Oncofertility: Standardizing Fertility Preservation Discussion and Referrals for Adolescents and Young Adults with Newly Diagnosed Breast Cancer

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BACKGROUND: Breast cancer (BC) is the most diagnosed cancer in adolescents and young adults (AYA). Patients in this population face unique challenges related to fertility risks posed by chemotherapy. Current evidence suggests that all patients in this population should have a documented conversation about fertility preservation when discussing treatment options and a referral to fertility specialists if warranted.

LOCAL PROBLEM: The setting of this evidence-based practice quality improvement (EBPQI) project was at a breast center located within an NCI-designated cancer center. The clinic did not have a standardized process for documenting fertility preservation discussions and implementing fertility referrals. The goal of this project was to increase documented fertility preservation discussions and completed referrals to fertility specialists by 50%.

METHODS: The Evidence-based Practice Improvement model was chosen as the guiding framework for this project. Based on current workflow and in conjunction with synthesis of best available evidence, implementation of a standardized process for fertility preservation discussions and referrals using an EHR-based best practice advisory (BPA) and oncofertility tool was recommended.

INTERVENTIONS: The BPA, which included a link to an oncofertility tool, was embedded into the EHR. During initial consultation encounters with newly diagnosed AYA patients with breast cancer requiring chemotherapy treatment, the BPA alerts providers to the need to discuss fertility preservation and assess oncofertilty concerns using a standardized tool. Referral was then placed based on risk and patient preference.

RESULTS: Documented fertility discussions increased by 42%; completed referrals decreased. While project aims were not met, the increase in discussions is clinically significant.

CONCLUSIONS: The BPA improved fertility preservation documentation but not completed referrals. Several barriers were identified during implementation including provider staffing, implicit bias, and treatment timeline limitations. To promote future progress toward goals and sustainability, increased efforts at provider education, identification of a physician champion, and fertility clinic collaborations are recommended.