Most Oncologists Do Not Follow ASCO Guidelines on Fertility Preservation Counseling

[Hopeful]

Elsevier Global Medical News. 2009 Jul 9, D McNamara


ORLANDO (EGMN) - Most oncologists are not following American Society of Clinical Oncology guidelines for counseling patients on fertility preservation, according to results of a survey sent to physicians in multiple areas of oncology.
Although 62% of the 613 respondents said they were aware of 2006 fertility preservation counseling guidelines from ASCO, fewer than half refer patients to specialists, and only about 40% sometimes or often provide educational material as suggested.
The guidelines say that physicians "should address the possibility of infertility with patients treated during their reproductive years and be prepared to discuss possible fertility preservation options or refer appropriate and interested patients to reproductive specialists" (J. Clin. Oncol. 2006;24:2917-31).
"We see this as a physician responsibility, but understand there may be significant barriers to having this discussion," Gwendolyn Quinn, Ph.D., said during a press briefing at the ASCO annual meeting. She cited lack of local resources, lack of awareness of local resources, and cost.
Among the respondents, 22% knew of the guidelines, but said they rarely or never use them. Another 18% said they used them always, and 22% said sometimes. What surprised the survey team was that "almost 38% had never heard of these ASCO guidelines," said Dr. Quinn, an investigator in the health outcomes and behavior program at the H. Lee Moffitt Cancer Center in Tampa.
"Thirty-eight percent have not heard of this? Perhaps I should resign as a cochair," said study discussant Dr. Kutluk Oktay, who served on the committee that developed the guidelines. "The presentation by Dr. Quinn, in my mind, gave us the practical analysis of how the guidelines are used or perceived, sort of a field study for the ASCO guidelines."
Dr. Quinn and her colleagues sent a 58-item questionnaire to a random sample of 1,979 U.S. oncologists from an American Medical Association database. Respondents were asked about their knowledge, attitudes, and practice behaviors related to fertility preservation. The 613 respondents (a 33% response rate) each received a $100 honorarium. The American Cancer Society sponsored the survey.
Most respondents (77%) said they discuss fertility preservation with their patients sometimes or often/always, but Dr. Quinn noted that the extent of the discussion is unknown. "It may be as simple as 'you may become sterile as result of your treatment' to a more comprehensive discussion about fertility preservation options," she said.
Options for fertility preservation before cancer treatment include sperm cryopreservation for men and embryo cryopreservation and ovarian transposition for women. Egg freezing is still considered experimental in most protocols, Dr. Quinn said.
"In Dr. Quinn's study, the main reason why oncologists did not want to refer is because they thought their patients were too ill, which is understandable," said Dr. Oktay, professor and director of the division of reproductive medicine at New York Medical College in Valhalla.
Among the reasons cited as always or often a barrier were the following:
- Severity of illness (35% of respondents). "Oncologists will say, 'I'm very uncomfortable saying to a patient, 'you have a 20% chance of survival, and by the way, have you ever thought about having kids?' " Dr. Quinn said.
- Financial constraints (29%). "No fertility preservation treatments are covered by insurance [for cancer patients], so it's something patients have to pay for out of pocket," Dr. Quinn said.
- Time constraints (12%). Most oncologists reported that their patients start treatment within 24 hours of diagnosis, so they did not discuss fertility preservation because they would not have time to pursue it.
Survey responses were stratified by type of oncologist, including hematologic, obstetric, surgical, urologic, gynecologic, medical, radiation, dermatologic, and musculoskeletal oncologists. Oncologists who were knowledgeable about fertility preservation were 2.6 times more likely to discuss the potential impact of cancer treatment, and 1.9 times more likely to report feeling comfortable about having such a discussion, compared with oncologists who said they were not knowledgeable. Gynecologic and medical/hematologic oncologists were 2.1 times more likely to report feeling comfortable having a discussion.
Oncologists with favorable attitudes toward fertility preservation were 4.9 times more likely to discuss the impact of cancer treatment on future fertility, compared with oncologists who had unfavorable attitudes, Dr. Quinn said.
In addition, female oncologists were 2.12 more likely to refer patients to specialist, such as a reproductive endocrinologist, compared with male colleagues. This was the only significant demographic difference in the study.
Dr. Oktay said the 2006 guidelines contained a lot of qualifiers and may have been too conservative. "They are screaming for an update."
Dr. Quinn recently applied for a grant to train nurses. "While we think physicians certainly need to present this information, nurses may be the more appropriate provider or have the time for the lengthy conversation and the follow-up, as well as to make the referral to the reproductive endocrinologist," she said.
Dr. Quinn and Dr. Oktay had no relevant disclosures.

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