Micro-video: Creating a Comprehensive Fertility Preservation Program
TRANSCRIPTHello, I am Joanne Kelvin, a clinical nurse specialist, recently retired from Memorial Sloan Kettering Cancer Center in NY. During my last 10 years at MSK, I built a Cancer and Fertility program. A key part of my role was to refer patients to community reproductive specialists for fertility preservation before cancer treatment, and my suggestions to you are based on that experience. I have no disclosures to report.
I believe that the essential elements needed for a comprehensive fertility preservation program are
- clinical expertise to offer a full range of standard fertility preservation services to patients with cancer
- organizational practices that ensure access to your program
- effective collaborative relationships with referring oncology clinicians
- and, sensitivity to the unique needs of cancer patients
Having clinical expertise is of course essential. In regard to oncology expertise,
- Learn about the common cancers you are likely to encounter in adolescent and young adult patients and how they typically present, as this may impact on the type of FP you can safely offer.
- Become familiar with the treatments these patients most commonly receive and their potential impact on fertility.
- When planning ovarian stimulation, be familiar with random start protocols and the use of aromatase inhibitors to reduce estrogen levels in patients with hormone-sensitive cancers
- And, consider issues that may impact on the feasibility and safety of egg retrieval. For example, in patients with hematologic malignancies, blood counts may not be adequate to prevent bleeding or infection; in those with pelvic disease, retrieval may not be doable without passing through tumor; and in those with disease in the chest, anesthesia may not be safe in your setting.
- Availability is key. Specifically, a willingness to see patients within 24-48 hours
- There must be a clear simple process for making the referral. Electronic orders are ideal if feasible in your health care system. Another option is secure email to a designated fertility preservation email address. Or having a designated fertility preservation phone number.
- A single point of contact for making the referral is preferred. This could be an individual or team within your center who checks for referrals throughout the day, identifies which physician can most quickly see the patient, and schedules the appointment with the patient.
- And equally important, a willingness to provide financial support to these patients, who have not had the time to plan for this unexpected expense. Examples include offering discounted rates, payment plans, access to free medications needed for stimulation, and a period of free storage.
- To overcome their lack of knowledge about available fertility preservation options, offer to share your expertise, for example through presentations at grand rounds or disease-specific service meetings. Also offer to be available to answer clinical questions that come up in their day-to-day practice.
- Oncology clinicians often feel they don’t have the time to discuss fertility preservation options in their clinics where they are focusing on planning and explaining the patient’s cancer treatment. Emphasize that if they introduce the topic of fertility preservation, ascertain patient interest, and make the referral, they don’t have to spend time going through the options in detail as this is what you will do during your consultation.
- Many oncology clinicians report that another barrier is a lack resources to help them discuss fertility preservation with their patients. Offer to help create or review educational material they can provide to patients.
- Communicating with the oncology clinician after each referral.
- After your consultation, report on the patient’s decision, and outline the plan and timeline.
- And again, after egg retrieval report on the outcome and describe any follow up issues that you or they need to address.
- You may also want to consider approaches to expand your availability. Examples include
- Offering a FP consultation clinic several days a week on site at the cancer center
- Designating an advanced practice provider to provide initial consultations on site or at the fertility center
- Supporting the cost of a patient navigator to have initial discussions with the patient - explaining what is involved, including the costs, confirming their interest, and facilitating the referral to you
- When providing information
- Present small amounts of information at a time
- Be brief, clear, unambiguous, and free of jargon
- And, check the patient's understanding of the information you are discussing by inviting questions as you move from topic to topic.
- When conveying information that may be emotionally charged, be open, honest, direct, and matter of fact.
- Plan extra time for teaching injection technique because of the considerable anxiety many patients will have about this.
- Listening to their fears and concerns may be uncomfortable for you, but allow patients to express their emotions.
- Respond empathically by acknowledging, validating, and normalizing their reactions.
- Be reassuring and comforting, without compromising honesty. No one can promise that "everything will be fine."
- Maintain as much consistency as you can in seeing the patient throughout the process.
- And finally, it is important to have a multidisciplinary team to ensure patients have all the information and support they need. This could include nurses designated to care for cancer patients, as well as mental health specialists, genetic counselors, and financial counselors who understand the billing and insurance issues associated with FP related to cancer diagnosis versus those associated with treatment for infertility.
- American Society for Reproductive Medicine. Fertility preservation in patients undergoing gonadotoxic therapy or gonadectomy: a committee opinion. Fertility and Sterility, 2013, 100(5):1214-1223.
- Anazodo A, et al. How can we improve oncofertility care for patients? A systematic scoping review of current international practice and models of care. Human Reproduction Update, 2019, 25(2):159–179.
- Linkeviciute A, Boniolo G, Chiavari L, & Peccatori FA. Fertility preservation in cancer patients: the global framework. Cancer Treatment Reviews, 2014, 40:1019–1027.
- Panagiotopoulou N, et al. Barriers and facilitators towards fertility preservation care for cancer patients: a meta-synthesis. European Journal of Cancer Care, 2018, 27(1), epub12428.