OBJECTIVE: To identify factors associated with ovarian reserve impairment during and immediately after chemotherapy. DESIGN: Prospective cohort study. SETTING: Four university hospitals. PATIENT(S): ...Forty-six adolescent and young adult women with a new diagnosis of cancer requiring chemotherapy. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Measurements of ovarian reserve via levels of serum follicle-stimulating hormone, luteinizing hormone, estradiol, inhibin B, and antimüllerian hormone (AMH) as well as antral follicle counts and mean ovarian volume at 3-month intervals. RESULT(S): Changes in ovarian reserve were quantified for both the acute impact of treatment using linear regression and the longitudinal recovery after therapy using mixed-effects models adjusted for baseline ovarian reserve, use of alkylating agent, and hormone use. The women had at least one pretreatment and two posttreatment study visits (mean follow-up interval: 12 months). All measures of ovarian reserve demonstrated statistically significant changes during chemotherapy. Alkylating agent exposure and baseline ovarian reserve were acutely associated with the magnitude of impairment, and pretreatment AMH levels were associated with the rate of recovery of AMH after treatment. In adjusted models, participants with a pretreatment AMH level >2 ng/mL recovered at a rate of 11.9% per month after chemotherapy, whereas participants with pretreatment AMH levels ≤2 ng/mL recovered at a rate of 2.6% per month after therapy. CONCLUSION(S): Baseline ovarian reserve and alkylating agent exposure effect the magnitude of acute changes in ovarian reserve from chemotherapy. The rate of recovery of AMH is impacted by pretreatment levels. This should be considered during pretreatment fertility preservation counseling.
BACKGROUND
While oncologists are aware that cancer treatments may impact fertility, referral rates for fertility preservation consultation (FPC) remain poor. The goal of this study was to identify ...predictors associated with FPC referral.
METHODS
This is a retrospective, cohort study of women aged 18–42 years diagnosed with a new breast, gynecologic, hematologic or gastrointestinal cancer at our institution between January 2008 and May 2010. Exclusion criteria included history of permanent sterilization, documentation of no desire for future children, stage IV disease, short interval (<4 days) between diagnosis and treatment and treatment that posed no threat to fertility. Demographic, socioeconomic and cancer variables were evaluated with respect to FPC. Logistic regression was used to determine the odds of referral for FPC based on specified predictors.
RESULTS
One hundred and ninety-nine patients were eligible for FPC and of those, 41 received FPC (20.6%). Women with breast cancer were 10 times more likely to receive FPC compared with other cancer diagnoses odds ratio (OR) 10.1; 95% confidence interval (CI) 3.8–26.8. The odds of FPC referral were approximately two times higher for Caucasian women (OR 2.4; 95% CI 0.9–6.2), three times higher for age <35 years (OR 3.3; 95% CI 1.4–7.7) and four times higher in nulliparous women (OR 4.6; 95% CI 1.9–11.3). There was no association between BMI, income, distance to our institution, being in a relationship and referral for FPC.
CONCLUSIONS
Overall referral rates for FPC are low, and there appear to be significant discrepancies in referral based on ethnicity, age, parity and cancer type. This highlights a need for further provider education and awareness across all oncologic disciplines.
OBJECTIVE: To evaluate predictors of undergoing fertility preservation treatment (FPT) in women with breast cancer. DESIGN: Secondary analysis of a clinical database. SETTING: Three academic ...fertility preservation centers. PATIENT(S): One hundred eight patients with breast cancer undergoing FPT and 77 patients with breast cancer not undergoing FPT from 2005 to 2010. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Patients’ demographic and medical information. RESULT(S): Women who had FPT were older, wealthier, and had lower cancer stage compared with women who did not have FPT. The rate of the administration of neoadjuvant chemotherapy (NAC) was significantly lower in women who underwent FPT. After adjusting for age, body mass index (BMI), income, cancer stage, and center, a negative correlation persisted between NAC and FPT (odds ratio 0.091, 95% confidence interval 0.009–0.904). When we stratified the women by center, women at center 1 had a significantly lower FPT rate, lower parity, higher BMI, more advanced cancer stage, and lower income compared with centers 2 and 3. The rates of NAC were significantly higher in center 1. CONCLUSION(S): Although age, BMI, income, cancer stage, center, and NAC seem to be associated with undergoing FPT, NAC is the only modifiable variable. Because NAC restricts the time available for FPT, oncologists may consider offering adjuvant chemotherapy, except in cases in which NAC clearly improves survival, in women who are interested in FPT.
Purpose
The purpose of the study was to investigate the association between patients’ decision-making about fertility preservation (FP) and time between cancer diagnosis and FP consultation in young ...female cancer survivors.
Methods
This is a pilot survey study of women aged 18–43 years seen for FP consultation between April 2009 and December 2010.
Results
Among 52 women who completed the survey, 15 (29 %) had their FP consultation more than 2 weeks after their cancer diagnosis (late referral group) and 37 (71 %) were within 2 weeks of their cancer diagnosis (early referral group). In univariate analysis, the only difference between the late referral and early referral groups was a higher decisional conflict scale (DCS) in late referral group (
p
= 0.04). In multivariable analysis, late referral group was more likely to have high DCS (>35) compared to early referral group (odds ratio 4.8, 95 % confidence interval 1.5, 21.6) after adjusting for age, center, and type of cancer.
Conclusion
Early referral to a fertility specialist can help patients make better decision about FP. This is the first study to suggest that early referral is important in patients’ decision-making process about FP treatment. Our finding supports the benefit of early referral in patients who are interested in FP which is consistent with prior studies about FP referral patterns.
To examine whether demographic and cancer-related characteristics and factors such as fertility discussion with a medical provider and fertility preservation use are associated with attempting ...pregnancy after adolescent and young adult cancer.
Cross-sectional online survey.
Not applicable.
Women with lymphoma, breast cancer, thyroid cancer, or gynecologic cancer diagnosed at 15-39 years from 2004 to 2016 were identified from the North Carolina Cancer Registry and the Kaiser Permanente Northern and Southern California health care systems and responded to an online survey addressing survivorship concerns, including fertility and reproductive outcomes.
Demographic characteristics, cancer characteristics, fertility discussion with a medical provider or fertility specialist between cancer diagnosis and starting cancer treatment, use of fertility preservation strategies (freezing embryos or oocytes) after cancer diagnosis.
Pregnancy attempt after cancer diagnosis, defined by either a pregnancy or 12 months of trying to become pregnant without pregnancy.
Among 801 participants who had not reached their desired family size at diagnosis, 77% had a fertility discussion with any medical provider between cancer diagnosis and treatment initiation, and 8% used fertility preservation after cancer diagnosis. At survey (median =7 years after diagnosis; interquartile range, 4-10), 32% had attempted pregnancy. Neither fertility discussion with any medical provider nor fertility counseling with a fertility specialist was significantly associated with pregnancy attempts. However, the use of fertility preservation was significantly associated with attempting pregnancy (prevalence ratios = 1.74; 95% confidence interval: 1.31-2.32). Other characteristics positively associated with pregnancy attempts included younger age at diagnosis, longer time since diagnosis, having a partner (at diagnosis or at survey), and having a history of infertility before cancer diagnosis.
Use of fertility preservation strategies was uncommon in our cohort but was associated with attempting pregnancy after cancer. Ensuring access to fertility preservation methods may help adolescent and young adult cancer survivors to plan and initiate future fertility.
Financial hardship among adolescents and young adults (AYA) with cancer who receive gonadotoxic treatments may be exacerbated by the use of fertility services. This study examined whether AYA women ...with cancer who used fertility preservation had increased financial hardship.
AYA women with cancer in North Carolina and California completed a survey in 2018-2019. Cancer-related financial hardship was compared between women who cryopreserved oocytes or embryos for fertility preservation after cancer diagnosis (n = 65) and women who received gonadotoxic treatment and reported discussing fertility with their provider, but did not use fertility preservation (n = 491). Multivariable log-binomial regression was used to estimate prevalence ratios and 95% confidence intervals (CI).
Women were a median age of 33 years at diagnosis and 7 years from diagnosis at the time of survey. Women who used fertility preservation were primarily ages 25 to 34 years at diagnosis (65%), non-Hispanic White (72%), and had at least a Bachelor's degree (85%). In adjusted analysis, use of fertility preservation was associated with 1.50 times the prevalence of material financial hardship (95% CI: 1.08-2.09). The magnitude of hardship was also substantially higher among women who used fertility preservation: 12% reported debt of ≥$25,000 versus 5% in the referent group.
This study provides new evidence that cryopreserving oocytes or embryos after cancer diagnosis for future family building is associated with increased financial vulnerability.
More legislation that mandates insurance coverage to mitigate hardships stemming from iatrogenic infertility could improve access to fertility preservation for young women with cancer.
The aim of this study was to evaluate the prevalence of menopausal symptoms in young cancer survivors immediately following the completion of chemotherapy.
This prospective cohort study followed 124 ...young females with a new diagnosis of cancer requiring chemotherapy to assess symptoms of menopause before treatment and immediately following chemotherapy. Symptoms were compared before and after treatment using the McNemar test and between cancer patients and 133 similar-aged healthy controls using Pearson χ2 and Fisher's exact tests.
Participants undergoing cancer therapy reported more menopausal symptoms compared to controls prior to the initiation of any treatment (hot flashes or night sweats 33 vs. 7%, p < 0.01, trouble sleeping 57 vs. 31%, p < 0.01, headaches 50 vs. 35%, p = 0.02, and decreased libido 36 vs. 16%, p < 0.01) and also reported a greater prevalence of symptoms immediately after cancer therapy compared to pretreatment prevalence (vasomotor symptoms, p < 0.01, vaginal dryness, p < 0.01, decreased concentration, p < 0.01, and body aches, p = 0.01). Cancer patients with lower anti-Müllerian hormone (AMH) levels after treatment (<0.10 ng/mL) had an increased risk of vasomotor symptoms (OR 2.2, p = 0.04), mood swings (OR 2.4, p = 0.03), feeling sad (OR 2.2, p = 0.04), trouble sleeping (OR 2.7, p = 0.02), and decreased libido (OR 3.0, p = 0.03) when controlled for age and cancer type, and the incidence of these symptoms was not affected by the use of systemic hormones or psychiatric medications. Treatment length, use of alkylating agents, pelvic radiation, and marital status were also not associated with the prevalence of menopausal symptoms.
Premenopausal women with a new cancer diagnosis have more menopausal symptoms than females of similar age before and after cancer treatment, the effects of which are not mitigated by systemic hormone use. Decreased AMH levels were associated with an increased likelihood of reporting physiologic symptoms after therapy.
This information is imperative for counseling; ultimately, improved symptom management during and after cancer therapies will improve quality of life in young cancer survivors.
The decision to pursue fertility preservation (FP) after a cancer diagnosis is complex. We examined the prevalence of high decisional conflict and specific factors that influence this decision using ...the Decisional Conflict Scale (DCS).
The FIRST project is a web-based survey of female cancer survivors (ages 18-44 years) who have undergone gonadotoxic treatment. We evaluated the association between recalled decisional conflict and referral to FP counseling and demographic, socioeconomic, and cancer variables.
Of 208 participants, 115 subjects (55%) had scores consistent with high decisional conflict (DCS score >37.5 of 100), and 43 (21%) were in the moderate range (25-37.5). In unadjusted analysis, high decisional conflict was associated with lack of referral to FP consultation, not undergoing FP treatment, concerns regarding FP cost, length of survivorship, lower income, education, partner status, and cancer type. In multivariable analysis, significantly higher prevalence of high decisional conflict was observed in participants who were not referred for FP consultation (prevalence ratio PR, 1.25; 95% confidence interval CI, 1.06-1.47), as well as in participants who reported cost of FP services to be prohibitive (PR, 1.16 95% CI, 1.03-1.31). Prevalence of high DCS was lower for women who underwent FP treatment (PR, 0.67 95% CI, 0.52-0.86).
In this study of female young adult cancer survivors, the majority recalled significant decisional conflict about FP at cancer diagnosis. Increasing access to FP via referral for counseling and cost reduction may decrease decisional conflict about FP for young patients struggling with cancer and fertility decisions.
Purpose
Women face multiple barriers to fertility preservation after cancer diagnosis, but few studies have examined disparities in use of these services.
Methods
Women aged 15–39 years diagnosed ...with cancer during 2004–2015 were identified from the North Carolina Central Cancer Registry and linked to the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System. Women who cryopreserved oocytes or embryos for fertility preservation (
n
= 96) were compared to women who received gonadotoxic treatment but did not use fertility preservation (
n
= 7964). Conditional logistic and log-binomial regression were used to estimate odds ratios (ORs) or prevalence ratios (PRs) and 95% confidence intervals (CIs).
Results
Few adolescent and young adult women with cancer in our study (1.2%) used fertility preservation. In multivariable regression, women less likely to use fertility preservation were older at diagnosis (ages 25–29 vs. 35–39: OR = 6.27, 95% CI: 3.35, 11.73); non-Hispanic Black (vs. non-Hispanic White: PR = 0.44, 95% CI: 0.24, 0.79); and parous at diagnosis (vs. nulliparous: PR = 0.24, 95% CI: 0.13, 0.45); or lived in census tracts that were non-urban (vs. urban: PR = 0.12, 95% CI: 0.04, 0.37) or of lower socioeconomic status (quintiles 1–3 vs. quintiles 4 and 5: PR = 0.39, 95% CI: 0.25, 0.61).
Conclusions
Women with cancer who were older, non-Hispanic Black, parous, or living in areas that were non-urban or of lower socioeconomic position were less likely to use fertility preservation.
Implications for Cancer Survivors
Clinical and policy interventions are needed to ensure equitable access to fertility services among women facing cancer treatment–related infertility.
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