National Survey of Physicians Practice 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, FLKarmanos Cancer Center, Detroit, MI

Fertility and Cancer Patients

• 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.

Cancer Related Infertility

The rates vary among patients and depend on a number of factors:

• Age• Sex• Diagnosis• Radiation field• Pretreatment of fertility

Infertility of Females and MalesFemales

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

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.

Risk Calculation

• http://www.fertilehope.org/tool-bar/risk-calculator.cfm

Patients Views on Infertility• 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

Fertility Preservation Options• Fertility

preservation (FP) options are available for cancer patients to preserve fertility prior to treatment.

FP Options for PatientsMale Option

– Sperm cryopreservation

Female Options– Embryo

cryopreservation – Egg freezing– Ovarian

transposition

ASCO Recommendations on Fertility Preservation 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.

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.

Survey Development Method• Literature Review• Focus Groups• Interviews with Physicians• Pilot Testing Instrument• Expert Reviews

“You have a 20% chance of survival – have you ever thought about having kids?”

“My patients usually start treatment within 24 hours”

“I’ve had to find shoes for my patients to go home in”

National Physician Survey

The purpose 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

Physician Survey• 58 items• Domains:

• Demographics / Medical Background (21)

• Knowledge (5)• Attitudes and Perceptions (10)• Barriers (6)• Practice Behaviors (11)

• Physicians were identified 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

Sampling: Inclusion CriteriaPhysicians in the following specialties:

•

HematologyObstetrics

GynecologyMedical

Surgical RadiationUrology Dermatology

Musculoskeletal

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)

Response Rate

• 33% response rate

• 613 completed surveys

• $100 honorarium

Factors Related to Discussion• 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.

Factors Related to Discussion• 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.

Factors Related to Referral• 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.

• m

Factors Related to Referral

• 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”.

Barriers to Discussing FP 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%

Practice Patterns Always/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 treatments on future fertility with my cancer patients. 77% 16% 7%

I provide my patients with educational materials about FP. 14% 26% 60%

National Physician Survey Results- Practice Patterns

Always/ 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.

Conclusions

The majority of physicians may not be

–Following ASCO guidelines–Consulting specialists

Future DirectionsA significant barrier 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.

Future Directions

• Development of physician and nurse training curricula.

• Interventions to facilitate discussion of FP between physicians and cancer patients.

Acknowledgements:• American Cancer Society• 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