By Carolyn Crist

(Reuters Health) – Although cancer doctors know it’s important to talk about fertility concerns with young women patients, they may feel uncomfortable and unprepared to discuss the issue, a study in Canada suggests.

The American Society of Clinical Oncology guidelines recommend discussing potential infertility resulting from cancer treatments, but many doctors and patients are still not having these talks, the study authors write in JAMA Network Open.

In part, that’s because doctors feel they don’t know the answers, the study found. Some clinicians interviewed also saw fertility as a “secondary” concern compared to saving the patient’s life.

“While clinicians are aware of guidelines, they often lack the confidence in their knowledge about fertility preservation. And this is for good reason – this is a rapidly changing field,” said Dr. Nancy Baxter of St. Michael’s Hospital in Toronto, Ontario, the study’s senior author.

Advances in assisted reproductive technology have opened-up the possibilities around fertility after cancer treatment, Baxter said. However, about half of women with cancer don’t know their options.

“For some cancer treatments, it can be difficult to predict fertility after treatment,” she told Reuters Health by email. “For women who undergo fertility preservation, it is still no guarantee that they will be able to successfully have their biological children.”

Past research has found that 50% of women cancer patients are not informed about fertility issues stemming from their cancer treatment, and even fewer are referred to a fertility specialist to address these issues, the study team writes.

To explore the reasons why, Baxter and colleagues did lengthy interviews with a sample of 22 cancer-center doctors and nurses in five Canadian provinces. The researchers found that most of the cancer specialists were aware of ASCO guidelines, but they generally lacked familiarity with fertility preservation.

One doctor called fellow oncologists “remarkably ignorant about it.” Another said doctors were only aware in a “sort of theoretical way.” Overall, providers also felt uninformed about the risks, the fertility preservation process, available technologies, costs and how to refer patients.

This lack of knowledge leads to a lack of confidence in discussing fertility options. Several doctors said the conversations were “really sensitive,” “awkward” and “tricky.” Most worried about giving inaccurate information.

They also voiced skepticism about fertility preservation and how it related to their practice. Some thought it was impractical and inappropriate with certain ages or advanced cancer stages. One said fertility considerations were a “luxury.” Another saw it as a burden and “one more thing to deal with” in an already traumatic situation. Others thought it might delay or interfere with cancer treatment.

“Many times, clinicians will decide the amount of information to provide to patients based on their own assumptions about the patient’s age/maturity, prognosis, quality of life, education, or desires to form a family in the future,” said Cecilia Vindrola of University College London in the UK, who wasn’t involved in the study.

“This means that patients are not able to make an informed choice in relation to treatment options as they cannot consider the potential impact the treatment might have on their own fertility,” she told Reuters Health by email.

One limitation of the study is that the interviews were completed in 2014. Since then, fertility education has been emphasized more at oncologist conferences, preservation procedures have improved and egg freezing can occur in less time, said Dr. Ellen Warner of Sunnybrook Hospital in Toronto, who also wasn’t involved in the study.

“If the study were done today, the results would have been significantly better, though still not good enough,” she told Reuters Health by email. “This topic needs to be emphasized continuously . . . until it becomes a routine part of the initial consultation.”

Baxter and colleagues created a tool to help young adults make fertility decisions and are testing it with a group of women with breast cancer. They’re also developing an app to help patients understand the potential effects of cancer treatment on fertility, as well as their options.

“Concern about fertility is one of the most distressing long-term effects of cancer treatment, which can impact psychological wellbeing and gender identity,” said Jane Ussher of Western Sydney University in Australia.

“People experience it as a biographical disruption, changing their expectations of their life course,” she told Reuters Health by email. “Clinicians need to inform people of the possible impact of treatment.”

SOURCE: JAMA Network Open, online November 6, 2019.