How Can Oncologists Make Fertility Preservation a Routine Part of Cancer Care?

CancerNetwork® spoke with Melody Rasouli, MD, MBA, FACOG, a reproductive endocrinology and infertility specialist at HRC Fertility in Newport Beach, CA, about her research assessing fertility preservation information on the websites of National Cancer Institute (NCI)-designated cancer centers from 2015 to 2020.¹ Rasouli discussed persistent disparities between male- and female-directed oncofertility content, how jargon and missing contact pathways can stand in the way of timely referrals, and operational fixes, including electronic health record (EHR) triggers, dedicated navigators, and formal partnerships with fertility practices, that can help ensure every eligible patient is offered a consultation. She also described random-start ovarian stimulation protocols that allow fertility preservation without lengthy treatment delays, the importance of communicating costs and coverage upfront, and the high-impact changes centers can make when auditing their own oncofertility resources.

CancerNetwork: What are some of the most critical deficiencies your research has uncovered regarding fertility preservation information on NCI-designated cancer center websites?

The most critical gap I saw was a basic one: not every NCI-designated cancer center’s website explained that cancer treatment can affect your fertility. When we looked at this in 2020, we saw that 86% of the 65 centers mentioned the risk, and 83% discussed fertility preservation. What’s interesting is that this didn’t increase significantly from 2015, so roughly 1 in 7 websites still didn’t mention the risk to fertility at all.¹

The encouraging finding was that other areas improved significantly. The share of websites with a standalone fertility preservation page increased from around 56% to 83%, and survivorship information on family building rose significantly, from 32% all the way to 82%.¹ That shows there were improvements in website content, and when it’s prioritized, these centers are able to do great things.

Where do the biggest disparities still exist between male and female oncofertility resources online, and how should institutions fix them?

Male-specific content lagged. Information directed toward men, such as sperm cryopreservation, increased from 60% to 70% over the course of our study, but that still left 30% of NCI-designated cancer center websites without fertility preservation information directed specifically toward men. That compared with around 80% for information on female infertility and the impact of cancer treatment. We also found that centers in the highest quartile of per capita income were significantly more likely to address male infertility, as were centers in areas with a higher density of fertility clinics and higher overall IVF volume.¹

How do we fix this? The first step is to recognize that male fertility is important and that we need to build content directed specifically at men. We can use the same structure we’ve laid out for female content, covering options, timing, and who patients can contact, and we can strengthen relationships with physicians in the area, especially in areas that have fewer fertility clinics overall. The good news is that sperm banking is fast and well established, so adding it clearly to websites is a very achievable improvement.

How do buried links, complex medical jargon, or missing contact pathways directly affect a patient’s ability to consider preserving fertility before starting therapy?

When someone has a new cancer diagnosis, they get so much information, and it’s hard to navigate that even without adding the fertility component. Anything we can do as their medical team to make this an easier process, we should do. If that means addressing buried links and avoiding big medical terms that confuse patients, that’s something we can actively be aware of. Instead of saying “sperm cryopreservation,” for example, we can talk about freezing your sperm.

The contact pathway is such a critical one. Nothing is as time sensitive as a cancer diagnosis. Having a referral pattern, where an oncologist or anyone treating someone with cancer, whether that’s their primary care physician or another provider, has a contact with a reproductive endocrinologist, helps make the transition smoother for the patient. It makes it easier for them to navigate, and we want to do that as much as possible.

Drawing on your MBA background, what specific system breakdowns most frequently delay or prevent a timely fertility referral in an oncology clinic?

From an operations perspective, the most common breakdown is probably unclear ownership. Fertility counseling sits somewhere between oncology and reproductive medicine, so it’s hard to know whether one team has covered it before the other. What’s interesting is that ASCO’s updated guidelines broadened the responsibility, changing it from the oncologist to the health care provider, which rightly makes it a team effort.²

It’s a shared task, so it’s good to have multiple people thinking about this component. We’re not relying on just one person who also has so many other components of that patient’s medical journey to keep track of and be responsible for. Having a navigator within the care team who can take ownership and build this step into the workflow would improve it on an operational level.

How can EHR triggers or clinical protocols ensure that every eligible patient is automatically offered a fertility consultation?

We’ve used EHR triggers for other indications that have worked well, such as sepsis protocols or reminders about allergies and cross-reactivity of medications. Going back to the operational standpoint, you take the human component out of it a bit and let the technology work for you, which is always great. If the EHR sees that a new cancer diagnosis was added as a problem, that should trigger a referral to reproductive endocrinology and infertility [REI]. It’s a simple click, and it’s already in the order set. That removes the factor of forgetting to do it.

In terms of documentation, it’s also great to have it in your note: “I offered, and the patient accepted,” or “I offered, and the patient declined the referral,” and to have that done before the first chemotherapy is ordered. That captures both your counseling and the patient’s choice, and it makes sure that conversation really happened.

What specific resources do oncology nurses and patient navigators need from leadership to effectively bridge the gap between the oncology and REI teams?

Oncology nurses and patient navigators are coordinating so much care, from chemotherapy to radiation to surgery. There’s so much that goes into a patient’s oncology care. Having protected time and a formal role for a team member who can take ownership of this helps, and that person is then able to build better contacts. They know the REIs who work closely with oncofertility patients. They have someone at the office who knows this patient needs to be prioritized for running their insurance. We need to prioritize not just seeing them, but all the other components that go into making sure someone can start an IVF cycle in an expedited fashion.

Our data showed that centers in areas with more fertility clinics were more likely to discuss fertility risks, which suggests that access is so important.¹ Formal partnerships are very valuable, especially where local fertility services may be more limited.

How can cancer centers better inform oncologists and patients about rapid-start fertility preservation protocols when treatment cannot be delayed?

This is a great area of our medicine. Right now, we’re able to start a woman on IVF or egg freezing right away, regardless of where she is in her menstrual cycle. That can take away some of the fear of delaying treatment, which is a barrier that has been previously described in the literature. Instead of thinking you need at least a month, maybe 6 weeks, we can do a random-start ovarian stimulation, and it can be done in about 10 to 14 days. In terms of protocols, we also add letrozole (Femara) for hormone-sensitive cancers; I often use that in my patients with breast cancer. For men, we can do sperm banking within days.

The way I’ve liked to do this in the past is to give oncologists a 1-page reference that lays out these timelines and how to reach our team, so they can refer with confidence that this is going to be an appropriate plan for the patient. Do they have this number of days to spare before starting treatment, or do they make the clinical decision with the patient that they don’t have those 2 weeks? Sometimes that is the case. It’s patient dependent, but there are things we can do to streamline that process.

How well are cancer centers communicating out-of-pocket costs, insurance coverage mandates, and financial assistance programs to patients upfront?

This is a tough one. I don’t think cancer centers are typically able to give these estimates, because it’s not what they do; it’s not what the billing department at an oncology center is responsible for. That relies on the fertility side and the practice that is used to running these insurances. Teamwork between the oncology practice and the fertility practice is so critical.

That’s one of the reasons I love working with patients who are going through this oncofertility journey. I work with my team to make sure we’re all very sensitive to how time specific this is, because we don’t have the luxury of the typical time to wait for things in the same way. As a team, we need to prioritize being as fast as possible, so we can be upfront with patients about what we think their insurance will cover, or whether there are state mandates that cover these cycles. That’s also very helpful to be able to share.

If a cancer center wanted to audit and update its oncofertility resources today, what are the top high impact changes it should make immediately?

One is going on the website and pretending you’re the patient. Imagine you are a patient with a given cancer, go to your own website, and try to navigate it. See what information you’re putting out there on fertility preservation, and ask whether, as a patient, it would be enough to let you know that your fertility is at risk and that options are available for women, men, adolescents, and children. Once you see your own gaps, we can work together to fill those gaps for patients.

Another thing that would be great is a direct path to consults: a named contact, such as an oncofertility navigator at your own clinic; a direct phone number to the fertility clinic or an intake form; or an electronic health record trigger that prompts the discussion with an REI referral. These are ways to get a patient from your office to the REI office in the fastest way.

Third, it’s about being aware of what your state covers, working with our insurance teams to check someone’s coverage quickly and give them a typical out-of-pocket cost, and connecting them with specific assistance programs. There are some great programs out there, like Livestrong Fertility and The Chick Mission, and other great ones too. We know cost is a very significant barrier patients face, and addressing it early can help them decide they feel empowered to make, not one they feel forced to make because they’re worried about finances.

References

1. Rasouli MA, de Haydu C, Liu AH, et al. Has oncofertility information for male patients improved? Objective assessment of internet-based fertility preservation resources at NCI cancer centers from 2015 to 2020. J Assist Reprod Genet. 2021;38(11):3057-3060. doi:10.1007/s10815-021-02302-1
2. Loren AW, Mangu PB, Beck LN, et al. Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013;31(19):2500-2510. doi:10.1200/JCO.2013.49.2678