Fertility Preservation in AYA Cancer Patients Prof Raymond Chan Professor – Cancer Nursing, Metro South Health and Queensland University of Technology

Fertility Preservation Options Fertility preservation options for girls and young women: •  Embryo cryopreservation •  Ovarian transposition •  Experimental – freezing mature oocytes (2-3% success rate) •  Experimental - gonadal protection – GnRHa (conflicting

evidence) •  Experimental – ovarian tissue cryopreservation*** Fertility preservation options for boys and young men: •  Semen collection and storage – potential surgical semen

extraction •  Testicular biopsy with freezing of testicular tissue or

spermatozoa retrieved from the tissue.

Focus of this Presentation

Fertility Preservation in AYA Cancer Patients • Healthprofessionals’andhealthservices’responsestotheneedsofcancersurvivors

•  Implementa6onresearchincancersurvivorship

ASCO Guidelines Bottom Line (2018 Update) RoleofHealthCareProvidersRecommenda)on4.1:Alloncologichealthcareprovidersshouldbepreparedtodiscussinfer6lityasapoten6alriskoftherapy(assoonaspossibleonceacancerdiagnosisismade).Recommenda)on4.3:Referpa6entswhoexpressaninterestinfer6lity,aswellasthosewhoareambivalentoruncertain,toreproduc6vespecialistsassoonaspossible.Recommenda)on4.4:Referpa6entstopsychosocialproviderswhentheyarediscussedaboutpoten6alinfer6lity.

Oktayetal2018JCO

COSA Guidelines COSAGuidelinesAYACancerFer)lityPreserva)on(2014):- Manyyoungpeoplereportfeelingthat:

•  Theywerenot,orwereinadequately,advisedoftheriskortheirop6onsforpreservingfer6lity.

•  Thedecisionaboutwhethertopursuefer6litypreserva6onornotwasmadeforthem

•  Theywerenotgivenenough6metodiscussconcerns•  Theydidnotfullyunderstandtheramifica6onsofthedecision.

COSA2014Leeetal,JCO,2006;AchilleetalHumReprod2006;CrawshawetalEurJCancerCare2009

Oncology Practitioners Perspective and Practices

Oncology Practitioners Perspective and Practices in the APAC Region (n=1,501) •  Shoulddiscussingfer,lityop,onsandissuesbepartofyourrole?

Totallyagree35%

Somewhatagree42%

Don'tknow13%

Somewhatdisagree

6%

Totallydisagree4%

Oncology Practitioners Perspective and Practices in the APAC Region (n=1,501) • Howconfidentareyouindiscussingfer,lityissuesandop,ons?Mean(SD)=5.69(3.05)

Confidencescores6-10/10

48%Confidencescores1-5/10

52%

Oncology Practitioners Perspective and Practices in the APAC Region (n=1,501) • Howfrequentlydoyoudiscussfer,lityop,onsandissuesinyourprac)ce?

Never25%

Occasionally28%

OYen17%

VeryOYen18%

Allofthe)me12%

Preparedness of Australian Oncology Health Professionals YouthCancerServices-QueenslandSurveyofHealthProfessionalEduca6onalNeeds(2013-n=122;2017-n=73)

Bradford,…Henney(2018)JAdolescYoungAdultOncol

43%Nursingstaff10%Medicalstaff46%AlliedHealth

Implementation Study Aim:Toimprovedocumenteddiscussionaboutriskofinfer6lityandfer6litypreserva6onop6onsPopula)on:AYApa)entsaged14-25yearsatthe)meofacancerdiagnosisduring2012-2014/2015-2016Interven)on:•  Year2015Datacollec)onperiods:•  Pre-test:2012-2014(MedicalRecords)•  Post-test:2015-2016(QOOLData)

Five Major Cancer Centres Ter)aryMetroQueensland,Australia:•  LadyCilentoChildren’sHospital• RoyalBrisbaneandWomen’sHospital• PrincessAlexandraHospitalTer)aryRegionalQueensland,Australia:•  TownsvilleHospital• GoldCoastUniversityHospital

Bundled Intervention • DevelopmentofQualityIndicators

•  Prospec6velycollectedandenteredintoQOOLforallpa6entsreferredtoYouthCancerServicesàregularfeedbacktoclinicians

•  TargetedEduca6on•  Forcliniciansatacrosscancercentres

• Pa6entResources•  Gender-specificpa6entresourcepacksfornewlydiagnosedpa6ents

• ReferralPathways•  Pathways,procedureandworkinstruc6onforms

Results Variable Pre-interven)on

(2012-2014)N=260%

Postinterven)on(2015-2016)

N=216%

Chisquarepvalue

Ageatdiagnosis 14-19 121 47% 102 47%

p=0.96 20-25 139 53% 114 53% Gender Male 153 59% 128 59%

p=0.93 Female 107 41% 88 41% CancerDiagnosis Leukaemia 50 19% 39 18%

p=0.46

Lymphoma 60 23% 63 29% Braincancer 35 13% 23 11% Bonesarcoma 26 10% 27 13% Soh6ssuesarcoma 18 7% 18 8% Germcelltumour 37 14% 29 13% Carcinoma 24 9% 13 6% Other 10 4% 4 2% Typeoftreatment Mul6modal 108 42% 96 44%

p=0.006 Chemotherapyonly 104 40% 102 47% Surgery+/-localisedradiotherapy 48 18% 18 8% Toxicityoftreatmentongonads Intermediatetohighrisk 195 75% 168 78%

p=0.55 Lowtonorisk 65 25% 48 22%

Results Variable Pre

interven)onN=260(%)

Postinterven)onN=216(%)

Chi-squarepvalue

Evidenceriskofinfer6litydiscussion

YesNo

159(61%)101(39%)

194(89%)22(11%)

p<0.001

Documentedfer6litypreserva6onoutcomes

YesNo

93(36%)167(64%)

100(46%)116(54%)

p=0.02

SignificantImprovementsobservedinpost-interven)ondatacollec)on:Evidenceofriskofinfer6litydiscussion(RR1.4795%CI:1.12-1.63,p<0.001)Documentedreferralstofer6lityspecialist(RR1.53,95%CI:1.26-1.87,p<0.001)Documentedfer6litypreserva6onoutcomes(RR2.56,95%CI:1.19-3.44,p<0.001)

Results – Number of Preservation

Counts–Preserva6onOutcomes

Interven6onrolloutin2015

Results – Documented Discussion

Results - Documented Preservation Outcomes

Results – Variables Associated with Documented Preservation Outcomes

Limitations • Retrospec6venatureofthepre-interven6oncohort(relianceonmedicalrecords)

• Pre-andpost-datacollec6onsourcesweredifferent(medicalrecordsvsaprospec6vedatarepor6ngmechanism)

• Nevertheless,documenta6onisextremelyimportantinsurvivorshipcareprac6ces.Failuretodocumentimpedesfutureclinicalinterven6onsandmayhavemedico-legalconsequences

Discussion •  Thedispari6esbetweengenderanddiseasegroupswereclosedtoacertainextentwiththeintroduc6onofinterven6ons

• Wewerenotabletodemonstrateimprovementsindocumentedreferralstospecialistsandoutcomesoffer;litypreserva;oninleukaemiapa6ents

•  Implementa6onresearch(qualityimprovementstudies)shouldbeaffordedinthelocalcontexttoenhanceguidelinesdrivencare

•  Thefieldofovarian6ssuecryopreserva6onisadvancingquicklyandwillcon6nuetoevolve–healthprofessionalsshouldpayno;cetonewevidence-basedguidelines

Thank you

Email:Raymond.Chan@qut.edu.au