Background
The global burden of cancer is increasing, particularly among women. Cancer has one of the highest mortality rates among high-development index countries, and breast cancer is the most diagnosed type worldwide [
1]. Among women impacted by cancer, up to a third of cases have been found to occur during the reproductive years [
1,
2]. Women diagnosed with cancer at this life stage have unique family planning needs, particularly given the increasing numbers of women being diagnosed before they have started or completed childbearing [
3]. Currently, there is recognition of, and recommendations around, the receipt of time-sensitive fertility counselling for young women (particularly those diagnosed and treated in childhood or adolescence) [
4‐
7]. Some of these guidelines (e.g. European Society of Medical Oncology guidelines) highlight the general need for effective contraception in the context of systemic anticancer treatment. However, there are no guidelines or clinically endorsed physician resources regarding tailored contraception recommendations for specific cancer types during or after cancer treatment [
8,
9]. This represents a critical gap in patient care as most women retain their fertility potential following cancer treatment, with the absolute risk of infertility remaining low (around 8% for childhood cancer survivors), even in the presence of gonadotoxic therapy [
10,
11]. As such, the gap in the provision of contraceptive care for women who have experienced cancer has been associated with higher rates of unintended pregnancy and medical abortion compared to other women [
12,
13].
It has been recommended that women undergoing cancer treatment or adjuvant therapy including surgery, radiotherapy and chemotherapy as well as hormonal and targeted therapies avoid pregnancy due to adverse maternal and foetal impacts [
2,
14,
15]. With most partnered women (83%) remaining sexually active during and after cancer treatment, contraceptive counselling should be an essential component of the treatment journey [
16,
17]. This is particularly important as the pill is the most popular contraceptive method across the reproductive life course, but avoidance of oestrogen and progestogen-containing hormones (present in the combined oral contraceptive pill) is recommended for women with specific cancer types [
18]. For women with a history of hormonally mediated cancer (e.g. breast and endometrial cancers) and women who have received thoracic radiation, it is argued that non-hormonal contraceptive methods should be considered as first-line approaches, due to the potential impacts on prognosis and cancer recurrence [
19]. In contrast, women who are at high risk of developing breast and ovarian cancers (i.e. have BRCA1 and BRCA2 mutations) could benefit from the use of combined hormonal contraception [
20]. A 2013 meta-analysis found that the use of the combined oral contraceptive pill reduced the risk of developing ovarian cancer by around 42%, and a non-significant association was found for breast cancer [
21]. In addition, medical eligibility guidelines generally recommend the use of higher effectiveness contraceptive methods such as long-acting reversible contraception [LARC] over lower efficacy methods such as the pill where possible, due to their increased ability to prevent pregnancy [
22]. As such, the receipt of time-sensitive contraceptive counselling to identify and facilitate access to contraceptive methods that not only take into account cancer type and stage along the cancer care continuum, but are also tailored to women’s reproductive goals, is of paramount importance [
23]. This may be critical to reducing unintended pregnancy risks and ensuring that pregnancies among cancer populations are planned for times of better health [
24].
Therefore, contraceptive counselling is as important as fertility preservation for women with cancer, and strategies that improve effective contraceptive uptake among these women are needed. However, there is some evidence to suggest that the provision of contraceptive counselling is suboptimal [
25,
26]. In addition, there is a lack of clarity regarding the effectiveness of current contraceptive counselling interventions and their role in increasing the uptake of tailored contraception (including LARC) [
27]. Given there are limited studies on the topic, there is a high need for a systematic review to assist with the development and delivery of effective contraceptive counselling programmes. Therefore, the aims of the review are twofold: (1) summarise and describe the prevalence and efficacy of contraceptive use among women with cancer and (2) evaluate contraceptive counselling practice and its effectiveness in improving the uptake of effective contraception among women with cancer.
Discussion
This timely systematic review and meta-analysis has found a lack of high-quality research focused on contraceptive use and contraceptive counselling interventions among women with cancer. A pooled prevalence found that only 64% of women who have experienced cancer were users of contraception. When individual studies were assessed, it was found that women who have experienced cancer were more likely to use low-efficacy contraception or be non-users of contraception compared to the general population. While this suggests a clear need for contraceptive counselling interventions, our review also showed that there is a lack of focus on improving contraceptive uptake among this population, with the prevalence of contraceptive counselling differing between studies. Studies varied widely depending on the type of cancer, data source and the point along the cancer care continuum contraceptive counselling was provided. A pooled prevalence revealed that only 50% of women received contraceptive counselling. When contraceptive counselling was implemented, it was found to be effective in increasing contraceptive use. However, there was some bias with women being more likely to receive contraceptive counselling if they were already contraceptive users. Beneficial outcomes of contraceptive counselling were also found to be variable.
Despite the lack of high-quality studies, the finding that women with cancer have suboptimal contraceptive practices at all stages along the cancer care continuum is concerning. Non-use of contraception or use of low-efficacy contraception with high typical failure rates (e.g. condoms, withdrawal and fertility-based awareness methods) places these women at high risk of unintended pregnancy. Such practices have also been found among women of reproductive age with other health conditions, including in a substantial number of women with unintended pregnancy histories [
50‐
52]. Although there is a lack of information on the overall prevalence of unintended pregnancy and abortion among women with cancer, women who have experienced cancer (including survivors of childhood cancer) have been found to have similar or higher rates of abortion compared to the general population and age-matched controls; however, specific rates are dependent on the cancer type [
2,
18]. An Australian data linkage study found that around half of pregnancies that occurred 2 years following a breast cancer diagnosis were terminated, with a large proportion of abortions occurring in the first 6 months following diagnosis and when undergoing active treatment [
53]. When experienced during treatment, unintended pregnancy places a significant burden on women, potentially impacting not only treatment options but also foetal outcomes [
54]. Cytotoxic chemotherapy during pregnancy, particularly in the first trimester, is associated with an increased risk of congenital malformations [
55]. Likewise, adverse maternal outcomes including caesarean delivery, gestational hypertension and in rare cases pregnancy-induced cardiomyopathy as well pregnancy outcomes such as pregnancy loss, preterm birth and low birth weight have been reported among childhood cancer survivors [
56‐
58]. As such, access to high-quality contraceptive counselling within oncology settings and long-term follow-up through primary care are critical to optimise long-term cancer and reproductive health outcomes for all women who have experienced cancer, regardless of when in the life course it was experienced. Yet, this review has found that contraceptive counselling is inadequate and haphazard in its implementation.
Our study found that few studies directly addressed contraceptive change (including reasons for change) across the cancer care continuum. Only one study reported on an RCT (although this was in abstract form), and only one cross-sectional study examined contraceptive use at the time of diagnosis, during treatment and post-treatment [
26,
47]. When aspects of received contraceptive counselling were reported by women, they indicated that the quality was poor with reasons to avoid pregnancy not adequately explained. Some women reported being informed of the risks of cancer recurrence and potential impact on the foetus, while others indicated that there was limited information on the impact of cancer apart from discontinuing hormonal contraception and changing to non-hormonal methods [
26,
48]. Bias in the delivery of contraceptive counselling interventions was also noted across the available studies. A US retrospective chart review study found that patients had a threefold increase in the receipt of contraceptive counselling if they were currently using a method of contraception at diagnosis. Contraceptive counselling was also less likely to be provided to women of older reproductive age [
59]. Lower contraceptive use at older reproductive age has been found in the general population and among women with chronic diseases across the reproductive life course [
60,
61]. Excluding the specific impact of cancer and its treatment on women, pregnancies over the age of 40 carry significant maternal and neonatal risks including increased risk of chromosomal abnormalities, miscarriage and premature delivery as compared to younger women. As such, guidelines indicate that women over the age of 40 years should use effective contraception until after menopause to prevent unintended pregnancies [
62,
63].
Health care providers are the gatekeepers of contraceptive knowledge particularly where health conditions are concerned. Yet, these findings point to unmet informational needs regarding evidence-based contraceptive advice and support for women with cancer across the reproductive life course, even when contraceptive counselling is indicated. Previous research has indicated that when asked about contraceptive screening and referral practices, health providers described conducting other forms of counselling or provided pregnancy screening in place of comprehensive and directed contraceptive counselling [
27,
64]. Furthermore, some providers described counselling to specifically avoid pregnancy without offering contraceptive counselling or referral to qualified specialists such as a gynaecologist. Meanwhile, others counselled women to avoid sex for certain indications such as infection during periods of neutropenia only or to prophylactically address issues around heavy bleeding [
27,
36]. As such, the source of contraception may play a key role in not only determining if contraceptive counselling is provided but the focus of the counselling. It has been suggested that women prefer to receive their contraceptive counselling from oncologists. However, it has been reported that although oncologists view contraceptive use as important in cancer surveillance, few provide recommendations, even when explicitly asked by patients [
14,
26]. Others, however, have posited that the dearth of contraceptive counselling is attributed to a lack of clear responsibility among oncology providers, communication issues between team members and other specialists as well as clinician-perceived lack of formalised medical education and training [
27]. While beyond the scope of this review, in order to design effective contraceptive counselling interventions, an in-depth understanding of the extent and nature of the barriers to its implementation and its impact on patient care is required.
While the findings report a lack of standardised contraceptive care for women with cancer, in general, women with breast cancer were found to use effective contraception at lower rates than women with non-breast malignancies, despite similar overall rates of contraceptive use [
43]. This gap in the provision of high-efficacy contraception may be attributed to the recommendations around the use of hormonal contraception. The UK Medical Eligibility guidelines do not recommend the use of hormonal-based methods in women with current breast cancer as they present an unacceptable health risk (category 4) [
22]. For women with a history of breast cancer, such methods are not recommended with the risks of the method outweighing the advantages (category 3). Therefore, given that hormonal methods such as the combined oral contraceptive pill are the most prevalent method of contraception across the reproductive life course [
61,
65], these women require appropriate advice regarding the efficacy of available non-hormonal methods. Although the copper IUD is regarded as a first-line contraceptive method for women with hormone-dependent cancer, the uptake of this method was found to be low. This indicates that significant barriers to its uptake exist. While studies on the barriers to the copper IUD among breast cancer patients are limited, it has been found that women have concerns about pain during placement (which echoes concerns about LARC in the general population) and potential infection risks [
26,
66]. This is despite guidelines recommending their use among immunocompromised women, including those with cancer.
Therefore, given a lack of effective contraceptive use (including LARC) was noted across most cancer types and points along the cancer care continuum (e.g. at diagnosis and survivorship), understanding patient-related barriers to their uptake is required. It is generally understood that a driving factor may be related to misperceptions surrounding fertility [
23,
33,
38]. Although chemotherapy-induced amenorrhea is common in women with cancer, even when exposed to gonadotoxic treatment, the impact on ovarian function varies widely, with a large portion of women maintaining reproductive function [
67]. Importantly, a large survey of premenopausal women with invasive breast cancer found that more than 85% of women reported resumption of menstruation 12 months after completion of chemotherapy, with the majority returning within 6 months [
68]. This suggests that a lack of menses is a poor marker of infertility in this population. However, Guth and colleagues found 16% of oncologists assessed contraceptive use in their patients only if menses resumed [
14]. While women in the general population choose their method of contraception for a number of reasons (and effectiveness being only one of them) [
69], apart from breast and gynaecological cancers, other cancer types have no contraindications to hormonal contraception following cessation of treatment, except where residual cardiotoxicity and the presence of any other comorbidities and complications exist [
22]. An Italian retrospective chart review study found that hormonal contraception was unsuitable in only four cancer survivors due to medical or oncology-related contraindications, yet a large proportion of patients still refused these methods following counselling [
34]. On the other hand, despite the existence of clinical medical eligibility guidelines, this review found the inappropriate selection of hormonal contraceptive methods among women with breast cancer [
47]. This finding further underscores the importance of targeted shared decision-making in counselling women with cancer based on their specific form of cancer.
A key strength of this review is that we used a comprehensive search for the best possible evidence currently available. Despite this, our review has some limitations. Included studies were heterogeneous in terms of study type, setting and population. There was a lack of clarity among studies in relation to the contraceptive counselling provided. Some studies were associated with small size and sampling bias as they were carried out using chart reviews or provided abstracts only. The available studies were largely from the US and primarily focused on breast cancer; most studies did not examine contraceptive use and change by cancer type, and there was a lack of population-level studies. Finally, no studies reported on the long-term benefits and effects of contraceptive counselling and contraceptive use among women with cancer.
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