National survey of physicians practice patterns: Fertility preservation and cancer patients

Reviewer: Arpi Thukral, MD
Abramson Cancer Center of the University of Pennsylvania
Last Modified: June 1, 2009

Presenter: G. Quinn
Presenter's Affiliation: Moffitt Cancer Center
Type of Session: Scientific

  • The treatment of cancer often poses a threat to fertility for young patients of child-bearing age. Various studies suggest that the ability to have biological children is of great importance to many people.
  • Approximately 450,000 cancer survivors in the U.S. are of reproductive age, and therefore addressing the impact of cancer treatment on fertility is a high priority in providing quality care to these patients.
  • Previous studies show that less than 50% of patients receive adequate information of fertility preservation before the initiation of cancer treatment.
  • Some factors that affect infertility in patients receiving cancer therapy include age, sex, diagnosis, chemotherapy used, and radiation fields.
  • Fertility preservation options include sperm cryopreservation for men and embryo cryopreservation, egg freezing, or ovarian transposition for women.
  • In 2005, ASCO published guidelines on fertility preservation that recommended that "oncologists should address the possibility of infertility with patients treated during their reproductive years and be prepared to discuss possible fertility preservation options or refer appropriate and interested patients to reproductive specialists, as part of education and informed consent before cancer therapy."
  • The purpose of this study was to assess oncologist practice patterns concerning discussion with their patients regarding fertility preservation.
    • The authors also attempted to identify perceptions of barriers to communication about fertility.
Materials and Methods
  • This study was conducted using a survey of 58 items addressing demographics, knowledge, attitude and perception, barriers, and practice behaviors of physicians related to fertility preservation in patients of child-bearing age.
    • The survey was developed by a review of the literature and previous qualitative interviews.
  • A random sample of physicians from the American Medical Association Master Member list was stratified by board specialty related to oncology.
  • Over 1900 surveys were mailed out to physicians across the United States in 3 waves.
  • Inclusion criteria:
    • Physicians who graduated medical school after 1945 and are likely to see cancer patients.
  • There were 1,979 physicians identified whom surveys were sent to.
    • Of these, 613 physicians completed surveys (33% response rate).
  • Physicians surveyed who had higher knowledge regarding fertility preservation were 2.6 times more likely to discuss the impact of cancer treatment on fertility with their patients.
  • Likewise, those physicians with favorable attitudes towards fertility preservation were 4.9 times more likely to discuss fertility with their patients compared to those with unfavorable attitudes.
  • Gyn and Medical Oncologists were 2.1 times more likely to discuss fertility preservation with their patients compared to other specialists. The same was true for female oncologists compared to male oncologists.
  • Physicians who had patients who asked about fertility preservation were twice as likely to discuss these issues with them.
  • The barriers to discussing fertility preservation that were reported by physicians included:
    • 1) patients being too ill and needing to start treatment within 24 hours, did not want to delay treatment (primary barrier identified)
    • 2) affordability of fertility preservation options
    • 3) time constraints during consultation
    • 4) patients not wanting to have the discussion
  • 77% of oncologists in this study reported discussing fertility preservation, but despite having the discussions with their patients, less than 25% of oncologists report referring patients for fertility preservation options.
  • Only 38% report knowing about the ASCO guidelines (mentioned above) which recommend discussing fertility preservation and referring patients of childbearing age to a fertility specialist.
Author's Conclusions
  • Although the majority of the physicians who participated in this national survey report discussing fertility preservation, they are not referring their patients to specialists or providing educational materials to their patients.
  • Future research must examine barriers to physicians having these important discussions with their patients and develop training curricula and interventions for both physicians and nurses to facilitate discussion of fertility preservation between physicians and cancer patients.
Clinical/Scientific Implications
  • Fertility for both men and women may be temporarily or permanently affected by cancer treatment (either chemotherapy, radiation, or hormonal agents). Infertility may also manifest later in women through premature ovarian failure.
  • For this reason, oncologists seeing reproductive-aged patients for consideration of cancer therapy should be addressing potential treatment-related infertility with them. It was to promote this practice that ASCO set forth guidelines in 2005 that recommended that physicians should have discussions about fertility preservation with their patients prior to starting cancer treatment. The guidelines state that "Clinician judgment should be employed in the timing of raising this issue, but discussion at the earliest possible opportunity is encouraged."
  • However, this study suggests that while many oncologists are discussing the possibility of treatment-related infertility with their patients, they are not following up with proper referrals to specialists or educating patients on what options are available to them.
    • As oncologists, we may not have the tools or knowledge necessary to quantify how fertile patients are after chemotherapy or educated them about what fertility preservation options are available. For this reason, it is imperative that referrals are made to reproductive endocrinologists so they can be assessed properly.
  • There are several reasons for why patients are not always referred to specialists which are well-illustrated in this study. Some of these barriers include patients being too ill and needing to start treatment immediately, cost of fertility preservation, and time constraints.
    • The issue of cost is very relevant as fertility treatments can be extremely expensive and often, these patients may not even have enough money to cover their cancer treatment costs. For example, embryo cryopreservation can cost over $20,000. In most states, insurance does not cover fertility preservation.
  • Additionally, although the data reported for the 33% responders of this survey seemed favorable for the majority of physicians at least discussing fertility preservation with their patients, the characteristics of the non-responders of the survey are unknown.
    • Could their answers have shifted the numbers seen in the data? Did they not participate because they didn’t care about fertility preservation?
    • Answers to these questions may add credence to the data seen in this study.
  • This data obtained in this study adds to the current literature on fertility preservation in cancer patients and allows us to identify potential ways to increased awareness amongst physicians and health care staff about the importance of discussing fertility with patients.
  • Furthermore, this data helps us to identify barriers to this practice and create policies to decrease the disparities that cancer patients may be experiencing due to the costs of fertility preservation.
    • We need to think of infertility as a side effect of cancer treatment just like alopecia and nausea which already have remedies such as wigs or anti-emetics, which are most often covered by insurance.
  • Future directions which need to be pursued include:
    • Lobbying for fertility preservation coverage by insurance companies.
    • Updating ASCO guidelines to recommend referral to fertility specialists as soon as possible.
    • Increasing education among physicians, fellows, residents, and nurses about the importance of fertility preservation discussions.

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