Significant Unmet Need in Fertility Counseling and Sperm Cryopreservation in Young Males with Cancer: A Single-Center Analysis

Background: Due to improved cancer survival rates as well as the current trend of delaying childbirth, fertility has become a growing issue among cancer patients. The American Society of Clinical Oncology recommends that oncologists discuss fertility preservation with all patients of reproductive age who are about to initiate treatment that may cause infertility. The purpose of this study was to evaluate the incidence of fertility counseling and sperm banking referral in male cancer patients of reproductive age at our center and to assess whether counseling is influenced by demographics or disease specific factors.

Methods: We used the University of North Carolina (UNC) Cancer Registry to identify male patients between the ages of 13-50 who received a new diagnosis of cancer between 1/1/2013 and 1/1/2015 and planned to initiate chemotherapy with curative intent. We excluded patients who initiated chemotherapy outside of UNC. We queried the electronic medical record (EMR) for demographic information such as age, race, insurance status, number of children, marital status, sexual orientation and disease-related variables such as type of cancer, type of treatments, and comorbidities. We reviewed the EMR for documentation of fertility counseling and identified patients who banked sperm at UNC since 1/1/2013. Fisher's Exact and Wilcoxon Rank Sum tests were used to compare characteristics between groups. Additionally, multivariable logistic regression modeling was used to evaluate associations after controlling for age.

Results: There were initially 594 male patients identified with new cancer diagnoses, of whom 160 received chemotherapy with curative intent. Of this final cohort of 160 patients, 76 had hematologic malignancies (33 with lymphoma, 30 with acute leukemia, and 13 with other hematologic malignancies). The median age was 42 (40 for hematologic malignancies). 41% of patients had children and 46% were married. Based on chart documentation, 28% of patients were counseled regarding fertility and 13% of patients attempted to bank sperm (46% of those receiving fertility counseling). Rates of counseling and sperm banking were similar for hematologic malignancy patients. Younger patients were significantly more likely to be counseled (p <0.001). Among patients with hematologic malignancies, 51% of patients under 30 years were counseled while 18% of patients ≥ 30 years were counseled (p=0.001). Across all cancer types, insurance type was not associated with fertility counseling (p=0.38) but was associated with attempted sperm banking (p=0.03). Having children, being married, and having a comorbidity were associated with a lower rate of counseling in univariate analysis, but not in multivariate analysis after controlling for age.

Conclusions: We found a significant unmet opportunity for fertility counseling and referral for sperm banking in young male cancer patients receiving chemotherapy with curative intent at our center. Low rates of counseling and sperm banking were particularly notable in patients over the age of 30. In addition to barriers in clinical practice, the association between insurance status and sperm banking also suggests a financial barrier to sperm cryopreservation. Further work is needed to develop interventions to improve rates of fertility counseling and opportunities for sperm banking in young male cancer patients.