Many physicians specializing in cancer care do not tell their patients about fertility preservation options before they undergo chemotherapy, radiation, or surgery, and fewer refer their patients to fertility specialists, according to a study from the University of South Florida in Tampa.
"It's kind of medical paternalism," says Gwendolyn Quinn, senior author of the study published in the current issue of Practical Radiation Oncology, a journal of the American Society for Radiation Oncology (ASTRO), and colleagues at Moffitt Cancer Center in Tampa.
"A physician may say, well, if the patient didn't mention it, it's not an issue. And if they do mention it, perhaps saying (something like) 'I'm willing to choose a less effective treatment in order to regain my fertility,' the physician may say, 'Well no you're not. It's my job to save your life, ' " Quinn says.
She adds that preserving quality of life is increasing in importance for cancer patients because with today's more successful treatments and earlier diagnoses, more patients are surviving longer. In fact, according to A Cancer Journal for Clinicians, of 11.2 million cancer survivors in the United States in 2007, 450,000 were of reproductive age.
Even if they didn't want children when they were diagnosed, they may decide as the years pass that at age 35 or so, they do. But chemotherapy and radiation treatments as well as surgery are estimated to cause sustained infertility in 50% to 95% of cancer survivors, the paper says.
What Quinn and her colleagues found is that "Oncologists are not trained to talk about this. Many of them don't feel comfortable, or they don't know what all the options are. It's ASTRO's suggestion, which I agree is a good one, that oncologists should plant a seed and tell patients that there's a possibility (of preserving fertility) and refer them to a practitioner who is trained to talk about this."
She adds, "In a perfect world several years from now, we'll have a better check-off system that will document in every person's medical record, so that we'll be able to see that someone, somewhere, at sometime has had this conversation with the patient. And ideally it's before any treatment has begun."
The study used the American Medical Association Masterfile to survey physicians specializing in oncology who reported that they see patients, both men and women, during their childbearing years, between 15 and 45 years of age. Of those surveyed, 32% responded, or 376.
This study, a subset of a 2010 paper that focused on all medical oncology specialists, focused on three oncology subspecialty practitioners who showed the highest variation in practice from the overall oncology practitioner population, surgical oncologists, medical oncologists and radiation oncologists.
For example, 82% of radiation oncologists and 84% of medical oncologists said they "always" or "often" discussed the impact of treatment on fertility, but only 52% of surgical oncologists answered the same way. None of the radiation oncologists, 4% of the medical oncologists and 20% of the surgical oncologists said they "never" discuss fertility treatments with their patients.
The three physician groups were similar in their relatively lower rates of patient referrals to reproductive specialists, which ranged between 40% and 46%.
Quinn says that it's important for all cancer patients to have this discussion with oncologists "regardless of what the treatment plan is," even if it's surgery, and even surgery on a part of the body that doesn't impact the reproductive system, "because you never know what's coming down the road.
"Nobody would have thought (a few years ago) that radiation to the brain would necessarily affect reproduction but it turns out it does, because it involves the thymus and the pituitary, and other types of endocrine function can be impacted."
Ability to afford fertility preservation treatments is an obvious issue, but Quinn says that Fertile Hope and Livestrong have programs that can help offset costs of preserving ovarian tissue or oocytes and embryos and insurance plans may in the future cover these strategies.
Quinn says "we've been arguing that this is a prophylactic measure in the same way that you don't need to become nauseous before you get anti-nausea medications and you don't need to loose your hair before insurance will pay for a wig."
"It shouldn't matter what your socioeconomic status is to get this information. It may be a shame if you can't avail yourself of it," she says. It should be required "both in a strict legal sense, and in a quality of life and well-being sense, because everybody should get this information."