Female cancer survivors have increased perceived infertility risk

Female survivors of adolescent and young adult (AYA) cancer have increased rates of perceived infertility risk, and often overestimate or underestimate their risk, according to a recent study published in JAMA Network Open.

Cancer treatment can deplete a woman’s finite ovarian reserve, disrupt hypothalamic-pituitary-ovarian function, and cause injury to the uterus. This leads to increased infertility rates and decreased live birth rates among survivors of AYA cancer.

Infertility concerns may lead to psychological distress while misunderstanding fertility potential can cause unplanned pregnancies. However, while data has indicated low agreement between perceived and objective fertility, there is little information on factors associated with how perceived risk compares with objective risk.

To determine factors associated with how perceived risk compares with objective risk among female AYA cancer survivors, investigators conducted a prospective cohort study. Participants were recruited from March 25, 2015, to September 14, 2018, with 1071 completing the baseline survey.

Patients included in the current analysis completed the baseline survey, had complete medical record abstraction of oncologic treatments, and had not received a hysterectomy. Participants were also aged 18 to 39 years, received a cancer diagnosis when aged 15 to 39 years, had completed primary cancer treatment, and had at least 1 ovary.

Follow-up lasted for 18 months. Participants completed a questionnaire and self-collected dried blood spots (DBSs) at baseline and at every 6 months following baseline, with 4 assessments total completed. Data obtained from the questionnaires included reproductive, cancer, demographic, medical, and lifestyle.

Perceived fertility risk data was obtained by a question asking, “How do you feel about your own fertility (ability to get pregnant) right now?” Responses included, “I feel I am more fertile,” “I think I am as fertile,” “I think I am less fertile,” and “I think I am unable to get pregnant.”

Cancer treatments were categorized by low, medium, and high gonadotoxicity. Menstrual patterns were evaluated based on the number of menses in the previous year and cycle variations in bleeding pattern. Irregular menstrual cycles were 9 or fewer menses in the past year. 

DBS collections were used to measure antimüllerian hormone and follicle-stimulation hormone levels. Infertility risk was determined using estimate treatment gonadotoxicity, hormone therapy receipt, and measures of ovarian function. Covariates included race and ethnicity, age, income, marital status, education, and health insurance coverage.

There were 785 patients included in the final analysis, aged a mean 25.9 years at diagnosis and 33.2 years at study enrollment. Excluded patients were more often Hispanic, parous, had worse general health, and were less likely to have completed college and to have breast cancer.

Being married or living with a partner was reported by 69.6% of participants and having completed college by 34.1%. The most common cancer types were leukemia or lymphoma in 34.1% of patients, followed by breast cancer in 26.6% and thyroid cancer in 19.6%. 

Low-, moderate-, and high-gonadotoxicity treatments were reported in 28.7%, 61%, and 10.3% of participants respectively. Of menstrual cycles, 40.3% were regular, 45.9% irregular, and 13.9% amenorrheic.

Factors associated with perceived infertility risk include treatment gonadotoxicity, menstrual pattern, cancer type and proximity to treatment, comorbidities, and reproductive characteristics. Perceived infertility risk was increased 2.73-fold in patients exposed to moderate-gonadoxicity and 15.39-fold in patients exposed to high-gonadoxicity.

An objective infertility risk was reported in 60.5% of patients and a not objective infertility in 22.8%, with 16.6% unable to be categorized.An accurate assessment was made by 63.8% of patients, while 12.7% overestimated their risk and 23.5% underestimated their risk.

Factors that made patients less likely to underestimate risks included being older, having endocrine comorbidity, and having prior infertility or gastrointestional cancer. Patients with a previous birth were more likely to underestimate their risk and less likely to overestimate their risk.

These results indicated increased perceived infertility risk among female AYA cancer survivors. Investigators recommended strategies be implemented to reduce misalignment between perceived risk and actual risk of infertility to allow for better informed reproductive decisions and reduced psychological distress.

Reference

Din HN, Singh-Carlson S, Corliss HL, et al. Perceived and objective fertility risk among female survivors of adolescent and young adult cancer. JAMA Netw Open. 2023;6(10):e2337245. doi:10.1001/jamanetworkopen.2023.37245