable model, use of any fertility-preserving interventions were more common in patients with breast cancer (adjusted risk ratio, 2.30, 95% confidence interval, 1.30-4.06), those in the Northeast (adjusted risk ratio, 1.24, 95% confidence interval, 1.10-1.40), and in younger women (18-35 years) (adjusted risk ratio, 2.59, 95% confidence interval, 2.32-2.89).

CONCLUSION

Although limited by lack of information regarding cancer stage and desire for future fertility, only a small fraction of reproductive-aged female cancer patients receiving chemotherapy are evaluated in a nationwide sample for fertility preservation or undergo fertility-preserving procedures.

Fertility preservation in patients with hematologic malignancies and recipients of hematopoietic cell transplants

Patients with hematologic malignancies and those undergoing hematopoietic cell transplantation (HCT) face a complex set of challenges when considering options for fertility preservation (FP). There are no standard options for prepubertal children, and women with hematologic malignancies may not be eligible for standard FP options. Fortunately, initial therapies for most blood cancers are not highly gonadotoxic, affording an important opportunity for postremission counseling and referrals to fertility specialists. These patients face a high risk of relapse, and many will be referred for autologous or allogeneic HCT, which carries an extremely high risk of infertility. The expanding indications for HCT to include benign hematologic disorders as well as autoimmune diseases mandate that all hematologists are familiar with these risks. Oncofertility researchers are continually pushing the boundaries of what may be possible for our patients; in the meantime, communication and shared decision-making between hematologists and patients, as well as program-building, education, and outreach are essential to ensure that these patients, many of whom will be cured, maintain all of their options for a fulfilling life after intensive therapy.

A randomized study to improve care for young women with breast cancer at community and academic medical oncology practices in the United States: The Young and Strong study

BACKGROUND

The authors conducted a cluster randomized study to determine the effect of an exportable educational intervention for young women with breast cancer (YWI) on improving care.

METHODS

Sites were randomized 1:1 to the YWI or a contact time control physical activity intervention (PAI) stratified by academic or community site. Up to 15 women aged ≤45 years with newly diagnosed breast cancer were enrolled at each of 14 academic sites and 10 were enrolled at each of 40 community sites. The primary endpoint, attention to fertility, was ascertained by medical record review. Statistical inferences concerning the effect of the intervention used general estimating equations for clustered data.

RESULTS

A total of 467 patients across 54 sites were enrolled between July 2012 and December 2013. The median age of the patients at the time of diagnosis was 40 years (range, 22-45 years). Attention to fertility by 3 months was observed in 55% of patients in the YWI and 58% of patients in the PAI (P = .88). Rates were found to be strongly correlated with age (P < .0001), and were highest in patients aged <30 years. Attention to genetics was similar (80% in the YWI and 81% in the PAI), whereas attention to emotional health was higher in patients in the YWI (87% vs 76%; estimated odds ratio, 2.63 [95% confidence interval, 1.20-5.76; P = .016]). Patients rated both interventions as valuable in providing education (64% in the YWI and 63% in the PAI).

CONCLUSIONS

The current study failed to demonstrate differences in attention to fertility with an intervention to improve care for women with breast cancer, although attention to fertility was found to be higher than expected in both groups and emotional health was improved in the YWI group. Greater attention to young women with breast cancer in general may promote more comprehensive care for this population.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

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

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

Advances in Fertility Preservation for Young Women With Cancer

Female patients of reproductive age with cancer often require treatment that can compromise their future fertility. Treatment-related infertility is an important cancer survivorship issue and is associated with depression and diminished quality of life. Recent advances in reproductive health care provide the opportunity to preserve fertility prior to the initiation of cancer therapy. Clinical guidelines recommend that oncology providers counsel patients about the risk of treatment-related infertility and fertility preservation options, and that they refer those who are interested in fertility preservation to fertility specialists. Guidelines endorse the use of assisted reproductive techniques (ART) provided by reproductive endocrinologists to preserve fertility in young female patients with cancer. In addition, ovarian suppression with gonadotropin-releasing hormone (GnRH) agonists may be considered for ovarian protection during chemotherapy. This article reviews currently available and emerging ART for fertility preservation in female patients of reproductive age with cancer and current data supporting the use of ovarian suppression for ovarian protection during chemotherapy in this population. We also review the uptake of fertility services and discuss barriers to fertility preservation in female patients of reproductive age with cancer.

Effect of a formal oncofertility program on fertility preservation rates-first year experience

Background

A formal fertility preservation program was initiated at our institution in 2016 as part of a multi-disciplinary oncofertility initiative to improve the reproductive needs of oncologic patients. After 1 year of initial experience, we assessed sperm banking rates in men diagnosed with cancer, as well as examined the trends in the use of fertility preservation services.

Methods

We performed a chart review from 2011 to 2017 for men newly diagnosed with cancer, and for all men who underwent fertility preservation during that period of time at our institution. We assessed the rates of sperm banking among patients newly diagnosed with cancer, before and after the implementation of a standardized oncofertility program in 2016. The program includes nursing and physician education regarding indications of fertility preservation. Additionally, we evaluated the overall population undergoing sperm cryopreservation at our institution during the study period.

Results

From 2011 to 2016, 30 of 902 oncologic patients underwent sperm banking prior to their treatment (3.3% of total cancer patients). After the program was implemented, 42 of 218 patients underwent fertility preservation between June 2016 and August 2017 (19.3% of total cancer patients). In this group, patients’ mean age was 30.14 years old (range, 13–69 years old), with 6 pediatric patients; 36 of the samples (85.7%) were obtained from masturbation. When viable sperm could not be obtained from ejaculation, patients underwent either testicular or epididymal sperm extraction (6 cases). Overall, 98 men used the formal fertility preservation service. Of these, 42 were cancer patients and 56 were non-cancer patients. Of the non-cancer patients, 17 banked sperm after varicocelectomy, 6 prior to vasectomy and 6 because of hypogonadism.

Conclusions

Rate of sperm banking increased nearly six-fold after institution of a formal fertility preservation program, indicating the clinical need for such a program at academic institutions. Oncofertility is a relevant part of the care for oncologic patients, and should be considered as part of counseling before cancer treatment.

Clinical practice guidelines for fertility preservation in young women undergoing gonadotoxic treatment: an overview and critical appraisal of methodological quality and content

RESEARCH QUESTION

What is the methodological quality and content of internationally available clinical practice guidelines (CPGs) on fertility preservation (FP) care in adult women?

DESIGN

Internationally available CPGs on FP care in adult women were identified after conducting an extensive literature search and consulting (inter)national key experts. The methodological quality of the CPGs was appraised by an (inter)national panel of experts using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. The content of the best CPGs, scoring ≥60% for the domain 'Rigour of development' of the AGREE II instrument, was extracted and categorized according to their topic.

RESULTS

Thirty of the 1808 documents found were included. After consulting (inter)national key experts, 30 CPGs were included, six of which scored ≥60% for their 'Rigour of development'. The number of FP-related topics discussed by these six CPGs ranged from 4 to 12. The number of recommendations provided by the CPGs on these topics varied. The number of topics to which ≥5 recommendations were dedicated ranged from 0 to 4 between CPGs.

CONCLUSION

CPGs on the subject of FP care are available, but there is room for improvement in quality and content. Although written for use in daily practice, the CPGs can also be used to develop quality indicators to monitor the quality of current FP care or to evaluate future improvement initiatives.

Fertility preservation for patients with breast cancer: The Korean Society for Fertility Preservation clinical guidelines

With advances in the methods of cancer treatment used in modern medicine, the number of breast cancer survivors has been consistently rising. As the number of women who wish to become pregnant after being diagnosed with breast cancer increases, it is necessary to consider fertility preservation in these patients. However, medical doctors may be unaware of the importance of fertility preservation among cancer patients because most patients do not share their concerns about fertility with their doctors. Considering the time spent choosing and undergoing treatment, an early referral to a reproductive specialist is the best way to prevent a delay in cancer treatment. Since it is not easy to make decisions on matters related to cancer diagnosis and fertility, patients should be provided with enough time for decision-making, and to allow for this, an early referral will provide patients with sufficient time to choose an appropriate method of fertility preservation. The currently available options of fertility preservation for patients with breast cancer include cryopreservation of embryos, oocytes, and ovarian tissue and gonadotropin-releasing hormone agonist treatment before and during chemotherapy. An appropriate method of fertility preservation must be selected through consultations between individual patients and health professionals and analyses of the pros and cons of different options.

Knowledge and Perceptions about Cancer Treatment-associated Infertility among Young Patients at a Tertiary Care Hospital in Pakistan

Introduction:

Infertility after cancer treatment can cause significant emotional stress and grief for cancer survivors. In this study we assessed knowledge and perceptions among young cancer patients regarding the topic of cancer and infertility related to different treatment options.

Material and Methods:

This cross-sectional study was conducted on young cancer patients in the Clinical Oncology Department, JPMC, Karachi, from January to August 2013. Patients were requested to fill in questionnaires. Comparisons between gender and age groups were performed using the Student’s t test and Pearson’s Chi-squared. Significance was concluded with a two tailed p-value less than 0.05.

Results:

The survey included 368 cancer patients, 194 males and 174 females. Ninety percent of respondents of either gender were not aware that cancer or cancer treatment can cause infertility, this being age dependent (P=0.06). However, on being made aware, 98% of males and 91% of females wanted their oncologist to discuss treatment-related infertility prior to initiating cancer treatment (P=0.005) and 92% and 78%, respectively, wanted to consider fertility preservation techniques prior to treatment (P<0.0001). Of age groups 15-30 years and 31-50 years, 91 % and 81% wanted to consider FP prior to cancer treatment (P =0.011). Among 226 married individuals, 89% males and 79% females underestimated that effects that infertility issues might have on their relationships with their spouses.

Conclusions:

We recommend physicians and oncology care givers to initiate discussion of the topic of cancer and treatment-related infertility with young cancer patients during their initial management planning.

Talking about women's sexual health after cancer: Why is it so hard to move the needle?

Despite increasing calls to integrate sexual health into routine cancer care, the majority of women diagnosed with cancer do not receive information about how their cancer treatments will affect their sexual health. With the significant challenges that exist to clinical discussion of sexual health, efforts on multiple fronts are needed to close the gap in the care of women diagnosed with cancer.

Fertility, Cardiac, and Orthopedic Challenges in Survivors of Adult and Childhood Sarcoma

The combination of cisplatin, doxorubicin, and methotrexate was established as the standard backbone of contemporary osteosarcoma therapy in 1986. Since then, however, further improving the survival of patients with osteosarcoma has been challenging-30% to 40% of patients with osteosarcoma still die of this disease. In addition, these patients often experience loss of fertility at a young age, short- and long-term treatment-related cardiotoxicity, and adverse orthopedic effects from surgical resection of the tumor or endoprosthetic reconstructions. Cancer treatment often markedly increases the risk of infertility later in life, causing many patients substantial distress and regret. Sperm banking and oocyte cryopreservation are standard of care and should be available to all at-risk patients. Newer techniques, such as autologous gonadal tissue transplant for prepubertal children, are being developed, and newer systemic agents have infertility risk profiles that remain undefined and warrant further study. Cost and access remain barriers to these options. The late effects of anthracycline-induced cardiotoxicity are also increasingly a problem for these patients. These effects are often progressive and can be disabling. Adding dexrazoxane to doxorubicin therapy significantly reduces the risk for most adverse cardiac outcomes without compromising the efficacy of induction chemotherapy. Limb salvage surgery remains the standard of care for treatment in the majority of patients with extremity sarcomas. Modular metal prostheses and allograft reconstructions comprised the majority of surgical procedures for limb salvage surgery. The most common mechanism of failure of these implants is infection and mechanical failure of the implant.

Fertility Preservation in Breast Cancer

As more young women survive breast cancer, fertility preservation (FP) is an important component of care. This review highlights the importance of early pretreatment referral, reviews the risks of infertility associated with breast cancer treatment, and defines existing and emerging techniques for FP. The techniques reviewed include ovarian suppression, embryo cryopreservation, oocyte cryopreservation, and ovarian tissue cryopreservation and transplantation. The barriers women face, such as not being appropriately referred and the costs of treatment, also are addressed. Multidisciplinary, patient-centered care is essential to discussing FP with patients with breast cancer and ensuring appropriate care that includes quality of life in survivorship.

Oncofertility in sarcoma patients

Treatment for sarcoma can significantly decrease fertility, both due to the irradiation of gonads, and the impact of chemotherapy on gametogenesis. Infertility in cancer survivors causes significant regret and decreased quality of life in their adulthood. As this cancer mainly affects children and young adults, fertility preservation is an essential part of survivorship care, however it remains one of the least implemented services in adolescent and young adult cancer patients. Success of fertility preservation is highly dependent on the referral prior to oncologic treatment. Early patient counseling with possible consult with oncofertility specialists should be offered to every oncologic patient in reproductive age or younger. There are several options available and in continuous evolution for fertility preservation. Cryopreservation of sperm and oocytes constitutes nowadays the standard of care, and should be offered to all patients. Other methods currently under development will potentially bring in the future reliable options for fertility preservation in a wider range of patients, such as those in pre-pubertal age at the time of diagnosis, or with an insufficient sperm count for semen banking. These include testicular sperm extraction (TESE), autologous ovarian tissue transplant, and in vitro maturation of gametes. Novel therapies such as molecular-targeted agents offer a safer toxicity profile regarding fertility, but further research is required to evaluate their impact on the long term, both alone and in combination therapies. Difficulties to access fertility preservation and its costs remain a significant impediment for many patients in need. Warranting access to all sarcoma patients should be a priority in all healthcare professionals involved in their care.

Fertility Preservation in Young Female Cancer Patients: Development and Pilot Testing of an Online Decision Aid

PURPOSE

Impairment of fertility is a common sequela of successful cancer treatment. Therefore, fertility preservation (FP) should be discussed with all young cancer patients. Decisions about FP are challenging. Patients wish more specific support and the first results concerning the helpfulness of decision aids (DA) were promising. Aside from describing the process of development and the content of an online DA in German, the objective of this study was to pilot test users' satisfaction with the DA and its effect on knowledge about FP and decisional conflict (DC).

METHODS

In this prospective consecutive study, a control group (n = 20, fertility counseling) was followed by and compared with an intervention group (n = 20, counseling and additional use of the DA, developed by an interdisciplinary team) of recently diagnosed female cancer patients between 18 and 40 years.

RESULTS

Nearly all participants who applied the DA considered it helpful for decision-making and recommendable. Knowledge about FP was high with regard to FP techniques women went for. DC was moderate according to the mean score (M = 27.92, standard deviation = 13.27) and only in 20%, the score was above the threshold for high DC. There was no difference between the control and intervention group for knowledge and DC.

CONCLUSION

The DA seems to serve as additional and well-accepted support tool in decision-making for patients and professionals. Referral to a reproductive specialist is crucial to warrant comprehensive information. These results need to be confirmed with the current ongoing randomized controlled study.

Nurse Perspectives on Referrals for Oncology Patients to Reproductive Endocrinologists: Results of a Learning Activity

BACKGROUND

Although concern about future fertility for adolescents and young adults (AYAs) with cancer is high, referrals to reproductive endocrinologists (REI) are low. Oncology nurses are well positioned to facilitate these referrals but may lack the knowledge and training. This report describes a learning activity in the Educating Nurses about Reproductive Issues in Cancer Healthcare (ENRICH) program whereby oncology nurses interviewed REIs.

METHOD

Participants were instructed to conduct an interview with an REI using a semistructured guide and provided a written report of the discussion. We examined responses to each question using qualitative content analysis.

RESULTS

Seventy-seven participants across 15 states provided a summary. Learner summaries highlighted four themes related to FP, including Cost, Time, Lack of Information or Referrals, and Learning About Available Options.

CONCLUSION

Oncology nurses have an opportunity for a partnership to ensure that concerns about fertility among AYA patients are addressed. J Contin Educ Nurs. 2016;47(8):376-384.

Assessing the usefulness and acceptability of a low health literacy online decision aid about reproductive choices for younger women with breast cancer: the aLLIAnCE pilot study protocol

Background

Young women diagnosed with breast cancer may be confronted by many difficult decisions, especially around fertility preservation prior to commencing cancer treatment. The information to be conveyed is complex, and it may be difficult to weigh up the risks and benefits of the different fertility preservation options available. This complexity is compounded by the widespread low levels of literacy and health literacy in Australia, which may result in greater difficulties in understanding available health information and in decision-making.

Methods/design

A working group of experts have developed a fertility-related online decision aid for a low health literacy population, guided by health literacy principles. The decision aid will be pilot tested with 30 women diagnosed with early breast cancer between 5 years and 6 months previously. To be eligible, at the time of diagnosis, women must be between 18 and 40 years (inclusive), pre-menopausal, have no history of metastatic disease, have not completed their families, be able to give informed consent and have low health literacy. Participants will be asked to reflect back to the time in which they were diagnosed. Participants will complete a questionnaire before and after reviewing the decision aid to determine the feasibility, use and acceptability of the decision aid. The decision aid will be modified accordingly. Participants may also choose to review a previously developed (high literacy) decision aid and provide feedback in comparison to the low health literacy decision aid.

Discussion

This project represents the first study to develop an online fertility decision aid developed from low health literacy models in the context of breast cancer. It is anticipated that the low health literacy decision aid will be useful and acceptable to young women with low health literacy who have been diagnosed with breast cancer and that it will be preferred over the high literacy decision aid.

Trial registration

ACTRN12615001364561p

Fertility preservation with ovarian stimulation and time to treatment in women with stage II-III breast cancer receiving neoadjuvant therapy

PURPOSE

To determine whether fertility preservation with ovarian stimulation (OS) results in treatment delay in breast cancer (BC) patients receiving neoadjuvant therapy (NAT).

METHODS

This is a retrospective study of women screened for the prospective neoadjuvant ISPY2 trial at the University of California San Francisco. All patients were <43, had stage II-III BC, and received neoadjuvant therapy. Time to initiation of NAT was compared between women who underwent OS (STIM) and women who did not (control). Patient and tumor characteristics, as well as oncologic outcomes, were compared between STIM and control groups.

RESULTS

82 patients were included (34 STIM and 48 control). STIM patients were overall younger (mean = 35 vs. 36.9 years old, p = 0.06), and more likely to be childless (79.4 vs 31.2%, p < 0.0001) than controls. Mean time from diagnosis to initiation of NAT was 40 days, with no significant difference between STIM and control groups (mean 39.8 days vs 40.9 days, p = 0.75). Mean time from diagnosis to fertility consultation was 16.3 days. With median follow-up of 79 months, 16 (19.5%) patients have recurred or died from BC. Rates of pCR, recurrence, and death were similar in both groups. Six of 34 STIM patients have undergone embryo transfer, resulting in one patient with two live births.

CONCLUSION

Fertility preservation with OS can be performed in the neoadjuvant setting without delay in initiation of systemic therapy and should be discussed with all early-stage BC patients of reproductive age.

Disparities in Counseling Female Cancer Patients for Fertility Preservation

BACKGROUND

Female cancer patients who are exposed to gonadotoxic chemotherapy are at risk of future infertility. Research suggests that disparities in fertility preservation counseling (FPC) may exist. Previous research is limited by recall bias; therefore, this study examined objective electronic medical chart data regarding FPC at an academic medical center.

MATERIALS AND METHODS

This study included reproductive-aged women (18-45 years old) with a diagnosis of breast, gynecological, or hematological cancer and who were exposed to a gonadotoxic chemotherapeutic agent from 2009 to 2013. Chi-square and logistic regression analyses were utilized to analyze disparities in FPC.

RESULTS

Two hundred fifty-nine women met the study criteria. One hundred eighty-one women were diagnosed with breast cancer, 52 with hematological cancer, and 26 with gynecological cancer. 160/259 (62%) women had documented counseling for fertility preservation (FP), 60 (23%) women were not counseled as counseling was determined to be "not applicable," 16 (6%) women were not counseled and no explanation was given for the lack of counseling, and counseling was not documented in 23 (9%) charts. Age, marital status, and racial/ethnic background were related to counseling status. Patients with gynecological or hematological cancer were more likely to be counseled than other patients. Logistic regression results demonstrated that FPC was largely driven by cancer diagnosis.

CONCLUSIONS

Although cancer diagnosis was the greatest predictor of FPC, disparities were evident in the counseling of female cancer patients for FP treatment. Equality in counseling female patients for FP treatment is imperative to reduce the risk of emotional harm and future infertility.

Fertility concerns among breast cancer patients in Mexico

OBJECTIVE

Young women represent a high proportion of the total number of breast cancer (BC) patients in Mexico; however, no previous studies addressing their attitudes regarding the risk of chemotherapy-induced infertility and its contributing factors are available. The aim of this study was to evaluate the concerns of young women with BC towards the risk of infertility in two referral centers in Mexico with access to public health services.

METHODS

A cross-sectional study including women with newly or previously detected BC aged 40 years or younger at diagnosis was conducted. Variables regarding concerns about fertility were collected from an adapted version of the Fertility Issues Survey.

RESULTS

134 consecutive eligible women responded to the in-person paper survey. 55% were partnered, 35.1% had no children, and 48% reported willingness to have children prior to BC diagnosis. Only 3% of patients considered to be able to afford extra expenses. At diagnosis, 44% of women expressed some level of concern about infertility risk. The only factor significantly associated with fertility concern was the desire of having children prior to diagnosis (OR 11.83, p = 0.006). Only 30.6% patients recalled having received information regarding infertility risk from their physicians.

CONCLUSION

A minority of young women with breast cancer in Mexico is informed about the risk of BC treatment-induced infertility, despite substantial interest. Informing all patients about infertility risk and available options for fertility preservation should be an essential aspect of the supportive care of young women with BC, even in low-middle income countries such as Mexico.

Which female cancer patients fail to receive fertility counseling before treatment in the state of Georgia?

OBJECTIVE

To assess which characteristics are associated with failure to receive fertility counseling among a cohort of young women diagnosed with cancer.

DESIGN

Population-based cohort study.

SETTING

Not applicable.

PATIENT(S)

A total of 1,282 cancer survivors, of whom 1,116 met the inclusion criteria for the analysis.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The main outcome in this study was whether or not women reported receiving any information at the time of their cancer diagnosis on how cancer treatment might affect their ability to become pregnant.

RESULT(S)

Forty percent of cancer survivors reported that they did not receive fertility counseling at the time of cancer diagnosis. Women were more likely to fail to receive counseling if they had only a high school education or less or if they had given birth. Cancer-related variables that were associated with a lack of counseling included not receiving chemotherapy as part of treatment and diagnosis with certain cancer types.

CONCLUSION(S)

Counseling about the risk of infertility and available fertility preservation options is important to cancer patients. Additionally, counseling can make women aware of other adverse reproductive outcomes, such as early menopause and its associated symptoms. Less-educated women and parous women are at particular risk of not getting fertility-related information. Programs that focus on training not just the oncologist, but also other health care providers involved with cancer care, to provide fertility counseling may help to expand access.

Discussions about reproductive and sexual health among young adult survivors of cancer

Fertility preservation and sexual health are increasingly important as more young cancer patients survive their disease. Our aims were to describe the frequency with which reproductive and sexual health discussions occur, and to identify clinical factors associated with these discussions. Medical records of patients aged 20–39 diagnosed with solid tumors from 2008–2010 who survived ≥2 years were retrospectively reviewed. Multivariate logistic models were used to explore the relationship between clinical factors and occurrence of discussions. We analyzed 427 survivors: median age was 35 years, 29% were men, 88% had baseline [Eastern Cooperative Oncology Group (ECOG)] ECOG 0, and 79% were in a relationship. Only 58% and 7% of patients received discussions about reproductive and sexual health, respectively, at their initial oncology consultation, most of which were led by medical oncologists. There was a significant association between reproductive and sexual health conversations, in that those who engaged in dialog about one topic were more likely to participate in discussions about the other (P = 0.01). Patients with gynecologic malignancies (P < 0.0001) were more inclined to engage in sexual health discussions. Only a minority (19%) of patients took specific action toward fertility preservation, but the receipt of reproductive health discussions was a strong and independent driver for pursuing fertility preservation (P < 0.0001). The impact of cancer and its treatment on fertility and sexual health was inadequately addressed at the time of diagnosis among young cancer survivors. This warrants specific attention since having reproductive health discussions was strongly predictive of patients pursuing fertility preservation strategies.

Cancer and fertility preservation: international recommendations from an expert meeting

In the last years, thanks to the improvement in the prognosis of cancer patients, a growing attention has been given to the fertility issues. International guidelines on fertility preservation in cancer patients recommend that physicians discuss, as early as possible, with all patients of reproductive age their risk of infertility from the disease and/or treatment and their interest in having children after cancer, and help with informed fertility preservation decisions. As recommended by the American Society of Clinical Oncology and the European Society for Medical Oncology, sperm cryopreservation and embryo/oocyte cryopreservation are standard strategies for fertility preservations in male and female patients, respectively; other strategies (e.g. pharmacological protection of the gonads and gonadal tissue cryopreservation) are considered experimental techniques. However, since then, new data have become available, and several issues in this field are still controversial and should be addressed by both patients and their treating physicians.In April 2015, physicians with expertise in the field of fertility preservation in cancer patients from several European countries were invited in Genova (Italy) to participate in a workshop on the topic of "cancer and fertility preservation". A total of ten controversial issues were discussed at the conference. Experts were asked to present an up-to-date review of the literature published on these topics and the presentation of own unpublished data was encouraged. On the basis of the data presented, as well as the expertise of the invited speakers, a total of ten recommendations were discussed and prepared with the aim to help physicians in counseling their young patients interested in fertility preservation.Although there is a great interest in this field, due to the lack of large prospective cohort studies and randomized trials on these topics, the level of evidence is not higher than 3 for most of the recommendations highlighting the need of further research efforts in many areas of this field. The participation to the ongoing registries and prospective studies is crucial to acquire more robust information in order to provide evidence-based recommendations.

Factors associated with the receipt of fertility preservation services along the decision-making pathway in young Canadian female cancer patients

PURPOSE

This study investigated the factors associated with the receipt of fertility preservation (FP) services along the decision-making pathway in young Canadian female cancer patients. The roles of the oncologists were examined.

METHODS

A total of 188 women who were diagnosed with cancer between the ages of 18-39 after the year 2000 and had finished active cancer treatment by the time of the survey (2012-2013) participated in the study. Logistic regression models and Pearson χ (2) tests were used for analyses.

RESULTS

The mean ages of participants at diagnosis and at survey time were 30.2 (SD = 3.7) and 33.9 (SD = 5.9). One quarter (n = 45, 23.9 %) did not recall having a fertility discussion with their oncologists. Of the three quarters who had a fertility discussion (n = 143, 76.1 %), discussions were equally initiated by oncologists (n = 71) and patients (n = 72). Of the 49 women (26 %) who consulted a fertility specialist, 17 (9 %) underwent a FP procedure. Fertility concern at diagnosis was the driving force of the receipt of FP services at all decision points. Our findings suggest that not only was the proactive approach of oncologists in initiating a fertility discussion important, the quality of the discussion was equally critical in the decision-making pathway.

CONCLUSIONS

Oncologists play a pivotal role in the provision of fertility services in that they are not only gate keepers, knowledge brokers, and referral initiators of FP consultation, but also they are catalysts in supporting cancer patients making important FP decision in conjunction with the consultation provided by a fertility specialist.

Impact of Fertility Concerns on Tamoxifen Initiation and Persistence

BACKGROUND

Adjuvant tamoxifen reduces breast cancer recurrence risk and mortality; however, initiation and treatment persistence are poor for younger patients. We hypothesized that a unique set of factors, including fertility concerns, would contribute to the poor tamoxifen use among premenopausal patients.

METHODS

From 2007 to 2012, 515 premenopausal patients younger than age 45 years, with stage 0 to III hormone receptor-positive breast cancer, for whom tamoxifen was recommended, were identified. Clinical and pathologic tumor characteristics, treatment regimens, and fertility concerns were recorded. Clinical factors associated with tamoxifen noninitiation and discontinuation were identified using univariate and multivariable analysis. After the recommendation for tamoxifen, patient reasons for tamoxifen noninitiation or discontinuation were also documented. All statistical tests were two-sided.

RESULTS

Based on multivariable analysis, fertility concerns were statistically associated with both noninitiation (odds ratio = 5.04, 95% confidence interval (CI) = 2.29 to 11.07) and early discontinuation (hazard ratio = 1.78, 95% CI = 1.09 to 3.38) of tamoxifen. Other independent predictors of noninitiation included a diagnosis of ductal carcinoma in situ, declining radiation, and not receiving chemotherapy (stage I-III). Additionally, smoking and not receiving radiation therapy were statistically significant predictors of early withdrawal from therapy. Primary patient reasons for noninitiation and early discontinuation included concerns about side effects and fertility.

CONCLUSION

This study provided insight into factors associated with tamoxifen use for reproductive-aged breast cancer survivors, with a new focus on fertility. Fertility concerns negatively impacted tamoxifen initiation and continuation among premenopausal patients. Interventions to optimize treatment initiation and persistence for young cancer patients should include access to fertility preservation options.

Unique aspects of caring for young breast cancer patients

Breast cancer is the most commonly diagnosed malignancy in young women in the USA. Although breast cancer mortality has decreased overall, survival rates in young women remain lower than those in older women. Young women with breast cancer comprise a special population due to the aggressive biology of their tumors as well as their unique psychosocial concerns. Although general treatment principles are similar regardless of age, recent developments from research focused on younger women have provided new insights to guide treatment of this special population. This article will focus on these new developments in areas including endocrine therapy and fertility preservation as well as the unique treatment-related sequelae and psychosocial concerns among young women with breast cancer face.