ASCO 2009: Fertility Preservation Guidelines Not Widely Followed

Roxanne Nelson

June 01, 2009

June 1, 2009 (Orlando, Florida) — Many oncologists are not following fertility preservation guidelines and are unaware of current guidelines regarding fertility preservation for cancer patients, according to the results of a survey presented here at the American Society of Clinical Oncology (ASCO) 45th Annual Meeting.

In 2006, ASCO issued guidelines regarding fertility preservation (J Clin Oncol. 2006;24:2917-2931), which recommended that oncologists "address the possibility of infertility with patients treated during their reproductive years and be prepared to discuss possible fertility preservation options or refer appropriate and interested patients to reproductive specialists."

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However, only 38% of the surveyed physicians stated that they were aware of ASCO's guidelines regarding infertility, said lead author Gwendolyn P. Quinn, PhD, from the H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida.

Among physician respondents, the majority of oncologists (79%) reported discussing fertility preservation with patients of childbearing age, but less than 25% referred such patients to reproductive specialists or reported distributing educational materials regarding fertility preservation.

"Studies show that loss of fertility is a main concern among cancer patients," said Dr. Quinn during the presentation. "It is under discussion whether or not women or men are more likely to be impaired as a result of cancer treatment, but estimates are that it may affect between 40% and 80% of women and between 35% and 75% of men."

Dr. Quinn pointed out that roughly 50% of patients do receive information about fertility from their physicians, but there is wide variation in the information that is disseminated. It can range from a brief mention about the risk for infertility to an in-depth discussion about the risks for impaired fertility and referrals to reproductive endocrinologists.

Practice Patterns and Barriers to Communication

Physicians reported that the primary barrier to discussion was a patient being too ill to delay treatment. Many respondents also said that they did not discuss fertility preservation when they believed that the patient had a poor prognosis. Another major concern cited by physicians was the cost involved in trying to preserve fertility.

To assess practice patterns and knowledge and to identify perceptions of barriers to communication about fertility, Dr. Quinn and colleagues distributed a 58-item survey to 1979 physicians. A total of 613 physicians completed the survey, with a 33% response rate among oncologists.

"The physicians who [completed] the survey were those most likely to see cancer patients in practice," she said.

The results of the survey showed that oncologists who were knowledgeable about fertility preservation were 2.6 times more like to discuss the impact of treatment on fertility and were 1.9 times more likely to feel comfortable discussing it.

Oncologists with favorable attitudes toward fertility preservation were 4.9 times more likely to discuss it with their patients, and female physicians were twice as likely as male physicians to refer patients to a reproductive endocrinologist. Compared with other specialists, gynecologic or medical/hematological oncologists were 2.1 times more likely to report feeling comfortable discussing fertility preservation their patients.

"A majority of physicians may not be following ASCO guidelines, and a significant barrier is limited time to discuss this issue," Dr. Quinn said. "We are developing a training curriculum for physicians and nurses — especially for nurses, as they may be the more appropriate provider for this."

Why Are Guidelines Not Followed?

"This presentation gave us a practical look at how ASCO guidelines are looked at and perceived," said Kuluk Oktay, MD, professor of obstetrics and gynecology and director of the Division of Reproductive Medicine & Infertility at New York Medical College in Valhalla. "These guidelines lay out certain conclusions, and state that fertility preservation is often possible for cancer patients and should be implemented as soon as possible."

Dr. Oktay, who served as a discussant for the paper, pointed out that the ASCO guidelines do not oblige physicians to discuss fertility preservation with patients; they simply make the recommendation. "It has a lot of qualifiers — even if oncologists read them, it is left up to them to discuss it with patients," he said.

Another issue is low rate of referral to specialists, he said. "It is not surprising to me because the issues are complicated and most techniques are perceived as experimental. Perhaps oncologists also perceive them that way."

Lack of Insurance Coverage for Fertility Preservation

An important barrier identified by both patients and clinicians is the high cost and the lack of insurance coverage for fertility-preservation services. In a related study, the research team from Moffitt took a closer look at state policies regarding insurance coverage as it related to infertility in cancer patients.

"The take-home message is that there is nothing on the books about infertility," said Susan T. Vadaparampil, PhD, MPH, lead author of this study. "Insurance requirements are not in place regarding infertility for cancer patients, and the unique situations of cancer patients are not addressed by current laws."

As of July 1, 2008, 15 states (29.4%) had laws relating to insurance coverage for infertility or in vitro fertilization (IVF) procedures, but none of them had laws or regulations addressing insurance coverage for fertility-preservation methods specific to cancer patients.

The researchers noted that laws are not uniform across states. For example, there are 9 states that mandate some type of coverage for fertility procedures, but Dr. Vadaparampil pointed out that there "are a lot of caveats to that."

Five states defined infertility, and although California mandated an offer of coverage for infertility, they did not specifically define the terminology. For laws concerning IVF, said Dr. Vadaparampil, 7 states mandated coverage and 2 states specifically excluded IVF from a mandatory offer of coverage.

"There is a strong argument for policies that require coverage or offer of coverage for infertility of cancer survivors and fertility-preservation options prior to treatment," she said. "We should think of this as a side effect of cancer treatment, the same as other side effects associated with a cancer diagnosis."

Cost is not only a problem for cancer patients, but for most people seeking treatments for infertility, noted Dr. Oktay. "It is not seen as being medically necessary."

The researchers have disclosed no relevant financial relationships.

American Society of Clinical Oncology (ASCO) 45th Annual Meeting: Abstract 9509 and CRA9508. Presented on May 30, 2009.

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