By Dr Shanna Logan & Dr Antoinette Anazodo for oncologynews.com.au
Oncofertility, as the emerging discipline of oncology and fertility related practice and care, is becoming ever important, with increased survival rates for younger cancer survivors. Given cancer as a disease and oncological treatment can both affect the future fertility potential for cancer patients, both national and international guidelines now advocate for oncofertility to be considered in all patients of a reproductive age (<45 years of age).[1-5]
These guidelines all broadly advocate for the timely provision of fertility information to cancer patients, ideally before the onset of oncological treatment; the opportunity to discuss fertility preservation medical practices that may allow patients the opportunity to have a biological child as a cancer survivor; and the referral to a fertility specialist to facilitate decision making or undertake a preservation procedure. In addition, given the significant psychological burden brought about by actual or threatened infertility, and the long term quality of life impacts that impaired fertility may induce in cancer survivors, some guidelines also advocate for the referral to a fertility counsellor; to minimise both current and potential long term psychological disruption.
Cancer patients of a reproductive age are at increased risk for later life disruptions brought about by impaired fertility, given they may not have yet had the opportunity to start or complete their family. For example, research indicates that a desire for a child in both nulliparous and women with parity increases the risk of poorer mental health and psychological distress in female cancer survivors with impaired fertility.[6, 7] Younger patients, including adolescents and young adults (AYA), also have particular support needs within their oncofertility care[8, 9], including; discussing reproduction for the first time with a medical practitioner; considering future parenthood when not ready to start a family; navigating treatment decision making with parental involvement; and undertaking fertility preservation procedures which may be seen to be invasive, confronting, embarrassing or even traumatic. As such it is important that as clinicians we are aware how best to support cancer patients of reproductive age with their oncofertility needs, such that the provision of treatment is optimal.
A growing body of literature within this area has afforded the opportunity to assess current oncofertility support needs of cancer patients of a reproductive age. As such, two systematic reviews were undertaken to better understand how patients feel their oncofertility support needs are being met (literature from the patient perspective) and how oncofertility service provision is being conducted, in line with current recommended guidelines (literature both on service provision and from the clinician perspective). These reviews were undertaken using one primary search to capture all literature within oncology, fertility and patient-clinician interactions. This analysis affords the opportunity to both better understand patients’ support needs and current clinical practices; and therefore to improve on current treatment approaches within this field.
Findings from the patient systematic review indicate that fertility is a topic of great importance to cancer patients. However, low or poor provision of fertility information, inadequate fertility discussions and low referral rates to fertility specialists or counselling all impact on level of support that patients regularly receive. When these factors are coupled with a desire for future parenthood that is not adequately addressed, it is likely that patient dissatisfaction and later psychological distress may prevail. The limited research investigating fertility interventions does indicate however, that the provision of fertility information improves patient satisfaction, fertility knowledge and reduces decisional conflict. Similarly, although research indicates that fertility counselling was not offered to all patients with a desire to undertake it, an intervention on fertility counselling was deemed to be helpful. As such, it seems that although current patient supports may be lacking, the provision of both information and services appears to lessen the impact.
Of particular note was a finding that female patients appear to report more barriers in receiving oncofertility care, relative to male patients of a reproductive age. Given the increased complexities and time that female preservation may take, relative to male patient procedures, this is perhaps not surprising. However, clinician factors may account for some of this difference; reporting greater ease discussing fertility and greater readiness to refer to specialist fertility services with male patients. This is problematic, given that female patients also tend to express a strong desire for parenthood at a younger age, and that unfulfilled desire for a child/more children is associated with clinically significant levels of anxiety and depression in female cancer survivors up to 15 years post diagnosis. There is therefore a duty of care to ensure that female patients continue to be supported in their oncofertility needs to lessen this later impact; through taking time to discuss fertility at the time of diagnosis; the opportunity to access fertility services; and ongoing fertility support such as counselling throughout cancer treatment and into survivorship.
Overall the literature from the clinician review indicates that current practices are lacking when compared to those that are recommended by both national and international guidelines. The vast majority of clinicians (most often oncologists) report regularly discussing fertility with their patients. However, the limited research on recorded rates of fertility or fertility preservation discussions within medical records indicate that recorded occurrences are significantly lower. This finding highlights that there is both a lack of systematic recording of fertility discussions and ambiguity as to the quality and extent of discussions that occur. Despite acknowledging that fertility was an important factor for their patients, many clinicians also lacked the appropriate knowledge, training or expertise to adequately or confidently assist their patients in fertility management. Moreover, lack of services, financial support, streamlined pathways or knowledge of processes and guidelines further hindered patients being able to access appropriate services.
These findings point to an uncertainty in the current guidelines, in that they do not stipulate whose responsibility it is, at what time points within a patients care, to manage and treat oncofertility. The implementation of a clear procedural pathway would assist clinicians in improving timely referral and access to fertility services. It appears that clinicians may also benefit from some support, in way of information provision and training, in order to be able to adequately provide oncofertility services. Despite these deficits, in more recent years the provision of fertility services has improved, in line with treatment advances; and the types of fertility preservation procedures that are being undertaken by clinicians (such as oocyte retrieval in female patients and sperm collection in male patients) are in line with current recommendations. There is therefore the potential for increased oncofertility patient support with an increased awareness of current treatment approaches. Taken together, these reviews indicate the current standing of oncofertility support for cancer patients of reproductive age is less than optimal; however, that both clinicians and patients hold a desire for an improved model of care.
- NCNN Clinical Practice Guidelines in Oncology for Adolescent and Young Adult (AYA) Oncology (Version I.2012), I. National Comprehensive Cancer Network, Editor. 2011: Fort Washington, PA.
- Fertility: Assessment and treatment for people with fertility problems (NICE clinical guideline CG156), N.I.f.H.a.C. Excellence, Editor. 2013: London.
- Long term follow up of survivors of childhood cancer (SIGN guideline no. 132), S.I.G.N. (SIGN), Editor. 2013: Edinburgh.
- Fertility preservation for AYAs diagnosed with cancer: Guidance for health professionals, C.O.S.o.A. AYA cancer fertility preservation guidance working group, Editor. 2014, Cancer Council Australia: Sydney.
- Loren, A.W., et al., Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol, 2013. 31(19): p. 2500-10.
- Armuand, G.M., et al., Desire for children, difficulties achieving a pregnancy, and infertility distress 3 to 7 years after cancer diagnosis. Supportive Care in Cancer, 2014. 22(10): p. 2805-2812.
- Canada, A.L. and L.R. Schover, The psychosocial impact of interrupted childbearing in long-term female cancer survivors. Psycho-Oncology, 2012. 21(2): p. 134-143.
- Wright, C.I., et al., ‘Just in case’: the fertility information needs of teenagers and young adults with cancer. Eur J Cancer Care (Engl), 2014. 23(2): p. 189-98.
- Shimizu, C., et al., Physicians’ knowledge, attitude, and behavior regarding fertility issues for young breast cancer patients: a national survey for breast care specialists. Breast Cancer, 2013. 20(3): p. 230-40.
- Logan, S., et al., A Systematic Review of Patient Fertility Support Needs in Reproductive Cancer Patients aged 14 to 45 years of age. Psycho-Oncology, 2017.
- Logan, S., et al., Clinician Provisions of Fertility Support in Paediatric and Young Adult Cancer Patients of a Reproductive Age: A systematic review. Psycho-Oncology, 2017.
Primary Author details: Dr Shanna Logan
Senior Author: Dr Antoinette Anazodo