Clinical Context

As cancer survival increases, quality of life, including fertility preservation, is an increasing concern for patients. Chemotherapy and radiotherapy are both effective cancer treatments but have persistent adverse effects on the reproductive system in both sexes.

For patients of reproductive age with newly diagnosed cancer, the opportunity to discuss fertility preservation is therefore crucial before starting chemotherapy or other treatment, as recommended by the American Society for Reproductive Medicine and the American Society of Clinical Oncology (ASCO). The goal of this cross-sectional study using survey data from the ASCO Quality Oncology Practice Initiative was to identify factors associated with fertility preservation counseling and referrals to reproductive specialists among patients of reproductive age before starting chemotherapy.

Study Synopsis and Perspective

Less than half of patients with cancer who are of reproductive age receive fertility counseling, despite guidelines recommending that these discussions be had with every eligible patient.

The findings come from the largest study on this subject to date. Researchers surveyed nearly 7000 patients with cancer who were reproductive age. The study was published online July 17 in JAMA Network Open.

Only 44% of patients with cancer reported having had a discussion with their clinician about the risk for infertility associated with chemotherapy, the study found. Clinicians were more likely to discuss the risk for infertility with female patients than male patients, as well as with younger patients.

One reason these discussions are not being held is because of time constraints, commented lead author Ranjith Ramasamy, MD, director of male reproductive medicine and surgery and an associate professor in the Department of Urology at the University of Miami, Florida.

"There is so much to discuss when a patient is first diagnosed with cancer," he told Medscape Medical News. "The patient wants to know about the treatment -- the different options, the side effects, prognosis, insurance coverage -- and fertility preservations gets pushed to the wayside.

"Providers often do not have the time or the resources to have these discussions, and the best solution is to make a referral to a specialist," said Dr Ramasamy. "It's not a big issue to do this, and the office staff can all play a very important role in arranging a referral."

He added that at his institution, making a referral for fertility preservation comes up as a best practice alert through the electronic medical records system.

Dr Ramasamy emphasized the importance of bringing up this topic, especially with younger patients. "About 75% to 80% of adolescents diagnosed with cancer are surviving, and it is incumbent upon doctors that we think about the future," said Dr Ramasamy. "Even if they're not thinking about it now, they may want a family in the future."

For several reasons, fertility is often overlooked by patients and physicians when cancer is first diagnosed, but as survival increases, so does the importance of future quality of life. The American Society for Reproductive Medicine and ASCO both recommend that clinicians discuss fertility preservation with adult and pediatric patients before the initiation of anticancer therapy.

Less Counseling for Men and for Older Patients

For their study, Dr Ramasamy and colleagues used data obtained from the ASCO Quality Oncology Practice Initiative. They identified 6976 patients as being of reproductive age, ranging from 18 to 40 years for women (n = 3405) and from 18 to 50 years for men (n = 3571).

Within this group, 3036 patients (44%) received counseling about the risk for infertility that was associated with their treatment. Women were more likely to be counseled (56%) than men (32%; P<.001).

Younger patients were more likely to be counseled. The frequency of discussions concerning infertility risk declined as the patient age increased (odds ratio [OR], 0.91; P<.001). Race/ethnicity did not appear to have an effect on the frequency of discussions (Black: OR, 1.03; Asian: OR, 1.14; Hispanic: OR, 1.04; other or not reported: OR, 0.99).

Overall, factors that were associated with a lower likelihood of having this discussion included male sex (OR, 0.73), increasing age (OR, 0.93), private practice setting (OR, 0.70), and a lack of a multidisciplinary team (OR, 0.54). Factors that were associated with a higher likelihood of discussion included having breast cancer (OR, 1.39) and lymphatic or hematopoietic cancers (OR, 1.79), treatment in an academic setting (OR, 1.45), and the practice's offering clinical trial enrollment (OR, 1.60).

Insurance may not cover the cost of fertility preservation, which may present a barrier for many patients. As of 2019, 5 states had passed laws that mandate coverage. In those states, patients were more often counseled or referred to a fertility specialist after the laws went into effect.

Barriers to Referral

Approached by Medscape Medical News for an independent comment, Maryam B. Lustberg, MD, MPH, associate professor of medicine and medical director of cancer support services, the Ohio State Comprehensive Cancer Center, Columbus, believes that these conversations are not happening for a number of reasons. These include a lack of time, a lack of awareness, competing priorities because of the need to treat an aggressive cancer quickly, assumptions as to what patients want and need and a failure to engage in shared decision making, and a lack of resources and access to fertility preservation counseling and services.

"A new diagnosis requires a lot of discussion points, and both patients and providers can feel overwhelmed to cover and take in all of these points," said Dr Lustberg. "If fertility is mentioned quickly in passing, the patient and family may not have time to process the information and may initially say they are not interested."

Another reason is that some oncologists may not be as aware of guidelines or assume some patients may not be able to afford the services or want the services. "Disparities in care due to socioeconomic and race are also a consideration," she said. "Additionally, some oncologists may make assumptions that patients with advanced cancers may not want to discuss this issue and therefore not bring it up."

Dr Lustberg also pointed out that there are some barriers to making referrals. "Navigators in young adult care and fertility preservation are definitely helpful and increase referrals, but not all oncology practices may have access to these," she said. "Virtually delivering counseling services to practices that may not have this will be helpful, and we are working toward implementing this type of services."

This study was funded by the Department of Urology, University of Miami Miller School of Medicine. The authors have disclosed no relevant financial relationships. Dr Lustberg has relationships with PledPharma, Disarm Therapeutics, and Hologic/Cynosure.

JAMA Netw Open. Published online July 17, 2020.^[1]

Clinical Implications

• Less than half of patients of reproductive age with cancer receive fertility counseling or referral before starting chemotherapy, with even lower rates in older patients and men, according to a cross-sectional study using survey data from the ASCO Quality Oncology Practice Initiative.
• To improve rates of fertility risk discussion and referrals to fertility specialists before the onset of chemotherapy, the investigators recommend greater awareness, dissemination, and implementation of ASCO guidelines and quality measures; ongoing educational initiatives between oncologists and fertility specialists; and additional research on unique barriers that may exist in private practice oncology settings.
• Implications for the Healthcare Team: The investigators suggest that the routine practice of oncology should include protecting options for future parenthood at the time of diagnosis with cancer and appropriate referral to a reproductive specialist.

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