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1. National Survey of
Physicians Practice Patterns:
Fertility Preservation and
Cancer Patients
G. Quinn, S. T. Vadaparampil, P. Jacobsen, J.
Lee,
J. Lancaster, G. Bepler, D. L. Keefe, T. L.
Albrecht
Moffitt Cancer Center, Tampa, FL
Karmanos Cancer Center, Detroit, MI

2. Fertility and Cancer Patients
• 450,000 cancer survivors in US
are of reproductive age (19-39) 1
• Cancer treatment may result in
loss of fertility. 2
–
1
Greenlee R, Hill-Harman M, T TM, al e. Cancer statistics, 2001. CA Cancer J Clin 2001;51:15-36.
– 2 Oktay K, Beck L, Reinecke J. 100 Questions and Answers About Cancer and Fertility. Sudbury, Mass: Jones And Bartlett Publishers, 2008.

3. Cancer Related Infertility
The rates vary among patients and
depend on a number of factors:
• Age
• Sex
• Diagnosis
• Radiation field
• Pretreatment of fertility

4. Infertility of Females and
Males
Females
40-80% chance of losing fertility
following chemotherapy or radiation
during reproductive years
• Males
30-75% of male cancer patients
become sterile after cancer
treatment

5. Chemotherapy and Fertility
• Chemotherapeutic agents have been implicated in ovarian failure.
These include alkylating agents, antimitotic antibiotics, and vinca
alkaloids that directly affect mitosis as well as antimetabolites that affect
DNA synthesis.
• Cyclophosphamide: Gonadotoxic doses for prepubertal females occur
at a cumulative dose of 400 mg/kg, slightly higher than for postpubertal
women, who are susceptible at doses of 200 to 300 mg/kg.
• Doxorubicin seems to decrease fertility
• Vinca alkaloids (vincristine and vinblastine) and antimetabolites
(fluorouracil, cytarabine, and methotrexate), both of which affect cell
division, have not been associated with ovarian failure.
• Regardless of the chemotherapeutic agent used, patient age is the
single most important determining factor for gonadal toxicity after
exposure to chemotherapy.
• The older the patient at the time of administration of systemic
chemotherapy, the greater the probability of permanent gonadal failure
Alexander, Carolyn J. M.D.; Tanner, Edward J. M.D.; Kolp, Lisa A. M.D. Fertility After Cancer Therapy. Postgraduate Obstetrics
& Gynecology. 25(5):1-7, March 15, 2005.
Alexander, Carolyn J. M.D.; Tanner, Edward J. M.D.; Kolp, Lisa A. M.D. Fertility After Cancer Therapy. Postgraduate
Obstetrics & Gynecology. 25(5):1-7, March 15, 2005.

6. Risk Calculation
• http://www.fertilehope.org/tool-bar/risk-
calculator.cfm

8. Patients Views on Infertility
• Studies of cancer patients report that loss of
fertility is an immense concern that may
cause great distress.
• Distress and concern often does not
manifest till post-treatment
• Many cancer patients prefer to have
biological children rather than adopt or use
third-party reproduction.
• Schover L, Brey K, Lichtin A, Lipshultz L, Jeha S. Knowledge and Experience Regarding Cancer, Infertility, and Sperm
Banking in Younger Male Survivors. Journal of Clinical Oncology 2002a;20:1880-9.
• Schover L, Rybicki L, Martin B, Bringelsen K. Having Children after Cancer: A Pilot Survey of Survivors' Attitudes and
Experiences. Cancer 1999;86:697-709

9. Fertility Preservation
Options
• Fertility
preservation (FP)
options are
available for
cancer patients
to preserve
fertility prior to
treatment.

10. FP Options for Patients
Male Option
– Sperm
cryopreservation
Female Options
– Embryo
cryopreservation
– Egg freezing
– Ovarian transposition

11. ASCO Recommendations on
Fertility Preservation in Cancer
Patients:
• What Is the Role of the Oncologist in
Advising Patients About Fertility
Preservation Options?
As with other potential complications of cancer
treatment, oncologists have a responsibility to
inform patients about the risk that their cancer
treatment will permanently impair fertility. An algorithm
for triaging fertility preservation referrals is presented in Figure 1, and suggested
talking points are illustrated in the sidebar.
• Journal of Oncology Practice, Vol 2, No 3 (May), 2006: pp. 143-146
© 2006 American Society of Clinical Oncology.

12. Recall of Discussion &
Referral
51% of young breast cancer
survivors were satisfied with their
fertility discussion
• 55% of male cancer survivors of
childbearing age received a referral
for sperm banking
• Leonard M, Hammelef K, Smith G. Fertility Considerations, Counseling, and Semen Cryopreservation for Males Prior to the Initiation of
Cancer Therapy. Clinical Journal of Oncology Nursing 2004;8(2):127-31.
• Schover L, Rybicki L, Martin B, Bringelsen K. Having Children after Cancer: A Pilot Survey of Survivors' Attitudes and Experiences. Cancer
1999;86:697-709.
• Zebrack B, Casillas J, Nohr L, al e. Fertility issues for young adult survivors of childhood cancer. Psychooncology 2004;13:689-699.
• Patridge AH, Gelber S, Pepperson J, Sampson E, Knudsen K, Laufer M, Rosenberg R, Przypyszny M, Rein A, Winer EP. Web-based survey
of Fertility issues in young women with breast cancer. Journal of Clinical Oncology 2004 22, 20 4174- 4183.

13. Survey Development Method
• Literature Review
• Focus Groups
• Interviews with Physicians
• Pilot Testing Instrument
• Expert Reviews

14. “You have a 20% chance of survival
– have you ever thought about
having kids?”

15. “My patients usually start
treatment within 24 hours”

16. “I’ve had to find shoes for my
patients to go home in”

17. National Physician Survey
The purpose of this study was to
assess oncologists’ practice patterns
concerning referral for FP and to
examine characteristics which may
impact referral of cancer patients of
childbearing age.
American Cancer Society

18. Physician Survey
• 58 items
• Domains:
• Demographics / Medical
Background (21)
• Knowledge (5)
• Attitudes and Perceptions (10)
• Barriers (6)
• Practice Behaviors (11)

19. • Physicians were identified through the
American Medical Association (AMA)
database
• Surveys were mailed to 1,979
physicians throughout the United States
• Modified Dillman method was used for
recruitment
Recruitment Methods

20. Sampling: Inclusion Criteria
Physicians in the following specialties:
•
Hematology
Obstetrics
Gynecology
Medical
Surgical Radiation
Urology Dermatology
Musculoskeletal

21. Sampling: Inclusion Criteria:
1) Graduation from medical school
after 1945
2) Practicing medicine in the US
including Puerto Rico
3) Likely to see cancer patients (i.e.
excluded those who did not list
patient care as their primary job and
locum tenens)

22. Response Rate
• 33% response rate
• 613 completed surveys
• $100 honorarium

23. Factors Related to Discussion
• Knowledge
–Oncologists who are
knowledgeable about FP were 2.6
times more likely to discuss the
impact of cancer treatment than
those who were not
knowledgeable.
–Oncologists who are
knowledgeable about FP are 1.9
times more likely to report feeling
comfortable discussing FP than
those who are not knowledgeable.

24. Factors Related to Discussion
• Favorable Attitudes
–Oncologists with favorable
attitudes towards FP were 4.9
times more likely to discuss the
impact of cancer treatment on
future fertility than those who had
unfavorable attitudes.
• Specialty
–GYN and Medical / Hematological
oncologists were most comfortable
discussing FP.

25. Factors Related to Referral
• Gender
–Female oncologists are 2.12 times
more likely to refer to REI than male
oncologists.
• Favorable Attitude
–Physicians with a favorable attitude
towards fertility preservation were
more likely to refer patients
compared to those with an
unfavorable attitude.

26. Factors Related to Referral
• Patient Inquiry
–Physicians who responded “always”
or “often” to the statement
“Patients ask me about the effects
of cancer treatment on their
fertility” were twice as likely to
refer patients - compared to those
who responded “sometimes,”
“rarely,” or “never”.

27. Barriers to Discussing FP
The primary barrier to discussion was inabilty to
delay treatment because patient too ill.
Always/Often
Sometimes Rarely/Never
A patient is too ill to delay treatment to pursue
FP.
35% 44% 21%
A patient can not afford FP. 29% 41% 29%
A patient does not want to discuss FP.
14% 50% 37%
There is no place/person to refer my patient to
for FP.
9% 13% 79%
Time constraints affect my ability to discussion
FP. 12% 23% 66%

28. Practice Patterns
Always/Often
Sometimes Rarely/Never
I consult an infertility specialist or reproductive
endocrinologist with questions about potential
fertility issues in my patients.
24% 29% 47%
I refer patients who have questions about
fertility to an infertility specialist or
reproductive endocrinologist.
47% 29% 24%
I discuss the impact of cancer treatments on
future fertility with my cancer patients. 77% 16% 7%
I provide my patients with educational
materials about FP.
14% 26% 60%

29. National Physician Survey
Results- Practice PatternsAlways/
Often Sometimes
Rarely/
Never
I consult an infertility specialist or
reproductive endocrinologist with
questions about potential fertility
issues in my patients.
24 29 47
I refer patients who have questions
about fertility to an infertility specialist
or reproductive endocrinologist.
47 29 24
I discuss the impact of cancer
treatment on future fertility with my
cancer patients.
77 16 7
I provide my patients with educational
materials about FP.
14 26 60
How often do you utilize the 2006
ASCO recommendations on FP in
cancer patients, when making
decisions about healthcare for your
patients?*
18 22 22
* 37.8% of physicians reported they were unaware of the guidelines.

30. Conclusions
The majority of physicians may not be
–Following ASCO guidelines
–Consulting specialists

31. Future Directions
A significant barrier is limited time to
discuss the cancer diagnosis and
treatment plan as well as to deal with the
psycho-social issues of a newly diagnosed
patient.

32. Future Directions
• Development of physician and nurse
training curricula.
• Interventions to facilitate discussion
of FP between physicians and cancer
patients.

33. Acknowledgements:
• American Cancer Society
• Moffitt Cancer Center
– William Dalton, MD
– Thomas Sellers, Ph.D.
• Karmanos Cancer Center
• All Children’s Hospital
– Michael Nieder, MD
• Mayatech
– Kerri Lowrey JD
• FertileHope
– Joyce Reinecke
– Lindsey Beck
• FORCE
– Sue Friedman
• Susan Vadaparampil, Ph.D., MPH
• David Keefe, MD
• Gerold Bepler, MD, Ph.D.
• Paul Jacobsen, Ph.D.
• Ji-Hyun Lee, Dr.PH
• Jonathan Lancaster, MD, Ph.D.
• Terrance L. Albrecht, Ph.D.
• Clement K. Gwede, Ph.D.
• Jordan Watson
• Michele Griffin