fertility preservation in aya cancer patients · fertility preservation options for boys and young...
TRANSCRIPT
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:[email protected]