at the front lines of fertility preservation
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Advances in both oncology and reproductive medicine have driven the need for more fertility services for cancer patients. In oncology:Improving survival rates have led to a greater emphasis on survivorship, late effects and quality of life.The development of AYA programs (for adolescents and young adults) has increased awareness of the needs of young patients with cancer, including preserving fertility for the future.There has been an increased focus on patient participation in treatment decision-making. The LIVESTRONG Foundation and other cancer support organizations empower patients to learn about their diagnosis, ask questions and consider all options, including fertility options.In reproductive medicine:Advances in technologies such as ICSI, egg freezing, and tissue freezing have expanded options for patients.2
Annually, more than 150,000 Americans are diagnosed with cancer during their reproductive years (under age 45).1
These include:More than 26,000 breast cancer patients2Approximately 13,500 children3Most commonly breast, thyroid, melanoma, testicular, cervical, HL and NHL and colon4 diagnosesAmong this population, cancer survivorship rates are generally high: 80% of patients under the age of 45 survive at least 5 years.5
See http://seer.cancer.gov/csr/1975_2010/results_single/sect_01_table.01.pdf (stating more than 1.66 M Americans will be diagnosed with cancer in 2013) and http://seer.cancer.gov/csr/1975_2010/results_single/sect_01_table.12_2pgs.pdf (stating that approximately 9% of those 1.66 M will be under the age of 45) National Cancer Institute. Surveillance Epidemiology and End Results. SEER Stat Fact Sheets 2013: Breast. Available at: http://seer.cancer.gov/statfacts/html/breast.html. See also http://www.youngsurvival.org/breast-cancer-in-young-women/learn/statistics-and-disparities/#sthash.f3l3TR8p.dpuf http://www.childrensoncologygroup.org/index.php/abouthttp://www.nccn.org/professionals/physician_gls/pdf/aya.pdfNational Cancer Institute. Surveillance Epidemiology and End Results. SEER Cancer Statistics Review 1975-2010. Table 2.8 All Cancer Sites (Invasive) 5-Year Relative and Period Survival by Race, Sex, Diagnosis Year and Age. Available at: http://seer.cancer.gov/csr/1975_2010/browse_csr.php?section=2&page=sect_02_table.08.html
Fertility Preservation Options Before Cancer Treatment sperm bankingtesticular shieldingtesticular tissue freezingembryo freezingegg freezingovarian tissue freezingovarian shieldingfertility sparing surgeriesovarian transpositionradiation shieldingReproductive Options After Cancer Treatment alternative sperm collection methodsIVF (In Vitro Fertilization)donor eggsdonor embryosdonor sperm
Fertility preservation is often possible for people who will undergo treatment for cancer. However, fertility risks and preservation approaches should be discussed as early as possible--before treatment starts--in order to allow access to the full range of preservation options.1For patients who are infertile after cancer treatment, parenthood options existincluding using donor eggs, embryos or sperm, surrogacy and adoption. Its never too late for patients within reproductive age to find out their options. Loren AW, Mangu PB, Beck LN, et al: Fertility Preservation for Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 10.1200/JCO.2013.49.2678
Delayed childbearing is a trend in the U.S. with the average age of first birth at 25.4.1 In the past, your patients of this age might have already started a family.
More and more, patients of reproductive age have not yet had children when diagnosed, but still wish to have biological offspring.2
Those who did not receive fertility information express ongoing, unresolved distress and regret, even many years after treatment.3, 4According to the CDC, in 2010, the average age for first birth was 25.4. http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_01.pdfSchover LR: Patient attitudes toward fertility preservation. Pediatr Blood Cancer. 2009 Aug;53(2):281-4. doi: 10.1002/pbc.22001Schover LR: Motivation for parenthood after cancer: a review. J Natl Cancer Inst Monogr. 2005(34):2-5.Canada AL, Schover LR: The Psychosocial Impact of Interrupted Childbearing in Long-term Female Cancer Survivors. Psychooncology 21: 134-143, 2010.
Although a significant percentage of patients (women 40-80%, men 30-75%) are at risk for reproductive compromise, studies continue to show that:
Less than 50% of patients recall discussing fertility risk with a health care provider. 1More than half of physicians who do discuss fertility preservation with patients often do not follow through by making referrals to specialists and support services. 2The majority of health care professionals have no formal procedures for fertility disclosures or referrals. 3Cancer centers are not utilizing ASCO guidelines for implementing these procedures.A survey of breast cancer survivors showed that 11% of patients received adequate information about fertility preservation from oncology health care professionals. 4(These are study findings from 2009 date.)Quinn GP, Vadaparampil ST, Lee JH, et al: Physician referral for fertility preservation in oncology patients: a national study of practice behaviors. J Clin Oncol 27(35):5952-7, 2009 Forman EJ, Anders CK, Behera MA: A nationwide survey of oncologists regarding treatment-related infertility and fertility preservation in female cancer patients. Fert Ster 94(5):1652-6, 2010Clayman M, Harper M, Quinn GP, et al: The status of oncofertility resources at NCI-designated comprehensive cancer centers. J Clin Oncol 29: 2011 (suppl; abstr 9123)Meneses K, McNees P, Azuero A, Jukkala A. Development of the Fertility and Cancer Project: An Internet Approach to Help Young Cancer Survivors. Oncology Nursing Forum. [10.1188/10.ONF.191-197]. 2010;37(2):191-7.
Despite a widespread appreciation of the effects of cancer therapies on future fertility, physicians report that a lack of education, resources and insufficient time hinder fertility preservation discussions with patients. 1Goldfarb SB, Dickler MN, McCabe MS, et al: Memorial Sloan-Kettering Cancer Center, New York, NY. J Clin Oncol 28, 2010 (suppl; abstr e19525).
Health care professionals need more information and support on: How to individualize their patients fertility risks and options.Current fertility preservation techniques and where to refer their patients. Health care professionals may be concerned about the treatment time limitations. Is there enough time for fertility treatment enough time cancer treatment begins and how long will it take? Will fertility treatment get in the way of your patient receiving the best cancer care?Health care professionals may have concerns about the appropriateness of discussing fertility with particular patients, for example:Those with a poor prognosis.People who live at a low socio-economic status.Those who may not be geographical located near available services.Health care professionals may not feel they have enough information about the safety and efficacy of fertility preservation methods. For example, for patients with breast cancers that are hormone-sensitive, how will they be affected by hormone-stimulating fertility medications to produce eggs for a harvest? Also, fertility preservation measures are not a guarantee for pregnancy. Patients are given hope but no guarantee.
The cost of fertility procedures can pose a financial burden on patientsProcedures are expensiveespecially for women.Theyre generally not covered by insurance.
Fertility TreatmentAverage CostSperm Banking$1000 - 1,500Testicular Tissue Freezing/TESE$6,000 $16,000 (+ IVF costs)Embryo Freezing$12,400 (+ meds & storage)Egg Freezing$11, 900 (+ meds & storage)Ovarian Tissue Freezing$10,000 (+ storage)Donor sperm$300 $750 per vial (+IUI or IVF costs)Donor embryos$5,000Donor eggs (including cycle of IVF)$22,000Surrogacy$60,000 - $80,000Adoption $0 - $40,000(domestic, international, public, private)
These valid concerns can be addressed by developing procedures and gathering educational resources to equip the clinical staff (such as nurses) to provide timely and accurate fertility information to patients.1Goldfarb SB, Dickler MN, McCabe MS, et al: Memorial Sloan-Kettering Cancer Center, New York, NY. J Clin Oncol 28, 2010 (suppl; abstr e19525).
The procedures should include tools and resources that enable health care professionals to adequately: Disclose fertility risks based on a persons cancer and treatmentInforming patients of their fertility preservation optionsAnd providing patients with referrals to specialists and other support services.
The medical community has taken action over the years to provide fertility preservation guidelines for this end. The following organizations have created guidelines and reports to inform health care professionals on how to implement fertility preservation procedures: 2004Presidents Cancer Panel Report on Survivorship recognized infertility as a top concern and issued recommendationsASRM Fertility-Preservation Special Interest Group formed
2005NIH Created specialized fertility preservation research section at NICHDASRM Issued Ethics Committee Report on Fertility Preservation
2006 2008ASCO Issued Fertility Preservation Guideline (2006)NIH Funded the Oncofertility Consortium (2006)AAP Guidelines for F.P. in peds (2008)
2008 presentNCCN Issued AYA Guideline; include fertility preservation recommendations (2012)ASCO Updated Fertility Preservation Guideline (2013)AMA Issued policy calling for insurance coverage for fertility preservation for cancer patients