Abstract
Purpose:
The advances of early cancer diagnoses and treatment methods allow many adolescent and young adult-aged cancer patients to live long lives after having cancer. There is a rising concern regarding cancer treatment-induced reproductive toxicities and infertility. Oncologists are the first line of medical professionals interacting with cancer patients and playing essential roles in oncofertility practice. This study aimed to assess the oncofertility knowledge, attitude, and practice of oncologists in China.
Methods:
We created an online questionnaire survey to examine 927 Chinese oncologists' demographics, knowledge, attitude, experience, and practice regarding young female cancer patients' infertility risk and fertility preservation.
Results:
Results showed that there is an inadequate oncofertility knowledge among surveyed oncologists, which was affected by oncologists' demographic background of education level, clinical title, and working experience. The majority of surveyed oncologists (84.8%–88.7%) held a positive attitude on young female cancer patients' infertility risk and their fertility preservation demand, but their attitude was impacted by marriage status and patients risk of cancer recurrence. Only 11.8% of surveyed oncologists often referred their patients for fertility preservation, while 66.3% and 21.9% of them have referred once or never, respectively. The oncologists' oncofertility practice was not correlated with their demographic background but was significantly influenced by their oncofertility knowledge and attitude.
Conclusion:
Our study demonstrates that there is an urgent unmet need to improve oncologists' oncofertility knowledge, attitude, and practice in China as well as remove the communication barrier between oncologists and fertility specialists.
Keywords: oncofertility, Chinese oncologist, fertility preservation, knowledge, attitude, practice
Introduction
The remarkable advances of cancer therapy allow for a prodigious rise in cancer survival rates.1,2 Since many adolescent and young adult (AYA)-aged female survivors can live long lives, there is now more awareness regarding the side effects of cancer treatments and long-term quality of life after cancer. Reproductive toxicity is one of the major off-target effects of cancer treatments for AYA-aged female cancer patients. Both chemotherapy and irradiation have been demonstrated to damage the ovaries, the female gonads, and increase cancer survivors' risks of premature ovarian insufficiency, early menopause, hormonal imbalance, and infertility.3,4 Currently, the cryopreservation of oocytes or embryos is the gold standard for preserving fertility for AYA-aged women with cancer. Recent advances of reproductive biology and medicine also allow for other methods under investigation such as the ovarian tissue cryopreservation and in vitro oocyte maturation.5,6 In 2020, the American Society for Reproductive Medicine (ASRM) stated that ovarian tissue banking is now considered an acceptable fertility preservation technique.7
China has the largest cancer population in the world.8 There were about 4.3 million newly diagnosed cancer cases in China in 2018, accounting for 23.7% of all cancer cases worldwide.8 Among all cancer patients in China, the proportion of childbearing-aged female cancer patients is 6.3%, which is significantly higher than the 3.7% in the United States and other developed countries.8 Although the assisted reproductive technology has been implemented in China for more than 30 years, there is no specific fertility preservation guideline for AYA-aged female cancer patients. For instance, the application of gonadotropin-releasing hormone agonist has been rarely applied in China.9 The ovarian tissue cryopreservation has recently been tested to restore women's fertility but is still under experimental stage.10 In addition, the oocyte or embryo cryopreservation for unmarried women, surrogacy, and oocyte donation are not allowed by the law in China.11
Oncologists are the first line of medical professionals interacting with cancer patients and play essential roles in oncofertility practice, including informing AYA-aged cancer patients of the infertility risks, referring patients for fertility preservation before or at early stages of cancer treatments, and communicating with reproductive specialists for coordinating the balance of saving life and saving fertility. The American Society of Clinical Oncology, ASRM, and European Society for Medical Oncology recommend oncologists to inform AYA-aged patients of the risks of infertility and fertility preservation options before any cancer therapy.12–15 However, there is still a significant engagement barrier between patients, oncologists, and reproductive specialists during oncofertility practice. For example, our recent studies also found that only half of the surveyed reproductive endocrinologists in China have been consulted by oncologists about AYA-aged cancer patients' infertility risk and fertility preservation options.16,17 These facts suggest that there is an urgent unmet need to improve oncofertility practice of oncologists. Therefore, the objective of our current study was to assess the oncofertility knowledge, attitude, and practice of oncologists in China.
Materials and Methods
Questionnaire design and analyses
The questionnaire was designed to evaluate Chinese oncologists' oncofertility knowledge, attitude, and practice based on two of our previous studies.16,17 There were 35 questions, including 11 demographic questions, 12 oncofertility knowledge questions, 3 oncofertility attitude questions, 1 oncofertility practice question, and 8 oncofertility experience questions. The 11 demographic questions were designed to collect participant information of gender, age, marital status, education background, geographic location, working hospital level and type, oncological specialty, clinical title, and working experience. The 12 oncofertility knowledge questions covered the aspects of reproductive toxicities of cancer therapy, female fertility preservation methods, short- and long-term cancer recurrence risk after fertility preservation, and medical insurance of fertility preservation, etc. The answers for the oncofertility knowledge questions included three choices, true, false, and uncertain. Only the selection of true or false was defined as the correct answer. If participants correctly answered an oncofertility knowledge question, 1 point was added to his/her total oncofertility knowledge score. The obtained oncofertility knowledge scores were used to divide participants into four quarters, with the lower, middle, and upper quartiles corresponding to the knowledge scores of 4, 6, and 7 and the knowledge score ranges of four quarters at 0–4, 5–6, 7, and 8–12. The three oncofertility attitude questions were scored so that each correctly answered question obtained 1 point and the wrong and uncertain answers obtained 0. Based on the gained total scores, participants' oncofertility attitude was divided into three different levels of L1, L2, and L3, with the score ranged at 0–1, 2, and 3, respectively.
Questionnaire distribution and survey completion
The questionnaire was distributed via WeChat, a Chinese social media platform, in November 2019. The link of the questionnaire was first sent to the chief physicians of Oncology in five different major cities in China, including Beijing, Shanghai, Changchun, Shenyang, and Mianyang. Then, more subjects were recruited by the snowball sampling method, in which the Oncology chief physicians sent the survey link to their departmental colleagues or oncologists they know. A total of 1000 participants from 29 provinces in China completed and submitted the survey, and 927 (92.7%) of them were valid questionnaires. All data were collected anonymously by the online survey software, Wenjuan. The study was reviewed and obtained an exemption from Human Research Subject Regulations by the Institutional Review Boards at both the University of South Carolina and the Capital Medical University.
Statistical analyses
SPSS 18.0 was used for data analyses. Descriptive data were illustrated using number (N), proportion (%), median, and interquartile range (25%–75%). For univariate analyses of several variables, including knowledge score, attitude score, and practice question, the Mann–Whitney test was used for gender and marital status factors, the Kruskal–Wallis test was used for specialty, and the Spearman's rank correlation was used for other ordered factors. To assess the impact of demographic factors to oncofertility knowledge, attitude, and practice, ordinal logistic regression models were applied. Ordinal logistic regression models were also used to determine the influence of knowledge scores to participants' attitude as well as knowledge and attitude toward oncofertility practice. The factors with p < 0.10 in univariate analyses were added into the multivariate analyses. All analyses were two-sided tests and the significant level was 0.05.
Results
Demographic characteristics of surveyed oncologists
Supplementary Table S1 lists the demographic characteristics of 927 surveyed oncologists. In brief, 37.4% of them were males and 62.6% were females, 73.2% of them were married, 85.4% of them had a bachelor's degree or higher, and 77.9% worked in the Level 3-A and 3-B hospitals. All surveyed oncologists had cancer-related professions, including Gynecologic Oncology (21.0%), Breast Oncology (10.4%), Medical Oncology (27.5%), Surgical Oncology (9.1%), Radiation Oncology (13.1%), Interventional Oncology (2.4%), and others (16.6%). About 73% of surveyed oncologists had junior clinical titles of Resident or Attending Physician, and 26.6% had senior titles of Assistant Director Physician or Director Physician. Of all the surveyed oncologists, there was a median age of 32 and working experience of 5 years.
Oncofertility knowledge of surveyed oncologists
The correct answer rate for each oncofertility knowledge question is listed in Supplementary Table S2. The average score for all 11 oncofertility knowledge questions was 5.7 ± 2.3, indicating an overall inadequate oncofertility knowledge. For the two questions with the highest correct answer rates, 72.8% and 77.9% of surveyed oncologists recognized that radiation/chemotherapy can damage female cancer patients' reproductive organs such as the ovaries and can result in infertility or other reproductive dysfunctions, respectively. For the two questions with the lowest correct answer rates, 16.2% of participants knew that fertility preservation does not increase women's risk of cancer recurrence in the future and 27.9% of participants agree that egg and embryo freezing does not have the same chances of future pregnancy.
The results of univariate analyses showed that the education level, clinical title, years of working experience, and specialty, but not gender, age, marital status, and hospital level, had significant impacts on oncologists' oncofertility knowledge (Table 1). Therefore, these four demographic factors were included in the following ordinal logistic regression model as well as the confounding factors of age and gender (Table 2). Results showed that oncologists who had a master or doctoral degree were more likely to obtain a higher oncofertility knowledge score than those having a lower educational background (p < 0.001). The years of working experience had a positive impact on their oncofertility knowledge scores (odds ratio [OR] = 1.03, p = 0.046). When they worked longer, they tended to obtain a higher oncofertility knowledge score. With respect to the specialty, oncologists who focused on breast and gynecologic cancers gained higher scores than oncologists with other specialties; however, the difference was not significantly different (OR = 1.47, p = 0.059; OR = 1.33, p = 0.067).
Table 1.
Univariate Analyses of Demographic Factors to Oncofertility Knowledge
| Quartiles of knowledge score |
|
||||||||
|---|---|---|---|---|---|---|---|---|---|
| Q1 |
Q2 |
Q3 |
Q4 |
p | |||||
| N | % | N | % | N | % | N | % | ||
| Gender | |||||||||
| Male | 99 | 28.5 | 129 | 37.2 | 46 | 13.3 | 73 | 21.0 | 0.364 |
| Female | 143 | 24.7 | 231 | 39.8 | 80 | 13.8 | 126 | 21.7 | |
| Age | |||||||||
| Median (interquartile range) | 31 | 10.25 | 32 | 12 | 31 | 12 | 33 | 12 | 0.252 |
| Marital status | |||||||||
| Yes | 168 | 24.7 | 290 | 42.7 | 81 | 11.9 | 140 | 20.6 | 0.506 |
| No | 74 | 29.8 | 70 | 28.2 | 45 | 18.1 | 59 | 23.8 | |
| Education level | |||||||||
| Less than or equal to Bachelor's degree | 154 | 26.9 | 243 | 42.5 | 75 | 13.1 | 100 | 17.5 | 0.003 |
| Master's and doctoral degree | 88 | 24.8 | 117 | 33.0 | 51 | 14.4 | 99 | 27.9 | |
| Hospital level | |||||||||
| Level 3-A | 157 | 25.1 | 247 | 39.5 | 85 | 13.6 | 137 | 21.9 | 0.287 |
| Level 3-B | 23 | 24.0 | 35 | 36.5 | 15 | 15.6 | 23 | 24.0 | |
| Less than Level 3-B | 62 | 30.2 | 78 | 38.0 | 26 | 12.7 | 39 | 19.0 | |
| Clinical title | |||||||||
| Director physician | 13 | 17.8 | 40 | 54.8 | 8 | 11.0 | 12 | 16.4 | 0.061 |
| Assistant director physician | 34 | 19.7 | 76 | 43.9 | 19 | 11.0 | 44 | 25.4 | |
| Attending physician | 81 | 24.3 | 133 | 39.8 | 50 | 15.0 | 70 | 21.0 | |
| Physician | 114 | 32.9 | 111 | 32.0 | 49 | 14.1 | 73 | 21.0 | |
| Years of working experience | |||||||||
| Median (interquartile range) | 5 | 8 | 6 | 10 | 5 | 8 | 5 | 10 | 0.075 |
| Specialty | |||||||||
| Gynecologic oncology | 35 | 17.9 | 95 | 48.7 | 22 | 11.3 | 43 | 22.1 | 0.080 |
| Breast oncology | 24 | 25.0 | 30 | 31.3 | 13 | 13.5 | 29 | 30.2 | |
| Others | 183 | 28.8 | 235 | 36.9 | 91 | 14.3 | 127 | 20.0 | |
Table 2.
Multivariate Analyses of Demographic Factors to Knowledge of Oncofertilitya
| Knowledge score |
p | ||
|---|---|---|---|
| OR | 95% CI | ||
| Education level | |||
| Less than or equal to Bachelor's degree | 1.00 | ||
| Master's and doctoral degree | 1.58 | 1.23–2.02 | <0.001 |
| Years of working experience | |||
| 1.03 | 1.00–1.06 | 0.046 | |
| Clinical title | |||
| Resident | 1.00 | ||
| Attending physician | 1.16 | 0.86–1.57 | 0.326 |
| Assistant director physician | 1.24 | 0.85–1.80 | 0.267 |
| Director physician | 0.98 | 0.59–1.62 | 0.929 |
| Specialty | |||
| Others | 1.00 | ||
| Breast oncology | 1.47 | 0.99–2.18 | 0.059 |
| Gynecologic oncology | 1.33 | 0.98–1.81 | 0.067 |
Further adjusted with age and gender.
OR, odds ratio; CI, confidence interval.
Oncofertility experience and attitude of surveyed oncologists
The results of oncologists' oncofertility experience and attitude are listed in the Supplementary Table S3. Of all the surveyed oncologists, they annually treated a median of 38 female cancer patients within female reproductive age. Most oncologists realized that AYA-aged female cancer patients would want to preserve their fertility (84.8%) and would take patients' infertility concerns into consideration during cancer therapy (88.7%). Regarding the psychological consultation for patients who will experience infertility risk from cancer treatments, 88.8% of the surveyed oncologists agreed on its importance, and 59.5% of their working hospitals provide this service. Moreover, only 18.3% of oncologists were familiar with fertility preservation, and 70.4% of them reported that they knew some or little. Furthermore, 71.0% of oncologists reported that they have been told the reproductive toxicities of cancer treatments by reproductive specialists, such as the obstetrician, gynecologist, and physicians from the reproductive medicine center. However, only 11.8% of them would actively refer their patients to reproductive specialists for fertility preservation. If oncologists were told that fertility preservation may interfere with cancer therapy, 19.0% of participants would not suggest this service regardless of its infertility risks to the patients. Most surveyed participants (90.1%) have ever been consulted by female cancer patients about their infertility concerns. Among these oncologists (835) who have been consulted, 71.6% of them estimated that these patients accounted for more than one-tenth of all their treated female cancer patients were at childbearing age. However, only 54.5% of oncologists reported that their hospitals offered fertility preservation service.
The results of univariate analyses showed that the marital status, specialty, and oncofertility knowledge significantly influenced oncologists' oncofertility attitude, while the gender, age, education level, hospital level, clinical title, and years of working experience had no impact (Table 3). Based on the results of multivariate analyses (Table 4), the married participants were more likely to hold a positive attitude than unmarried participants (OR = 1.76, p = 0.006). Compared to oncologists who had their specialty in the fields of nongynecological oncology, the gynecological oncologists received higher oncofertility attitude scores; similarly, the difference was not statistically significant (OR = 1.50, p = 0.065). When participants received a high oncofertility knowledge scores, they were more likely to have a positive oncofertility attitude (p < 0.001).
Table 3.
Univariate Analyses of Demographics and Knowledge to Attitude Scores
| Attitude score |
p | ||||||
|---|---|---|---|---|---|---|---|
| L1 |
L2 |
L3 |
|||||
| N | % | N | % | N | % | ||
| Gender | |||||||
| Male | 36 | 10.4 | 44 | 12.7 | 267 | 76.9 | 0.961 |
| Female | 51 | 8.8 | 86 | 14.8 | 443 | 76.4 | |
| Age | |||||||
| Median (interquartile range) | 31 | 12 | 32 | 13.25 | 32 | 12.25 | 0.818 |
| Marital status | |||||||
| Yes | 61 | 9.0 | 85 | 12.5 | 533 | 78.5 | 0.032 |
| No | 26 | 10.5 | 45 | 18.1 | 177 | 71.4 | |
| Education level | |||||||
| Less than or equal to Bachelor's degree | 28 | 7.9 | 52 | 14.6 | 275 | 77.5 | 0.522 |
| Master's and doctoral degree | 59 | 10.3 | 78 | 13.6 | 435 | 76.0 | |
| Hospital level | |||||||
| Level 3-A | 55 | 8.8 | 84 | 13.4 | 487 | 77.8 | 0.238 |
| Level 3-B | 11 | 11.5 | 15 | 15.6 | 70 | 72.9 | |
| Less than Level 3-B | 21 | 10.2 | 31 | 15.1 | 153 | 74.6 | |
| Clinical title | |||||||
| Director physician | 8 | 11.0 | 9 | 12.3 | 56 | 76.7 | 0.575 |
| Assistant director physician | 19 | 11.0 | 20 | 11.6 | 134 | 77.5 | |
| Attending physician | 28 | 8.4 | 46 | 13.8 | 260 | 77.8 | |
| Physician | 32 | 9.2 | 55 | 15.9 | 260 | 74.9 | |
| Years of working experience | |||||||
| Median (interquartile range) | 5 | 8 | 5 | 8 | 5 | 8 | 0.289 |
| Specialty | |||||||
| Gynecologic oncology | 12 | 6.2 | 23 | 11.8 | 160 | 82.1 | 0.023 |
| Breast oncology | 7 | 7.3 | 10 | 10.4 | 79 | 82.3 | |
| Others | 68 | 10.7 | 97 | 15.3 | 471 | 74.1 | |
| Quartiles of knowledge score | |||||||
| Q1 | 59 | 24.4 | 40 | 16.5 | 143 | 59.1 | <0.001 |
| Q2 | 20 | 5.6 | 49 | 13.6 | 291 | 80.8 | |
| Q3 | 2 | 1.6 | 21 | 16.7 | 103 | 81.7 | |
| Q4 | 6 | 3.0 | 20 | 10.1 | 173 | 86.9 | |
Table 4.
Multivariate Analyses of Demographics and Knowledge to Attitude Scoresa
| Attitude score |
p | ||
|---|---|---|---|
| OR | 95% CI | ||
| Marital status | |||
| Unmarried | 1.00 | ||
| Married | 1.76 | 1.18–2.62 | 0.006 |
| Specialty | |||
| Others | 1.00 | ||
| Breast oncology | 1.52 | 0.86–2.68 | 0.148 |
| Gynecologic oncology | 1.50 | 0.98–2.29 | 0.065 |
| Quartiles of knowledge score | |||
| Q1 | 1.00 | ||
| Q2 | 3.20 | 2.22–4.62 | <0.001 |
| Q3 | 3.80 | 2.25–6.42 | <0.001 |
| Q4 | 5.35 | 3.29–8.71 | <0.001 |
Further adjusted with age and gender.
Oncofertility practice of surveyed oncologists
With respect to the oncofertility practice, the results of univariate analyses showed that all the demographic factors had no significant impact on the oncofertility practice (Table 5). However, the surveyed oncologists who received higher oncofertility knowledge and attitude scores were more likely to have a positive oncofertility practice (p < 0.001). The results of multivariate analyses showed that oncologists with an oncofertility knowledge of Q4 were more active in oncofertility practice than oncologists with Q1 level (OR = 1.96, p = 0.001). When the surveyed oncologists held a positive attitude, they were more likely to practice actively (L3: OR = 2.07, p = 0.003). These results suggest that the oncofertility knowledge and attitude have a positive impact on oncofertility practice (Table 6).
Table 5.
Univariate Analyses of Demographics, Knowledge, and Attitude to Practice Questions
| Q22 Have you ever referred childbearing cancer patients to reproductive specialists? |
|||||||
|---|---|---|---|---|---|---|---|
| Never |
Once |
Often |
p | ||||
| N | % | N | % | N | % | ||
| Gender | |||||||
| Male | 80 | 23.1 | 231 | 66.6 | 36 | 10.4 | 0.305 |
| Female | 123 | 21.2 | 384 | 66.2 | 73 | 12.6 | |
| Age | |||||||
| Median (interquartile range) | 31 | 12 | 32 | 13 | 31 | 12 | 0.686 |
| Marital status | |||||||
| Yes | 151 | 22.2 | 451 | 66.4 | 77 | 11.3 | 0.512 |
| No | 52 | 21.0 | 164 | 66.1 | 32 | 12.9 | |
| Education level | |||||||
| Less than or equal to Bachelor's degree | 71 | 20.0 | 239 | 67.3 | 45 | 12.7 | 0.234 |
| Master's and doctoral degree | 132 | 23.1 | 376 | 65.7 | 64 | 11.2 | |
| Hospital level | |||||||
| Level 3-A | 137 | 21.9 | 411 | 65.7 | 78 | 12.5 | 0.637 |
| Level 3-B | 21 | 21.9 | 66 | 68.8 | 9 | 9.4 | |
| Less than Level 3-B | 45 | 22.0 | 138 | 67.3 | 22 | 10.7 | |
| Clinical title | |||||||
| Director physician | 20 | 27.4 | 46 | 63.0 | 7 | 9.6 | 0.674 |
| Assistant director physician | 27 | 15.6 | 129 | 74.6 | 17 | 9.8 | |
| Attending physician | 71 | 21.3 | 223 | 66.8 | 40 | 12.0 | |
| Physician | 85 | 24.5 | 217 | 62.5 | 45 | 13.0 | |
| Years of working experience | |||||||
| Median (interquartile range) | 5 | 8 | 5 | 9 | 5 | 9.25 | 0.137 |
| Specialty | |||||||
| Gynecologic oncology | 44 | 22.6 | 129 | 66.2 | 22 | 11.3 | 0.546 |
| Breast oncology | 17 | 17.7 | 66 | 68.8 | 13 | 13.5 | |
| Others | 142 | 22.3 | 420 | 66.0 | 74 | 11.6 | |
| Quartiles of knowledge score | |||||||
| Q1 | 64 | 26.4 | 155 | 64.0 | 23 | 9.5 | <0.001 |
| Q2 | 93 | 25.8 | 229 | 63.6 | 38 | 10.6 | |
| Q3 | 23 | 18.3 | 90 | 71.4 | 13 | 10.3 | |
| Q4 | 23 | 11.6 | 141 | 70.9 | 35 | 17.6 | |
| Attitude score | |||||||
| L1 | 34 | 39.1 | 43 | 49.4 | 10 | 11.5 | <0.001 |
| L2 | 38 | 29.2 | 80 | 61.5 | 12 | 9.2 | |
| L3 | 131 | 18.5 | 492 | 69.3 | 87 | 12.3 | |
Table 6.
Multivariate Analyses of Factors to Practice Questiona
| Q22 Have you ever referred childbearing cancer patients to reproductive specialists? |
p | ||
|---|---|---|---|
| OR | 95% CI | ||
| Quartiles of knowledge score | |||
| Q1 | 1.00 | ||
| Q2 | 0.91 | 0.64–1.29 | 0.599 |
| Q3 | 1.20 | 0.75–1.91 | 0.439 |
| Q4 | 1.96 | 1.30–2.98 | 0.001 |
| Attitude score | |||
| L1 | 1.00 | ||
| L2 | 1.30 | 0.74–2.29 | 0.356 |
| L3 | 2.07 | 1.28–3.34 | 0.003 |
Further adjusted with age and gender.
Discussion
As the first line of medical professionals interacting with cancer patients, oncologists play essential roles in oncofertility practice. However, research found that the reproductive issues were usually ignored when oncologists discussed the side effects of cancer treatments with patients,18 and there were also communication gaps between oncologists and fertility specialists.19 In the present study, we conducted a questionnaire survey to assess the oncofertility knowledge, attitude, and practice of oncologists in China. Of all the surveyed oncologists, 62.6% of them were females and 37.4% were males. The percentage of female oncologists here is higher than the percentage of all medical disciplines in China (45.8%).20 This may be due to the fact that >90% of participants were nonsurgical oncologists, in which there are more females, particularly in the Departments of Gynecological Oncology and Breast Oncology. Of all the surveyed oncologists, 73.4% of them had junior clinical titles, including residents and attending physicians, which is similar to the overall percentage of junior clinicians in China (73.2%).20
We first accessed surveyed oncologists' oncofertility knowledge. Compared to our previous studies using the same questions but targeting reproductive professionals in China,16,17 the surveyed oncologists here obtained a significantly lower oncofertility knowledge score (5.7 ± 2.3 vs. 6.4 ± 2.9). For example, 29.8% of oncologists correctly answered that different fertility preservation methods may have different pregnancy success. In contrast, 60%–84.8% of reproductive professionals knew this. In fact, embryo vitrification has been shown to have the highest pregnancy success among all fertility preservation treatments.21 In addition, 27.9% of oncologists knew that egg and embryo freezing had different chances of future pregnancy, but 53.9%–73.9% of reproductive professionals knew that embryo freezing achieves higher pregnancy rate than egg freezing.22
When considering the demographic characteristics, oncologists with higher educational background and longer working experience were more likely to have a higher oncofertility knowledge score, indicating that the systematic medical training and working experience will enable oncologists to obtain a better oncofertility knowledge. Moreover, breast oncologists and gynecologists gained higher oncofertility scores compared with oncologists with their specialties focused on breast, cervix, uteri, and ovary cancers. These findings were consistent to the results from Quinn et al. and indicate that oncologists' specialties influence their oncofertility knowledge.23 Taken together, consistent to the results in other countries,23–26 Chinese oncologists also have an inadequate oncofertility knowledge, and systemic education and training are required.
The overall oncofertility attitude of surveyed oncologists is positive. For example, most of surveyed oncologists agreed that AYA-aged female cancer patients would want to preserve their fertility (84.8%) and would also consider patients' fertility preservation demand (88.7%) before cancer treatments. However, only 18.3% of them reported to be familiar with the specific fertility preservation methods. We performed the Kruskal–Wallis test between the availability of oncofertility services in participants' working hospitals (Q24) and participants' familiarity with fertility preservation methods (Q15). Results showed that there is a statistically significant distribution between these two parameters (p < 0.001), indicating that the accessibility of the oncofertility service will impact their familiarity of fertility preservation methods (Supplementary Table S4). Regarding the impact of demographic factors on oncologists' oncofertility attitude, married oncologists were more likely to hold a positive attitude than unmarried oncologists. Also, the gynecological and breast oncologists, who have more background on female reproductive medicine, had a more positive oncofertility attitude than oncologists in other oncological disciplines. Consistently, a previous study from Forman et al. also found that gynecological and breast oncologists are more likely to consider cancer patients' infertility risks.27 These results suggest that the oncofertility training and education toward oncologists can be designed based on their specialties. The positive correlation between oncologists' knowledge and attitude demonstrates that oncologists' oncofertility knowledge to some extent determine their attitude. Therefore, enriching oncologists' knowledge levels through seminars and other educations materials can be effective methods to improve oncologists' oncofertility attitude.
We also investigated oncologist’ oncofertility practice through the question of “Have you ever referred childbearing cancer patients to reproductive specialists for fertility preservation?” Results showed that 78.1% of surveyed oncologists have referred their patients for fertility preservation at least once. However, only 11.8% of them were self-identified as “often”, 66.3% of them have referred once, and 21.9% of them have never done it before (Table 5). Considering oncologists' demographic background, interestingly, none of the analyzed demographic factors showed significant impact on their oncofertility practice (Table 5), such as the gender, age, marital status, education levels, and so on. However, oncologists who obtained higher oncofertility knowledge scores and had positive oncofertility attitude were more likely to do the fertility preservation referral.
The percentage of surveyed oncologists who often do fertility preservation referral (11.8%) is lower than the percentages in two previous studies conducted in the United States.28,29 Quinn et al. reported that 46.7% of 516 participants always or often refer patients to a reproductive specialist.28 Rosenberg et al. reported that 73% always, 23% often, 2% rarely, and 1% never refer patients to a reproductive endocrinologist.29 These results indicate a communication gap between oncologists and fertility specialists. With respect to the oncologists, the main communication barrier might be caused by the inadequate oncofertility knowledge. Our results showed that when an oncologist gets a higher knowledge score, their referral practice becomes more active. The influence of fertility preservation on cancer therapy also affects their oncofertility attitude or practice. If oncologists were told that fertility preservation may increase the risk of cancer recurrence at a level of >10%, more than 60% would not recommend fertility preservation to their patients. Furthermore, nearly 20.0% of participants would not suggest it regardless of its risk on cancer recurrence. To fill the communication gap, oncologists can take actions by increasing awareness of cancer patients' fertility preservation and referring them to a reproductive specialist. Reproductive health professionals also play important roles such as disseminating oncofertility knowledge to both oncologists and female cancer patients. Another option is to include patient navigators who can offer infertility risks from cancer therapy and fertility options, and referral to professional psychologists and fertility specialists.30–32
Our study has several limitations. First, selection bias may exist because most of oncologists were recruited through snowball sampling method, suggesting that those who completed the survey may be more interested in the topics of female fertility preservation. In future studies, we can explore and use more representative survey sampling methods to avoid this bias. Second, the number of recruited subjects was not big enough, which may be the reason that the specialty significantly influenced oncofertility knowledge and attitude in univariate analyses, while not in multivariate analyses. Third, although the recruited oncologists were from 29 provinces in China, the number of participants in each province was unbalanced and there might be some deviations, and we cannot exactly study the impact of geographic location and hospital size/levels on oncologists' oncofertility attitude, knowledge, and practice. Finally, our study comprehensively focused on reproductive-aged women (18–45) and did not consider the specific characteristics of these patients. For example, oncologists might give different fertility preservation recommendations when facing patients at different ages and they have children already.
We have summarized the relationships between oncologists' demographics, oncofertility knowledge, attitude, and practice in Figure 1. Our results suggest that there is an inadequate oncofertility knowledge among oncologists in China and oncologists' demographic characteristics affect their knowledge level such as the education background and years of working experience. Most of surveyed oncologists hold a positive attitude on AYA-aged female cancer patients' fertility preservation, but they do not often refer their patients for fertility preservation. There is no strong correlation between oncologists' demographic characteristics and their oncofertility practice; however, oncologists' oncofertility knowledge and attitude show a significant impact on their oncofertility practice.
FIG. 1.
The relationships between oncologist's demographics, oncofertility knowledge, attitude, and practice based on the results of multivariate analysis. The solid lines indicate statistically significant impacts with p < 0.05 and the dashed lines indicate potential impacts with p < 0.1.
Authors' Contributions
Y.Z. and X.Z. contributed to the questionnaire design, data collection and analyses, and article writing. M.E.Z., Y.X., Y.L., X.Z., and Q.S. contributed to the data analyses and article writing. S.X. conceived of the project, designed questionnaire, collected, analyzed and interpreted data, wrote the article, and provided final approval of the article.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This work was supported by the Start Up Fund of the Environmental and Occupational Health Sciences Institute at Rutgers University to S.X. and the Organization Committee of Beijing Municipal (2018000021223TD09) to Q.S.
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