Oncofertility: a grand collaboration between reproductive medicine and oncology

An update on oncofertility in prepubertal females

Cancer is a life-threatening event for pediatric patients. Treatment advancements in pediatric cancer have improved prognosis, but some of these treatments have gonadotoxic potential and may affect fertility in different ways. Due to the growing interest of the research community in the life prospects of young cancer survivors, there has been a demand to intersect reproductive medicine and oncology, which is referred to as "oncofertility". There are various fertility preservation options according to gender and pubertal status, and shared decisions must take place at the time of diagnosis. This study aims to provide a critical review of current and emerging strategies for preserving and restoring fertility in prepubertal females, ranging from established methods to experimental approaches that can be offered before, during, and after anticancer therapies. Additionally, the author aims to review how clinicians' awareness of oncofertility options and the latest advancements in this field, timely referral, and proper consultations with patients and their families are vital in addressing their concerns, providing emotional support, and guiding them through the decision-making process, as well as potential barriers that may hinder the fertility preservation process.

Patient-Reported Outcomes (PROs) and Patient Experiences in Fertility Preservation: A Systematic Review of the Literature on Adolescents and Young Adults (AYAs) with Cancer

With better survival rates for patients diagnosed with cancer, more attention has been focused on future risks, like fertility decline due to gonadotoxic treatment. In this regard, the emphasis during counselling regarding possible preservation options is often on the treatment itself, meaning that the medical and emotional needs of patients regarding counselling, treatment, and future fertility are often overlooked. This review focuses on patient-reported outcomes (PROs) and patient experiences regarding fertility preservation (FP)-among adolescents and young adults (AYAs) with cancer. A systematic review of the literature, with a systematic search of online databases, was performed, resulting in 61 selected articles. A quality assessment was performed by a mixed methods appraisal tool (MMAT). Based on this search, three important topics emerged: initiating discussion about the risk of fertility decline, acknowledging the importance of future fertility, and recognizing the need for more verbal and written patient-specific information. In addition, patients value follow-up care and the opportunity to rediscuss FP and their concerns about future fertility and use of stored material. A clear FP healthcare pathway can prevent delays in receiving a referral to a fertility specialist to discuss FP options and initiating FP treatment. This patient-centered approach will optimize FP experiences and help to establish a process to achieve long-term follow up after FP treatment.

Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of melanoma, version 3.0

Since the first approval for immune checkpoint inhibitors (ICIs) for the treatment of cutaneous melanoma more than a decade ago, immunotherapy has completely transformed the treatment landscape of this chemotherapy-resistant disease. Combination regimens including ICIs directed against programmed cell death protein 1 (PD-1) with anti-cytotoxic T lymphocyte antigen-4 (CTLA-4) agents or, more recently, anti-lymphocyte-activation gene 3 (LAG-3) agents, have gained regulatory approvals for the treatment of metastatic cutaneous melanoma, with long-term follow-up data suggesting the possibility of cure for some patients with advanced disease. In the resectable setting, adjuvant ICIs prolong recurrence-free survival, and neoadjuvant strategies are an active area of investigation. Other immunotherapy strategies, such as oncolytic virotherapy for injectable cutaneous melanoma and bispecific T-cell engager therapy for HLA-A*02:01 genotype-positive uveal melanoma, are also available to patients. Despite the remarkable efficacy of these regimens for many patients with cutaneous melanoma, traditional immunotherapy biomarkers (ie, programmed death-ligand 1 expression, tumor mutational burden, T-cell infiltrate and/or microsatellite stability) have failed to reliably predict response. Furthermore, ICIs are associated with unique toxicity profiles, particularly for the highly active combination of anti-PD-1 plus anti-CTLA-4 agents. The Society for Immunotherapy of Cancer (SITC) convened a panel of experts to develop this clinical practice guideline on immunotherapy for the treatment of melanoma, including rare subtypes of the disease (eg, uveal, mucosal), with the goal of improving patient care by providing guidance to the oncology community. Drawing from published data and clinical experience, the Expert Panel developed evidence- and consensus-based recommendations for healthcare professionals using immunotherapy to treat melanoma, with topics including therapy selection in the advanced and perioperative settings, intratumoral immunotherapy, when to use immunotherapy for patients with BRAFV600-mutated disease, management of patients with brain metastases, evaluation of treatment response, special patient populations, patient education, quality of life, and survivorship, among others.

Oncofertility awareness among primary care physicians in India

BACKGROUND

Primary care physicians not only coordinate referrals to oncology services but can play a crucial role in successful fertility preservation referrals in cancer-diagnosed patients. Hence, it is important to assess their knowledge and attitudes towards fertility preservation.

METHODS

An eighteen-item oncofertility survey was administered to primary care physicians between May 2019 to September 2020.  Results: A total of forty-six responses were received and analysed. About 60% of primary care physicians did not have adequate knowledge about available fertility preservation options and only 26-32% were aware of international guidelines recommending fertility preservation in cancer patients.  Conclusions: Imparting awareness and knowledge of fertility preservation and its options to primary care physicians could enable an integrated cancer care model while also facilitating successful oncofertility referrals in countries like India.

Body image disturbances in adolescent and young adult cancer patients confronting infertility risk and fertility preservation decisions

PURPOSE

Body image is a major psychosocial concern for all cancer patients but can affect the adolescent and young adult (AYA) population in distinct ways. Similarly, the prospect of infertility and the fertility preservation process can create additional stress during cancer treatment. Discussions regarding infertility inherently implicate the body and its reproductive function, but downstream effects on self-perception have not been previously described. The aim of this study was to explore the experiences of AYAs as they considered their risk of infertility and options for fertility preservation (FP), specifically the ways in which this impacted body image and FP decision-making.

METHODS

AYA cancer patients (n = 27) aged 12-25 years whose cancer and treatment conferred risk of infertility were recruited through electronic health record query at an NCI-Designated Comprehensive Cancer Center. Participants completed semi-structured interviews, which were recorded, transcribed, and deductively coded for themes related to information needs, knowledge of treatment effects on fertility, and reproductive concerns after cancer. Emergent, inductive themes related to body image were identified.

RESULTS

Body image concerns, related to both physical appearance and body functioning emerged. Common concerns included anticipating change as it pertains to the body and its functions, physical discomfort, fear of judgment, and meeting expectations of the body. While these themes are broad in nature, they have been previously explored in relation to body image in general and their emergence in the oncofertility space provides guidance for further optimization of infertility and fertility preservation discussions.

CONCLUSIONS

AYA cancer patients experience a multitude of body image related disturbances when faced with the possibility of infertility and fertility preservation. In identifying and exploring these themes, future opportunities for improving oncofertility practice and discussions among AYAs with a focus on body image positivity are called upon.

Fertility-sparing surgery: a hopeful strategy for young women with cancer

Fertility preservation in cancer patients is currently based on either assisted reproductive technology or fertility-sparing surgery. Loss of fertility may be caused by excisional surgery associated with an adnexal or uterine pathology or secondary to gonadal insufficiency caused by chemotherapy or radiation. The counseling of these patients is very important, being carried out jointly by the oncologist, gynecologist, and reproductive medicine specialist. Reproductive surgery usually requires avoiding laparotomy to significantly reduce the formation of adhesions and trauma or tissue damage. This is done using standard laparoscopic surgery or robotic surgery (computer-assisted laparoscopy), a method increasingly used and accessible to all specialists who want to maintain the fertility of their patients with various oncological diseases.

Fertility options after chemotherapy in young premenopausal patients

Context

Infertility affects more and more younger patients nowadays. Life-saving cancer treatments - chemotherapy and radiation therapy unfortunately damage oocytes and reduce the window of fertility in women. There were an estimated 14.1 million cases of cancer worldwide in 2012, of which 6.7 million were in women.

Aim

We are reviewing fertility options and treatments for women fighting oncological diseases. It is important to promote that there is a possibility for these patients to know all they can do in order to preserve their fertility and our government should help all these young patients.The trend of delayed childbearing has increased worldwide duet o increased life costs, difficulty of finding a suitable partner and carier options, while the number of women facing a cancer diagnosis is rising.

Material and methods

We describe a review regarding the impact of these treatments for the fertility of these patients.

Results

Show that informed patients can better cope with their diagnostic and have a better prognosis.

Conclusions

Improving survival rates and current data have created a new medical field oncofertility. The term was first introduced in 2015 and is being used all over clinics that treat young patients nowadays.

Asherman Syndrome after Uterine Artery Embolization: A Cohort Study about Surgery Management and Fertility Outcomes

STUDY OBJECTIVE

To study the severity of intrauterine adhesions (IUA) after uterine arterial embolization and to evaluate fertility, pregnancy, and obstetrical outcomes after hysteroscopic treatment.

DESIGN

Retrospective cohort.

SETTING

French University Hospital.

PATIENTS

Thirty-three patients under the age of 40 years who were treated by uterine artery embolization with nonabsorbable microparticles between 2010 and 2020 for symptomatic fibroids or adenomyosis, or postpartum hemorrhage.

INTERVENTIONS

All patients had a diagnosis of IUA after embolization. All patients desired future fertility. IUA was treated with operative hysteroscopy.

MEASUREMENTS AND MAIN RESULTS

Severity of IUA, number of operative hysteroscopies performed to obtain a normal cavity shape, pregnancy rate, and obstetrical outcomes. Of our 33 patients, 81.8% had severe IUA (state IV et V according to the European Society of Gynecological Endoscopy or state III according to the American fertility society classification). To restore fertility potential, an average of 3.4 operative hysteroscopies had to be performed [CI 95% (2.56-4.16)]. We reported a very low rate of pregnancy (8/33, 24%). Obstetrical outcomes reported are 50% of premature birth and 62.5% of delivery hemorrhage partly due to 37.5% of placenta accreta. We also reported 2 neonatal deaths.

CONCLUSION

IUA after uterine embolization is severe, and more difficult to treat than other synechiae, probably related to endometrial necrosis. Pregnancy and obstetrical outcomes have shown a low pregnancy rate, an increased risk of preterm delivery, a high risk of placental disorders, and very severe postpartum hemorrhage. Those results have to alert gynecologists and radiologists to the use of uterine arterial embolization in women who desire future fertility.

Reproductive Outcomes in Young Breast Cancer Survivors Treated (15-39) in Ontario, Canada

We conducted a population-based, retrospective, matched-cohort study to examine the impact of breast cancer diagnosis and treatment on fertility outcomes. Relative risks of infertility, childbirth, premature ovarian insufficiency (POI; age < 40) and early menopause (age < 45) were calculated using modified Poisson regression. Our primary cohort included young women (15-39) with early stage BC diagnosed 1995-2014. Five cancer-free patients were matched to each BC patient by birth year and census subdivision. The BC cohort was further divided by treatment with chemotherapy vs. no chemotherapy treatment. 3903 BC patients and 19,515 cancer-free women. BC patients treated with chemotherapy were at increased risk of infertility (RR 1.81; 95% CI 1.60-2.04), and POI (RR 6.25; 95% CI 5.15-7.58) and decreased childbirth (RR 0.85; 95% CI 0.75-0.96), compared to women without cancer. BC patients who did not receive chemotherapy were also at increased risk of infertility (RR 1.80 95% CI 1.48-2.18) and POI (RR 2.12 95% CI 1.37-3.28). All young BC survivors face an increased risk of diagnosed infertility and POI relative to women without cancer, independent of chemotherapy. These results emphasize the importance of pre-treatment fertility counselling for young women diagnosed with BC.

Risk factors on testicular function in adolescents

PURPOSE

Adolescence represents an important window for gonadal development. The aim of this review is to carry out a critical excursus of the most recent literature on endogenous and exogenous risk factors related to testicular function, focusing the research on adolescence period.

METHODS

A comprehensive literature search within PubMed was performed to provide a summary of currently available evidence regarding the impact on adolescence of varicocele, cryptorchidism, cancer, diabetes, lifestyle factors, endocrine disruptors, obesity and sexually transmitted diseases. We focused on human studies that evaluated a possible impact of these factors on puberty timing and their effects on andrological health.

RESULTS

Evidence collected seems to suggest that andrological health in adolescence may be impaired by several factors, as varicocele, cryptorchidism, and childhood cancer. Despite an early diagnosis and treatment, many adolescents might still have symptoms and sign of a testicular dysfunction in their adult life and at the current time it is not possible to predict which of them will experience andrological problems. Lifestyle factors might have a role in these discrepancies. Most studies point out towards a correlation between obesity, insulin resistance, alcohol, smoking, use of illegal drugs and testicular function in pubertal boys. Also, endocrine disruptors and sexually transmitted diseases might contribute to impair reproductive health, but more studies in adolescents are needed.

CONCLUSION

According to currently available evidence, there is an emerging global adverse trend of high-risk and unhealthy behaviors in male adolescents. A significant proportion of young men with unsuspected and undiagnosed andrological disorders engage in behaviors that could impair testicular development and function, with an increased risk for later male infertility and/or hypogonadism during the adult life. Therefore, adolescence should be considered a key time for intervention and prevention of later andrological diseases.

Partner perspectives on women's sexual and reproductive healthcare in cystic fibrosis

BACKGROUND

Women with cystic fibrosis (CF) face many sexual and reproductive health (SRH) concerns. Studies suggest that educating and involving partners in SRH care can improve outcomes. This study investigated partners' perceptions of and preferences for women's SRH care in CF.

METHODS

We surveyed partners of women with CF from ten United States (U.S.) CF centers regarding their attitudes and preferences related to CF SRH care. Items assessed experiences with SRH care, sexual relationships, family planning, pregnancy, fertility, and parenthood. We used descriptive statistics to assess results related to the timing, content, setting and delivery of CF SRH care.

RESULTS

A total of 94 partners completed the survey (94% male; average age 36±1 years; 70% married; 36% parents). Among those who/whose partners experienced a pregnancy, 48% received preconception counseling and 29% fertility testing/treatment. One-third of all respondents (32%) worried their children would have CF and 86% would undergo CF genetic testing if their CF partner became pregnant. One-third (34%) indicated that they did not have any SRH conversations with their partner's CF team, while 70% would like to have such discussions. The topics that respondents would most like to discuss were pregnancy (50%), fertility (43%), sexual functioning (36%), sexual activity (31%) and parenthood (29%).

CONCLUSIONS

Partners report gaps in SRH care and counseling despite the majority wanting to discuss SRH concerns with their partner's CF team. CF partners serve as key supports for women with CF and results can be used to design patient-centered interventions to optimize CF SRH care.

A synopsis of global frontiers in fertility preservation

Since 2007, the Oncofertility Consortium Annual Conference has brought together a diverse network of individuals from a wide range of backgrounds and professional levels to disseminate emerging basic and clinical research findings in fertility preservation. This network also developed enduring educational materials to accelerate the pace and quality of field-wide scientific communication. Between 2007 and 2019, the Oncofertility Consortium Annual Conference was held as an in-person event in Chicago, IL. The conference attracted approximately 250 attendees each year representing 20 countries around the world. In 2020, however, the COVID-19 pandemic disrupted this paradigm and precluded an in-person meeting. Nevertheless, there remained an undeniable demand for the oncofertility community to convene. To maintain the momentum of the field, the Oncofertility Consortium hosted a day-long virtual meeting on March 5, 2021, with the theme of "Oncofertility Around the Globe" to highlight the diversity of clinical care and translational research that is ongoing around the world in this discipline. This virtual meeting was hosted using the vFairs ® conference platform and allowed over 700 people to participate, many of whom were first-time conference attendees. The agenda featured concurrent sessions from presenters in six continents which provided attendees a complete overview of the field and furthered our mission to create a global community of oncofertility practice. This paper provides a synopsis of talks delivered at this event and highlights the new advances and frontiers in the fields of oncofertility and fertility preservation around the globe from clinical practice and patient-centered efforts to translational research.

Nurse’s perceptions of support for sexual and reproductive issues in adolescents and young adults with cancer

Adolescent and young adult (AYA) with cancer are at risk for developing sexual and reproductive problems; therefore, they have special needs. AYA with cancer treated in both pediatric and adult wards are a minority in Japan; thus, accumulating experience for supporting this unique patient population is difficult for nurses. Hence, this study aimed to clarify nurses’ perceptions on support for sexual and reproductive issues among AYA with cancer. A questionnaire survey was administered to nurses at designated cancer hospitals across Japan who had been working for at least 1 year in a department involved in the treatment or follow-up of patients aged 15–39 years. Nurses were asked regarding their perceptions on support for sexual and reproductive issues faced by AYA with cancer. A total of 865 nurses responded to this survey; nurses affiliated with adult departments, those with more experience in cancer nursing, those affiliated with cancer-related academic and professional societies, and certified nurse specialists or certified nurses significantly recognized insufficient support for sexual and reproductive issues. However, nurses were hesitant and found it difficult to intervene in such issues. Nurses recognized the importance of providing support for sexual and reproductive issues but faced difficulties in addressing them. They need to discuss these issues and improve the care provided to AYA with cancer.

Development and Validity Testing of an Assessment Tool for Oncofertility Barriers in Multidisciplinary Healthcare Providers on the Breast Cancer Team

BACKGROUND

Multidisciplinary healthcare providers, especially clinical nurses, lack a valid tool to assess the comprehensive barriers affecting oncofertility care in breast cancer treatment.

PURPOSE

The aims of the research were to develop a self-assessment scale on oncofertility barriers and test its validity and reliability.

METHODS

This was a methodological study. The initial 36 items of the developed Oncofertility Barrier Scale (OBS) were generated through qualitative study and a review of the literature. This scale was further refined using expert validity (n = 10), face validity (n = 10), and item analysis (n = 184). Exploratory factor analysis with principal axis factoring and direct oblimin rotation was used to determine the construct validity. The reliability of the OBS was evaluated using internal consistency and test-retest analyses.

RESULTS

The mean item-level and scale-level content validity indices of the initial OBS were higher than .96. The data were shown to be feasible for the factor analysis, and a six-factor solution was chosen that accounted for approximately 57.6% of the total variance. These factors included (a) lack of information and education, (b) rigid thinking toward oncofertility care, (c) cancer patient stereotypes, (d) fertility risk, (e) insufficient support, and (f) interrupted oncofertility care. The Cronbach's alpha of the 27-item OBS was .91, and the test-retest reliability coefficient was .55.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The final version of the developed OBS has acceptable reliability, content validity, and construct validity. This scale is appropriate for use in research and clinical practice settings to identify the barriers to fertility cancer care that should be resolved by the breast cancer care team.

Oncofertility and Reproductive Counseling in Patients with Breast Cancer: A Retrospective Study

Introduction. Improving the prognosis of breast cancer patients is of utmost importance in terms of increasing survival rates. Modern medicine has therefore prioritized better quality of life for patients, even after the disease, through a better management of the potential long-term side effects induced by anticancer treatments. Fertility preservation and family planning are therefore crucial issues to be addressed in all cancer patients of reproductive age. Along those lines, a new branch of medicine with distinct multidisciplinary characteristics has developed over the years: oncofertility. Although both national and international guidelines value reproductive counseling as an essential aspect of the diagnostic-therapeutic pathway, part and parcel of the informed consent process, it is not included within the protocols adopted by the operating units for the care and management of neoplastic diseases. Objective. This study aimed to evaluate the activity of the Breast Unit of the Policlinico Umberto I Hospital, Rome, Italy, and the degree of compliance with guidelines. By knowing the strengths and weaknesses of such approaches, the standards of care offered to breast cancer patients can be improved. Materials and methods. A retrospective study based on a review of medical records was conducted between 2014 and 2021. Patients under 40 years of age diagnosed with non-metastatic malignancies were included who received chemotherapy treatment, namely neoadjuvant, adjuvant or adjuvant hormone therapy. Results. The data were extracted from the medical records of 51 patients who met the inclusion criteria, 41% of whom received reproductive counseling, and of these, 43% decided to undertake a path of fertility preservation. Factors such as the absence of children and young age reportedly favored both the interest in counseling proposals by the medical staff and the decision to undertake a path of fertility preservation. Conclusions. The study shows that there has been growing interest in the topic of oncofertility, especially in light of law 219/2017. Therefore, since 2018, multiple proposals for reproductive counseling have been set forth, but there was not an equally growing demand for fertility preservation practices, which can be explained by the invasive nature of such practices, the patients’ concern about their own state of health, and poor or inadequate information. Such impediments highlight the importance of standardized counseling and the need for a multidisciplinary medical team to support the patient in the decision-making process. The study also revealed a drop in the number of patients receiving counseling due to the COVID-19 pandemic, contrary to the positive trend that was recorded prior to the pandemic.

An assessment of oncofertility content on reproductive endocrinology and infertility clinic websites

PURPOSE

To assess oncofertility content on fertility clinic websites as indicated by eight relevant keywords. Additionally, we sought to describe the relationship between oncofertility content and five predetermined clinic characteristics.

METHODS

We examined 381 fertility clinic websites that are members of the Society for Associated Reproductive Technology (SART). Extracted data included clinic location, practice type (private vs academic), size (cycles/year), type of NCI designated center (cancer center vs comprehensive cancer center), and distance from the nearest NCI center. Additionally, we documented whether the clinic was located in a state mandating reproductive and infertility services and/or included fertility preservation for "iatrogenic infertility" as reported by the American Society for Reproductive Medicine (ASRM). Data were summarized using descriptive statistics and compared using chi-squared or t-test as appropriate.

RESULTS

Of the 381 fertility clinic websites analyzed, 322 (85%) contained at least one oncofertility-related keyword. Most frequently used terms included cancer (79%) and fertility preservation (78%), while less frequently used terms included suppression (9.4%) and shielding (5.0%). Practices that initiated ≥ 501 cycles per year were more likely to mention one of the oncofertility keywords (OR 1.2; 95% CI 1.1-1.3). The associations of oncofertility website content with practice type, state-mandated fertility insurance coverage, and distance from an NCI-designated cancer center were not statistically significant. Large clinic size was the only predictive factor for inclusion of oncofertility website content. Further studies are required to evaluate whether inclusion of oncofertility content on clinic websites impacts the use of these services by patients with cancer.

CONCLUSION

This is the first study correlating availability of oncofertility content on SART fertility clinic websites with consideration of geographic proximity to NCI designated cancer centers. Large clinic size was the only predictive factor for inclusion of oncofertility website content.

Oncofertility and COVID-19: At the Crossroads between Two Time-Sensitive Fields

Background: COVID-19 infection has dominated our lives and left its mark on it. The impact on fertility is major, and the long-term consequences may be disastrous. When we talk about oncofertility, we are talking about those patients worried about the delay in receiving medical services (possible cancelation of surgery, decreased availability of medical services, reorientation of medical resources) due to COVID-19. Finally, patients’ worsening biological and reproductive statuses, associated with high levels of anxiety and depression, are closely related to social restrictions, economic impact, reorientation of medical resources, health policies, and fears of SARS-CoV-2 infection. Aim: We reviewed the current literature on fertility during the COVID-19 pandemic and its effect on cancer patients. Specifically, how cancer treatment can affect fertility, the options to maintain fertility potential, and the recovery options available after treatment are increasingly common concerns among cancer patients. Methods: A systematic literature search was conducted using two main central databases (PubMed^®/MEDLINE, and Web of Science) to identify relevant studies using keywords SARS-CoV-2, COVID-19, oncofertility, young cancer patient, cryopreservation, assisted reproductive techniques (ART), psychosocial, telemedicine. Results: In the present study, 45 papers were included, centered on the six main topics related to COVID-19. Conclusions: Fertility preservation (FP) should not be discontinued, but instead practiced with adjustments to prevent SARS-CoV-2 transmission. The increased risk of SARS-CoV-2 infection in cancer patients requires screening for COVID-19 before FP procedures, among both patients and medical staff in FP clinics, to prevent infection that would rapidly worsen the condition and lead to severe complications.

Oncofertility care: A qualitative study to understand personal perspectives and barriers in the multidisciplinary breast care team in Taiwan

Background:

Previous studies indicate significant gaps exist in current practices and perceptions of oncofertility care.

Objectives:

We aim to understand the clinical experience regarding oncofertility care among health providers in a multidisciplinary breast care team.

Methods:

A qualitative, descriptive study was conducted. Data were collected through in-depth interviews with 16 health care providers who worked in a hospital in Taipei. Verbatim transcriptions were analyzed using constant analysis methods.

Results:

Health care providers’ experiences regarding fertility care for reproductive-age women with breast cancer were divided into two themes: personal perspectives and barriers. Personal perspectives consisted of six subthemes including empathizing with the patient’s suffering during the diagnosis and treatment, safety as a prerequisite, satisfying the women’s needs, respecting the women’s choice, questioning women’s ability to raise children, and returning to family life. There were also six subthemes under barriers. These subthemes were poor communication among the multidisciplinary team, lack of initial screening, insufficient support in the women’s families, treatment considerations, lack of evidence-based information regarding oncofertility, and non-follow-up protocol.

Conclusion:

Nurses should evaluate the fertility needs of women with cancer and identify potential gaps during oncofertility care. Education strategies and tactics should be improved in order to overcome difficulties arising from health care providers’ personal perspectives and barriers to the provision of optimal fertility care in women with cancer.

Female Oncofertility: Current Understandings, Therapeutic Approaches, Controversies, and Future Perspectives

Recent advances in early detection and oncological therapies have ameliorated the survival rate of young cancer patients. Yet, ovarian impairment induced by chemotherapy and radiotherapy is still a challenging issue. This review, based on clinical and lab-based studies, summarizes the evidence of gonadotoxicity of chemoradiotherapy, the recent approaches, ongoing controversies, and future perspectives of fertility preservation (FP) in female patients who have experienced chemo- or radio-therapy. Existing data indicate that chemotherapeutic agents induce DNA alterations and massive follicle activation via the phosphoinositide 3-kinase (PI3K)/Akt signaling pathway. Meanwhile, the radiation causes ionizing damage, leading to germ cell loss. In addition to the well-established methods, numerous therapeutic approaches have been suggested, including minimizing the follicle loss in cryopreserved ovarian grafts after transplantation, in vitro activation or in vitro growing of follicles, artificial ovarian development, or fertoprotective adjuvant to prevent ovarian damage from chemotherapy. Some reports have revealed positive outcomes from these therapies, whereas others have demonstrated conflictions. Future perspectives are improving the live birth rate of FP, especially in patients with adverse ovarian reserve, eliminating the risk of malignancy reintroducing, and increasing society’s awareness of FP importance.

Oncofertility Knowledge and Communication: Comparison Between Medical and Surgical Oncologists and Breast Cancer Patients in Academic Chinese Centers

Background: As cancer has become a major public health issue in China, fertility preservation remains limited despite the wide application of Assisted Reproductive Technology (ART) throughout the country.

Objective: This study aimed to identify gaps in knowledge and communication as well as referrals in the previous year regarding oncofertility among medical and surgical oncologists and breast cancer patients (BCPs) in Chinese academic settings to target areas of needed improvement.

Materials and Methods: A WeChat online questionnaire was designed, distributed, and compared between medical and surgical oncology specialists and reproductive age BCPs in academic teaching settings in Shanghai.

Results: Sixty-one medical and surgical oncologists and 125 BCPs responded to the survey. 63.3% of oncologists were familiar with the term “oncofertility” compared to 25.6% of BCPs (p < 0.001). Oncologists were more likely to correctly know the costs associated with treatment (59.0 vs. 32.0%, p < 0.001); patient did not have to be married to undergo oncofertility treatment (50.8 vs. 24.8%, p < 0.001). Both oncologists and BCPs were similarly unlikely to know when patients could utilize cryopreserved tissue in the future (37.7 vs. 22.2%, p = 0.056). While oncologists reported they discussed all oncofertility options (41.0%) and offered psychological counseling (98.4%), significantly fewer BCPs reported receiving information on all options and offered counseling (3.2%, p < 0.001 and 85.6%, p < 0.01). Knowledge of oncofertility was the most important predictor for providing and receiving counseling from oncologists [OR = 6.44 (95% CI = 1.59–26.1, p = 0.009] and BCPs (OR = 3.73 95% CI: = 1.36–10.2, p = 0.011). Overall, 57.4% of oncologists referred <10 patients and none referred more than 25 patients in the past year.

Conclusion: Data suggests a significant knowledge gap and ineffective communication/comprehension exists between academic Chinese oncologists and BCPs. Continued education and raised awareness are needed to optimize utilization of oncofertility services in China.

Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of breast cancer

Breast cancer has historically been a disease for which immunotherapy was largely unavailable. Recently, the use of immune checkpoint inhibitors (ICIs) in combination with chemotherapy for the treatment of advanced/metastatic triple-negative breast cancer (TNBC) has demonstrated efficacy, including longer progression-free survival and increased overall survival in subsets of patients. Based on clinical benefit in randomized trials, ICIs in combination with chemotherapy for the treatment of some patients with advanced/metastatic TNBC have been approved by the United States (US) Food and Drug Administration (FDA), expanding options for patients. Ongoing questions remain, however, about the optimal chemotherapy backbone for immunotherapy, appropriate biomarker-based selection of patients for treatment, the optimal strategy for immunotherapy treatment in earlier stage disease, and potential use in histological subtypes other than TNBC. To provide guidance to the oncology community on these and other important concerns, the Society for Immunotherapy of Cancer (SITC) convened a multidisciplinary panel of experts to develop a clinical practice guideline (CPG). The expert panel drew upon the published literature as well as their clinical experience to develop recommendations for healthcare professionals on these important aspects of immunotherapeutic treatment for breast cancer, including diagnostic testing, treatment planning, immune-related adverse events (irAEs), and patient quality of life (QOL) considerations. The evidence-based and consensus-based recommendations in this CPG are intended to give guidance to cancer care providers treating patients with breast cancer.

Risk of infertility in female adolescents and young adults with cancer: a population-based cohort study

STUDY QUESTION

Do female adolescents and young adults (AYAs) with cancer have a higher risk of subsequent infertility diagnosis than AYAs without cancer?

SUMMARY ANSWER

Female AYAs with breast, hematological, thyroid and melanoma cancer have a higher risk of subsequent infertility diagnosis.

WHAT IS KNOWN ALREADY

Cancer therapies have improved substantially, leading to dramatic increases in survival. As survival improves, there is an increasing emphasis on optimizing the quality of life among cancer survivors. Many cancer therapies increase the risk of infertility, but we lack population-based studies that quantify the risk of subsequent infertility diagnosis in female AYAs with non-gynecological cancers. The literature is limited to population-based studies comparing pregnancy or birth rates after cancer against unexposed women, or smaller studies using markers of the ovarian reserve as a proxy of infertility among female survivors of cancer.

STUDY DESIGN, SIZE, DURATION

We conducted a population-based cohort study using universal health care databases in the province of Ontario, Canada. Using data from the Ontario Cancer Registry, we identified all women 15-39 years of age diagnosed with the most common cancers in AYAs (brain, breast, colorectal, leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma, thyroid and melanoma) from 1992 to 2011 who lived at least 5 years recurrence-free (Exposed, n = 14,316). Women with a tubal ligation, bilateral oophorectomy or hysterectomy previous to their cancer diagnosis were excluded. We matched each exposed woman by age, census subdivision, and parity to five randomly selected unexposed women (n = 60,975) and followed subjects until 31 December 2016.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Infertility diagnosis after 1 year of cancer was identified using information on physician billing codes through the Ontario Health Insurance Plan database (ICD-9 628). Modified Poisson regression models were used to assess the risk of infertility diagnosis (relative risk, RR) adjusted for income quintile and further stratified by parity at the time of cancer diagnosis (nulliparous and parous).

MAIN RESULTS AND THE ROLE OF CHANCE

Mean age at cancer diagnosis was 31.4 years. Overall, the proportion of infertility diagnosis was higher in cancer survivors compared to unexposed women. Mean age of infertility diagnosis was similar among cancer survivors and unexposed women (34.8 years and 34.9 years, respectively). The overall risk of infertility diagnosis was higher in cancer survivors (RR 1.30; 95% CI 1.23-1.37). Differences in infertility risk varied by type of cancer. Survivors of breast cancer (RR 1.46; 95% CI 1.30-1.65), leukemia (RR 1.56; 95% CI 1.09-2.22), Hodgkin lymphoma (RR 1.49; 95% CI 1.28-1.74), non-Hodgkin lymphoma (RR 1.42; 95% CI 1.14, 1.76), thyroid cancer (RR 1.20; 95% CI 1.10-1.30) and melanoma (RR 1.17; 95% CI 1.01, 1.35) had a higher risk of infertility diagnosis compared to women without cancer. After stratification by parity, the association remained in nulliparous women survivors of breast cancer, leukemia, lymphoma and melanoma, whereas it was attenuated in parous women. In survivors of thyroid cancer, the association remained statistically significant in both nulliparous and parous women. In survivors of brain or colorectal cancer, the association was not significant, overall or after stratification by parity.

LIMITATIONS, REASONS FOR CAUTION

Non-biological factors that may influence the likelihood of seeking a fertility assessment may not be captured in administrative databases. The effects of additional risk factors, including cancer treatment, which may modify the associations, need to be assessed in future studies.

WIDER IMPLICATIONS OF THE FINDINGS

Reproductive health surveillance in female AYAs with cancer is a priority, especially those with breast cancer, leukemia and lymphoma. Our finding of a potential effects of thyroid cancer (subject to over-diagnosis) and, to a lesser extent, melanoma need to be further studied, and, if an effect is confirmed, possible mechanisms need to be elucidated.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was provided by the Faculty of Health Sciences and Department of Obstetrics and Gynecology, Queen's University. There are no competing interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Restricted access to assisted reproductive technology and fertility preservation: legal and ethical issues

Access to assisted reproductive technology (ART) and fertility preservation remains restricted in middle and low income countries. We sought to review the status of ART and fertility preservation in Brazil, considering social indicators and legislative issues that may hinder the universal access to these services. Although the Brazilian Constitution expressly provides the right to health, and ordinary law ensures the state is obliged to support family planning, access to services related to ART and fertility preservation is neither easy nor egalitarian in Brazil. Only a handful of public hospitals provide free ART, and their capacity far from meets demand. Health insurance does not cover ART, and the cost of private care is unaffordable to most people. Brazilian law supports, but does not command, the state provision of ART and fertility preservation to guarantee the right to family planning; therefore, the availability of state-funded treatments is still scarce, reinforcing social disparities. Economic projections suggest that including ART in the Brazilian health system is affordable and may actually become profitable to the state in the long term, not to mention the ethical imperative of recognizing infertility as a disease, with no reason to be excluded from a health system that claims to be 'universal'.

Oncofertility in Islam: The Malaysian Perspective

The implementation of oncofertility services is of great importance among cancer survivors of reproductive age to ensure a good quality of life. However, the uptake of this service among Muslim patients is very challenging because of inconclusive laws or evidence based on the Islamic perspective. Hence, we summarized the limited evidence available to consolidate current recommendations for oncofertility practices in the Muslim population in Malaysia. The available “fatwa” and “muzakarah” regarding reproductive procedures and gamete cryopreservation in Islam was searched from the recommendations of local and international bodies, including published and unpublished sources. The relevant information was then extracted according to the current understanding of dilemmas in oncofertility practices in Malaysia, tabulated, and consolidated. Most of the available “fatwa” has been revised by recent “muzakarah” to suit current oncofertility practices. Most Islamic organizations support the practice of oncofertility in Muslim hence indicates that oncofertility services are permissible. Therefore, proper recommendations and counseling are paramount to ensure understanding among Muslim patients.

Immature Follicular Origins and Disrupted Oocyte Growth Pathways Contribute to Decreased Gamete Quality During Reproductive Juvenescence in Mice

Egg quality dictates fertility outcomes, and although there is a well-documented decline with advanced reproductive age, how it changes during puberty is less understood. Such knowledge is critical, since advances in Assisted Reproductive Technologies are enabling pre- and peri-pubertal patients to preserve fertility in the medical setting. Therefore, we investigated egg quality parameters in a mouse model of the pubertal transition or juvenescence (postnatal day; PND 11-40). Animal weight, vaginal opening, serum inhibin B levels, oocyte yield, oocyte diameter, and zona pellucida thickness increased with age. After PND 15, there was an age-associated ability of oocytes to resume meiosis and reach metaphase of meiosis II (MII) following in vitro maturation (IVM). However, eggs from the younger cohort (PND 16-20) had significantly more chromosome configuration abnormalities relative to the older cohorts and many were at telophase I instead of MII, indicative of a cell cycle delay. Oocytes from the youngest mouse cohorts originated from the smallest antral follicles with the fewest cumulus layers per oocyte, suggesting a more developmentally immature state. RNA Seq analysis of oocytes from mice at distinct ages revealed that the genes involved in cellular growth signaling pathways (PI3K, mTOR, and Hippo) were consistently repressed with meiotic competence, whereas genes involved in cellular communication were upregulated in oocytes with age. Taken together, these data demonstrate that gametes harvested during the pubertal transition have low meiotic maturation potential and derive from immature follicular origins.

A View from the past into our collective future: the oncofertility consortium vision statement

Purpose

Today, male and female adult and pediatric cancer patients, individuals transitioning between gender identities, and other individuals facing health extending but fertility limiting treatments can look forward to a fertile future. This is, in part, due to the work of members associated with the Oncofertility Consortium.

Methods

The Oncofertility Consortium is an international, interdisciplinary initiative originally designed to explore the urgent unmet need associated with the reproductive future of cancer survivors. As the strategies for fertility management were invented, developed or applied, the individuals for who the program offered hope, similarly expanded. As a community of practice, Consortium participants share information in an open and rapid manner to addresses the complex health care and quality-of-life issues of cancer, transgender and other patients. To ensure that the organization remains contemporary to the needs of the community, the field designed a fully inclusive mechanism for strategic planning and here present the findings of this process.

Results

This interprofessional network of medical specialists, scientists, and scholars in the law, medical ethics, religious studies and other disciplines associated with human interventions, explore the relationships between health, disease, survivorship, treatment, gender and reproductive longevity.

Conclusion

The goals are to continually integrate the best science in the service of the needs of patients and build a community of care that is ready for the challenges of the field in the future.

Ethical Considerations of Fertility Preservation for Transmasculine and Nonbinary Youth

An increasing number of young adolescents who identify as transgender or nonbinary are presenting to the health care system for gender affirmation therapy before the full progression of puberty. Gender-affirming therapy may impair future fertility, but options exist for fertility preservation. This perspective reviews these options for transmasculine and nonbinary youth, and explores related ethical considerations. The authors support the right of transgender and nonbinary youth to utilize available reproductive technologies, provide recommendations for treating health professionals, and advocate for increased research efforts and tools to aid patient decision making.

Building Oncofertility Core Competency in Developing Countries: Experience From Egypt, Tunisia, Brazil, Peru, and Panama

PURPOSE

Little is known about oncofertility practice in developing countries that usually suffer from a shortage of health services, especially those related to cancer care.

MATERIALS AND METHODS

To learn more about oncofertility practice in developing countries, we generated a survey to explore the barriers and opportunities associated with oncofertility practice in five developing countries from Africa and Latin America within our Oncofertility Consortium Global Partners Network. Responses from Egypt, Tunisia, Brazil, Peru, and Panama were collected, reviewed, and discussed.

RESULTS

Common barriers were identified by each country, including financial barriers (lack of insurance coverage and high out-of-pocket costs for patients), lack of awareness among providers and patients, cultural and religious constraints, and lack of funding to help to support oncofertility programs.

CONCLUSION

Despite barriers to care, many opportunities exist to grow the field of oncofertility in these five developing countries. It is important to continue to engage stakeholders in developing countries and use powerful networks in the United States and other developed countries to aid in the acceptance of oncofertility on a global level.

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

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

Modest Increase in Fertility Consultations in Female Adolescents and Young Adults with Lymphoma: A Population-Based Study

While survival after hematological malignancies in adolescent and young adult patients is improving, patients report poor oncofertility care. This population-based, retrospective, cohort study used data from the Ontario Cancer Registry and billing codes to identify fertility consultations for lymphoma patients between 2000 and 2018. Consultation trends across time and different patient and physician characteristics were analyzed. We identified 2088 patients and a consultation rate of 3.4% (increasing from 1% in 2000–2006 to 8% in 2014–2018). Patient parity and regional deprivation scores decreased rates. Despite mild improvement, there is ample missed opportunity for fertility discussions.

2019 Pediatric Initiative Network: Progress, Proceedings, and Plans

Impairment of fertility and sexual/reproductive health are common after oncologic therapy, and are known to have negative impacts on romantic relationships and psychosocial well-being among childhood cancer survivors. The Pediatric Initiative Network (PIN) is an international, multidisciplinary group of providers within the Oncofertility Consortium dedicated to preserving and protecting the fertility of children and adolescents at risk for infertility due to medical conditions or treatments. The PIN and its Best Practices and Research committees meet virtually throughout the year, with one annual in-person meeting. The purpose of this "proceedings" is to highlight key discussion points from the annual PIN meeting which took place on November 11, 2019, to 1) provide a context for pediatric groups across the country on what oncofertility programs are currently doing and why, and 2) inform stakeholders of past, present and future initiatives that may be of value to them and the patient populations they serve.

Installing oncofertility programs for common cancers in limited resource settings (Repro-Can-OPEN Study): An extrapolation during the global crisis of Coronavirus (COVID-19) pandemic

PURPOSE

The state of limited resource settings that Coronavirus (COVID-19) pandemic has created globally should be taken seriously into account especially in healthcare sector. In oncofertility, patients should receive their fertility preservation treatments urgently even in limited resource settings before initiation of anticancer therapy. Therefore, it is very crucial to learn more about oncofertility practice in limited resource settings such as in developing countries that suffer often from shortage of healthcare services provided to young patients with cancer.

METHODS

As an extrapolation during the global crisis of COVID-19 pandemic, we surveyed oncofertility centers from 14 developing countries (Egypt, Tunisia, Brazil, Peru, Panama, Mexico, Colombia, Guatemala, Argentina, Chile, Nigeria, South Africa, Saudi Arabia, and India). Survey questionnaire included questions on the availability and degree of utilization of fertility preservation options in case of childhood cancer, breast cancer, and blood cancer.

RESULTS

All surveyed centers responded to all questions. Responses and their calculated oncofertility scores showed different domestic standards for oncofertility practice in case of childhood cancer, breast cancer, and blood cancer in the developing countries under limited resource settings.

CONCLUSIONS

Medical practice in limited resource settings has become a critical topic especially after the global crisis of COVID-19 pandemic. Understanding the resources necessary to provide oncofertility treatments is important until the current COVID-19 pandemic resolves. Lessons learned will be valuable to future potential worldwide disruptions due to infectious diseases or other global crises.

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

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

Fertility preservation in women affected by gynaecological cancer: the importance of an integrated gynaecological and psychological approach

Gynaecological cancer treatment significantly affects the fertility of women in reproductive age. Surgery, chemotherapy and radiotherapy are the mainstays of ovarian, cervical and endometrial cancers and anatomically or functionally impact the uterus and ovaries. Moreover, the sexual function and psychological wellbeing of patients are highly weakened after a cancer diagnosis: depression, anxiety and impairment of quality of life represent a relevant concern for patient care. The potential loss of fertility could be more distressing than cancer itself. For this reason, it is of paramount importance to try to preserve fertility in women affected by gynaecological cancers. Recently, tailored fertility preservation therapies have been developed to meet the childbearing demand from more than half of women between 18 and 40 years with a diagnosis of cancer. Currently, fertility preservation techniques play a significant role in improving the quality of life of women with gynaecological cancer. In this scenario, we propose a narrative overview of the recent literature about the importance of a multidisciplinary approach in the management of fertility preservation in the case of gynaecological cancers.

Oncofertility Treatment Among Breast Cancer Women: A Paradigm Shift of Practice After a Decade of Service

Purpose: Our center is known as a pioneer center initiating oncofertility service since 2010 in Japan. We demonstrate our transition of this service in regional university hospitals ingenuously. Methods: We compared two phases of service: initial phase (2011 and 2012) and current phase (2019). The comparison included the number of women attending the oncofertility unit, diversity of breast cancer cases, the acceptability of preservation service, and the type of fertility preservation (FP) option offered in between these phases. Results: A total of 58 women were seen during the initial phase as compared with 41 women in the later phase. The mean age at diagnosis was not significantly different between the two periods. The majority of them were married and diagnosed with stage II luminar type. The current phase had a tendency to have a higher anti-Müllerian hormone level although not reaching significance. At least 50% of them declined FP and 84.5% never received ovarian control stimulation in the initial phase. Otherwise, 61% used aromatase inhibitor in the current phase. Only 15.5% in the initial phase received control ovarian stimulation whereas 63.4% in the current phase received it. The ovarian tissue cryopreservation was highly chosen during the initial phase (25.9%), whereas embryo cryopreservation (39%) was highly opted for during the current phase. All of our parameters are comparable between these two phases (p > 0.05). Conclusion: The significant changes of oncofertility practice were observed mainly due to the understanding of the oncofertility concept among reproductive physicians and the acceptance environment, including standard guidelines, supportive society, as well as advancements in cryobiology technique.

Preserving fertility in female patients with hematological malignancies: a multidisciplinary oncofertility approach

Oncofertility is a new interdisciplinary field at the intersection of oncology and reproductive medicine that expands fertility options for young cancer patients. The most common forms of hematological malignancies that occur in girls and young women and therefore necessitate oncofertility care are acute lymphocytic leukemia, acute myeloid leukemia, non-Hodgkin's lymphoma, and Hodgkin's lymphoma. Aggressive gonadotoxic anticancer regimens including alkylating chemotherapy and total body irradiation are used often in treating girls and young women with hematological malignancies. The risks of gonadotoxicity and subsequent iatrogenic premature ovarian insufficiency and fertility loss depend mainly on the type and stage of the disease, dose of anticancer therapy as well as the age of the patient at the beginning of treatment. To avoid or at least mitigate the devastating complications of anticancer therapy-induced gonadotoxicity, effective and comprehensive strategies that integrate different options for preserving and restoring fertility ranging from established to experimental strategies should be offered before, during, and after chemotherapy or radiotherapy. A multidisciplinary approach that involves strong coordination and collaboration between hemato-oncologists, gynecologists, reproductive biologists, research scientists, and patient navigators is essential to guarantee high standard of care.

The "Begin Exploring Fertility Options, Risks and Expectations" (BEFORE) decision aid: development and alpha testing of a fertility tool for premenopausal breast cancer patients

BACKGROUND

Premenopausal breast cancer patients are at risk of treatment-related infertility. Many patients do not receive sufficient fertility information before treatment. As such, our team developed and alpha tested the Begin Exploring Fertility Options, Risks, and Expectations decision aid (BEFORE DA).

METHODS

The BEFORE DA development process was guided by the International Patient Decision Aids Standards and the Ottawa Decision Support Framework. Our team used integrated knowledge translation by collaborating with multiple stakeholders throughout the development process including breast cancer survivors, multi-disciplinary health care providers (HCPs), advocates, and cancer organization representatives. Based on previously conducted literature reviews and a needs assessment by our team - we developed a paper prototype. The paper prototype was finalized at an engagement meeting with stakeholders and created into a graphically designed paper and mirrored online decision aid. Alpha testing was conducted with new and previously engaged stakeholders through a questionnaire, telephone interviews, or focus group. Iterative reviews followed each step in the development process to ensure a wide range of stakeholder input.

RESULTS

Our team developed an 18-page paper prototype containing information deemed valuable by stakeholders for fertility decision-making. The engagement meeting brought together 28 stakeholders to finalize the prototype. Alpha testing of the paper and online BEFORE DA occurred with 17 participants. Participants found the BEFORE DA usable, acceptable, and most provided enthusiastic support for its use with premenopausal breast cancer patients facing a fertility decision. Participants also identified areas for improvement including clarifying content/messages and modifying the design/photos. The final BEFORE DA is a 32-page paper and mirrored online decision aid ( https://fertilityaid.rethinkbreastcancer.com ). The BEFORE DA includes information on fertility, fertility options before/after treatment, values clarification, question list, next steps, glossary and reference list, and tailored information on the cost of fertility preservation and additional resources by geographic location.

CONCLUSION

The BEFORE DA, designed in collaboration with stakeholders, is a new tool for premenopausal breast cancer patients and HCPs to assist with fertility discussions and decision-making. The BEFORE DA helps to fill the information gap as it is a tool that HCPs can refer patients to for supplementary information surrounding fertility.

Insights into the Pathophysiology of Infertility in Females with Classical Galactosaemia

Classical galactosaemia (CG) (OMIM 230400) is a rare inborn error of galactose metabolism caused by the deficiency of the enzyme galactose-1-phosphate uridylyltransferase (GALT, EC 2.7.7.12). Primary ovarian insufficiency (POI) is the most common long-term complication experienced by females with CG, presenting with hypergonadotrophic hypoestrogenic infertility affecting at least 80% of females despite new-born screening and lifelong galactose dietary restriction. In this review, we describe the hypothesized pathophysiology of POI from CG, implications of timing of the ovarian dysfunction, and the new horizons and future prospects for treatments and fertility preservation.

Oncofertility: Pharmacological Protection and Immature Testicular Tissue (ITT)-Based Strategies for Prepubertal and Adolescent Male Cancer Patients

While the incidence of cancer in children and adolescents has significantly increased over the last decades, improvements made in the field of cancer therapy have led to an increased life expectancy for childhood cancer survivors. However, the gonadotoxic effect of the treatments may lead to infertility. Although semen cryopreservation represents the most efficient and safe fertility preservation method for males producing sperm, it is not feasible for prepubertal boys. The development of an effective strategy based on the pharmacological protection of the germ cells and testicular function during gonadotoxic exposure is a non-invasive preventive approach that prepubertal boys could benefit from. However, the progress in this field is slow. Currently, cryopreservation of immature testicular tissue (ITT) containing spermatogonial stem cells is offered to prepubertal boys as an experimental fertility preservation strategy by a number of medical centers. Several in vitro and in vivo fertility restoration approaches based on the use of ITT have been developed so far with autotransplantation of ITT appearing more promising. In this review, we discuss the pharmacological approaches for fertility protection in prepubertal and adolescent boys and the fertility restoration approaches developed on the utilization of ITT.

Fertility Preservation in Women With Malignancy: Future Endeavors

The area of fertility preservation is constantly developing. To date, the only noninvestigational and unequivocally accepted methods for fertility preservation are cryopreservation of embryos and unfertilized oocytes. This article is one of several in a monogram on fertility preservation. The debate, pros and cons, and equivocal data on the use of GnRH analogues for fertility preservation are elaborated by 3 other manuscripts, in this monogram. A repeat of the arguments, pros and cons of this debatable issue, would be a repetition and redundancy of what is already included in this monogram. The subject of ovarian cryopreservation for fertility preservation is also elaborated by several other authors in this monogram. It is possible that, in the not too far future, the technologies of in vitro maturation of primordial follicles to metaphase 2 oocytes, and the “artificial ovary,” will turn clinically available. These technologies may bypass the risk of resuming malignancy by autotransplantation of cryopreserved-thawed ovarian tissue in leukemia and diseases where malignant cells may persist in the cryopreserved ovarian tissue. We summarize here the suggested options for future endeavors in fertility preservation.

Oncofertility to Evidence-Based Practice: Changes in Fertility Intention and Symptom Burden in Reproductive-Age Women With Breast Cancer

BACKGROUND

Infertility is negatively related to the quality of life in reproductive-age women with breast cancer. The nurses who care for these patients lack a comprehensive understanding of the changes in fertility intention that patients undergo from the time of cancer diagnosis, throughout treatment, and after treatment. A fertility intention assessment is the first step in discerning the patient's ideas toward future pregnancy.

AIMS

This study examined the changes in fertility intention and symptom burden in reproductive-age women with breast cancer before, during, and after treatment. We also explored predictors of fertility intention among the women.

METHODS

The study was guided by the theory of planned behavior. A longitudinal and observational study was conducted with 151 women with breast cancer who were treated at a teaching hospital in Taipei. The participants were interviewed using a structured questionnaire before, during, and after chemotherapy from July 2016 to March 2018. Fertility intention was assessed using the Fertility Intention Scale. The M.D. Anderson Symptom Inventory-Taiwanese version was used to measure the symptom burden. The generalized linear mixed model was used for multivariate analysis.

RESULTS

Patients had significantly lower scores for fertility intention after treatment than before treatment. The study patients had substantially worse symptom burden during treatment than before or after treatment. Symptom burden scores, especially for symptom interference, correlated significantly with fertility intention. A higher Fertility Intention Scale score was significantly associated with younger age.

LINKING EVIDENCE TO ACTION

Fertility intention decreased over time in women with breast cancer. Understanding fertility intention and controlling symptom burden throughout the course of treatment and beyond might help nurses provide better care for preserving fertility and maintaining fertility options for these women with breast cancer.

FertiPROTEKT, Oncofertility Consortium and the Danish Fertility-Preservation Networks - What Can We Learn From Their Experiences?

Fertility preservation is an increasingly important discipline. It requires close coordination between reproductive medicine specialists, reproductive biologists, and oncologists in various disciplines. In addition, it represents a particular health policy challenge, since fertility-protection measures are to be understood as a treatment for side effects of gonadotoxic treatments and would therefore normally have to be reimbursed by health insurance companies. Therefore, it is inevitable that fertility-preservation activities should organise themselves into a network structure both as a medical-logistic network and as a professional medical society. The necessary network structures can differ significantly at regional, national, and international level, as the size of the regions to be integrated and the local cultural and geographical conditions, as well as the political conditions are very different. To address these issues, the current review aims to point out the basic importance and the chances but also the difficulties of fertility-protection networks and give practical guidance for the development of such network structures. We will not only discuss network structures theoretically but also present them based on three established, different sized networks, such as the Danish Network (www.rigshospitalet.dk), representing a centralised network in a small country; the German-Austrian-Swiss network FertiPROTEKT® (www.fertiprotekt.com), representing a centralised as well as decentralised network in a large country; and the Oncofertility® Consortium (www.oncofertility.northwestern.edu), representing a decentralised, internationally oriented network, primarily serving the transfer of knowledge among its members.

Female oncofertility attitude and knowledge: a survey of reproductive health professionals in Shanghai, China

AIM

To evaluate the female oncofertility attitude and knowledge of reproductive health professionals in China.

METHODS

An online survey was distributed to reproductive health professionals in Shanghai, China.

RESULTS

Female professionals were more likely to consider that cancer patients would want to preserve their fertility. Participants with higher educational background tended to have a more positive attitude toward oncofertility. The majority of the participants (71.0%) obtained a fair or low level of oncofertility knowledge, and only 25.3% of them received scores at the 'good knowledge' level.

CONCLUSION

There are significant gaps in the current oncofertility knowledge among reproductive health professionals in China, suggesting an urgent, unmet need for establishing an interdisciplinary fertility preservation training and service system.

Sexuality and cancer: The experience of adolescents and young adults

There are many components affecting the experience of sexuality for adolescents and young adults living with and beyond cancer. For patients, the interruption to normal socialization creates gaps in information and experience that potentially hinder development. In clinical practice, conversations relating to sexual consequences of illness or treatment are rare, as are age-appropriate assessment and intervention. In service design, the collaborative approach of oncofertility has yet to be replicated for sexuality. This paper considers how these obstacles can be overcome through local service development to address unmet need and promote sexual well-being for this group of patients.

The National Physicians Cooperative: transforming fertility management in the cancer setting and beyond

Once unimaginable, fertility management is now a nationally established part of cancer care in institutions, from academic centers to community hospitals to private practices. Over the last two decades, advances in medicine and reproductive science have made it possible for men, women and children to be connected with an oncofertility specialist or offered fertility preservation soon after a cancer diagnosis. The Oncofertility Consortium's National Physicians Cooperative is a large-scale effort to engage physicians across disciplines – oncology, urology, obstetrics and gynecology, reproductive endocrinology, and behavioral health – in clinical and research activities to enable significant progress in providing fertility preservation options to children and adults. Here, we review the structure and function of the National Physicians Cooperative and identify next steps.

Oncofertility-An emerging discipline rather than a special consideration

Originally absent from the oncologist's consult, then placed in a 'quality of life' rubric, oncofertility should now be an essential part of a comprehensive cancer treatment plan in patients of reproductive age, including adolescents and young adults (AYAs). Oncofertility encompasses the endocrine health of the patient, as well as fertility management options. Thus, pubertal transitions in males and females, bone health, and menstrual health are all part of this discipline, enabling practitioners to work in interdisciplinary teams to solve problems in reproductive health. This review provides a summary of the essential considerations required for the assessement of reproductive risk and choice of fertility preservation options as well as considerations for developing oncofertility services for AYAs.

A Survey Study of Attitude and Knowledge Regarding Female Fertility Preservation Among Reproductive Health Professionals in Fujian, China

PURPOSE

Oncofertility is a newly developed medical field dedicated to preserving adolescent and young adult-aged cancer patients' fertility. For female cancer patients who desire to have children, fertility preservation has become an important concern before the cancer therapy. This study for the first time aimed to investigate attitude and knowledge regarding female fertility preservation among reproductive health professionals in China.

METHODS

An online questionnaire assessing participants' demographics, experience, attitude, and basic knowledge regarding oncofertility was designed and distributed to reproductive health professionals in Fujian, one of the major regions for cancer and reproductive care in southeast China.

RESULTS

The majority of participants (96.6%) who were familiar with fertility preservation were willing to collaborate with oncologists on preserving patients' fertility. However, ∼20% of participants were not familiar with the term fertility preservation, and 30.4% and 52.2% of them were never consulted by a cancer patient or an oncologist about the infertility risk from cancer therapy, respectively. Years of working experience, but not gender, educational background, and marital status, was significantly associated with participants' oncofertility experience and attitude. A majority of participants (79.3%) had a middle or low level of oncofertility knowledge, which was significantly linked to their educational background.

CONCLUSION

Most of the surveyed reproductive health professionals held a positive attitude toward interdisciplinary collaboration with oncologists during oncofertility practice. However, the lack of their oncofertility knowledge highlighted the need of standard oncofertility education and training in China.