Fertility preservation lacking in male cancer patients

November 1, 2008

Physician attitudes, actions at odds over preserving fertility in adolescent men with cancer.

Chicago-Pediatric oncologists appear strongly motivated to preserve fertility in male adolescent cancer patients, although there remains a disconnect between their attitudes and practices in terms of referring patients for available services, according to the Survey for Preservation of Adolescent Reproduction (SPARE) study.

SPARE was undertaken by researchers in the department of urology and members of the Oncofertility Consortium, Northwestern University's Feinberg School of Medicine, Chicago. At the AUA annual meeting in Orlando, FL, results were presented for answers pertaining to male adolescent patients with cancer based on responses received from 207 oncologists. The results were presented by first author Tobias S. Köhler, MD, MPH, an andrology fellow at Northwestern working with Robert Brannigan, MD, and colleagues.

"Intracytoplasmic sperm injection [ICSI], first successfully used in 1992, opened the door for fertility preservation in pediatric and adult male and female cancer patients," Dr. Köhler explained. "However, after multiple studies reported that only a minority of oncologists were even aware of ICSI-let alone appropriately referring patients-the American Society of Clinical Oncology published fertility preservation recommendations (ASCOR) in 2006, which stressed sperm cryopreservation strategies and fertility specialist referral if appropriate.

The survey is an Internet-based, comprehensive instrument comprising 61 items addressing knowledge specific for fertility preservation, attitudes, practices, and methods, as well as questions relating specifically to the ASCOR and assisted reproductive techniques. Demographic analysis of the 207 oncologists who were included for the AUA report showed that the vast majority (>92%) were pediatric oncologists and affiliated with a university practice (80%). They were about equally divided by gender.

Almost all of the respondents agreed that pubertal as well as prepubertal patients should be told about potential drug or radiation damage from cancer treatment, and about 80% indicated that the threat to fertility was a major concern to them as physicians and for the parents or patients themselves.

However, more than half (55%) of the respondents had not heard of the 2006 ASCOR, and only 41% of all survey respondents applied the recommendations for decision-making at least 50% of the time.

"Only 56% of the respondents knew what ICSI was. Responses to this question provide a good surrogate marker of knowledge of current fertility preservation practice," said Dr. Köhler.

While the majority (86%) of respondents agreed that all pubertal male patients should be referred to a fertility preservation specialist, less than half (47%) of those individuals actually referred patients more than 50% of the time. Ninety-two percent of respondents agreed pubertal male cancer patients should be offered sperm banking, but only about three-fourths made the referral more than half of the time.

There was less agreement about offering cryopreservation of testicular tissue for patients who were azoospermic or unable to ejaculate. The majority (60%) disagreed with that practice; the rest were either neutral in their view or agreed. Only 7% of the respondents made these referrals more than 50% of the time. Almost three-fourths of respondents agreed all pubertal male patients should be offered fertility referral postcancer therapy, but only 30% of them made the referral more than 50% of the time.

"All of these findings reveal a persistent disconnect between fertility preservation attitudes and actual practices," Dr. Köhler said.

He said that while these initial findings provide a good platform to re-emphasize the ASCOR to the medical community, they are also relevant to urologists who offer fertility services, as they suggest a need to inform potential referring physicians, patients, and their families that specific expertise in fertility preservation is available.

"General urologists should also keep in mind the issue of fertility preservation, since they may be the specialist who first diagnoses certain malignancies in young male patients, such as a testicular cancer or lymphoma that present in the testes," he said.

The research was supported by the Oncofertility Consortium NIH 1 UL1 RR024926-01 Pilot Project as part of the NIH Roadmap Interdisciplinary Research Consortia.