Discussing fertility preservation options with patients with cancer.

IN JUNE 2006, THE AMERICAN SOCIETY OF CLINICAL ONcology published a series of recommendations on fertility preservation for patients with cancer, concluding that “To preserve the full range of options, fertility preservation approaches should be considered as early as possible during treatment planning.” These guidelines reflect the greater attention that has been given in recent years to the fertility complications that can occur as a result of cancer treatment (eg, chemotherapies and radiation). Other professional and collaborative societies, including the Oncofertility Consortium, Fertile Hope, the American Academy of Pediatrics, and the American Society for Reproductive Medicine, also have developed best-practice guidelines and educational resources to provide patients and physicians with the most recent research on fertility preservation treatments. Investigators within the field of oncofertility have examined how patients with a cancer diagnosis learn about the potential of cancer-related infertility, including how such patients weigh fertility preservation options. In understanding this information exchange and medical decision, researchers and best-practice guidelines have looked to the patient-physician relationship, particularly those relationships between patients and oncologists, as the primary opportunity for patients to become aware of potential fertility complications related to cancer treatment. However, a distressing information gap has been identified in which oncologists often do not discuss the issue of possible infertility with patients prior to initiating potentially damaging cancer treatments. Research (including studies of men and women patients and of patients diagnosed when younger than 18 years) has consistently shown that patients diagnosed with cancer do not routinely discuss cancer-related infertility with their physicians. This information gap severely limits the ability of patients with cancer to take proactive steps to help safeguard their future fertility potential prior to fertility-compromising cancer treatments (TABLE). In light of these findings, researchers have begun to examine factors that may have prevented this exchange of information between patient and oncologist. Some research has suggested that oncologists may not be aware of bestpractice guidelines, including ASCO recommendations, and that their knowledge on the topic may not be up to date. The lack of interprofessional networks with reproductive endocrinologists and fertility preservation facilities may further hinder oncologists from raising the issue. Another inhibiting factor is the nature of the relationship between patient and oncologist. For example, Rieker et al have suggested that oncologists may be more likely to discuss sperm banking with patients with whom they share a perceived similar status (eg, highly educated patients). Physicians have reported that certain patient characteristics can influence the likelihood that they would discuss fertility preservation, including a patient’s prognosis, sex, parenting status, marital status, age/pubertal status, ability to pay for such treatments, and even whether a patient is homosexual or is infected with human immunodeficiency virus. The inability of cancer survivors to become parents is an increasing concern within the oncofertility community, and, as the above research suggests, some patient groups may have less access to fertility preservation options prior to cancer treatment. More research is needed to identify additional constituents who may be missing this information, and best-practice guidelines would benefit from highlighting potentially vulnerable groups and suggesting strategies to meet their unique fertility concerns. Research is needed to examine the conditions under which this sensitive issue is effectively discussed in the clinical setting. Among patients who do discuss potential infertility, many feel their concerns are not adequately addressed. The topic of fertility preservation may be understated when it is presented along with myriad other potential adverse effects. Additionally, more effective educational materials may be required to help facilitate these conversations. Researchers also should consider how other health care professionals can be integrated into these discussions, along with an understanding of what fertility concerns may remain fol-