Oncologists' Role in Patient Fertility Care: A Call to Action.

Oncofertility is a term coined just a few years ago to address the urgent, unmet needs of young cancer patients who were offered life-preserving but fertilitythreatening treatments. The issue for many oncologists was not that they did not want to provide options to their patients; rather, the option list and the physician groups on the fertility side were limited. This issue has largely been addressed and the remaining barriers are few. Here are answers to the questions most frequently asked of oncologists by patients. 1.Dopatientscareaboutfertilityinthefaceofacancerdiagnosis?Yes,manystudiesconductedoverthepast 5yearshaveshownthatyoungwomenandmenareconcernedabout theirendocrinehealthandthe fertilityconsequencesofcancer treatment.Patientswhoarenottold about later fertilityconcernsat thetimeofdiagnosishave stress levels in the rangeofposttraumatic stressdisorder duringsurvivorship.1,2Thus,oncologistsareurgedtoprovideafertilityconsultationtomitigatethelong-termhealth consequence associatedwith treatment. 2.What amount of time is necessary forwomen to leave oncology care, be assessed by a reproductive endocrinologist, decidewhatmethod to use for fertility preservation, go through the fertility care cycle, and return to oncology care? Five years ago, ovarian stimulation cycles could take up to 6 weeks to time the start of the cycle. This is no longer standard of care. “Random start” fertility cycles induce ovarian follicle development at anytime during the cycle and take about2weeksfromthestartofovarianstimulationmedications tooocyte retrieval.3 Thisminimizes the timebetween diagnosis and cancer treatment. Moreover, egg cryopreservation isnowstandardofcare,eliminatingdifficult decisions regarding use of a partner’s or donor’s sperm and long-term storage of embryos.4 3. Do hormones cause cancer? For most cancers inmales, females, andpediatric patients, hormones are not involved in the onset or progression of disease. Youngbreastcancerpatientsmayrequirehormonemanagement, and because of this, some breast oncologists are reluctant toprovide fertility care.5 Therearenodata to support acceleration of disease if breast cancer patientsdoopt foroneroundofhormonetreatment tocollect eggs for cryopreservation, and many oncofertility clinics stimulate the ovarian cycle in the presence of letrozole, an estrogen-receptor antagonist. In a recent study5 of tamoxifen adherence, fertility concerns were the number 2 reason given for not following the 5and 10-yearguidelines. Thus, the importantmessage foroncologists is that attending to patients’ fertility concerns,evenforbreastcancerpatients,may improve longterm outcomes because adherence tomedications like tamoxifen could be greater. 4. Is fertility care affordable?There is a great deal of work toward affordability of fertility care options by oncofertilityclinics.Someinsurancecompanieswill cover fertility options as long as they are coded appropriately, using the cancer diagnosis. Certain advocacy organizationsprovidediscounted services at specific clinics, free stimulation medications, and/or grants for patientsundergoing fertilitypreservation. In today’s social media-fueled world, many patients find ways to cover the fertility costs throughcrowdfundingand from friendsandfamily.Thebottomline is thatall youngmales and females should be advised of the fertility threat of their cancer care to enable the financial decisions to be made by the patient, not by the clinician before any irreversible damage to the gonads is done.6 5.What fertility preservation options are available?Thenumberofoptions formalesandfemales, from birthupwards,continues to increaseasexperimentaloptions of ovarian and testicular tissue freezing come to fruition incenters around theglobe.Adetailed list ofoptions is available on Northwestern’s oncofertility website (http://oncofertility.northwestern.edu)aswell asaccess toanationalpatientnavigatorwhocanhelppatients and oncologists navigate existing and emerging options (http://preservefertility.northwestern.edu). There is no one-size-fits-all approach to fertility preservation, so a timely referral is key. Moreover, nonbiological options (like adoption services) are available and not just those that require immediate intervention. In some cases, the oncology treatment strategy is unlikely to cause permanent infertility, which can offer reassurance topatients.Even if apatient isnot interested in talking to an oncofertility specialist because they already have children, the conversation is not limited to fertility but can also include contraception during cancer treatment. 6. Besides fertility, what other reproductive health concerns should I be aware of? Not all female patients will lose their fertility; some will go through a short period of infertility, return to cyclicity and then enter early menopause. Issues of menopausal symptom management will be important for discussion or referral. Vaginal dryness, irregular or absent periods with episodic menstrual pain management, and weight fluctuations are a few of the issues associated with the profound menopausal symptoms young women face when they go into an immediate menopause. Vaginal creams that include estrogens or other hormones can mitigate many of these symptoms, with little risk for adverse effect on the cancer, and enable more attention to restoring long-term health and quality of life. The subjects of sex and sexuality can often be overlooked in a busy oncology practice. Asking a VIEWPOINT