Cancer treatments may cause impairment of fertility, and fertility preservation provides patients with options for family-building after they successfully fight their disease. Duke University researchers utilized oncofertility navigation to reduce access barriers to fertility counseling and preservation.
Impairment of Fertility Due to Cancer Treatment
Impaired fertility is a common late effect of cancer treatment for male and female survivors.
Cancer treatments such as surgery, chemotherapy, and radiation can affect fertility by impacting several biologic systems which include the neuroendocrine axis, the immature and growing follicles within the ovaries, and the reproductive organs necessary for a woman to carry a pregnancy to term.
According to research studies on fertility and cancer treatment, the fertility impairments may include:
- Female survivors of acute leukemia are less likely to have liveborn infants.
- Among female survivors who reported a pregnancy by age 25 years, 41% were treated with chemotherapy only and 18.4% were treated with both chemotherapy and prophylactic CRT.
- The fertility rate of female survivors was significantly lower than that of their siblings.
Multiple reports from the Childhood Cancer Survivor Study (CCSS), the largest cohort of survivors of cancer diagnosed during childhood or adolescence, have demonstrated associations between chemotherapy use and risk of clinical infertility, never achieving pregnancy, and premature menopause.
Infertility among male cancer survivors is also common. Researchers found that sperm counts fall dramatically within 2 months following chemotherapy or radiation, and recovery of spermatogenesis can occur up to 5 years after treatment.
Barriers to Fertility Preservation
Fertility preservation (FP) is the process of saving or protecting eggs, sperm, or reproductive tissue so that a person can use them to have biological children in the future. Fertility preservation can lead to greater options for family-building following cancer treatment.
Researchers find that, despite the availability of FP, only 4% to 41% of females and 11% to 43% of males undergo fertility preservation. Patient-, provider-, health system-, and societal-level barriers to FP exist and may influence FP uptake.
Patient-Level Barriers. If survivors do not fully appreciate the potential impact of cancer and treatments on fertility, they may not pursue FP. Patients pursuing FP often face limited or no insurance coverage for FP. For patients aged 18 years or younger, FP decisions may be influenced by parents or guardians.
Provider-Level Barriers. Despite established guidelines and recommendations from professional organizations, the number of formal FP referrals remains low for reasons such as the providers have limited knowledge of FP, viewing infertility as secondary to cancer treatment, having concerns about cost, etc.
Health System–Level Barriers. Variations in the structure, availability, and insurance coverage for reproductive healthcare contribute to health system-based barriers to FP. Most adult patients receive cancer care in community settings, and very few community cancer centers have an affiliated fertility center.
Societal-Level Barriers. There are notable disparities in FP counseling and referrals among cancer patients. Particularly, disparities have been reported based on gender, education, cancer type, age, marital status, and race/ethnicity.
Oncofertility Program with Patient Navigation
To increase patient referrals for FP counseling and reduce barriers to accessing FP, researchers at Duke University created an oncofertility program, with the intention to identify and mitigate barriers to FP through education, assistance, advocacy, and institutional organization and commitment.
Among other things, researchers hired a dedicated oncofertility patient navigator, and this role proved instrumental to program implementation, growth, improvement, and sustainability.
In addition to carrying out the program goals, the navigator’s early involvement in patient care has reduced provider burden by serving as a resource to equip patients with fertility education and access to referrals outside of an oncology visit.
Researchers reported that prior to establishing the oncofertility program, referrals for oncology patients to fertility center in the prior 2 years averaged 54 referrals per year. Since hiring a designated navigator (February 2020-January 2021), the oncofertility program had received a total of 103 referrals, close to doubling the historical average within a 1-year period.
During this period, patients who had access to the navigator were offered oncofertility education, support, and resources. If patients chose to undergo FP, they were supported in applying for financial assistance through grants and philanthropic funds when eligible.
To learn more about this oncofertility program, read Addressing Barriers to Fertility Preservation for Cancer Patients: The Role of Oncofertility Patient Navigation.
Dorfman CS, Stalls JM, Mills C, et al. Addressing Barriers to Fertility Preservation for Cancer Patients: The Role of Oncofertility Patient Navigation. Journal of Oncology Navigation & Survivorship. 2021;12:333-348.
Green DM, Nolan VG, Kawashima T, et al. Decreased fertility among female childhood cancer survivors who received 22–27 Gy hypothalamic/pituitary irradiation: a report from the Childhood Cancer Survivor Study. Fertility and Sterility. 2011;95:1922-1927.
Poorvu PD, Frazier AL, Feraco AM, et al. Cancer treatment-related infertility: a critical review of the evidence. JNCI Cancer Spectr. 2019;3:pkz008.
Waimey KE, Smith BM, Confino R, et al. Understanding fertility in young female cancer patients. J Womens Health (Larchmt). 2015;24:812-818.