Better patient–physician communication could improve fertility preservation in men with cancer

CHICAGO — Despite technological improvements in sperm banking, many patients undergoing cancer treatments are unaware of their options for fertility preservation and providers are uncomfortable counseling them, according to a presentation at the joint meeting of the International Congress of Endocrinology and the Endocrine Society.

“Most of us realize that the focus used to be primarily on survival alone, but at this point in time, we’re seeing a change with survivorship issues really taking a foothold not only in the world of oncology but in the overlay with reproduction,” Robert E. Brannigan, MD, assistant professor of urology at the Feinburg School of Medicine at Northwestern University, Chicago, said in his presentation. “Patients are indeed very often living beyond their cancer and they expect to lead full, happy, productive lives. We know, though, that after cancer treatment, male infertility is a common consequence. ... Many of these patients before they receive one drop of chemotherapy or one ray of radiation therapy, come to us with presenting with impaired fertility.”

Brannigan presented examples of cases — ranging from an adult man attempting conception after chemotherapy to a teenage male undergoing cancer treatment and no longer producing sperm — that showed the long-lasting effects of oncology treatments on male fertility.

He listed the excuses often given for not banking sperm: favorable treatment protocols, no time to bank due to acute health issues, poor semen parameters and the priority of survival.

The adolescent male

Many previous studies discouraged sperm banking due to poor outcomes, but Brannigan said times have changed and providers in oncology may not be as aware as those in endocrinology or urology. He explained that at Northwestern, they began outreach and efforts to improve awareness but although Brannigan said he has seen an increase in adult males undergoing chemotherapy who are pursuing sperm banking, he was not seeing pediatric patients.

“Keep in mind that adolescent males are every bit as susceptible to the effects of chemotherapy as an adult male. It’s just a more challenging, targeted group to deal with,” Brannigan said.

Robert E. Brannigan

Brannigan and colleagues surveyed a group of pediatric oncologists and 209 responded (mean age, 45). Of those responders, 80% were at university-based institutions and were seeing up to 30 new adolescent patients per year.

Still, only 45% reported being familiar with the American Society of Clinical Oncology recommendations for fertility preservation, though two-thirds said they were familiar with fertility preservation research.

Brannigan reported that the majority either agreed or strongly agreed that fertility threats to their male patients were a concern for the oncologists; that fertility threats were a concern for the parents; and that the parents and the patients were asking about fertility issues.

In the same survey, 50% of respondents said they never used the ASCO recommendations and 80% said use them half the time or less, so Brannigan and colleagues asked about attitudes vs. practice patterns.

In that survey, 86% of respondents thought it would be a good idea to send patient for referral to a fertility preservation specialist prior to cancer therapy, but only 47% actually sent their patients more than half the time. Additionally, 92% thought patients should be offered sperm banking, but 75% did so more than half the time.

There is “clearly a breakdown between what they want to do and what they’re doing,” Brannigan said.

Quality of sperm

To challenge the notion that sperm quality in patients with cancer is lower than that of the average male, Brannigan and colleagues also conducted a retrospective study with “somewhat surprising” results, he said.

Of the 32 males treated in his practice, 30 were able to provide semen samples and 28 successfully banked sperm, Brannigan reported.

“Their sperm concentration was normal, motility was near normal and morphology was normal,” he said. “The samples these individuals are giving are good quality and can be used for assisted reproductive techniques down the road.”

Even the youngest of those patients produced comparable sperm, he said.

PAGE BREAK

Building a team

“While the issue of fertility preservation is something that a lot of us want to pursue and implement, actually getting the boots on the ground and underway is not so easy,” Brannigan said.

In a previously published study, Brannigan and colleagues conducted focus groups with adult survivors of pediatric cancer and their parents. In these focus groups, “regret dominated the discussion,” he said.

Patients and their parents regretted the lack of fertility discussion and also expressed that if an oncologist were to discuss fertility, it offers hope that there will be a need for it in the future, Brannigan said. Failing to discuss that aspect of survivorship signals to parents that survival may not be the likely outcome, he said.

To further examine the delivery of these messages, Brannigan and colleagues surveyed physicians, nurse practitioners (NPs) and registered nurses (RNs). Their responses showed that while 80% of physicians and NPs were comfortable discussing fertility, only one-third of RNs were comfortable doing so. Half of physicians and NPs were unfamiliar with the ASCO recommendations, but 80% of RNs were unfamiliar.

“If these individuals are not comfortable delivering this care, it’s simply not going to happen,” Brannigan said.

Looking at all respondents, 90% said they had no formal training on how to address fertility with their patients and 80% of physicians and NPs would find that useful while 95% of RNs would.

Brannigan said the team mentality begins with the phone receptionist, the insurance clerk, the patient navigator, but the patient requires the buy-in from their oncologist.

“The patients want their provider in oncology to be on board with this. They look at that person as the captain of the ship and if they’re not interested in it, the patient doesn’t want to pursue it,” he said. “This is a real opportunity for us as clinicians and is an important health issue that is being overlooked.”

For more information: Brannigan RE. Symposium: Fertility Preservation in Cancer Survivors. Presented at: The joint meeting of the International Congress of Endocrinology and the Endocrine Society; June 21-24, 2014; Chicago.

Disclosure: Brannigan reported no relevant financial disclosures.