Facing a cancer diagnosis: empowering parents to speak with adolescents about sperm banking

December, 2017 - Article courtesy of Fertility & Sterility, Vol. 108, Issue 6, Pages 957-958

Both pediatric oncologists and reproductive urologists share
a joint responsibility to educate, treat, and advocate for male
adolescent and young adult (AYA) cancer patients who
require gonadotoxic therapy. The importance of fertility
preservation coincides with the ever-growing number of
pediatric cancer survivors, because most children now survive
their malignancy into adulthood and ultimately desire
family building. Unfortunately, the risk of infertility in
this population is remarkably high.

Green et al. reviewed the Childhood Cancer Survival Study cohort, ultimately
including 6,224 men in their final analysis (1). Compared
with healthy siblings, pediatric cancer survivors were
roughly one-half as likely to have fathered children (hazard
ratio 0.56, 95% confidence interval [CI] 0.49 to 0.63). The
reproductive consequences were greatest with the use of
alkylating agents and when radiation involved the testis.
Fortunately, the solution for fertility preservation is often
straightforward for boys who have entered puberty: preemptive
sperm banking before any exposure of a reproductive
insult.
For parents and male AYA patients facing a new cancer
diagnosis, the process of sperm banking for future fertility
can be overwhelming. In addition, the providers meeting
with these patients may not feel comfortable with broaching
the subject or are not prepared to practically facilitate
referral (2). These conditions have resulted in poor rates of
sperm banking for adolescent cancer patients, which have
been reported to be as low as 17.8% by one large retrospective
series (3). The low rate of utilization represents
failure of counseling on the part of the treatment teams
despite clear guidelines from organizations including the
American Society of Clinical Oncology, the American Society
for Reproductive Medicine, the National Comprehensive
Cancer Network, and the Association of Pediatric Hematology/
Oncology Nurses (2, 3).
Several groups have attempted to identify the barriers
related to fertility preservation in pediatric oncology. To
better understand these impediments, one must first appreciate
the unique perspectives of providers, parents, and the
patients themselves. Fuchs et al. petitioned the attitudes
and practices of 326 oncology providers, which included
physicians, nurses, and advanced practice nurses (2). Within
their cohort, 92% of respondents reported no history of
formal training in fertility preservation. Consequently,
only 48% of providers were familiar with intracytoplasmic
sperm injection, a basic fertility intervention available to
these patients and a marker of overall understanding.
Although 93% of responding physicians reported routinely
discussing fertility preservation with their adolescent
patients, only 78% reported feeling comfortable with the
topic. It is intuitive to suspect that sperm banking outcomes
coincide with provider competence and comfort with the
material.
In addition, it has been observed that the provider's
perception of the parent(s)' and patient's interests in
fertility preservation often does not align with their actual
attitudes and concerns (4). Providers tend to focus on expediting
treatment because they typically believe that parents
prioritize timely oncologic therapy over fertility. Clinicians
may also perceive many adolescent males to be uninterested,
embarrassed, or too immature to consider sperm
banking. Unfortunately, these misperceptions result in superficial
and brief discussions of future fertility. Meanwhile,
parents are rarely embarrassed to discuss the
subject of fertility and are appreciative of the dialogue.
In the parents' minds, prioritizing expedited cancer treatment
is not mutually exclusive of fertility preservation,
which is actually interpreted as a sign of hope. Also, it is
now well known that many adolescent male patients are
interested in future family building and prefer engagement
in these types of discussions. Common to both patient and
parent is the hindsight desire that providers be more
proactive.
Stein et al. broadened our understanding of attitudes toward
fertility preservation by attempting to separately characterize
the perspectives of patients and their parents, and if
they exist, any conflicts of interest among these stakeholders
(4). Both parties expressed significant regret that
fertility preservation was not adequately addressed at the
time of cancer diagnosis. These feelings became most
apparent to the patients as they survived their diagnosis,
began relationships, and started to entertain the notion of
family building with their partners. Many patients stressed
their immaturity at the time of treatment and the need for
both provider and parent to propel fertility preservation as
a worthwhile objective. Parents, however, often perceived
that their children were much more equipped for these conversations.
This discordance between the patient's actual
maturity and their maturity as perceived by their parents
may give the AYA patient inappropriate responsibility for
driving fertility preservation as a priority (4).
In this issue of Fertility and Sterility, Klosky et al. elucidate
the impact that parental influence has on fertility preservation
outcomes (5). These data are clinically relevant
because parental factors can be influenced through appropriate
counseling. Within their cohort, 55% of patients attempted
sperm banking, for which 83% successfully
resulted in cryopreservation of a sample. The authors demonstrate
that parents who actively recommended sperm banking
to their children imparted an odds ratio [OR] of 3.7 (95% CI
1.18–11.76) in favor of attempted banking. The significance
of this relationship was more pronounced when the recommendation
came from the father, with a resulting OR of 8.3
(95% CI 3.0–22.8). Finally, there was a weak but statistically
significant relationship of the parents' perceived selfefficacy
to facilitate a banking attempt.
The data of Stein et al. and Klosky et al. highlight the
unique environment that exits among male AYA patients
diagnosed with cancer. In contrast to adult cancer patients, treatment of AYA patients requires a much
more coordinated attempt on the part of the treating
provider, primary caretaker, and patient. In addition,
parents need to take more of a leadership role, which
may be facilitated through the guidance of providers.
The parental attitudes as well, especially regarding
self-efficacy, are undoubtedly heavily influenced by
provider guidance and counseling. Likely, the most
noteworthy implication of this study is the required
involvement of not one but both parents, if present, in
the care of AYA cancer patients. It seems that the idea
of a supportive ‘‘team’’ would portend a more comprehensive
outlook and an even higher rate of fertility
preservation. To help facilitate this, both parents and
patients require better provider input, intervention,
and informational resources. Herein lies immense opportunity
to diminish a major barrier to pretreatment
sperm banking.
Future work should continue to explore and define
actionable interventions that clinicians can take during
fertility discussions. Additional future cohorts should also
include underrepresented populations to allow for generalizability,
because cultural and religious differences are likely to
be important. Such studies will allow providers to leverage the
opportunity uncovered by the Klosky et al. data and thereby
ensure that all parents can be empowered to help their sons
to preserve fertility.

Russell P. Hayden, M.D.
James A. Kashanian, M.D.
Department of Urology, Weill Cornell Medicine, New York,
New York
https://doi.org/10.1016/j.fertnstert.2017.09.035
You can discuss this article with its authors and with other
ASRM members at
https://www.fertstertdialog.com/users/16110-fertilityand-
sterility/posts/20650-25060
REFERENCES
1. Green DM, Kawashima T, Stovall M, Leisenring W, Sklar CA, Mertens AC,
et al. Fertility of male survivors of childhood cancer: a report from the Childhood
Cancer Survivor Study. J Clin Oncol 2010;28:332–9.
2. Fuchs A, Kashanian JA, Clayman ML, Gosiengfiao Y, Lockart B, Woodruff TK,
et al. Pediatric oncology providers' attitudes and practice patterns regarding
fertility preservation in adolescent male cancer patients. J Pediatr Hematol Oncol
2016;38:118–22.
3. Neal MS, Nagel K, Duckworth J, Bissessar H, Fischer MA, Portwine C, et al.
Effectiveness of sperm banking in adolescents and young adults with cancer:
a regional experience. Cancer 2007;110:1125–9.
4. Stein DM, Victorson DE, Choy JT,Waimey KE, Pearman TP, Smith K, et al. Fertility
preservation preferences and perspectives among adultmale survivors of pediatric
cancer and their parents. J Adolesc Young Adult Oncol 2014;3:75–82.
5. Klosky JL, Flynn JS, Lehmann V, Russell KM, Wang F, Hardin RN, et al. Parental
influences on sperm banking attempts among adolescent males newly diagnosed
with cancer. Fertil Steril 2017;108:1043–9.
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