Oncofertility Knowledge, Attitudes, and Practices of Canadian Breast Surgeons

Abstract

Background

Guidelines recommend that oncologists discuss treatment-related fertility issues with young cancer patients as early as possible after diagnosis and, if appropriate, expedite referral for fertility preservation (FP). This study sought to determine the attitudes and practices of Canadian breast surgeons regarding fertility issues, as well as barriers to and facilitators of fertility discussion and referrals.

Methods

Semistructured telephone interviews were conducted with 28 site lead surgeons (SLSs) at 28 (97 %) of 29 centers (25 % cancer centers, 64 % teaching hospitals) across Canada participating in RUBY, a pan-Canadian research program for young women with breast cancer. In addition, 56 (65 %) of 86 of their surgical colleagues (non-site lead surgeons [NSLSs]) completed an online survey of their oncofertility knowledge, attitudes, and practices.

Results

Of the 28 SLSs (43 % male, 36 % in practice <10 years), 46 % had inadequate oncofertility knowledge, 25 % discussed fertility only if mentioned by the patient, 21 % believed fertility discussion and referral were the mandate of the medical oncologist, and 45 % did not know of an FP center in their area. More than 80 % of the NSLSs (54 % male, 30 % in practice <10 years) were unfamiliar with oocyte or embryo cryopreservation; 36 % never or rarely discussed fertility issues; and 51 % thought referral to a fertility specialist was not their responsibility.

Conclusions

Oncofertility knowledge was low among the SLSs, especially the NSLSs, and barriers to referral were identified. An oncofertility knowledge translation intervention specifically for breast surgeons is being developed to increase surgeon knowledge and awareness of oncofertility issues and referral.

Appendices

APPENDIX 1: Key Recommendations of ASCO Oncofertility Guidelines11,12

• Discuss fertility preservation with all patients of reproductive age (and with parents or guardians of adolescents) if infertility is a potential risk of therapy.

• Refer patients who express an interest in fertility preservation (and patients who are ambivalent) to reproductive specialists.

• Address fertility preservation as soon as possible, before treatment starts.

• Document fertility preservation discussions in the medical record.

• Answer basic questions about whether fertility preservation may have an impact on successful cancer treatment.

• Refer patients to psychosocial providers if they experience distress about potential infertility.

• Encourage patients to participate in registries and clinical studies.

APPENDIX 2: Non-Site Lead Surgeon Questionnaire

YWBC refers to newly diagnosed Young Women With Breast Cancer 40 years of age or older.

• 1. Gender: male or female

• 2. Age (i.e., <30, 30–39, 44–49, 50–59, 60–69, 70+ years)

• 3. Number of years in practice as a breast surgeon after training.

• 4. What percentage of your practice is breast cancer surgery? (i.e., <25 %, 25–49 %, 50–74 %, >75 %, 100 %)

• 5. Location of facility (i.e., Atlantic, Québec, Ontario, Prairies, West Coast, Northern Territories)

• 6. What type of facility do you work at? (i.e., specialized cancer center, university-affiliated teaching hospital, non-teaching hospital or health center, or other, please specify)

• 7. Number of staff surgeons at your center performing breast cancer surgery.

• 8. What is your level of familiarity with the following fertility preservation options for YWBC on a scale from 1 (not familiar at all) to 5 (highly familiar): (a) Oocyte cryopreservation. (b) Embryo cryopreservation. (c) Ovarian tissue cryopreservation.

• 9. How comfortable are you discussing the following fertility preservation options with your YWBC on a scale from 1 (not comfortable at all) to 5 (very comfortable): (a) Oocyte cryopreservation. (b) Embryo cryopreservation. (c) Ovarian tissue cryopreservation.

• 10. Do you think there is enough clinical evidence in the research literature to support referring YWBC for fertility preservation? Please respond on a scale from 1 (strongly disagree) to 5 (strongly agree).

• 11. How much time do you think would be required for a patient to complete the following fertility preservation procedures? (i.e., <1 week, 1–2 weeks, 3–4 weeks, 5–6 weeks, >6 weeks, not sure)

  • a. Oocyte cryopreservation

  • b. Embryo cryopreservation using partner sperm

  • c. Embryo cryopreservation using donor sperm

  • d. Ovarian tissue cryopreservation

• 12. Which of the following are possible side effects of cancer treatment on YWBC? (i.e., extremely unlikely, unlikely, neutral, likely, extremely likely, not sure)

  • a. Damage and destroy egg supply permanently

  • b. Impairs ovaries ability to make hormones.

  • c. Menstrual periods stopped temporarily

  • d. Infertility

  • e. Premature ovarian failure (premature menopause)

  • f. Subfertility

  • g. Birth defects in future offspring

  • h. Higher risk for miscarriage

• 13. How many YWBC do you see per month? (i.e., 0, 1–2, 3–4, 5, or more)

• 14. What percentage of your YWBC inquire about the side effects of cancer treatment on their capacity to have children post-treatment? (i.e., 0 %, ≤25 %, 26–50 %, 51–75 %, 76–100 %)

• 15. How often do you initiate a discussion mentioning the effects of cancer treatment on fertility? (i.e., never, rarely, sometimes, most of the time, routinely)

• 16. How often do you discuss fertility preservation options? (i.e., never, rarely, sometimes, most of the time, routinely, only if asked by patient)

• 17. What percentage of your YWBC at risk for infertility do you refer for fertility preservation consultation with an infertility specialist? (i.e., 0 %, ≤25 %, 26–50 %, 51–75 %, 76–100 %)

• 18. Typically when do you refer your YWBC patients for fertility preservation consultation? (i.e., as soon as breast cancer is suspected even if pathology is pending, as soon as a cancer diagnosis is confirmed even if biomarkers are pending, after cancer diagnosis and biomarkers are confirmed but before surgery, after surgery when final pathology is available, typically I do not refer for fertility preservation consultation)

• 19. Do you know where to refer your YWBC for the following fertility preservation options? (i.e., yes, no, not sure)

  • a. Oocyte or embryo cryopreservation

  • b. Ovarian tissue cryopreservation

• 20. Do you know a fertility clinic with expertise in fertility preservation for YWBC within your area? (i.e., no, not sure, if yes, please specific distance from your center in km)

• 21. How long do you think YWBC have to wait to see a fertility specialist after a referral is made? (i.e., a few days, 1 week, 1.5 weeks, 2 week, 2.5 weeks, ≥3 weeks)

• 22. Does your clinic have guidelines or protocols for referring YWBC for fertility preservation procedures? (i.e., no, not sure, if yes, please elaborate)

• 23. What factors would you consider when deciding whether to refer YWBC for fertility preservation? (i.e., more likely to refer, less likely to refer, no effect)

  • a. Patient is married/partnered

  • b. Patient is single

  • c. Patient already has children

  • d. Patient is <25 years old

  • e. Patient is >35 years old

  • f. Patient is in a same-sex relationship

  • g. Patient is HIV positive

  • h. Patient has infectious disease (e.g., hepatitis B, C)

  • i. Patient has an aggressive form of cancer

  • j. Patient has a poor prognosis

  • k. Patient urgently needs to start cancer treatment

  • l. Patient has low socioeconomic status

  • m. Patient has preexisting fertility problems before cancer diagnosis

  • n. Patient is highly anxious and stressed about cancer diagnosis

  • o. Availability of fertility preservation educational materials within facility

  • p. Availability of assistance from colleagues (e.g., nurses and allied health) to make referral

  • q. Availability of institutional referral protocols

  • r. Others, please specify

• 24. What is your level of support or opposition for recommending fertility preservation to YWBC with the following cancer stage? (i.e., strongly oppose, somewhat oppose, neutral, somewhat favor, strongly favor, no opinion). Please elaborate in the space provided.

  • a. Oligometastatic (i.e., 1 or 2 bone mets)

  • b. Locally advanced or inflammatory

  • c. 10 or more positive lymph nodes

  • d. 4–9 positive lymph nodes

  • e. 1–3 positive lymph nodes

  • f. Node negative, triple negative, >2 cm

  • g. All other node-negative patients who may require systemic therapy

• 25. With regard to providing fertility preservation to YWBC, who at your center (i.e., staff surgeon, surgical fellow or resident, clinic nurse, social worker, medical oncology team, family physician) is primarily responsible for

  • a. Initiating the fertility discussion

  • b. Referring patient to see a fertility specialist

• 26. Do you think there are psychological benefits for YWBC receiving a fertility preservation consultation? Rate on a scale from 1 (strongly disagree) to 5 (strongly agree)

• 27. Are you aware of any clinical practice guidelines on fertility preservation for cancer patients published by medical societies? (i.e., no, don’t know, if yes, please specify)

• 28. Are you aware of any Canadian organizations that provide information, services and/or resources on fertility preservation to health care providers and cancer patients? (i.e., no, don’t know, if yes, please specify)

• 29. Any other comments about this topic?