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Fertility preservation in cancer patients
This national survey of physicians found that while most discuss the impact of cancer treatment on fertility, barriers remain. Physicians with more knowledge and favorable attitudes about fertility preservation were more likely to discuss it. The main barrier to discussion was patients being too ill to delay treatment. Female physicians and those whose patients inquire about fertility were more likely to refer patients. Future directions include improving physician education and developing interventions to facilitate discussion.
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Fertility preservation in cancer patients
- 1. National Survey of PhysiciansPractice Patterns: Fertility Preservation and Cancer Patients G. Quinn, S. T. Vadaparampil, P. Jacobsen, J. Lee, J. Lancaster, G. Bepler, D. L. Keefe, T. L. Albrecht Moffitt Cancer Center, Tampa, FL Karmanos Cancer Center, Detroit, MI
- 2. Fertility and CancerPatients • 450,000 cancer survivors in US are of reproductive age (19-39) 1 • Cancer treatment may result in loss of fertility. 2 – 1 Greenlee R, Hill-Harman M, T TM, al e. Cancer statistics, 2001. CA Cancer J Clin 2001;51:15-36. – 2 Oktay K, Beck L, Reinecke J. 100 Questions and Answers About Cancer and Fertility. Sudbury, Mass: Jones And Bartlett Publishers, 2008.
- 3. Cancer Related Infertility Therates vary among patients and depend on a number of factors: • Age • Sex • Diagnosis • Radiation field • Pretreatment of fertility
- 4. Infertility of Femalesand Males Females 40-80% chance of losing fertility following chemotherapy or radiation during reproductive years • Males 30-75% of male cancer patients become sterile after cancer treatment
- 5. Chemotherapy and Fertility •Chemotherapeutic agents have been implicated in ovarian failure. These include alkylating agents, antimitotic antibiotics, and vinca alkaloids that directly affect mitosis as well as antimetabolites that affect DNA synthesis. • Cyclophosphamide: Gonadotoxic doses for prepubertal females occur at a cumulative dose of 400 mg/kg, slightly higher than for postpubertal women, who are susceptible at doses of 200 to 300 mg/kg. • Doxorubicin seems to decrease fertility • Vinca alkaloids (vincristine and vinblastine) and antimetabolites (fluorouracil, cytarabine, and methotrexate), both of which affect cell division, have not been associated with ovarian failure. • Regardless of the chemotherapeutic agent used, patient age is the single most important determining factor for gonadal toxicity after exposure to chemotherapy. • The older the patient at the time of administration of systemic chemotherapy, the greater the probability of permanent gonadal failure Alexander, Carolyn J. M.D.; Tanner, Edward J. M.D.; Kolp, Lisa A. M.D. Fertility After Cancer Therapy. Postgraduate Obstetrics & Gynecology. 25(5):1-7, March 15, 2005. Alexander, Carolyn J. M.D.; Tanner, Edward J. M.D.; Kolp, Lisa A. M.D. Fertility After Cancer Therapy. Postgraduate Obstetrics & Gynecology. 25(5):1-7, March 15, 2005.
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- 8. Patients Views onInfertility • Studies of cancer patients report that loss of fertility is an immense concern that may cause great distress. • Distress and concern often does not manifest till post-treatment • Many cancer patients prefer to have biological children rather than adopt or use third-party reproduction. • Schover L, Brey K, Lichtin A, Lipshultz L, Jeha S. Knowledge and Experience Regarding Cancer, Infertility, and Sperm Banking in Younger Male Survivors. Journal of Clinical Oncology 2002a;20:1880-9. • Schover L, Rybicki L, Martin B, Bringelsen K. Having Children after Cancer: A Pilot Survey of Survivors' Attitudes and Experiences. Cancer 1999;86:697-709
- 9. Fertility Preservation Options • Fertility preservation(FP) options are available for cancer patients to preserve fertility prior to treatment.
- 10. FP Options forPatients Male Option – Sperm cryopreservation Female Options – Embryo cryopreservation – Egg freezing – Ovarian transposition
- 11. ASCO Recommendations on FertilityPreservation in Cancer Patients: • What Is the Role of the Oncologist in Advising Patients About Fertility Preservation Options? As with other potential complications of cancer treatment, oncologists have a responsibility to inform patients about the risk that their cancer treatment will permanently impair fertility. An algorithm for triaging fertility preservation referrals is presented in Figure 1, and suggested talking points are illustrated in the sidebar. • Journal of Oncology Practice, Vol 2, No 3 (May), 2006: pp. 143-146 © 2006 American Society of Clinical Oncology.
- 12. Recall of Discussion& Referral 51% of young breast cancer survivors were satisfied with their fertility discussion • 55% of male cancer survivors of childbearing age received a referral for sperm banking • Leonard M, Hammelef K, Smith G. Fertility Considerations, Counseling, and Semen Cryopreservation for Males Prior to the Initiation of Cancer Therapy. Clinical Journal of Oncology Nursing 2004;8(2):127-31. • Schover L, Rybicki L, Martin B, Bringelsen K. Having Children after Cancer: A Pilot Survey of Survivors' Attitudes and Experiences. Cancer 1999;86:697-709. • Zebrack B, Casillas J, Nohr L, al e. Fertility issues for young adult survivors of childhood cancer. Psychooncology 2004;13:689-699. • Patridge AH, Gelber S, Pepperson J, Sampson E, Knudsen K, Laufer M, Rosenberg R, Przypyszny M, Rein A, Winer EP. Web-based survey of Fertility issues in young women with breast cancer. Journal of Clinical Oncology 2004 22, 20 4174- 4183.
- 13. Survey Development Method •Literature Review • Focus Groups • Interviews with Physicians • Pilot Testing Instrument • Expert Reviews
- 14. “You have a20% chance of survival – have you ever thought about having kids?”
- 15. “My patients usuallystart treatment within 24 hours”
- 16. “I’ve had tofind shoes for my patients to go home in”
- 17. National Physician Survey Thepurpose of this study was to assess oncologists’ practice patterns concerning referral for FP and to examine characteristics which may impact referral of cancer patients of childbearing age. American Cancer Society
- 18. Physician Survey • 58items • Domains: • Demographics / Medical Background (21) • Knowledge (5) • Attitudes and Perceptions (10) • Barriers (6) • Practice Behaviors (11)
- 19. • Physicians wereidentified through the American Medical Association (AMA) database • Surveys were mailed to 1,979 physicians throughout the United States • Modified Dillman method was used for recruitment Recruitment Methods
- 20. Sampling: Inclusion Criteria Physiciansin the following specialties: • Hematology Obstetrics Gynecology Medical Surgical Radiation Urology Dermatology Musculoskeletal
- 21. Sampling: Inclusion Criteria: 1)Graduation from medical school after 1945 2) Practicing medicine in the US including Puerto Rico 3) Likely to see cancer patients (i.e. excluded those who did not list patient care as their primary job and locum tenens)
- 22. Response Rate • 33%response rate • 613 completed surveys • $100 honorarium
- 23. Factors Related toDiscussion • Knowledge –Oncologists who are knowledgeable about FP were 2.6 times more likely to discuss the impact of cancer treatment than those who were not knowledgeable. –Oncologists who are knowledgeable about FP are 1.9 times more likely to report feeling comfortable discussing FP than those who are not knowledgeable.
- 24. Factors Related toDiscussion • Favorable Attitudes –Oncologists with favorable attitudes towards FP were 4.9 times more likely to discuss the impact of cancer treatment on future fertility than those who had unfavorable attitudes. • Specialty –GYN and Medical / Hematological oncologists were most comfortable discussing FP.
- 25. Factors Related toReferral • Gender –Female oncologists are 2.12 times more likely to refer to REI than male oncologists. • Favorable Attitude –Physicians with a favorable attitude towards fertility preservation were more likely to refer patients compared to those with an unfavorable attitude.
- 26. Factors Related toReferral • Patient Inquiry –Physicians who responded “always” or “often” to the statement “Patients ask me about the effects of cancer treatment on their fertility” were twice as likely to refer patients - compared to those who responded “sometimes,” “rarely,” or “never”.
- 27. Barriers to DiscussingFP The primary barrier to discussion was inabilty to delay treatment because patient too ill. Always/Often Sometimes Rarely/Never A patient is too ill to delay treatment to pursue FP. 35% 44% 21% A patient can not afford FP. 29% 41% 29% A patient does not want to discuss FP. 14% 50% 37% There is no place/person to refer my patient to for FP. 9% 13% 79% Time constraints affect my ability to discussion FP. 12% 23% 66%
- 28. Practice Patterns Always/Often Sometimes Rarely/Never Iconsult an infertility specialist or reproductive endocrinologist with questions about potential fertility issues in my patients. 24% 29% 47% I refer patients who have questions about fertility to an infertility specialist or reproductive endocrinologist. 47% 29% 24% I discuss the impact of cancer treatments on future fertility with my cancer patients. 77% 16% 7% I provide my patients with educational materials about FP. 14% 26% 60%
- 29. National Physician Survey Results-Practice PatternsAlways/ Often Sometimes Rarely/ Never I consult an infertility specialist or reproductive endocrinologist with questions about potential fertility issues in my patients. 24 29 47 I refer patients who have questions about fertility to an infertility specialist or reproductive endocrinologist. 47 29 24 I discuss the impact of cancer treatment on future fertility with my cancer patients. 77 16 7 I provide my patients with educational materials about FP. 14 26 60 How often do you utilize the 2006 ASCO recommendations on FP in cancer patients, when making decisions about healthcare for your patients?* 18 22 22 * 37.8% of physicians reported they were unaware of the guidelines.
- 30. Conclusions The majority ofphysicians may not be –Following ASCO guidelines –Consulting specialists
- 31. Future Directions A significantbarrier is limited time to discuss the cancer diagnosis and treatment plan as well as to deal with the psycho-social issues of a newly diagnosed patient.
- 32. Future Directions • Developmentof physician and nurse training curricula. • Interventions to facilitate discussion of FP between physicians and cancer patients.
- 33. Acknowledgements: • American CancerSociety • Moffitt Cancer Center – William Dalton, MD – Thomas Sellers, Ph.D. • Karmanos Cancer Center • All Children’s Hospital – Michael Nieder, MD • Mayatech – Kerri Lowrey JD • FertileHope – Joyce Reinecke – Lindsey Beck • FORCE – Sue Friedman • Susan Vadaparampil, Ph.D., MPH • David Keefe, MD • Gerold Bepler, MD, Ph.D. • Paul Jacobsen, Ph.D. • Ji-Hyun Lee, Dr.PH • Jonathan Lancaster, MD, Ph.D. • Terrance L. Albrecht, Ph.D. • Clement K. Gwede, Ph.D. • Jordan Watson • Michele Griffin