Modifiable factors can increase sperm banking among adolescents newly diagnosed with cancer

James L. Klosky

Researchers have identified modifiable factors that can increase utilization of sperm banking among adolescents newly diagnosed with cancer.

James L. Klosky, PhD, ABPP — director of psychology at Aflac Cancer and Blood Disorders Center of Children’s Healthcare of Atlanta, as well as acting professor in the department of pediatrics at Emory University School of Medicine — and colleagues assessed the effect of several factors on fertility preservation outcomes among 146 at-risk adolescent males (mean age, 16.49 years; Tanner stage 3).

The prospective, single-group, observational study included participants from eight pediatric oncology centers in the United States and Canada.

Participants completed questionnaires within 1 week of cancer treatment initiation.

The researchers used multivariable logistic regression to calculate ORs.

Results showed that 53.4% of participants made a collection attempt. The majority (82.1%) of those who made a collection attempt successfully banked sperm; this group represented 43.8% of all study participants.

Factors associated with increased likelihood of a collection attempt included a consultation with a fertility specialist (OR = 29.96; 95% CI, 2.48-361.41), parent recommendation (OR = 12.3; 95% CI, 2.01-75.94) and higher Tanner stage (OR = 5.42; 95% CI, 1.75-16.78).

HemOnc Today spoke with Klosky about the importance of fertility preservation for younger patients, the modifiable factors that could increase likelihood of fertility preservation attempts, and the types of questions providers should ask younger patients and their parents about fertility preservation.

Question: How important is fertility preservation for younger patients?

Answer: Approximately 50% of adolescent males diagnosed with cancer will be at risk for infertility. This is problematic, as having children is among the top three life goals for these adolescents, and fertility loss often is associated with psychological distress in adulthood. Our clinical objective is to provide every child treated for cancer an opportunity to live a full life as an adult. As a result, we frequently provide opportunities for our at-risk patients to engage in fertility preservation prior to the initiation of gonadotoxic therapy. This can be tricky, as adolescents typically take steps to avoid pregnancy, and yet we are asking them to consider preserving their fertility at a time that they have just been diagnosed with cancer. We have to walk a fine line between providing these patients and families timely and accurate information about risk of infertility and sperm banking, while remaining sensitive to the familial decision-making processes — regardless of the decision — in the context of a recent cancer diagnosis.

Q : How did this study come about?

A: Prior to starting my position at Aflac Cancer and Blood Disorders Center, I was the director of psychology for the survivorship program at St. Jude Children’s Research Hospital. In this setting, we frequently had patients coming to clinic who had recently become engaged or married and, when they tried to start a family, they discovered they were infertile. This realization was particularly difficult for those patients who were diagnosed later in adolescence and do not remember being provided the opportunity to bank sperm before treatment. Sometimes there was anger toward their parents or the medical team, or sadness regarding their fertility loss and the lost opportunity of having biological children with their partner. My clinical experiences working with these survivors made me particularly sensitive to their plight and motivated me to better understand the factors that contributed to banking outcomes. As a result, this study was developed.

Q: What did you find?

A: Of the 146 adolescent participants, 53% made a collection attempt and 44% successfully banked sperm. We also examined what predicts making a collection attempt and found the primary factors associated with this outcome were meeting with a fertility specialist and getting a parent recommendation to bank. In addition to parent recommendation, we found that history of masturbation, medical team recommendation to bank, and higher adolescent banking self-efficacy or confidence in completing all aspects banking were associated with successful sperm banking completion.

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Q: Can you discuss the modifiable factors that you identified and how these factors would be beneficial?

A: Having a specialized fertility consultation was significantly predictive of making a collection attempt, which is frequently the clinical target in sperm banking interventions. As reproductive endocrinology and infertility specialists primarily work with adults, it is sometimes difficult to send an adolescent patient to these clinics, which have been designed with adults in mind. Completing a consultation with a fertility specialist — broadly defined — who is trained in working with pediatric or adolescent patients appears to be key. This specialist may be a physician, nurse practitioner, physician assistant, nurse, psychologist, social worker or other professional who is specialty trained and comfortable talking to adolescents about the very personal aspects of specimen collection.

Many professionals are not comfortable having these conversations, especially in the context of a new cancer diagnosis. Having fertility specialists who can liaise to the clinics where the tissues are collected and stored is one example of a modifiable factor that can be worked into our clinics. Additionally, parent recommendations can be modified. Many times, an adolescent patient can be shy or embarrassed and not want to talk about this important feature of health care in front of others. As a result, there can be situations in which the parent and child privately discuss the fertility information that has been presented, and the parent can be directed by the team to discuss and recommend sperm banking to their child as appropriate within more of a one-on-one setting. To be clear, there should be a direct recommendation from the physician to the adolescent, as well, but a patient’s parent will frequently have more influence on the child in the decision-making process. In terms of successfully banking, talking to the adolescent and determining if there are any barriers specific to banking — eg, novelty to masturbation, financial worries, pain, side effects of medication or fatigue — also should be discussed and targeted within solution-based problem-solving interventions.

Q: Can you provide practical advice for providers about the types of questions they should ask or discussions they should hav e with younger patients and their parents about the potential benefits of fertility preservation?

A: Professionals offering this type of counseling should be comfortable in terms of using slang and less formal language when conducting their psychosexual assessment with the adolescent and describing the procedural demands associated with collecting sperm. Another important thing to note is that there are no right or wrong answers when it comes to sperm banking. It is our job as medical professionals to provide timely and accurate information on the front end of treatment and to make banking recommendations for appropriate candidates. Once we’ve done that, the decision is up to our patients and families as to whether or not they want to pursue fertility preservation. As a mental health professional, my goal is to promote a sense of contentment and general satisfaction regarding the decisional process and banking outcome — regardless of what that is — and I want patients and families to feel supported and respected as these difficult decisions are made. One of my first recommendations to providers is to include the adolescent in the conversation about fertility risk and preservation options. It is also OK to meet with the adolescent alone and to do an assessment in such a way that the patient does not have the pressure of discussing private aspects of their lives (eg, history of masturbation or sexual activity) in front of their parent. It also is important for the provider to become comfortable having these conversations. They should relax, communicate, and not be uptight or rushed because the teen will take their cues from the provider. It is also important for the conversations to be more of a dialogue. This will allow the provider to assess specific barriers or misperceptions that the adolescent or his parent may have, and it will allow patients the opportunity to ask questions. Providers should additionally utilize other resources. For example, if a patient or family has a question about religion or its rules surrounding masturbation in the context of medical care, refer the patient and their parent back to their religious leader or place of worship. Talk to social work if you are unsure of how much sperm banking will cost or the different hospital-based programs that provide funding for these procedures. Going that extra step to make sure the patient’s needs are met could have a big effect on the decision-making process.

Q: Do you have anything else that you would like to mention ?

A: For many of us, being a parent is a central feature of our identity, and research shows that becoming a parent in the future is a top life priority for our young patients. In the frenzy of diagnosing, treating and curing a patient’s cancer, slow down and talk — or have a team member talk — to your patients about treatment-related fertility risk and options for fertility preservation. A small investment of your time could have enormous payoffs in the future. – by Jennifer Southall

Reference:

Klosky JL, et al. J Clin Oncol. 2017;doi:10.1200/JCO.2016.70.4767.

For more information:

James L. Klosky, PhD, ABPP, can be reached at Emory University School of Medicine, 2015 Uppergate Drive, ECC #412, Atlanta, GA 30322; email: james.klosky@emory.edu.

Disclosure: Klosky reports no relevant financial disclosures.