Expansion of the Fertility Preservation Program to All Newly Diagnosed Prepubertal Patients with Cancer at a Pediatric Hospital

Abstract

Background: As the majority of pediatric patients with cancer survive their disease, generating a population of over 500,000 childhood cancer survivors in the United States, it is imperative to minimize the lifelong consequences of treatment, which include temporary or permanent infertility caused by certain cancer treatments. A fertility consultation at diagnosis can provide patients and families with the opportunity to be informed regarding the likelihood of gonadal dysfunction and to consider fertility preservation. Method: After our pediatric hospital started to offer tissue cryopreservation, we initiated this evidence-based interventional quality improvement project. Our primary aim was to ensure that all newly diagnosed prepubertal patients with cancer who met the criteria for fertility tissue preservation were correctly identified and offered an educational consultation and preservation. Results: Between July 15, 2022 and October 30, 2022, 54 patients’ treatment plans were evaluated to determine treatment-related infertility risk using the Oncofertility Consortium Pediatric Initiative Network's Risk Assessment tool. Fifteen patients were at a high level of significantly increased risk and 13 were eligible for consultation. Seven (46%) patients and their families received a consultation. Initiation of treatment before referral was the primary reason for lack of consultation. Six of seven patients receiving consultation (86%) elected to undergo preservation. Preservation procedures did not cause a delay in starting treatment for those patients. Discussion: A fertility preservation program with established policies and processes can increase the likelihood that prepubertal patients at high risk for infertility are correctly identified, educated, and offered preservation.

Keywords

fertility preservation pediatric cancer health-related quality of life quality improvement

Introduction

Problem Description

Fertility preservation, the opportunity to preserve one's ability to have genetically related children prior to damaging or destroying the reproductive system, is a young but rapidly expanding field (Johnson et al., 2017). The majority of pediatric patients with cancer survive their disease, generating a population of over 500,000 childhood cancer survivors in the United States. It is imperative to intervene early when possible to minimize the lifelong reproductive consequences of treatment (Hoyos-Martinez et al., 2021; Meacham, Williamson-Lewis, et al., 2020). Certain chemotherapies, radiation to the brain or pelvic region, hematopoietic stem cell transplantation, or surgery to the reproductive organs may cause temporary or permanent infertility, known as gonadal dysfunction, and many of these patients may be eligible to preserve their fertility (Hoyos-Martinez et al., 2021; Johnson et al., 2017; Vindrola-Padros et al., 2016).

Available Knowledge

Historically, attempts to preserve fertility have only been available to postpubertal male and female patients with cancer via sperm and oocyte cryopreservation. Recent advances allow prepubertal patients who are diagnosed with cancer and meet eligibility criteria to preserve their fertility via gamete tissue cryopreservation (Nahata et al., 2020; Vindrola-Padros et al., 2016). The American Society of Clinical Oncology, American Academy of Pediatrics, and American Society for Reproductive Medicine have all endorsed that risk assessment and fertility preservation options should be offered to all newly diagnosed patients/families with cancer regardless of sex or pubertal status (Corkum et al., 2019; Hoyos-Martinez et al., 2021; Oktay et al., 2018). Additionally, the development of the Oncofertility Consortium Pediatric Initiative Network's (OCPIN) evidence-based risk stratification system allows for risk to fertility to be calculated based on type and dose of treatment, sex, and pubertal status (Meacham, Burns, et al., 2020).

Despite guidelines being in place for several years, counseling rates for all ages remain low nationally, and integrating recommendations into practice has been challenging, leading to a lack of education and underutilization of fertility preservation (American Society for Reproductive Medicine, 2022; Patel et al., 2020; Taylor & Ott, 2016; Vindrola-Padros et al., 2016). This lack of education about available methods leads to a missed opportunity to preserve what will be lost as a result of treatment, which may impact quality of life (Taylor & Ott, 2016). Studies have confirmed that the majority of survivors do not recall receiving education at diagnosis and many young adult survivors and their parents have expressed disappointment with how the impact of treatment on their fertility was communicated to them by their healthcare professionals (Cherven et al., 2015; Gupta et al., 2016; Vindrola-Padros et al., 2016; Zebrack et al., 2004).

Rationale

A fertility consultation at diagnosis can provide patients and families with the opportunity to be informed regarding the likelihood of gonadal dysfunction and to choose whether to pursue fertility preservation (Lehmann et al., 2019). Establishing a program with a dedicated fertility preservation coordinator (FPC) within a cancer center has been shown to not only increase preservation rates but also improve patient satisfaction (Kelvin et al., 2016; Saraf et al., 2018). Education can provide patients and families with information about infertility risk and allow for informed decisions about preservation, thus decreasing distress and improving quality of life (Logan et al., 2018; Meacham, Williamson-Lewis, et al., 2020).

Project Aims

The main purpose of this evidence-based interventional quality improvement project was to ensure that all newly diagnosed prepubertal patients with cancer who met the criteria for fertility tissue preservation at the project site were correctly identified and were offered an educational consultation and methods of preservation. An algorithm, Figure 1, was developed for the purpose of this project and followed the criteria provided by the OCPIN's risk assessment tool to evaluate which patients should have consultation prior to initiating treatment.

Figure 1

Fertility preservation decision tool for newly diagnosed prepubertal patients with cancer. Note. RPLND = retroperitoneal lymph node dissection.

The project's aims were to

achieve a 90% rate of identification of all prepubertal patients newly diagnosed with cancer who were at high risk for infertility and were eligible for fertility tissue preservation prior to the initiation of oncology treatment;

for these patients, determine fertility preservation consultation rates for families to receive education on the risk of treatment-induced infertility and fertility tissue preservation options;

assess the rate of high-risk prepubertal patients who undergo fertility tissue preservation following educational consultation;

monitor time from cancer diagnosis to start of treatment for prepubertal patients pursuing fertility tissue cryopreservation to assure there was no clinically significant delay after implementation of innovation.

Method

Context

This quality improvement project took place within the Hematology Oncology Department at a free-standing pediatric hospital in Texas, which treats approximately 200 new cancer diagnoses each year. Prior to proposing this intervention, we had a policy to provide fertility counseling to all newly diagnosed postpubertal patients with cancer; however, prepubertal patients with cancer rarely receive a fertility consultation due to a lack of preservation options available locally. Once ovarian tissue cryopreservation was clinically approved and we opened a testicular tissue cryopreservation study, we sought to expand our counseling and offering of preservation to all newly diagnosed prepubertal patients determined to be at high risk for infertility.

One benefit of our program is the availability of philanthropic funds designated for fertility preservation that provide families with needs-based financial assistance, given the significant expense associated with this procedure. The family is then only responsible for the shipping, tissue preservation, and storage costs for ovarian tissue cryopreservation and only responsible for annual storage for testicular tissue cryopreservation, increasing equitable access to preservation. At our hospital, more than 50% of our patient population receive Medicaid, illustrating their financial need. Additionally, our institution is in a state without any legislative mandate for insurance coverage for fertility preservation.

Intervention

Sample

For 4 months, all newly diagnosed prepubertal patients with cancer, defined as less than 13 years of age at the time of diagnosis were evaluated to determine if they met the criteria for a high level of significantly increased risk for infertility. Patients at high risk for infertility were included in the eligible intervention cohort. Interpreters were readily available and therefore, language was not an exclusion criterion. Patients who had complex guardianship issues, however, were evaluated case by case for appropriateness of cryopreservation offering, as legal guardianship is required to consent for fertility tissue preservation of a minor.

Identification

Each weekday, the FPC reviewed the list daily of newly diagnosed prepubertal patients with cancer admitted to the hospital as well as the providers’ outpatient clinic schedules. “New diagnosis” emails sent routinely by the diagnosing oncologist to all oncology staff to notify the team of the new patient and the expected treatment start date were also reviewed.

Assessment of Risk

The FPC then evaluated the planned treatment for the patient to determine eligibility for fertility tissue preservation. The OCPIN risk assessment tool was strictly followed to identify patients at high risk for infertility (Meacham, Burns, et al., 2020). For these eligible patients, the treating oncologist was asked to place an order for the fertility preservation consultation.

Consultation

The consultation occurred as soon as possible and prior to initiating treatment. Counseling usually took place the same day as patient identification in the patient's room if inpatient, or via telemedicine if outpatient to avoid travel. Parents and/or caregivers were the main recipients of information given the age of the patients and the requirement for parental consent to participate in preservation.

Each consultation reviewed the patient's diagnosis and treatment plan, the anticipated impact of treatment on the patient's fertility, and the available preservation methods. Future use of tissue collected via cryopreservation, costs, and available financial assistance resources were discussed. If requested or deemed necessary, a psychologist, interpreter, and/or chaplain was included in the conversation. The session length varied widely, and sometimes multiple conversations occurred prior to the family reaching a decision. As much time as possible to decide about preservation was granted but sometimes, due to the need to initiate treatment quickly, the family was asked to decide within hours. Factors that impacted the length of the discussion included the number of participants in the consultation, the age and developmental level of the child, and the number of questions asked. The level of risk to the patient's fertility, length of consultation, and discussion outcome were all tracked in a secure Excel spreadsheet. A templated note and flowsheet in the electronic medical record were also developed for clinical documentation to increase efficiency and data collection. If the family elected to preserve fertility, their oncologist was notified so that treatment could be timed accordingly, and then a surgical consultation was completed.

Outcome Measures

A postimplementation design was used to evaluate project outcomes, which included four outcome measures. The primary outcome measure of project success was the volume of patients and families educated rather than the percentage of families who ultimately choose to preserve their child's fertility, which aligned with the department's goals for this initiative and is similar to programs at other hospitals (Carlson et al., 2017). Awareness of risks to fertility is a crucial component of consent prior to initiating treatment and this initiative ensured that all families fully understood the risks of treatment to fertility and were presented with options to preserve when eligible. All procedures were to be scheduled at the time of another procedure to increase the likelihood of insurance coverage and minimize delays.

The first measure was to determine how many prepubertal patients with cancer were at significantly high risk for infertility and met the criteria to be offered fertility tissue preservation. The second measure was the rate of FPC consultation with eligible patients and families. We aimed to identify 90% as this was the percentage goal that a similar pediatric hospital met during their first year after establishing a fertility preservation program (McClendon et al., 2022). Prior to this project, the rate of identification for prepubertal patients was assumed to be 0. Additionally, we expected that we would be unable to identify, assess risk, and complete a consultation on every patient prior to initiating treatment as the nature of some aggressive pediatric cancers may prevent the opportunity to consult prior to initiating treatment. The third outcome measure was the rate of preservation procedures completed on eligible patients. Details including the method and date of preservation completed were also collected. The fourth measure was the oncologist's assessment of whether treatment start was delayed by more than 24 h specifically for those who elected to pursue fertility tissue preservation.

Analysis and Ethical Considerations

Descriptive statistics were used to summarize the data collected for all four aims. Data analysis was completed in Excel. This quality improvement initiative was reviewed by the project site's institutional review board and a letter of exemption was received as it did not involve research of human subjects. The information collected was deidentified so as not to reveal any protected health information and only collected and accessible by the FPC.

Results

Between July 15, 2022, and November 30, 2022, 54 patients’ treatment plans were evaluated to determine if they placed patients at a high risk for treatment-related infertility as per the OCPIN risk assessment tool. To our knowledge, all the patients diagnosed during the project were evaluated, exceeding the 90% goal. Half of the evaluated patients were male, ages were 0–12 years (Mdn = 5). Eighty-five percent of the patients were Caucasian and 30% of the patients identified as Hispanic or Latino. Diagnoses included leukemia and lymphoma (48%), solid tumors (29%), neuro-oncology tumors (17%), and neuroblastoma (6%).

Fifteen of the 54 (27%) patients met the criteria for high-risk treatment-related infertility and were therefore eligible for consultation. Two families declined consultation for different reasons prior to consultation. One patient had significant developmental challenges that would have made it difficult for him to parent a child. Forgoing consultation was agreed upon by the family and the oncologist. Lastly, one family declined a consultation, citing religious beliefs that would prohibit preservation. While both patients were ineligible for consultation due to family declining consultation, they are included here for additional context as both patients were in fact high-risk and the decision not to receive a consultation after collaborative discussions that involved the FPC. Of the six patients who did not receive consultations, five patients had treatment started by the provider urgently, which eliminated the opportunity for pretreatment consultation and offering of preservation. One patient already had all pretreatment procedures (e.g., biopsy and central line placement) completed and would not have the opportunity to bundle preservation with another anesthesia (a criterion of the hospital administration to increase the likelihood of insurance coverage).

Seven of the remaining 13 patients and their families received an educational consultation. Six of the patients who received education elected to undergo fertility preservation (three completed testicular tissue cryopreservation; three completed ovarian tissue cryopreservation). Figure 2 summarizes the results. In reference to the fourth outcome measure, none of the patients experienced a delay in starting treatment due to fertility tissue preservation.

Figure 2

Flow diagram summarizing results.

Discussion

This quality improvement project met all four of its aims. The process of evaluating each newly diagnosed patient's risk of infertility developed an invaluable workflow and led to a high rate of identification. Additionally, the providers were aware that this project was taking place and kept the FPC updated on newly diagnosed patients, which contributed to the high rate of assessed patients. Similar studies have demonstrated the impact of hiring an FPC on education rates (Dorfman et al., 2021; Wright et al., 2022).

Of the 15 high-risk patients, 46% of eligible patients did not receive counseling prior to the initiation of treatment. The missed opportunities illustrate several complexities associated with implementing consultation for all high-risk patients. Five patients had treatment initiated before counseling could occur. Interestingly, all five patients had been diagnosed with acute lymphoblastic leukemia, were male, and were started on the same treatment regimen. While this regimen places these patients at high risk for infertility, other regimens for the same disease do not meet this criteria, such as the Children's Oncology Group protocol AALL1731, illustrating the value of an assessment of each patient's treatment (Inaba, 2017; National Cancer Institute, n.d.).

Our study did not collect provider input on reasons for starting treatment before fertility consultation. Given the number of patients who were not referred before initiating treatment, further inquiry into physician reasoning would be beneficial. Highlighting high-risk and frequently used regimens via consistent provider education could be helpful going forward to increase the likelihood of referral for consultation. We also recognize that leukemia treatment often must be started urgently, limiting the window for fertility preservation counseling and procedures (Dai et al., 2021). Lastly, the concern for seeding of leukemia cells with reimplantation of preserved tissue may have led the providers to assume fertility tissue preservation was not an option, when in fact ex-vivo maturation of the tissue may be a possibility in the future (Edmonds et al., 2019). In our consultations, we educate families that we are uncertain how the tissue will be utilized given possible technological advances, but that tissue preservation provides future options.

Our project highlighted several scenarios that can keep a high-risk patient from receiving consultation. Some of these are noted in our algorithm as exclusion criteria (family choice, palliative care only). Another issue that can arise is an ethical question regarding the appropriateness of preservation in a developmentally delayed child or a child with a poor prognosis. Also, until procedures are covered by insurance, there may be financial considerations; although our institution has philanthropic support, this does not include covering costs for a stand-alone preservation procedure.

A high percentage (86%) of families who received consultation discussing the high risk of treatment-related infertility decided to pursue tissue cryopreservation, illustrating significant interest in fertility preservation when offered. Several factors may have contributed to the high rate of preservation. During the COVID-19 pandemic, telemedicine was implemented and proved to be valuable for this delicate conversation, allowing families to process information at home. Additionally, evidence-based written materials and additional resources, including links to videos and articles, provided further education following consultation and could be shared with family members. Lastly, having the FPC located in the oncology unit with a flexible schedule allowed for accommodation of the unpredictable pace of these decisions.

Regarding the fourth aim, to evaluate whether preservation delayed cancer treatment following diagnosis, the six patients who preserved fertility did not experience treatment delays, providing reassurance to providers and families going forward. For postpubertal patients, the literature demonstrated that physicians identified a concern for delay in treatment initiation as a barrier to discussing and offering fertility preservation (Alshamsan et al., 2022; Zhang et al., 2019). As tissue cryopreservation becomes more available, data on delays in treatment initiation will be important to collect.

Several strengths specific to our institution increased the successful implementation of this programmatic expansion. First, the hospital's volume of newly diagnosed patients increased the project's feasibility. Second, the philanthropic funding obtained to cover out-of-pocket procedural, shipping, and preservation costs increased the likelihood that families would participate in preservation, which promoted equitable access. Procedural costs have been identified as the most commonly noted barrier for preservation programs nationally, indicating that this issue persisted outside of this institution (Frederick et al., 2022). Third, the success of timely identification, risk assessment, and counseling of newly diagnosed patients is dependent on the availability and flexibility of the FPC. Our staffing ensured that patients could be seen at short notice, including after hours and on weekends, which was atypical.

Our project supported the concern that this level of care requires significant manpower. A 2022 report from the Children's Oncology Group identified the value of dedicated fertility preservation personnel to ensure access to services. The report also questioned the capacity of pediatric oncology programs to counsel all eligible patients as most lacked the needed infrastructure (Frederick et al., 2022). To ensure sustainability at our institution, a full-time FPC/nurse practitioner role was created at the conclusion of this project who will be dedicated to coordinating the program and counseling patients. Backup coverage for the FPC would also be beneficial.

As a quality improvement project seeking to explore the use of an FPC in counseling prepubertal patients with cancer about novel fertility cryopreservation offerings, we feel we learned how to identify high-risk patients within our hospital as per the OCPIN risk stratification system and implemented sustainable procedures. The next steps at our institution include seeking ongoing philanthropic support to ensure financial barriers do not impact decision-making and advocating for insurance coverage for fertility preservation. Additionally, it is expected that referrals from providers increase as awareness of the program grows within the department, with fewer missed counseling opportunities going forward, similar to other fertility preservation quality improvement projects (Dargan et al., 2022; Sena et al., 2022). We believe that this project could be reproduced at other hospitals aiming to initiate or expand a fertility preservation program. We recommend utilizing the algorithm to identify high-risk patients and follow the outlined procedures. Financial support for preservation, however, through philanthropic funds or ideally insurance coverage is crucial to ensure equity and access for all patients and their families.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclose the following financial support: Rutledge Cancer Foundation (grant number: N/A).

ORCID iD

Antonia P. Leavitt

References

Alshamsan

Kushnir

Al-Saadi

Srikanthan

(2022). Perceptions and attitudes of medical oncologists regarding fertility preservation and pregnancy in high-risk cancer patients: A survey among Canadian medical oncologists. Cancer Medicine, 12(2), 1912–1921. https://doi.org/10.1002/cam4.5023

American Society for Reproductive Medicine. (2022). Office of Personnel Management expands fertility coverage. ReproductiveFacts.org. https://www.reproductivefacts.org/news-and-publications/news-and-research/press-releases-and-bulletins/office-of-personnel-management-expands-fertility-coverage/#:∼:text=All%20federal%20insurance%20carriers%20will,and%20surgical%20gender%20transition%20treatment

Carlson

C. A.

Kolon

T. F.

Mattei

Hobbie

Gracia

C. R.

Ogle

Ginsberg

J. P.

(2017). Developing a hospital-wide fertility preservation service for pediatric and young adult patients. Journal of Adolescent Health, 61(5), 571–576. https://doi.org/10.1016/j.jadohealth.2017.07.008

Cherven

B. O.

Mertens

Wasilewski-Masker

Williamson

Meacham

L. R.

(2015). Infertility education: Experiences and preferences of childhood cancer survivors. Journal of Pediatric Oncology Nursing, 33(4), 257–264. https://doi.org/10.1177/1043454215607342

Corkum

K. S.

Rhee

D. S.

Wafford

Demeestere

Dasgupta

Baertschiger

Malek

M. M.

Aldrink

J. H.

Heaton

T. E.

Weil

B. R.

Madonna

Lautz

T. B.

(2019). Fertility and hormone preservation and restoration for female children and adolescents receiving gonadotoxic cancer treatments: A systematic review. Journal of Pediatric Surgery, 54(11), 2200–2209. https://doi.org/10.1016/j.jpedsurg.2018.12.021

Dai

Liu

Wang

Peng

Shi

Guo

Yang

Zhang

Jiang

(2021). Longer time intervals from symptom onset to diagnosis affect the overall survival in children with acute lymphoblastic leukemia. Journal of Pediatric Hematology/Oncology, 44(6), 285–292. https://doi.org/10.1097/MPH.0000000000002344

Dargan

Mc Dermott

Chesbro

Trout

Terwilliger

Hilyard

Flynn

Fulbright

(2022). Standardization of fertility preservation discussion among pediatric oncology and bone marrow transplant patients: A single institution experience. Journal of Adolescent and Young Adult Oncology, 12(2), 259–265. https://doi.org/10.1089/jayao.2022.0003

Dorfman

C. S.

Stalls

J. M.

Mills

Voelkel

Thompson

Acharya

K. S.

Baker

K. C.

Wagner

L. M.

Miller

Boswell

Corbett

(2021). Addressing barriers to fertility preservation for cancer patients: The role of oncofertility patient navigation. Journal of Oncology Navigation & Survivorship, 12(10), 332–348.

Edmonds

M. E

., Orwig

K. E

., & Brannigan

R. E

. (2019). Fertility preservation and restoration in pediatric males. In T. K. Woodruff, D. K. Shah & W. S. Vitek (Eds.), Textbook of oncofertility research and practice (pp. 385–394). Springer International Publishing.

10.

Frederick

N. N.

Klosky

J. L.

Meacham

L. R.

Quinn

G. P.

Kelvin

Cherven

Freyer

D. R.

Dvorak

C. C.

Brackett

Ahmed-Winston

Bryson

Chow

E. J.

Levine

(2022). Infrastructure of fertility preservation services for pediatric cancer patients: A report from the Children's Oncology Group. JCO Oncology Practice, 18(3), e325–e333. https://doi.org/10.1200/OP.21.00275

11.

Gupta

A. A.

Donen

R. M.

Sung

Boydell

K. M.

K. C.

Stephens

Pritchard

Portwine

Maloney

Lorenzo

A. J.

(2016). Testicular biopsy for fertility preservation in prepubertal boys with cancer: Identifying preferences for procedure and reactions to disclosure practices. Journal of Urology, 196(1), 219–224. https://doi.org/10.1016/j.juro.2016.02.2967

12.

Hoyos-Martinez

Hoyos

L. R.

Putra

Armstrong

A. A.

Rambhatla

Allen-Rhoades

Brennan

(2021). Availability of fertility preservation information on the websites of U.S. News and world report top-ranked pediatric cancer programs. Journal of Adolescent and Young Adult Oncology, 10(1), 66–70. https://doi.org/10.1089/jayao.2020.0003

13.

Inaba

(2017). Total therapy XVII for newly diagnosed patients with acute lymphoblastic leukemia and lymphoma (Identifier NCT03117751). https://clinicaltrials.gov/ct2/show/NCT03117751

14.

Johnson

E. K.

Finlayson

Rowell

E. E.

Gosiengfiao

Pavone

Lockart

Orwig

K. E.

Brannigan

R. E.

Woodruff

T. K.

(2017). Fertility preservation for pediatric patients: Current state and future possibilities. Journal of Urology, 198(1), 186–194. https://doi.org/10.1016/j.juro.2016.09.159

15.

Kelvin

J. F.

Thom

Benedict

Carter

Corcoran

Dickler

M. N.

Goodman

K. A.

Margolies

Matasar

M. J.

Noy

Goldfarb

S. B.

(2016). Cancer and fertility program improves patient satisfaction with information received. Journal of Clinical Oncology, 34(15), 1780–1786. https://doi.org/10.1200/JCO.2015.64.5168

16.

Lehmann

Kutteh

W. H.

Sparrow

C. K.

Bjornard

K. L.

Klosky

J. L.

(2019). Fertility-related services in pediatric oncology across the cancer continuum: A clinic overview. Supportive Care in Cancer, 28(8), 3955–3964. https://doi.org/10.1007/s00520-019-05248-4

17.

Logan

Perz

Ussher

J. M.

Peate

Anazodo

(2018). Systematic review of fertility-related psychological distress in cancer patients: Informing on an improved model of care. Psycho-Oncology, 28(1), 22–30. https://doi.org/10.1002/pon.4927

18.

McClendon

T. B.

Jutca

Appiah

Frias

O. J.

Bourlon

(2022). Tips and resources for starting or expanding a fertility preservation program [Paper Presentation]. 2022 Oncofertility Conference, May 1–4, 2022, Pittsburgh, PA, USA. https://oncofertility2022.vfairs.com/en/

19.

Meacham

L. R.

Burns

Orwig

K. E.

Levine

(2020). Standardizing risk assessment for treatment-related gonadal insufficiency and infertility in childhood adolescent and young adult cancer: The pediatric initiative network risk stratification system. Journal of Adolescent and Young Adult Oncology, 9(6), 662–666. https://doi.org/10.1089/jayao.2020.0012

20.

Meacham

L. R.

Williamson-Lewis

Cherven

B. O.

Effinger

K. E.

Klosky

J. L.

Gilleland-Marchak

(2020). Educational intervention to address infertility-related knowledge gaps among adolescent and young adult survivors of childhood cancer. Journal of Adolescent and Young Adult Oncology, 9(4), 472–480. https://doi.org/10.1089/jayao.2019.0156

21.

Nahata

Gomez-Lobo

Meacham

Appiah

Childress

Hoefgen

Dwiggins

Whiteside

Bjornard

Rios

Anazodo

Finlayson

Frias

Woodruff

Moravek

(2020). 2019 Pediatric initiative network: Progress, proceedings, and plans. Journal of Adolescent and Young Adult Oncology, 9(4), 457–463. https://doi.org/10.1089/jayao.2020.0020

22.

National Cancer Institute. (n.d.). A study to investigate blinatumomab in combination with chemotherapy in patients with newly diagnosed b-lymphoblastic leukemia . https://www.cancer.gov/about-cancer/treatment/clinical-trials/search/v?id=NCT03914625&r=1

23.

Oktay

Harvey

B. E.

Partridge

A. H.

Quinn

G. P.

Reinecke

Taylor

H. S.

Wallace

Wang

E. T.

Loren

A. W.

(2018). Fertility preservation in patients with cancer: ASCO clinical practice guideline update. Journal of Clinical Oncology, 36(19), 1994–2001. https://doi.org/10.1200/JCO.2018.78.1914

24.

Patel

Kohn

T. P.

Cohen

Shiff

Kohn

Ramasamy

(2020). Evaluation of reported fertility preservation counseling before chemotherapy using the quality oncology practice initiative survey. JAMA Network Open, 3(7), Article e2010806. https://doi.org/10.1001/jamanetworkopen.2020.10806

25.

Saraf

A. J.

Stanek

Audino

DaJusta

Hansen-Moore

McCracken

Whiteside

Yeager

Nahata

(2018). Examining predictors and outcomes of fertility consults among children, adolescents, and young adults with cancer. Pediatric Blood & Cancer, 65(12), Article e27409. https://doi.org/10.1002/pbc.27409

26.

Sena

L. A.

Sedhom

Scott

Kagan

Marple

A. H.

Canzoniero

J. V.

Hsu

Qasim Hussaini

S. M.

Herati

A. S.

Reschke

Antero

Christianson

M. S.

Binder

A. F.

Chen

A. R.

Donehower

R. C.

Marrone

K. A.

Gupta

(2022). Trainee-led quality improvement project to improve fertility preservation counseling for patients with cancer. JCO Oncology Practice, 18(3), e403–e411. https://doi.org/10.1200/OP.21.00479

27.

Taylor

J. F.

Ott

M. A.

(2016). Fertility preservation after a cancer diagnosis: A systematic review of adolescents’, parents’, and providers’ perspectives, experiences, and preferences. Journal of Pediatric and Adolescent Gynecology, 29(6), 585–598. https://doi.org/10.1016/j.jpag.2016.04.005

28.

Vindrola-Padros

Dyer

K. E.

Cyrus

Lubker

(2016). Healthcare professionals’ views on discussing fertility preservation with young cancer patients: A mixed method systematic review of the literature. Psycho-Oncology, 26(1), 4–14. https://doi.org/10.1002/pon.4092

29.

Wright

M. L.

Theroux

C. I.

Olsavsky

A. L.

DaJusta

McCracken

K. A.

Hansen-Moore

Yeager

N. D.

Whiteside

Audino

A. N.

Nahata

(2022). The impact of hiring a full-time fertility navigator on fertility-related care and fertility preservation at a pediatric institution. Pediatric Blood & Cancer, 69(9), e29857. https://doi.org/10.1002/pbc.29857

30.

Zebrack

B. J.

Casillas

Nohr

Adams

Zeltzer

L. K.

(2004). Fertility issues for young adult survivors of childhood cancer. Psycho-Oncology, 13(10), 689–699. https://doi.org/10.1002/pon.784

31.

Zhang

Wang

Jiang

Cao

Jiang

Yin

Zhang

(2019). The knowledge, attitude, and self-reported behaviors of oncology physicians regarding fertility preservation in adult cancer patients. Journal of Cancer Education, 35(6), 1119–1127. https://doi.org/10.1007/s13187-019-01567-6