Introduction
As advances in oncology in recent decades have led to high peak improvements in the survivorship rates of young people diagnosed with cancer, fertility preservation (FP) has become an important consideration for patients with cancer [
1‐
3]. Female patients of reproductive age undergoing gonadotoxic anticancer therapy are at high risk for premature ovarian failure (POF) and infertility or subfertility [
3]. Chemotherapy, radiotherapy or their combination are a great threat to fertility among women with cancer. FP has become an integral part of the care of young female cancer patients (FCPs). It is increasingly recognized that these patients, especially those undergoing novel oncological treatments, have to deal with their quality of life (QoL) in addition to a life-threatening diagnosis [
1,
4‐
7]. Young FCPs have to make difficult decisions involving the concept of QoL, which is a vague and complex concept with multiple definitions and ‘many diverse facets and components’ [
4].
It is widely argued in the literature that reproductive capacity in humans and especially in women is strictly related to their (reproductive) autonomy and well-being [
6‐
8]. FP should be regarded as a medical treatment, especially in light of the new holistic-positive definition of the concept of health. Indeed, there is a need for a ‘shift from a biomedical approach of cancer treatment towards a holistic understanding of the impact of cancer on the individual’s quality of life’ [
7]. Oncofertility, namely, FP for cancer patients, is a novel discipline [
9]. Oncofertility involves medical, surgical and laboratory procedures to preserve fertility in young FCPs whose reproductive potential is at high risk of being lost [
2,
7,
10,
11]. Most importantly, oncofertility involves various health care professionals (HCPs) and many difficult ethical dilemmas.
There are various FP methods that are currently available to a young female patient recently diagnosed with cancer. Oocyte or embryo cryopreservation are well-established methods for adults and postpubertal girls, and ovarian tissue cryopreservation is being offered as an experimental method for prepubertal girls and adult female patients whose medical conditions do not allow for their cancer treatment to be postponed for at least two weeks [
2].
While FP is of great importance to reproductive-aged FCPs, it remains underutilized in clinical practice for various reasons. Most importantly, it is well known in the literature that reproductive-aged FCPs are often provided with inadequate information about the FP options that are available to them. While the literature states that HCPs should always provide optimal counselling [
1], many primary care physicians are unaware of the possible negative impact of anticancer treatment on patient fertility [
12]. Health care professionals’ lack of knowledge about how to manage FP conversations with young FCPs seems to be a major reason behind these patients’ unmet needs regarding FP [
13]. Early referral to specialists who are able and willing to discuss FP options is strongly recommended [
12].
Ultimately and most importantly, it should be pointed out that very substantial knowledge gaps still remain in the available literature regarding cancer patients’ experiences, and they need to be filled [
14,
15]. More specifically, substantial knowledge gaps have been identified regarding cancer patients’ specific feelings or needs for FP options [
14,
16]. This study aimed to contribute to filling these knowledge gaps.
Discussion
While most of the participants in this study suffered from breast cancer, six out of nineteen participants suffered from cancer primarily located in other organs: cervical (two participants), ovarian, stomach, colon, and lymphoma. It should be noted that ‘the incidence of colorectal cancer among premenopausal women is increasing’ [
17]. The diversity of cancer types in our small sample is in line with the available literature. Importantly, despite the enormous need of premenopausal women with cancer for FP prior to treatment, only a small percentage of these patients actually managed to do so.
Participants in this study experienced a lack of close collaboration among all relevant stakeholders involved in their FP decisions. That situation goes against the promotion of the patient’s autonomy and well-being. As oncofertility is an emerging and multidisciplinary field [
3], the produced international or national guidelines should be multidisciplinary [
18,
19]. FP guidelines have been implemented since 2013. In 2020, the European Society of Human Reproduction and Embryology (ESHRE) published a detailed guideline ‘written by a multidisciplinary group with gynaecologists and fertility specialists, oncologists, a psychologist, a bioethicist, an embryologist, a scientist, and patient representatives’ [
18]. The same goes for other guidelines developed in the US, Spain and France [
19‐
22].
Furthermore, comprehensive fertility counselling and optimal care should be provided by a multidisciplinary team of health providers, including ‘oncologists, reproductive endocrinologists, mental health counsellors and clinical researchers’ [
23]. A close and strong collaborative effort of all relevant stakeholders is required [
3,
18,
19,
23‐
26]. The appropriate FP method in a given case must follow multidisciplinary strategies. It must be carefully selected upon shared decision-making [
18,
27,
28]. The selection of the most appropriate option should be individualized and may be determined by factors such as patient age, patient characteristics, desire for conception, disease, treatment plan and socioeconomic status [
19,
25]. FP decision-making in women with cancer is a complex process [
29].
Many participants in this study felt that they had received inadequate information. However, some participants felt that they had been adequately informed on their own initiative. These participants were classified into two categories: those who declined further information and those who sought more information and asked further questions of health providers. That is, health providers would only give enough information on the patient’s request.
It is essential that health care professionals (especially oncologists and haematologists) provide adequate information to reproductively active women with cancer about the feasibility of preserving fertility as early as possible prior to the initiation of anticancer treatment [
18‐
20]. The American Society of Clinical Oncology (ASCO) [
20] and the European Society of Human Reproduction and Embryology (ESHRE) [
18] embrace this view. Furthermore, many authors share the consideration that FP in cancer patients protects their mental health and promotes their quality of life, enables patients to better cope with their cancer-related stress, can ‘boost their confidence in treatment’, ‘reduces their long-term regret or disappointment concerning fertility’, and facilitates patients in making well-informed decisions about their cancer care [
3,
19,
21,
22,
26,
29,
30]. It is argued that it is physicians’ moral obligation [
3,
18,
20,
21]. The information provided should be tailored to the needs of the various subgroups of women [
31]. Importantly, the provision of information should be combined with ‘appropriate and effective fertility-related’ psychological support (fertility counselling) [
26]. Nevertheless, oncofertility counselling is ‘underutilized’ for female patients for various reasons [
3,
2,
24,
28,
32‐
34].
Indeed, only a small percentage of young women with cancer receive suboptimal counselling and/or receive referrals to FP services. This emerged as a recurrent finding in the literature review [
2,
3,
9,
24,
35]. A retrospective study has shown that ‘of all the 918 surveyed cancer survivors who had potential reproductively toxic cancer treatments, 61% of them were counselled by an oncologist about their infertility risk, but only 5% of them visited a fertility specialist and 4% of them ultimately chose to preserve their fertility’ [
3]. Covelli et al. cited a literature review to suggest that despite the existing guidelines (i.e., ASCO guidelines, ‘an estimated 50% of women with cancer remain uninformed about the potential for cancer-related infertility, and even fewer are referred to fertility specialists’) [
36]. This happens for a variety of reasons [
24]. For example, it is argued in the literature that while ‘66–100% of patients with cancer expressed a need for fertility information’, ‘about half of patients (43–62%) felt that relevant information was provided inadequately and that their information needs were not addressed’ [
35]. Suboptimal counselling is a factor that serves as a critical barrier to FP [
2]. Furthermore, it should be noted that the volume and content of FP information that should be provided to reproductively active women with cancer are not clear and commonly accepted. Importantly, the ESHRE provided detailed guidelines for addressing this issue [
18].
Most participants in this study had not received a referral for FP options. Although women with cancer may be focused initially on their diagnosis, to increase the likelihood of future child-bearing potential, reproductively active women with a cancer diagnosis should be promptly referred to reproductive specialists before treatment initiation [
2,
21,
28,
29,
37].
In this study, data analysis implicates physicians’ lack of knowledge about cancer-related FP. The literature states that a lack of information for patients and, ‘unfortunately’, a lack of knowledge for professionals are critical barriers to FP services [
9]. The findings of a study conducted by Covelli et al. suggest that medical education has not kept pace with FP technologies, which has left many clinicians uninformed about them” [
36]. Health providers should be prepared to discuss FP options with their female patients who receive a cancer diagnosis, provide adequate information to them, assist them in making the best possible choices and refer them properly as soon as possible [
21,
24,
33].
All participants in this study were offered narrow FP options, mostly oocyte and embryo cryopreservation. Selection of the appropriate FP option for a particular patient includes a variety of factors cited in a study conducted by Logan and Anazodo [
26].
In this study, physicians remained concerned about the safety of controlled ovarian stimulation (COS) for FP before initiating anticancer treatment, particularly in patients with hormone-sensitive cancer. It is true that the safety of FP treatments in cancer patients is a matter of paramount importance. However, this seems to be due to their lack of experience in communicating state-of-the-art knowledge. While FP provided before starting cancer treatment can significantly delay cancer treatment initiation, it is argued that performing FP treatments involving COS before anticancer treatment in young women with breast cancer does not seem to be associated with increased cancer recurrence or mortality [
10,
38‐
40].
Oocyte and embryo cryopreservation are widely available, long- and well-established preservation options that are most effective for reproductively active women with cancer [
3,
18,
20,
21,
29,
41]. The literature states that ‘embryo cryopreservation has slightly higher success than oocyte cryopreservation in achieving pregnancy’ [
42]. Embryo cryopreservation is considered ‘the most widely available option’; however, it requires the existence of a partner or the woman’s openness to sperm donation [
24,
29]. Given that cryopreserved (frozen) embryos could be considered the joint property of the couple, this method of FP can give rise to difficult questions such as who gets the embryos in case of relationship breakdown [
18,
29].
Almost all participants in this study were not given information about the technique of OTC as an FP option for selected patients. OTC, in vitro oocyte maturation, ovarian transposition, ovarian suppression, and adjuvant therapy are included among the experimental FP options for these patients [
3,
18]. OTC, which has substantially expanded the field of FP, seems to be the front-runner among the experimental options and is on the verge of becoming a well-established FP option [
30,
41,
42]. Importantly, ovarian tissue can restore ovarian function and does not require prior ovarian stimulation [
21,
42]. While OTC remains an experimental FP option, it can be an option for specific patients [
17,
18,
21,
42]. Currently, OTC is indicated in patients whose fertility is at very high risk due to anticancer treatment [
22]. For instance, ESHRE acknowledged that OTC can be performed when there is not sufficient time for COS [
18]. OTC is considered ‘a secure tool in human fertility preservation’ [
43]. In Sweden, OTC is an option available at many reproductive health care centres [
39].
Moreover, the literature states that ‘in vitro oocyte maturation (IVM) can also be considered, and in some cases, there may be a possibility of combining different approaches’ [
18].
While embryo cryopreservation is a method for FP that gives rise to ethical concerns and legal questions, oocyte and embryo cryopreservation are currently routinely applied methods for FP in young women with cancer. However, some young women with cancer cannot undergo routinely applied FP methods for medical reasons. These women might undergo other less routine FP methods. OTC is currently the most common technique for FP in (selected) cancer patients. While OTC seems to be currently the front-runner among the less routine FP methods, IVM is also a similar method. Importantly, OTC as an FP method is currently an ongoing process. The standardization of protocols for OTC and OTT is currently ongoing. At any rate, it should be highlighted that there are discrepancies between countries regarding the accessibility of FP services to patients. These discrepancies arise because of different ethical considerations. A joint effort to achieve resonance of counselling in the field of oncofertility is required [
44].
Cancer diagnosis enhanced the desire for biological offspring in participants in this study (especially in participants with a strong desire for children at the time of diagnosis). However, in some participants (especially those with a weak previous desire for children), cancer diagnosis reduced their desire for biological offspring for various reasons reported by them. An unfulfilled desire for biological offspring can be associated with impaired mental health [
26]. Thus, it is not surprising that young women’s desire for biological offspring seems to remain strong after cancer diagnosis or even after cancer treatment, especially in patients who are nulliparous at the time of diagnosis [
27]. This is in line with findings in this study. Follow-up studies have shown that women who have a desire for biological parenthood at the time of initial cancer treatment are more prone to seek and receive FP consultations [
24]. Surprisingly, it is argued that ‘it would be wrong to assume cancer patients with advanced disease…have no desire to preserve their fertility’ [
24].
Furthermore, in this study, financial issues emerged as a fairly important factor affecting FP decisions. Patients with cancer should be made aware of the available financial assistance programs to become more flexible in addressing ‘this complex and heterogeneous landscape’ [
21] ‘during an uncertain and challenging time in their lives’ [
33]. Financial constraints are critical obstacles that prevent young breast cancer and other cancer patients from accessing FP services [
33,
45]. Assisted reproduction services are too expensive in many countries, and many women with cancer have no access to FP services not only in low- or middle-income countries but also in high-income countries [
24]. It is argued that in the US, ‘utilization of financial assistance for FP was low despite literature pointing to the need for such assistance’ [
46]. It is argued that in the US, better insurance coverage could facilitate access to FP services and ultimately ‘improve long-term cancer survivorship’ [
47]. The use of fertility services may increase financial hardship among cancer patients in countries where lack of or inadequate insurance coverage prevents cancer patients from accessing FP services [
24]. Nevertheless, there are countries where these services are totally or partly subsidized. In Sweden, FP in cancer patients is publicly funded [
39]. In the Czech Republic, FP in cancer patients is partially covered by health insurance companies [
9].
In this study, religious belief emerged from data analysis as a slightly important or not at all important factor affecting FP decisions. The different religions vary considerably in their attitudes and beliefs on the morality of artificial reproduction. ‘While most forms of artificial reproduction are acceptable in Hinduism and Buddhism, its acceptance in Christianity and Islam is variable depending on the branches or sects within the religious group’ [
24]. For instance, all forms of assisted reproductive techniques are unacceptable in Roman Catholicism, while acceptance is varied among Orthodox Christians [
24].
Religious beliefs are included among the factors influencing the patient’s decision on which preservation options may be available to them [
26]. Furthermore, in line with the results of this study, it is argued that women with cancer may have religious or ethical objections to embryo cryopreservation [
21].
The barriers to FP utilization in young women with cancer are multifactorial, including patient factors, health care provider-related factors, socioeconomic factors and institutional factors [
24]. Ojo et al. cited further details [
24].
Ultimately and most importantly, it should be noted that as the distress of making a fertility decision is further complicated by the concurrent distress of the cancer diagnosis, patients are most likely to become easily ‘overwhelmed and ill-equipped to manage this complex multistep decision-making process’ [
26]. Other studies are in a similar vein [
33,
48,
49]. Kim et al. conducted a survey completed by 204 participants. They found that 64% of participants ‘reported that they were too overwhelmed at the time of their cancer diagnosis to consider FP options’ [
48]. Logan et al. conducted a systematic literature review and found that some women with cancer endorsed the need for information at the time of diagnosis, while other women highlighted ‘the importance of receiving fertility information during cancer treatment decision-making and in follow-up’ [
49]. At any rate, for women with a cancer diagnosis, choosing FP is a complex emotional process of making ‘one of the most difficult decisions ever made’ [
26].
Implications for future policies
As assisted reproduction is further developing in Greece, relevant services are becoming accessible for larger parts of the Greek population. However, at present, there are no official data regarding patients who are undergoing FP procedures prior to cancer treatments. The results of this research can contribute to identifying the needs of patients together with gaps in health services and assist further improvements in the management of premenopausal women diagnosed with cancer.
Strengths and limitations of the study
Most participants were recruited through the snowball sampling technique. This enhances the diversity of the study and can be regarded as a strength. Furthermore, the sample consisted of women with various types of cancer. This can also be seen as a strength. However, this study should be interpreted in light of certain limitations. Almost all participants were between 30 and 45 years old, with the exception of only one participant who was a very young woman (eighteen years old). Moreover, potential self-selection bias cannot be ruled out. Women who were particularly interested in preserving their fertility were more likely to have responded to our call for research participation. In addition, recall bias cannot be excluded to some extent, at least with regard to certain findings. Finally, participants were not asked for feedback or to check the consistency between their intentions and the results obtained by the researchers. This fact limits the reliability of the study in terms of confirmability.