An assessment of fertility preservation practices among oncology providers.
Authors: DeCarli Kathryn , Tanzer Joshua Ray , Tajik Amelia , Higel-Mcgovern Camille , Duffy Christine Mary , Lopresti Mary Lorraine 
Published: September 2021

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Background: Chemotherapy accelerates the natural decline of ovarian reserve. Women with a new cancer diagnosis commonly experience psychosocial distress around anticipated fertility loss. Fertility preservation via oocyte cryopreservation or temporary ovarian suppression with GnRH agonists may address this concern. ASCO guidelines recommend early discussion of fertility, preservation methods, psychosocial distress counseling, and referral to a fertility specialist. Disparities have been shown in fertility counseling rates based on patient age, race and cancer type. We sought to identify patterns in fertility preservation practices at Lifespan Cancer Institute. Methods: We retrospectively reviewed the medical record of female patients aged 18-45 years at time of solid tumor or lymphoma diagnosis in the years 2014-2019 who received chemotherapy. We compared documented fertility discussions and referrals across patient demographics and provider characteristics. Generalized mixed effects modeling was used with a logit link or a log link (negative binomial or zero inflated truncated Poisson distribution). Results: Among 181 patients who met eligibility criteria, the median age was 38 years with 140 (77.3%) White and 23 (12.7%) Hispanic. Only 112 patients (61.9%) had a conversation about fertility documented by a medical oncologist. Overall, 42 (23.2%) were referred to a fertility specialist and 28 (15.5%) received fertility preservation. Older patients and patients with higher parity were less likely to have a conversation about fertility with their oncologist (parity: OR = 0.33, p = 0.0020; age: OR = 0.64, p = 0.0439) or to be referred to a fertility specialist (parity: OR = 0.87, p = < 0.0001; age: OR = 0.97, p < 0.0001). Male providers were less likely to refer patients to a specialist (OR = 0.85, p = 0.0155) or discuss fertility (OR = 0.02, p = 0.0164). On average, male providers had much shorter conversations about fertility (Cohen’s d = 1.01, p = 0.0007). Male providers were slightly more likely to refer patients of color to a fertility specialist than White patients (OR = 1.26, p = 0.0684). Patients with breast cancer were more likely to have discussions about fertility than patients with other cancers ( p < 0.0001). Conclusions: We found disparities among patient age, parity, cancer type and provider sex in fertility preservation practices at our institution. Though not statistically significant, we also found disparities among patient race. Nearly all breast cancer providers at our institution are female and use a note template that includes fertility preservation. Providers in other cancer subtypes may be less accustomed to addressing fertility based on their patient populations. A major limitation is that we were only able to capture explicitly documented conversations. This needs assessment supports implementation of a systematic approach to promote fertility preservation as a quality measure across all cancer types.