Impact of physicians’ personal discomfort and patient prognosis on discussion of fertility preservation with young cancer patients
Introduction
Due to advances in medical technologies over the past two decades, pediatric and adult cancer survival rates have improved greatly, resulting in a focus on improving quality of life for survivors. One side effect of treatment that may adversely affect quality of life is the potential for infertility or sterility [1], [2]. Some cancers and the associated treatment may compromise fertility in male and female patients [3], [4]. The specific risk of infertility varies by cancer site, stage, treatment type, and age of the patient [2], [5], [6], [7], [8], [9]. There are established options for preserving fertility prior to cancer treatment in post-pubertal cancer patients. For males, sperm cryopreservation (i.e., freezing sperm) is the only established FP option [7]. For females, embryo cryopreservation, or the freezing of fertilized eggs for later use with in vitro fertilization (IVF), is considered the most established FP method for female patients [7]. Ovarian transposition, also called oophoropexy, involves moving the ovaries out of the field of radiation, is also an established option, appropriate only for females receiving pelvic radiation [7], [10].
Cancer survivors have reported interest in having children and believe their cancer diagnosis will make them better parents [11]. Infertility after cancer treatment can cause emotional stress and grief for survivors [7], [11], [12]. The 2006 American Society of Clinical Oncology (ASCO) Recommendations on Fertility Preservation in Cancer Patients advises that all oncologists seeing patients of childbearing age should address potential treatment-associated infertility with patients, or parents of pediatric patients. The guidelines also suggest oncologists should be able to answer basic questions about FP options, and refer patients to reproductive specialists and psychosocial providers as needed [7]. Lee et al. (2006) reports that physicians cannot know how important FP is to patients unless they ask, since many patients do not bring up the topic. Research suggests that referrals from physicians make patients more likely to seek FP [7], [13], [14]. It is important to refer patients to reproductive specialists as soon as possible, since females often require FP to be timed with the menstrual cycle. Opportunities to grieve the potential loss of biological parenthood or to consider other parenting options such as adoption are added benefits of fertility-related discussions [7]. Additionally, some patients and their families choose to consider posthumous parenting, that is, they intend to use the stored sperm or embryos whether or not the patient survives. While this is an ethically charged situation, the American Society for Reproductive Medicine recommends physicians do not deny patients assistance for this form of reproduction and also cautions that “precise instructions” be given by the patient in the event of his or her death [15].
Despite these guidelines and the distress infertility can cause patients, recent studies show the rate of FP discussions by health care providers, including oncologists, with patients, is infrequent and not occurring on a regular basis [1], [2], [7], [13], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26]. In addition, Schover et al. (1999) found that only 57% of survivors recalled receiving information about the risks of infertility from their cancer treatment [11]. Thus, available data suggest the FP discussion is not occurring on a regular basis between oncologists and cancer patients. The current study attempts to probe deeper into the reasons why physicians may not be discussing FP.
This study presents data from two larger studies in which barriers to FP discussions among adult and pediatric oncologists were examined [21], [22]. In this study we sought to determine if physicians’ personal comfort or discomfort with the topic of FP and a patient's prognosis would have an impact on the likelihood of discussing FP with cancer patients of childbearing age.
Section snippets
Methods
Data were pooled from two studies focused on adult and pediatric oncology providers [21], [22]. Both studies used qualitative, semi-structured, in-depth interviews with oncology care physicians to obtain information about discussions of FP among providers. Upon obtaining institutional board approval, physicians for both studies were selected using a purposeful sample strategy, whereby those individuals most likely to be familiar with the topic (discussion of FP options) were recruited to
Results
Results show that across both pediatric and adult oncologist respondents, personal comfort with the topic of FP was related to whether or not a physician typically discussed or referred for FP. Personal discomfort manifested in five themes: (a) lack of knowledge or training on the subject of FP; (b) perceived language or cultural barriers between physician and patients; (c) belief that discussion of fertility with a newly diagnosed patient added stress to patient; (d) uncertainty of success and
Discussion
The majority of respondents noted there were at least some barriers to discussions of FP. While we have reported on these barriers within specific health care provider groups in our previous work [21], [22], in examining the data in the aggregate, the issue of personal discomfort is present among both pediatrics and adult oncologists. All physicians noted they did not feel knowledgeable about the topic and this contributed to their discomfort. This lack of knowledge about options or places to
Role of funding
This work was supported in part by the American Cancer Society [RSGPB-07-019-01-CPPB]. The sponsor did not contribute to the study design, collection, analysis and interpretation of data, writing the report and in the decision to submit for publication.
Conflict of interest
There is no conflict of interest from any author.
Acknowledgement
The work contained within this publication was supported in part by the Survey Methods Core Facility at the Moffitt Cancer Center.
References (53)
- et al.
Fertility preservation for young patients with cancer: who is at risk and what can be offered?
Lancet Oncol
(2005) - et al.
Male gonadal dysfunction in patients with Hodgkin's disease prior to treatment
Ann Oncol
(2001) - et al.
Assisted conception is a risk factor for postnatal mood disturbance and early parenting difficulties
Fertil Steril
(2005) - et al.
Barriers to fertility preservation among pediatric oncologists
Patient Educ Couns
(2008) - et al.
Physicians’ comfort in caring for patients with chronic nonmalignant pain
Am J Med Sci
(2007) - et al.
Nurse practice issues regarding sperm banking in adolescent male cancer patients
J Pediatr Oncol Nurs
(2006) Cryopreservation of testicular tissue in young cancer patients
Hum Reprod Update
(2001)- et al.
Fertility preservation in young women undergoing breast cancer therapy
Oncologist
(2006) - et al.
Subfertility in children and young people treated for solid and haematological malignancies
Br J Haematol
(2005) - et al.
Fertility options in young breast cancer survivors: a review of the literature
Oncol Nurs Forum
(2004)