Prior to initiating treatment, clinicians may frequently fail to discuss infertility risks associated with chemotherapy with patients of reproductive age, despite the existence of the American Society of Clinical Oncology (ASCO) guidelines on fertility preservation counseling, according to results of a study published in JAMA Network Open.
The cross-sectional study aimed to identify factors associated with fertility preservation counseling among adult patients prior to initiating chemotherapy. The investigators leveraged data collected by the ASCO Quality Oncology Practice Initiative, which surveyed approximately 400 oncology practices biannually, between January 2015 and June 2019.
The primary outcome was the discussion of reproductive risks before initiation of chemotherapy. Factors that were assessed for association with fertility preservation counseling were age, sex, race/ethnicity, cancer type, year of study, region, clinic type, annual clinic volume, and rates of insurance coverage. Data from patients with known infertility were excluded from the study.
Of 136,746 reviewed charts, 6976 patients (mean age [SD], 42.5 [7.1] years) were identified as being of reproductive age (defined as 18-40 years for women and 18-50 years for men); of these patients, 3405 were women (49%) and 3571 were men (51%).
A total of 3036 patients (44%) received counseling about the risk of infertility associated with chemotherapy. Women were significantly more likely than men to be counseled (56% vs 32%; P <.001).
In a multivariate logistic regression, factors associated with reduced likelihood of discussion on reproductive risks associated with chemotherapy were being men (odds ratio [OR], 0.73; 95% CI, 0.60-0.90), older age (overall OR, 0.93; 95% CI, 0.92-0.94; 36-40 years OR, 0.29; 95% CI, 0.21-0.40; 41-45 years OR, 0.23; 95% CI, 0.16-0.33; 46-50 years OR, 0.21; 95% CI, 0.14-0.29), gastrointestinal malignancy (OR, 0.77; 95% CI, 0.62-0.94), private practice setting (OR, 0.70; 95% CI, 0.53-0.93), increasing prevalence of patients with Medicare (OR, 0.99; 95% CI, 0.99-1.00), practice offering multiple oncologic specialties (OR, 0.70; 95% CI, 0.61-0.81), and lack of multidisciplinary team planning (OR, 0.54; 95% CI, 0.41-0.70).
Factors associated with increased likelihood of discussion on reproductive risks associated with chemotherapy were having breast cancer (OR, 1.39; 95% CI, 1.12-1.73), having lymphatic or hematopoietic cancers (OR, 1.79; 95% CI, 1.33-2.40), practice located in the Northeast (OR, 1.89; 95% CI, 1.43-2.51), participating in each study year (OR, 1.16; 95% CI, 1.08-1.24), receiving care in an academic clinic (OR, 1.45; 95% CI, 1.05-2.01), and practice offering clinical trial enrollment (OR, 1.60; 95% CI, 1.13-2.29).
The investigators also found that states with legislatively mandated insurance coverage of fertility preservation had significantly higher rates of fertility risk discussion with patients prior to chemotherapy compared with states without such legislation (48.6% vs 39.6%; P <.001).
Limitations of the study included potential data errors due to self-reporting, the retrospective nature of the study, and unknown reproductive histories for the patients. The authors indicated that the number of children a patient already had could have influenced whether a patient ultimately received fertility preservation counseling. They also noted that discussion could have occurred without having been officially documented and the scope or extent of the documented discussions were not recorded.
“The findings suggest that clinicians are more likely to counsel younger patients and female patients about reproductive risks before initiation of chemotherapy,” concluded the authors. “Further awareness and implementation of ASCO guidelines appear to be needed to improve rates of fertility risk discussion and referrals to infertility specialists before chemotherapy.”
Patel P, Kohn TP, Cohen J, Shiff B, Kohn J, Ramasamy R. Evaluation of reported fertility preservation counseling before chemotherapy using the quality oncology practice initiative survey. JAMA Netw Open. 2020;3(7):e2010806.