Recent advances in cancer treatment have resulted in an increased number of long-term cancer survivors (1). Currently, the 5-year survival of childhood cancers lies between 75-80% (2) and the cure rate for certain malignancies may exceed 90% (3). Estimates suggest that by 2010, about one in every 250 people will be a survivor of childhood cancer (4). Depending on the type of cancer, fertility might be impaired by the disease itself, or through gonadal damage as a consequence of aggressive radio-chemotherapy regi mens, as well as bone marrow transplantations (5). The resulting infertility might be temporary or permanent.
For all pre pubertal children affected by cancers that could impair their fertility, strategies to preserve their fertility and the ability to bear their own children may be of utmost importance (6). All the concerned parties, patients as well as their families and the medical staff who are responsible for their care, are confronted with this unique and challenging situation that demands special consideration and research with regard to its psychological impacts and consequences (7). Guidelines on fertility preservation underline the importance of informing the affected patients about the possible fertility impairment due to cancer treatment and the available options to preserve it (8). The percentage of patients recalling counseling about the impact of cancer treatment on fertility ranges from 34-72% (9).
The aim of the present article is to evaluate a group of Iranian oncologists’ attitude toward fertility preservation.
This research is based on an attitude assessment questionnaire. An author-designed questionnaire with 5 items was prepared by a team consisting of an oncologist, a psychiatrist, an andrologist and a psychologist. The questionnaire was filled by five specialists a in pilot study and its validity was approved by the expert team. For its reliability, the data were analyzed and Cronbach's alpha was calculated (0.72). The study group consisted of pediatric oncologists, hematologists, radiotherapist and other child cancer therapists in child cancer centers in Tehran: Mahak, Aliasghar, Tebbi Koodakan and Shohada hospitals.
The questions were as they follow:
Q1: How much damage to reproductive organ is due to radio-chemotherapy?
Q2: How much are you concerned about fertility preservation in the pre-treatment stage?
Q3: Have you ever given consultation to the patients' parents about fertility preservation?
Q4: Does fertility preservation make you hesitate about the start of cancer treatment?
Q5: How much do you know about ART (Assisted Reproductive Techniques)?
We asked the participants some other questions regarding their specialty, experience, and also the greatest barriers regarding the patients' parents about the acceptance of fertility preservation.
We sent the questionnaires to the aforesaid specialists by mail and asked them to answer the questions honestly and send them back. We committed ourselves to keeping the gathered information confidential. The data were analyzed by SPSS 11.5 software.
Thirty specialists replied, the response rate being 75%. 85% of the respondents were oncologist and 15% were from other specialties involved in cancer treatment. More than half of the oncologists were pediatric oncologists. More than half of the oncologists believed that radio-chemotherapy had destructive effects on reproductive organs.
67% of the respondents reported that they were attentive about the damaging effects of radio-chemotherapy on fertility at the time of diagnosis.
The important reason preventing the parents of children with cancer not to attend fertility presservation programs before cancer treatment, are shown in Figure 1.
A minority of the respondents (15%) had started treatment after referring more than 50% of their patients to fertility preservation centers.
Only 46% of oncologists knew about fertility preservation techniques such as intracytoplasmic sperm injection (ICSI). This study showed lack of knowledge and attitudes regarding fertility preservation in a number of Iranian oncologists. The results from questions 1 to 5 have been categorized by “little” and “much” and shown in Figure 2.
The study conducted by Shover et al. showed that as high as 91% of oncologists believed that fertility preservation should be offered to all patients at risk, but only 48% of them brought up the topic and less than 25% never mentioned it (10). In our study, although the oncologists believed that radio-chemotherapy had a 30% damage rate on the reproductive organs, but as many as 67% believed that the offer should be made to all patients, but only 40% of them recalled counselling patients on the subject (11).
In a study composed of 657 breast cancer survivors, 72% of women reported that they had discussed fertility concerns with a doctor and 17% had discussed the issue with a fertility specialist (12). Half of the women felt that their concerns about fertility were adequately addressed but a substantial minority of women (20%) reported that their concerns had not been adequately addressed at the time of diagnosis (13). In our study, only 15% of the oncologists had delayed the treatment to refer the patients to fertility preservation centers.
A cross-sectional study by Duffy et Al. on 107 patients undergoing chemotherapy for breast cancer showed a low odds ratio for counseling with more advanced age and higher anxiety levels (14). In a study by Zapalka et al., only 26% of oncologists knew about intracytoplasmic sperm injection (ICSI). In our study, 46% of the oncologists knew about infertility preservation techniques such as ICSI. The study which was carried out by Goodwin et al. and assessed pediatric health professionals’ knowledge about advanced fertility preservation showed lack of knowledge and attitude on the issue. Moreover, there were limited interdisciplinary interchange, for example with infertility specialists, and 64.3% reported difficulties with regard to access to such centers. Most parents (85.7%) and more than half of the patients (57.2%) had been concerned about fertility impairment and broached the subject themselves. Similarly, a qualitative study on pediatric oncologists revealed lack of knowledge on fertility preservation resources as a major barrier to discussion (6).
As counselling has to be offered within a short period of time between the diagnosis of cancer and its treatment, time pressure may affect decisions on treatment strategies. The patients who are already concerned about the disease once again have to make an additional decision about fertility preservation. This moment is described as a life crisis and considerable challenge by most parents ad patients.
In conclusion, counselling seems to be far from being offered globally to all patients and providing information seems to be selective. Therefore, a team composed of an oncologist, an infertility specialist, a psychologist and a social worker is recommended for these settings.