in 2012 , an estimated 790,000 women in the united states were diagnosed with cancer , of whom 10% were of reproductive age ( american cancer society , 2012 , schover , 2005 ) .
[ nih surveillance ] ( national institute of health , 2010 , society of family planning , 2012 ) addressing the possibility of future pregnancy is an important aspect of survivorship and quality of life for patients undergoing cancer treatment , and several ways to preserve fertility during cancer therapy have been developed and studied ( letourneau et al . , 2012 ,
as background , 49% of pregnancies in the united states are unintended and unplanned ( the alan guttmacher institute ( agi ) , 2013 ) .
patients with medical co - morbidities , including those undergoing cancer treatment and/or surveillance , are among this group .
it is estimated the incidence of malignancy and pregnancy is approximately 1:1000 ( pavlidis , 2002 , smith et al . , 2003 ) . although rare , pregnancy in the setting of cancer treatment may create clinical and ethical dilemmas , with potential increased risks for both the patient and gestation .
these dilemmas are further compounded when a pregnancy in this setting is unplanned . among women who have undergone or are currently undergoing cancer treatment
, there is limited data regarding the rate of unintended pregnancy or patients ' impression of fertility .
it has been previously reported that childhood cancer survivors between 15 and 30  years old were more likely to terminate a pregnancy compared to age - matched controls ( green et al . , 2002 ) .
a survey of female cancer patients revealed that 55% believed that they could not become pregnant after cancer treatment , and 45% of the same group denied using any contraception method ( patel et al . , 2009 ) .
both of the aforementioned studies support the notion that we could improve counseling in this patient population regarding fertility potential and contraception planning . in gynecologic cancer patients , women with early stage cancers may be eligible for fertility sparing treatment , and therefore may be at risk for unplanned pregnancy after therapy if contraception is not addressed as well ( mclaren and bates , 2012 ) . for this reason
, we conducted a survey of current members of the society of gynecologic oncology ( sgo ) regarding reproductive counseling , practices , and experience with unplanned pregnancy in this population .
after obtaining approval from our institutional review board , a list of member email addresses was obtained from the sgo .
an email statement of confidentiality with the questionnaire link was emailed to all listed members . following the initial e - mail , members received two additional follow - up e - mails , two and four weeks respectively , after the initial contact .
the survey remained open for responses for two weeks following the third , and final , reminder .
survey monkey was utilized to create and administer a nineteen question survey regarding demographics , contraception counseling and use practices , referral patterns , and incidence of unplanned pregnancy .
demographic data queried were age , gender , region of country of current residence , medical specialty , level of training , description of clinical practice , and number of years caring for gynecologic oncology patients .
questions regarding consistency to which the provider addresses contraception and fertility concerns were answered using a likert - type scale ( i.e. , always , sometimes , rare , never , not applicable ) .
the remaining questions were answered using a yes / no or a multiple - choice format .
the multiple - choice questions specifically addressed the frequency of contraception methods counseling and administration , and number of patients experiencing unplanned pregnancy .
participants were asked to check all contraceptive methods that they counseled and administered / prescribed .
contraceptive methods specifically included were the oral contraception pill ( ocp ) , injectable , intrauterine device ( iud ) , or subdermal levonorgestrel implant .
prevalence of unplanned pregnancy was evaluated by asking practitioners to estimate prevalence of unplanned pregnancy among their patients ( during or after treatment ) in the previous one and five years respectively .
we excluded the responses of anyone who reported that he / she was retired or did not provide information on their reproductive counseling patterns .
logistic regression analysis was used to model separately the odds of  always  or  sometimes  offering fertility and/or contraceptive counseling .
all analyses were conducted using stata 13.0 ( statacorp , college station , texas ) .
questionnaires were completed by 261 respondents , yielding a response rate of 18% . among the respondents 21 ( 8% ) reported that they were retired and/or did not provide information regarding their reproductive counseling patterns and thus were excluded from the analysis .
overall , the respondents had a mean age of 47  years with a slight predominance of females ( 52% ) , which is consistent with sgo demographics ( mean age of male members 50  years old , mean age of female members 45  years old ) .
our survey had a higher proportion of fellow respondents ( 24% ) than sgo as a whole ( 9% ) [ gynecologic oncology 2015 : state of the subspecialty ] selected characteristics of respondents are presented by reproductive counseling status in table 2 . among respondents ,
34.6% reported sometimes or always providing counseling on fertility and contraception , 19.2% reported providing fertility counseling only , 15.8% reported providing contraception counseling only , while 30.4% reported not routinely providing counseling on either topic .
in general , providers who reported providing reproductive counseling on neither topic were more likely to be male and/or a fellow .
they also tended to be <  40  years of age , though this difference was not statistically significant .
physicians who reported not routinely counseling on either topic were less likely to report prescribing or administering contraception and/or were less likely to report referring to reproductive endocrinology .
in contrast , those who reported providing counseling on both fertility and contraception were more likely to be female and/or an attending .
they also were more likely to be older ; although that difference was not statistically significant . providers who reported sometimes or always providing counseling on both reproductive topics were also more likely to report providing or administering contraception and/or to refer to reproductive endocrinology . there were no notable differences in reproductive counseling status by u.s .
next , we examined what factors were associated with an increased odds of reporting providing fertility counseling sometimes or always ( table 3 ) .
after adjustment for gender , we found that the odds of reporting providing fertility counseling were nearly three times higher among attending physicians as compared to fellows [ aor  =  2.72 ; 95% ci  =  ( 1.44 , 5.12 ) ] . in examining contraceptive counseling ( table 4 )
, we found that the odds of reporting providing contraceptive counseling was 2.8 times higher in women as compared to men and was 4.91 times higher in individuals age 50  + compared to those <  40 after adjustment for level of practice .
overall , 81.7% of providers reported counseling , prescribing , or administering contraception to their patients . among these individuals ,
the most frequently cited contraceptive that providers reported addressing with their patients included : oral contraceptive pills ( 81% ) , intrauterine devices ( 73% ) , depot medroxyprogesterone acetate ( dpma ) injections ( 56% ) , and contraceptive implants ( 21% ) .
the most frequently cited contraceptives that providers reported prescribing or administering included : oral contraceptive pills ( 80% ) , intrauterine devices ( 62% ) , dpma injections ( 48% ) , and contraceptive implants ( 9% ) .
the reported prevalence of unplanned pregnancy among the surveyed providers ' patients was relatively rare , perhaps because it is not routinely addressed .
most providers ( 95% ) reported 05 unplanned pregnancies among their patients in the last 5  years , with only 3 providers ( 1% ) reporting more than ten unplanned pregnancies .
unplanned pregnancy in the setting of cancer treatment or surveillance is a complicated issue , and may create clinical and ethical dilemmas for the patient , partner , family , and treatment team .
the majority of survey respondents appropriately acknowledged the risk of unplanned pregnancy among gynecologic cancer patients maintaining fertility potential .
however , only half reported addressing contraception planning in this population on a consistent basis ( 52%  always  addressing contraception , versus 35%  sometimes  ) . regarding the consistency with which contraception is addressed ,
these findings are consistent with a retrospective chart review completed at our institution where 45% of initial consultations documented a contraception plan in fertile patients of reproductive age , and 32% of follow - up visits for those that maintained fertility potential after cancer treatment ( crafton et al . , 2016 ) . depending on individual circumstances
patient 's reproductive goals should be determined in order to tailor fertility - sparing treatment , when possible , versus contraception planning .
unfortunately , only half of respondents reported always addressing fertility concerns with patients in this population .
this is consistent with the fact 59% of those surveyed routinely offer referral for preconception counseling for those patients considering fertility preservation options or planned pregnancy .
referral specifically for contraception counseling was reported less frequently , and even fewer reported follow up for plan establishment .
our study was unable to determine which patients or providers relied on the patient 's primary care physician or gynecologist for the establishment of a contraception plan .
the incidence of unplanned pregnancy in this population is reportedly rare , with 96% of responding physicians experiencing <  5 unplanned pregnancies in the previous five years .
this may be under - reported , as oncologists may be unaware of pregnancies , especially during disease surveillance . despite the rarity ,
eleven providers report experiencing an estimated 620 unplanned pregnancies during that time same . the opportunity to avoid even a fraction of those merits further acknowledgement of this topic .
it is reassuring that the large majority of providers reportedly counsel for and administer contraception methods , including 89% reportedly counseling for the iud and 77% employing its use .
however , it was not specified in this survey if the indication for oral contraceptive pills ( ocps ) or an iud was for contraception planning or cancer therapeutic purposes . of reported methods ,
ocps were the most frequent contraception method both counseled for and administered . when compared to implantable methods , both the iud and subdermal implant , both actual and ideal use of ocps
have a higher failure rate , and therefore more reliable methods should be considered first , barring contraindications ( centers for disease control and prevention , 2010 ) .
given our findings that the attending cohort was more likely to provide contraception and/or fertility counseling sometimes or always compared to the fellow respondents ( table 2 , table 3 ) , there seems to be an opportunity to improve education for fellows regarding fertility preservation options for these patients . as seen in other survey - based studies ,
the primary limitation of the study is the modest response rate , despite multiple recruitment attempts and limiting the length of the survey ( cunningham et al . , 2015 ) .
given the response rate , the potential for selection and survey content bias ( i.e. , only those who were interested in the topic responded ) is present thus the results may have limited external validity .
however , as aforementioned , our respondent cohort is comparable to the data published in the 2015 society of gynecologic oncology : state of the subspecialty .
inclusion of both fellows in training and retired members also limits the external validity of the survey regarding current members , but we felt inclusions of these populations were interesting and important in order to compare potential generational differences .
many gynecologic cancer diagnoses are made in peri - menopausal or postmenopausal women ; therefore assessing what portion of a provider 's practice is of reproductive age could aid discussion and interpretation of results .
likewise , as the type of cancer and respective treatment options may change the potential for or etiology of infertility , assessing providers ' experience with specific disease processes , such as gestational trophoblastic neoplasia , also could aid discussion , and intervention .
we acknowledge that a contraception plan may not appropriate for all patients undergoing cancer care , especially for who decline fertility sparing treatment , have been previously sterilized , or are actively attempting conception / currently pregnant .
however , routine recognition of reproductive goals should be addressed by providers to alleviate potential biases or assumptions regarding patients ' reproductive goals or sexual activity .
previous literature has reported providers ' lack of counseling and patients ' misunderstanding of reproductive potential after cancer treatment , and therefore a patient survey would be as valuable as the provider 's impression we report ( patel et al . , 2009 , karaoz et al . , 2010 ) .
as life expectancy following cancer treatment diagnosis and treatment improves , and quality of life of survivors is emphasized , helping women meet their reproductive goals should remain an important focus .
comprehensive reproductive counseling should be emphasized , including both fertility sparing options and contraception planning , with the ultimate goal of decreasing unplanned pregnancy .
 we sought to identify how gynecologic oncologists approach reproductive counseling for their fertile , reproductive age patients , and their experience with unplanned pregnancies.members of the society of gynecologic oncology ( sgo ) were surveyed electronically regarding consistency of counseling patterns of contraception and fertility concerns , most and least common contraceptive methods utilized , referral patterns , and incidence of unplanned pregnancy . of the 1424 sgo members identified , 261 participated in the questionnaire , yielding a response rate of 18% . 
 eighty - two percent of respondents agreed unplanned pregnancy is a potential problem , but only 57% believed their patients understood unplanned pregnancy is possible during treatment . 
 half of respondents report  always  in terms of frequency that contraception is addressed among their high - risk patients . after adjustment for gender 
 , we found that the odds of reporting providing fertility counseling were nearly three times higher among attendings as compared to fellows [ aor  =  2.72 ; 95% ci  =  ( 1.44 , 5.12 ) , three times higher in women as compared to men [ aor  =  2.80 ; 95% ci  =  ( 1.46 , 5.38 ) ] , as well as in individuals 50  + years as compared to those <  40  years old [ aor  =  4.91 ; 95% ci  =  ( 2.05 , 11.74 ) ] . 
 ninety - six percent reported <  5 unplanned pregnancies , to their knowledge , in the previous five years of clinical practice . 
 most providers acknowledge that unplanned pregnancy is a potential risk in fertile gynecologic oncology patients , but only half believe their patients understand an unplanned pregnancy is possible . 
 an opportunity exists to provide more directed counseling regarding fertility during and after cancer therapy , and to educate patients and providers regarding more reliable , long acting contraceptive methods . 