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

Impact of cancer during reproductive age on the probability of livebirth after cancer: a register-based cohort study among Danish women aged 18-39 with and without cancer

PURPOSE

This register-based study investigates the probability of a livebirth after cancer during the female reproductive age.

METHODS

The study population, derived from the DANAC II cohort, included women aged 18-39 diagnosed with cancer between 1978 and 2016, matched with 60 undiagnosed women each from the general population. Primary outcome was a livebirth after cancer with follow-up until death, emigration, or end of follow-up. Hazard ratios (HR) were calculated using multivariable Cox regression analyses.

RESULTS

The population included 21,596 women with cancer and 1,295,760 without. The 20-year cumulative incidence of livebirth after cancer/study entry was lower among women with cancer (0.22 [95% CI 0.22-0.22]) compared to those without (0.34 [95% CI 0.34-0.34]). The HR of a livebirth after cancer was 0.61 [95% CI 0.59-0.63]; highest at age 18-25 (HR = 0.72 [95% CI 0.68-0.76]); and lowest at age 33-39 (HR = 0.50 [95% CI 0.47-0.54]). Nullipara women had higher HR of a livebirth than those with children (HR = 0.72 [95% CI 0.69-0.75] vs. HR = 0.48 [95% CI 0.46-0.51]). HR was lowest for women with breast, gynecological, central-nerve-system cancer, and leukemia. Women with/without cancer were comparable in assisted reproductive technology initiation after cancer/study entry, but HR was higher among nullipara than in those with prior children.

CONCLUSIONS

Cancer during reproductive years significantly and negatively impacts HR of a livebirth after cancer, particularly as age at diagnosis increases. Low HR of livebirth is observed in specific cancer groups.

IMPLICATIONS FOR CANCER SURVIVORS

Results underscore the importance of oncofertility counseling at diagnosis, referral to fertility specialist before treatment, and follow-up after cancer, focusing on cancer type, parity status, and age at diagnosis.

Planned Immediate Chemotherapy and Cryopreservation of Oocytes or Embryos for Fertility Preservation in Women with Malignancies

Purpose: Oocyte and embryo cryopreservation before gonadotoxic treatment are established methods to increase the likelihood of live births. Although several sociodemographic factors were found to be associated with undergoing fertility preservation (FP) treatment, clinical characteristics such as planned immediate chemotherapy were not fully investigated. We aimed to investigate whether the planned immediate chemotherapy is related to the decision to undergo oocyte/embryo cryopreservation for FP with adjustment for other clinical characteristics. Methods: This institutional cohort study included 491 premenopausal women aged 19 years or older who visited the FP clinic at a tertiary medical center between 2006 and 2019. The primary outcome was whether the participants underwent oocyte/embryo cryopreservation. We evaluated the odds ratios (ORs) and corresponding 95% confidence intervals (CIs) of undergoing oocyte/embryo cryopreservation according to whether immediate chemotherapy was planned using univariable and multivariable logistic regression. Results: Women scheduled for immediate chemotherapy were much less likely to undergo oocyte/embryo cryopreservation than women not scheduled for immediate chemotherapy (OR = 0.46, 95% CI 0.27-0.76) in univariable logistic regression analysis. After adjustment for covariates such as marital status, type of malignancies, and calendar year period, women scheduled for immediate chemotherapy were still less likely to undergo oocyte/embryo cryopreservation than women not scheduled for immediate chemotherapy (OR = 0.31, 95% CI: 0.17-0.56). The association was not different according to the type of malignancies (p for interaction = 0.13). Regarding breast cancer, the OR for undergoing oocyte/embryo cryopreservation in women scheduled for immediate chemotherapy was robust compared with those not planned for immediate chemotherapy (OR = 0.25, 95% CI: 0.12-0.53). Conclusion: The present study demonstrated that planned immediate chemotherapy was negatively associated with undergoing oocyte/embryo cryopreservation. This information can be helpful for FP counseling.

Patient-Related Awareness of Impact of Cancer-Directed Therapy on Fertility in Young Women Diagnosed of Breast Cancer

Nita S. Nair Chemotherapeutic agents used in the treatment of breast cancer (BC) adversely impact growing ovarian follicles and can induce permanent premature ovarian failure or reduce ovarian reserve in younger women. As treatments result in improved survival of BC patients, young survivors face quality of life (QOL) issues, including treatment-related infertility. We conducted a survey to evaluate awareness among patients regarding the impact of cancer-directed therapy on fertility and available options of fertility preservation (FP). We interviewed 350 women with BC under 40 years of age at the start of treatment, of which 321 (91.70%) were in varying stages of follow-up, 8 women (2.30%) were scheduled to start treatment, and 21 (6.00%) women were under treatment. All received chemotherapy or hormone therapy with or without ovarian suppression. Of the 350 women who responded to the survey, 321 (91.70%) women were on follow-up, 8 (2.30%) women were due to start treatment, and 21 (6%) women were on treatment. The median age at diagnosis was 35 years, with 12.9% of women aged less than 30 years, 15 (4.28%) were unmarried, 31 (8.85%) were nulliparous, and 98 (28%) had one child. Overall, 271 (77.42%) women were aware (at the start of treatment) of impact of therapy on fertility, but only 48/271(17.71%) women were aware of the options of FP. In this cohort, 94/350 (26.85%) women felt FP was a priority, 64/350 (18.28%) women perceived their family as incomplete, and 17/64 (26.56%) women were willing to consider invasive reproductive assistance (IRA). Reasons for refusal for IRA included cost, risk of relapse, and delay of treatment. There was an association between being unmarried ( p  = 0.00), having an incomplete family (0.00), considering more children ( p  = 0.00) and willingness to consider IRA. FP is a priority for women treated for BC and an important QOL domain that needs to be addressed at the start of treatment We found a high level of awareness of impact of cancer-directed therapy to fertility in this cohort, but low awareness and acceptance for options for FP.

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.

Fertility Preservation in Children and Adolescents during Oncological Treatment-A Review of Healthcare System Factors and Attitudes of Patients and Their Caregivers

Oncofertility is any therapeutic intervention to safeguard the fertility of cancer patients. Anti-cancer therapies (chemotherapy, radiation therapy, etc.) entail the risk of reproductive disorders through cytotoxic effects on gamete-building cells, especially those not yet fully developed. This literature review analyzes the available data on securing fertility in pediatric and adolescent populations to identify the methods used and describe aspects related to financing, ethics, and the perspective of patients and their parents. Topics related to oncofertility in this age group are relatively niche, with few peer-reviewed articles available and published studies mostly on adults. Compared to pubertal individuals, a limited number of fertility preservation methods are used for prepubertal patients. Funding for the procedures described varies from country to country, but only a few governments choose to reimburse them. Oncofertility of pediatric and adolescent patients raises many controversies related to the decision, parents' beliefs, having a partner, ethics, as well as the knowledge and experience of healthcare professionals. As the fertility of young cancer patients is at risk, healthcare professionals should make every effort to provide them with an opportunity to fulfill their future reproductive plans and to have a family and offspring. Systemic solutions should form the basis for the development of oncofertility in pediatric and adolescent populations.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Reproductive concerns among young adult women with breast cancer: a systematic review protocol

INTRODUCTION

Reproductive concerns refer to worries about impaired or lost reproductive ability due to disease or/and treatment. Many young female patients with breast cancer experience reproductive concerns because they still desire to have children at the time of diagnosis. Reproductive concerns can impact patients' treatment decision-making as well as their psychological health and quality of life. Understanding the situation, contributing factors and health-related consequences of reproductive concerns among patients with breast cancer is essential to minimise their impacts.

METHODS AND ANALYSIS

A systematic review will be conducted. We will search five English databases (PubMed, Embase, CINAHL, Web of Science and APA PsycInfo) and four Chinese databases (Wang Fang database, VIP, CBM and CNKI) for pertinent studies. Other relevant studies will be identified from the reference lists of included studies. Two reviewers will independently perform study selection, data extraction and quality appraisal. Any discrepancies between the two reviewers will be resolved through consultation and discussion with the senior reviewer. A formal narrative synthesis will be performed to summarise the findings of individual studies. This review aims to improve understanding of the level of reproductive concerns, factors associated with reproductive concerns and health-related consequences of reproductive concerns among patients with breast cancer. The findings can contribute to the development of tailored interventions to alleviate reproductive concerns of patients with breast cancer, enhancing their psychological health and quality of life.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review, as it will be based on published studies. The findings will be disseminated by publishing in a journal.

PROSPERO REGISTRATION NUMBER

CRD42022375247.

Efficacy of Video-based Education in Improving Understanding of Pediatric Fertility Preservation

Eighty percent of children diagnosed with cancer in childhood survive into adulthood. Fertility preservation (FP) is an important consideration, and procedures are available to reduce the risk of infertility following gonadotoxic therapies. Discussing FP options eases decision-making and minimizes regret; however, poor comprehension of these topics remains a challenge. This study evaluates if video-based educational tools increase understanding of FP options among pediatric patients and families. Videos were first tested among participants not at risk of infertility to ensure objective utility and optimize quality. In part 1, parents of pediatric surgical patients were randomized to view 2 publicly available educational videos on FP in differing orders. Each group completed pre-surveys and post-surveys assessing the comprehension and perception of video quality. In part 2, the parent and patient participants completed a comprehension assessment before and after viewing our institution-specific educational video, designed based on participant feedback from part 1. Part 1 results demonstrated a significant increase in participant knowledge and perceived understanding after viewing the videos ( P <0.001), regardless of order. In part 2, the post-test comprehension scores were significantly improved for all participants and all subgroups, P <0.01. Results suggest that video-based educational tools may help to reduce barriers to FP in pediatric oncology.

Effectiveness and feasibility of online fertility preservation decision aids for young female patients with cancer: a systematic review protocol

INTRODUCTION

Cancer diagnosis and treatment can impair fertility, and younger female patients with cancer have a particularly strong need for fertility preservation. Fertility preservation decision aids are thought to help patients make proactive and informed treatment decisions. This systematic review aims to assess the effectiveness and feasibility of online fertility preservation decision aids for young female patients with cancer.

METHODS AND ANALYSIS

PubMed, Web of Science Core Collection, Embase, The Cochrane Central Register of Controlled Trials, PsycINFO and CHINAL, along with three grey literature sources (Google Scholar, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform), will be searched from each database's establishment to 30 November 2022. Two trained reviewers will independently screen the articles, and the data extraction and methodological quality of eligible randomised controlled trials and quasiexperimental studies will be assessed. A meta-analysis will be performed using Review Manager V.5.4 (Cochrane Collaboration) software, and heterogeneity will be assessed using I² statistics. If a meta-analysis is not possible, a narrative synthesis will be done.

ETHICS AND DISSEMINATION

Since this systematic review is based on published data, no ethical approval is required. The study's findings will be disseminated through peer-reviewed publications and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42022363287.

Access to information and oncofertility consultation for young women with breast cancer: a population-based study

Non-menopausal women with breast cancer treated with chemotherapy are at intermediate risk of post-treatment amenorrhea and decreased fertility. Although they should receive appropriate information, studies until now show that this is inadequate. We investigated the proportion of women who received information about this risk during the pre-treatment consultation, and those who received an oncofertility consultation to preserve their gametes. We also analysed the medical and non-medical factors influencing the transmission of information to patients and their uptake of oncofertility consultations. We included women aged 18-40 years treated with chemotherapy for breast cancer between 2012 and 2017 in the Midi-Pyrénées region (ca. 3 million inhabitants), France. Studied variables were included in a multilevel model. Among the 575 women, 41% of the women received information and 28% received an oncofertility consultation. These two steps on the care pathway were significantly influenced by the type of care structure, the woman's age, her parity at the time of diagnosis, and the metastatic status of the cancer. Female oncologist gender was significantly associated with higher transmission rate. We found no association between neoadjuvant chemotherapy status, level of deprivation (EDI), triple-negative status, marital status, and first-degree family history of cancer and information transmission or uptake of oncofertility consultation. Our study shows that not enough women are informed and have recourse to an oncofertility consultation. Despite a legal obligation, the health care system does not offer the necessary conditions for access to oncofertility care.

Fertility preservation is an imperative goal in the clinical practice of radiation oncology: a narrative review

With reduced cancer mortality in recent years, increased efforts must be put into safeguarding cancer survivors' long-term quality of life (QOL). Fertility preservation is recognised as a key component of QOL in survivorship. Concerns about fertility have been seen to significantly impact cancer patients' emotional and mental health as, generally, both malignancy and its treatment may cause a temporary or permanent reduction in infertility. This article reviews the primary effects of radiation therapy on male and female gonads and has further highlighted procedures through which the functioning of these organs can be protected before or during radiation treatment. We have also emphasised the importance of the establishment of multidisciplinary tumour boards and patient education regarding future reproductive function which is an important component of the care of individuals with cancer. This article highlights that infertility is a persistent and major concern that can add to long-term stress in cancer survivors, and education about fertility preservation before the initiation of any treatment is especially important.

Ovarian tissue cryopreservation and transplantation for fertility preservation

Background: As the number of cancer survivors has increased with advancements in cancer treatment, fertility preservation has become a treatment goal. Ovarian tissue cryopreservation (OTC) and transplantation (OTT) has made great progress over the past few decades. It has become the treatment of choice for fertility preservation in adolescents or patients in urgent need of chemotherapy. However, it is considered to be experimental compared with oocyte or embryo cryopreservation in some countries. Nevertheless, OTC and OTT is regarded as the more ideal method for fertility preservation in that it can also restore hormonal functions.Current Concepts: Currently, over 200 live births have been reported worldwide after OTC and OTT, proving the excellence of the technology. However, before its application in clinical settings, some challenges, including cryoinjury, ischemic injury, and cancer cell reimplantation, should be overcome. For cryoinjury, studies are underway on protocol improvement with the addition of agents such as antifreeze protein during cryopreservation. For ischemic injury, various agents have been studied to promote angiogenesis or revascularization. Furthermore, studies are underway on artificial ovary or xenotransplantation for fertility preservation in an effort to avoid cancer cell metastasis.Discussion and Conclusion: OTC and OTT is a clinically applicable option for fertility preservation. To set OTC and OTT as an established method for fertility preservation, further research is necessary to overcome the current challenges.

Planned oocyte cryopreservation for fertility preservation

Background: Oocyte cryopreservation opens up opportunities for women to preserve fertility when it is necessary to postpone pregnancy. After the advent of vitrification, the results of oocyte cryopreservation were significantly improved compared to conventional slow-freezing. Through these improvements, oocyte cryopreservation was introduced to overcome a decline in fecundity due to an increase in age, and this modality is defined as planned oocyte cryopreservation.Current Concepts: Oocytes cryopreserved through vitrification appear to result in similar clinical pregnancy rates and live birth rates compared to fresh oocytes, though the evidence is still limited. It has been reported that the live birth rate increases when the planned oocyte cryopreservation is performed at a younger age. Obstetrical and neonatal outcomes appear similar between vitrified and fresh oocytes.Discussion and Conclusion: Preliminary data supports planned oocyte cryopreservation as a feasible modality resulting in fertility preservation and subsequent live births. The fact that performing the procedure at a younger age can increase the oocyte yield, oocyte efficacy, and live birth rate can be discussed along with patient consultation. However, as there is still a lack of data on the standardized live birth rate, the number of oocytes to be collected, and the long-term effect on the children; more well-designed studies are needed to improve counseling and decision-making in patients seeking this treatment.

Cryopreservation of oocytes and embryos for fertility preservation

Background: In recent years, the demand for fertility preservation for both oncologic and nononcologic reasons, as well as for personal reasons, has increased dramatically.Current Concepts: Currently, embryo and oocyte cryopreservation after ovarian stimulation are the mainstays of fertility preservation treatment in women. Embryo cryopreservation is an established and the most successful method of fertility preservation when sufficient time (approximately 2 weeks) is available to perform ovarian stimulation. Recent advances in freezing techniques (vitrification) have significantly improved the outcomes from oocyte cryopreservation that are comparable with those from embryo cryopreservation.Discussion and Conclusion: This review focuses on the indications for the two techniques of fertility preservation and their results. For women to receive timely opportunities to preserve fertility, it is necessary to raise awareness among all medical departments and the public.

History of fertility preservation

Background: Fertility preservation refers to a procedure performed to maintain the ability to become pregnant before receiving treatment with a risk of fertility loss, such as chemo- or radiation therapy. Examples of fertility-preserving procedures include freezing, sperm freezing, embryo freezing through in vitro fertilization, and ovarian tissue freezing.Current Concepts: Until the late 1990s, awareness of fertility preservation among clinicians and patients was relatively low, and the only way to preserve and restore fertility in women with cancer was the cryopreservation of embryos. However, as the survival rate of cancer patients increased and the treatment results of various diseases improved, interest in quality of life such as pregnancy and childbirth after treatment gradually increased, and became a driving force for the development of fertility preservation. In the 2000s, several centers began cryopreserving ovarian tissue, including primordial follicles from young patients before chemotherapy. Currently, ovarian tissue cryopreservation can be used in combination with in vitro maturation and egg vitrification techniques. Novel methods to improve follicle survival after transplantation are currently being investigated. Methods to improve follicle survival after transplantation and new ovarian protective agents to protect the ovaries from cytotoxic agents are currently being studied.Discussion and Conclusion: Advances in fertility-preserving technologies in the future will contribute to the delivery of healthy children by providing tailored treatments and more individualized fertility-preserving strategies to patients whose fertility is at risk.

Precursor B-cell acute lymphoblastic leukaemia-a global view

As haematologists, we always seek to follow standardised guidelines for practice and apply the best treatment within our means for our patients with blood diseases. However, treatment can never follow an exact recipe. Opinions differ as to the best approach; sometimes more than one treatment approach results in identical outcomes, or treatments differ only by the manner in which they fail. Furthermore, the haematologist is faced with constraints relating to the local economic environment. Patients too are not the same the world over. Early presentation is commoner in the developed world, as is the patient’s understanding of the disease process. This in turn has an impact on the way patients are managed, the rigorousness of patient adhesion to the treatment schedule and the outcome. Here we take a look at the precursor B‐cell acute lymphoblastic leukaemia in an adolescent in a range of different settings from low‐ to high income countries with widely differing challenges for diagnosis, therpy and follow‐up. For these reasons, given the same starting conditions, patients will be treated differently according to the institute and the country they are in. Experts from around the world have been tasked to describe their management plan and rationale for a specific disease presentation. Here they explore the management of precursor B‐cell acute lymphoblastic leukaemia (pre‐B ALL) in five different institutions worldwide with a focus on those with more or less strained economies. We end with a conclusion from an expert in the field comparing and contrasting these different management styles and considering their merits and limitations.

Addressing Barriers to Fertility Preservation for Cancer Patients: The Role of Oncofertility Patient Navigation

BACKGROUND

Infertility is a common late effect for cancer survivors. Whereas assisted reproductive technology has made it possible for survivors to take steps to preserve fertility before starting treatment, only a minority of patients proceed with preservation. Patient-, provider-, health system-, and societal-level barriers to fertility preservation (FP) exist. Oncofertility patient navigation is a valuable resource for addressing FP barriers.

OBJECTIVES

To highlight the critical role of oncofertility patient navigation in addressing barriers to FP within an academic oncofertility program.

METHODS

The role of the oncofertility patient navigator in reducing FP barriers, promoting informed decision-making, and ensuring program sustainability is described. Program metrics illustrating the impact of oncofertility patient navigation on referrals for FP counseling and access to FP in the last year also are provided.

DISCUSSION

The oncofertility program at our academic adult and pediatric medical centers aims to facilitate rapid referral to fertility counseling and preservation services for postpubertal cancer patients. The patient navigator is integral to the success of the program. The navigator ensures that patients are: (1) well-informed about the potential impact of cancer on fertility and FP options, (2) aware of available resources (eg, financial) for pursuing FP, (3) able to access FP services if desired, and (4) well supported in making an informed FP decision. The inclusion of the patient navigator has led to an almost 2-fold increase in referrals for FP counseling in the past year over the historic annual average.

CONCLUSIONS

Our institution's oncofertility program, with patient navigation at the core, provides a potential model for increasing patient access to oncofertility care and promoting program sustainability. Oncofertility patient navigation is a valuable resource for providing patients and families with education and support regarding FP decision-making, as well as addressing the multilevel barriers to FP.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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