Download Fertiliyy preservation in cancer patients

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, FL
Karmanos 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
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2 Oktay K, Beck L, Reinecke J. 100 Questions and Answers About Cancer and Fertility. Sudbury, Mass: Jones And Bartlett Publishers,
2008.
Greenlee R, Hill-Harman M, T TM, al e. Cancer statistics, 2001. CA Cancer J Clin 2001;51:15-36.
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 Males
Females
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
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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/riskcalculator.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.
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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 Patients
Male 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
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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. Webbased survey of Fertility issues in young women with breast cancer. Journal of Clinical Oncology 2004 22, 20 4174- 4183.
Survey Development Method
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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)
Recruitment Methods
• 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
Sampling: Inclusion Criteria
Physicians in the following specialties:
Hematology
Obstetrics
Surgical
Urology
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Gynecology
Medical
Radiation
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.
A patient is too ill to delay treatment to pursue FP.
A patient can not afford FP.
A patient does not want to discuss FP.
There is no place/person to refer my patient to for FP.
Time constraints affect my ability to discussion FP.
Always/Often
Sometimes
Rarely/Never
35%
44%
21%
29%
41%
29%
14%
50%
37%
9%
13%
79%
12%
23%
66%
Practice Patterns
I consult an infertility specialist or reproductive
endocrinologist with questions about potential
fertility issues in my patients.
I refer patients who have questions about fertility to
an infertility specialist or reproductive
endocrinologist.
I discuss the impact of cancer treatments on future
fertility with my cancer patients.
I provide my patients with educational materials
about FP.
Always/Often
Sometimes
Rarely/Never
24%
29%
47%
47%
29%
24%
77%
16%
7%
14%
26%
60%
National Physician Survey
Results- Practice Patterns
Always/
Often
Sometimes
Rarely/
Never
24
29
47
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
I consult an infertility specialist or
reproductive endocrinologist with
questions about potential fertility
issues in my patients.
I refer patients who have questions
about fertility to an infertility specialist
or reproductive endocrinologist.
How often do you utilize the 2006
ASCO recommendations on FP in
cancer patients, when making
18
22
decisions about healthcare for your
patients?*
* 37.8% of physicians reported they were unaware of the guidelines.
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Conclusions
The majority of physicians may not be
– Following ASCO guidelines
– Consulting specialists
Future Directions
A 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 • Susan Vadaparampil, Ph.D., MPH
• Moffitt Cancer Center
• David Keefe, MD
– William Dalton, MD
• Gerold Bepler, MD, Ph.D.
– Thomas Sellers, Ph.D.
• Paul Jacobsen, Ph.D.
• Karmanos Cancer Center • Ji-Hyun Lee, Dr.PH
• All Children’s Hospital
• Jonathan Lancaster, MD, Ph.D.
– Michael Nieder, MD
• Terrance L. Albrecht, Ph.D.
• Mayatech
• Clement K. Gwede, Ph.D.
– Kerri Lowrey JD
• Jordan Watson
• FertileHope
• Michele Griffin
– Joyce Reinecke
– Lindsey Beck
• FORCE
– Sue Friedman