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Fertility preservation for people with cancer

Referral pathways

Clinical Question

Does the provision of oncofertility services or referral pathways influence the referral of patients with cancer to fertility preservation specialists?

A number of studies suggest that the provision of oncofertility services and referral pathways results in an increase in the number of referrals for fertility preservation. Patient experience of oncofertility care in Australia has informed the development of the Australasian Oncofertility Consortium Charter which contains eight key elements of quality oncofertility care.[1] To maximize referral pathways a number of components are necessary: the education for health professionals, electronic or printed materials for patients, development of clear referral pathways between cancer and fertility centres, clear consultation between multidisciplinary teams, the establishment of specific paperwork and telephone numbers for referrals pathways for fertility providers and reproductive laboratories, and coordinated care.[2] Enhancing oncofertility research through registries can improve oncofertility service use, referral pathways and fertility outcomes in addition to supporting collaborative and multi-disciplinary working teams.[3][1][4][5]

In one medical centre in Israel, establishment of a fertility program for patients about to receive highly gonadotoxic chemotherapy increased the rate of referral for fertility preservation procedures. The program centres on an oncologist with a background in reproductive biology who is notified of new paediatric oncology patients. This oncologist discusses the risk to fertility from cancer treatment with the patient and their parents. If the patient wants to proceed with fertility preservation a referral to the reproductive endocrinology facility is made. Here the patient and their parents have an appointment with a team consisting of the oncologist, a reproductive specialist and psychologist.[6]

A significant increase in referrals for fertility preservation was observed at a youth cancer service in Australia that used a multifaceted approach, including: quality indicators for youth cancer fertility, education sessions for medical and senior nursing clinicians, patient resource packs given to newly diagnosed patients, fertility referral pathways, procedures and work instruction forms.[7]

While ovarian tissue preservation is no longer considered experimental (ASRM 2019), it is recommended that fertility preservation still requires careful governance in children (Nahata 2020). Paediatric centres have developed multidisciplinary intersectoral pathways with steering committees.[8] A formalised program at an Australian paediatric centre delivers fertility care under three levels of governance (as a novel technology with institutional reporting, research via an oncofertility registry for safety and efficacy monitoring, and clinical ethics governance for individual cases). Families have fertility discussions with nurse coordinators and paediatric oncologists, and those at medium to high risk or who request it are referred to in-house paediatric oncofertilty clinicians in gynaecology or endocrinology. Close partnerships with reproductive laboratories ensure tissue dispatch and processing and referral for egg collection.[8] The program has significantly improved organisational capacity and fertility care.[9]

Establishment of a hospital-wide fertility preservation service at the Children’s Hospital of Philadelphia more than doubled the number of referrals for fertility preservation. The core team of the service is composed of a paediatric oncologist, nurse practitioner, nurse coordinator/research nurse, psychologist, reproductive endocrinologist, general surgeon, and urologist. Along with increased referral for both oncology and non-oncology patients establishment of the program also provided opportunities for professional development and research.[10]

Development of an oncofertility clinic at the Massachusetts General Hospital in 2013 also led to an increase in referrals for fertility preservation. Education for health professionals and patients complemented the establishment of the clinic.[11]

The establishment of a referral system for fertility preservation at the H. Lee Moffitt Cancer Center in Texas involved the development of an information brochure for patients and a referral process with an IVF clinic. This resulted in a nine-fold increase in the referral of patients of reproductive age to a fertility specialist.[12]

Evidence Summary

Evidence summaryLevelReferences
The provision of a fertility preservation program within a multidisciplinary team is associated with improved referral pathways and timely fertility preservation discussion and treatment if required.IV[7], [13], [14], [15], [8], [9]

Recommendation

Evidence-based recommendationGrade
Cancer services are encouraged to establish referral pathways with fertility preservation services to enable rapid referral of newly diagnosed cancer patients for fertility preservation discussion and procedures. This may involve establishment of an internal fertility preservation program or the development of a relationship with an established fertility preservation service provider.C


References

  1. Anazodo AC, Gerstl B, Stern CJ, McLachlan RI, Agresta F, Jayasinghe Y, et al. Utilizing the Experience of Consumers in Consultation to Develop the Australasian Oncofertility Consortium Charter. J Adolesc Young Adult Oncol 2016 Sep;5(3):232-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/26981709.
  2. Anazodo A, Laws P, Logan S, Saunders C, Travaglia J, Gerstl B, et al. How can we improve oncofertility care for patients? A systematic scoping review of current international practice and models of care. Hum Reprod Update 2018 Nov 20 Available from: http://www.ncbi.nlm.nih.gov/pubmed/30462263.
  3. Winkelman WD, Rosen MP, Mok-Lin E. Fertility Preservation Services for Women With Newly Diagnosed Cancer: A National Assessment. Am J Clin Oncol 2018 Oct;41(10):1031-1035 Available from: http://www.ncbi.nlm.nih.gov/pubmed/29315172.
  4. Blough K, Mansfield C, Kondapalli LA. Seamless integration of clinical care and research in an innovative fertility preservation program: the Colorado Oncofertility Program model. J Cancer Surviv 2014 Dec;8(4):533-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24806262.
  5. Chatterton F, Kay V. An audit of Ninewells Hospital fertility preservation service. J Obstet Gynaecol 2018 Jul;38(5):732 Available from: http://www.ncbi.nlm.nih.gov/pubmed/29944041.
  6. Ben-Aharon I, Abir R, Perl G, Stein J, Gilad G, Toledano H, et al. Optimizing the process of fertility preservation in pediatric female cancer patients - a multidisciplinary program. BMC Cancer 2016 Aug 9;16:620 Available from: http://www.ncbi.nlm.nih.gov/pubmed/27506811.
  7. Bradford NK, Walker R, Henney R, Inglis P, Chan RJ. Improvements in Clinical Practice for Fertility Preservation Among Young Cancer Patients: Results from Bundled Interventions. J Adolesc Young Adult Oncol 2018 Feb;7(1):37-45 Available from: http://www.ncbi.nlm.nih.gov/pubmed/28934554.
  8. Kemertzis MA, Ranjithakumaran H, Hand M, Peate M, Gillam L, McCarthy M, et al. Fertility Preservation Toolkit: A Clinician Resource to Assist Clinical Discussion and Decision Making in Pediatric and Adolescent Oncology. J Pediatr Hematol Oncol 2018 Apr;40(3):e133-e139 Available from: http://www.ncbi.nlm.nih.gov/pubmed/29481385.
  9. Hand M, Kemertzis MA, Peate M, Gillam L, McCarthy M, Orme L, et al. A Clinical Decision Support System to Assist Pediatric Oncofertility: A Short Report. J Adolesc Young Adult Oncol 2018 Aug;7(4):509-513 Available from: http://www.ncbi.nlm.nih.gov/pubmed/29733237.
  10. Carlson CA, Kolon TF, Mattei P, Hobbie W, Gracia CR, Ogle S, et al. Developing a Hospital-Wide Fertility Preservation Service for Pediatric and Young Adult Patients. J Adolesc Health 2017 Nov;61(5):571-576 Available from: http://www.ncbi.nlm.nih.gov/pubmed/28917444.
  11. Hariton E, Bortoletto P, Cardozo ER, Hochberg EP, Sabatini ME. The Role of Oncofertility Clinics in Facilitating Access to Reproductive Specialists. J Patient Exp 2016 Dec;3(4):131-136 Available from: http://www.ncbi.nlm.nih.gov/pubmed/28725849.
  12. Quinn GP, Vadaparampil ST, Gwede CK, Reinecke JD, Mason TM, Silva C. Developing a referral system for fertility preservation among patients with newly diagnosed cancer. J Natl Compr Canc Netw 2011 Nov;9(11):1219-25 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22056654.
  13. Lewin J, Ma JMZ, Mitchell L, Tam S, Puri N, Stephens D, et al. The positive effect of a dedicated adolescent and young adult fertility program on the rates of documentation of therapy-associated infertility risk and fertility preservation options. Support Care Cancer 2017 Jun;25(6):1915-1922 Available from: http://www.ncbi.nlm.nih.gov/pubmed/28155019.
  14. Razzano A, Revelli A, Delle Piane L, Salvagno F, Casano S, Randaccio S, et al. Fertility preservation program before ovarotoxic oncostatic treatments: role of the psychological support in managing emotional aspects. Gynecol Endocrinol 2014 Nov;30(11):822-4 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25054374.
  15. Takeuchi E, Kato M, Miyata K, Suzuki N, Shimizu C, Okada H, et al. The effects of an educational program for non-physician health care providers regarding fertility preservation. Support Care Cancer 2018 Oct;26(10):3447-3452 Available from: http://www.ncbi.nlm.nih.gov/pubmed/29681013.

Body of evidence

What is the effect of providing onco-fertility services or referral pathways on the referral of cancer patients to fertility specialists?

CitationLevel of EvidenceQuality of EvidenceSize of EffectNumber of PatientsRelevance of Evidence
Ben-Aharon I, Abir R, Perl G, Stein J, Gilad G, Toledano H, et al. Optimizing the process of fertility preservation in pediatric female cancer patients - a multidisciplinary program. BMC Cancer 2016 Aug 9;16:620 Available from:http://www.ncbi.nlm.nih.gov/pubmed/27506811IVLow4622
Bradford NK, Walker R, Henney R, Inglis P, Chan RJ. Improvements in Clinical Practice for Fertility Preservation Among Young Cancer Patients: Results from Bundled Interventions. J Adolesc Young Adult Oncol 2018 Feb;7(1):37-45 Available from:http://www.ncbi.nlm.nih.gov/pubmed/28934554IVMedium24762
Carlson CA, Kolon TF, Mattei P, Hobbie W, Gracia CR, Ogle S, et al. Developing a Hospital-Wide Fertility Preservation Service for Pediatric and Young Adult Patients. J Adolesc Health 2017 Nov;61(5):571-576 Available from:http://www.ncbi.nlm.nih.gov/pubmed/28917444IVLow52541
Hariton E, Bortoletto P, Cardozo ER, Hochberg EP, Sabatini ME. The Role of Oncofertility Clinics in Facilitating Access to Reproductive Specialists. J Patient Exp 2016 Dec;3(4):131-136 Available from:http://www.ncbi.nlm.nih.gov/pubmed/28725849IVLow21501
Preaubert L, Pibarot M, Courbiere B. Can we improve referrals for fertility preservation? Evolution of practices after the creation of a fertility network. Future Oncol 2016 Oct;12(19):2175-7 Available from:http://www.ncbi.nlm.nih.gov/pubmed/27513104IVMedium51071
Quinn GP, Vadaparampil ST, Gwede CK, Reinecke JD, Mason TM, Silva C. Developing a referral system for fertility preservation among patients with newly diagnosed cancer. J Natl Compr Canc Netw 2011 Nov;9(11):1219-25 Available from:http://www.ncbi.nlm.nih.gov/pubmed/22056654IVHigh27762
Srikanthan A, Amir E, Warner E. Does a dedicated program for young breast cancer patients affect the likelihood of fertility preservation discussion and referral? Breast 2016 Jun;27:22-6 Available from:http://www.ncbi.nlm.nih.gov/pubmed/27212696IVLow51622
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Acknowledgement Image Title
Cancer Council Australia