Abstract
Objectives
To determine the rates of parenthood projects among two-year cancer survivors with a preserved fertility, and to identify factors associated with parenthood project, opposing cancer-related factors to socio-demographic factors usually associated with parenting in healthy individuals.
Methods
Among 6,957 adult cancer patients randomly selected in the Long Duration Disease File of the French National Health Insurance Fund between September and October 2002, still alive and not hospitalised two years after diagnosis, 4,270 responded to this cross-sectional questionnaire study of whom 969 reported having preserved fertility.
Results
Among women aged 20–44 (n=175) and men aged 20–70 (n=784), 26.3% and 6.1% respectively planned to have a child or another child. Such plans were more frequently reported by in younger patients but were also reported by the oldest ones (until 70 years old for men).
33.5% of the 257 male and female survivors, aged 20–45, had parenthood project. After adjustment for age, previous children, and gender, only high education level (adjusted odds ratio: 3.1, 95% confidence interval 1.3 to 7.8) and stability or increase of financial resources (2.4, 1.0 to 5.7) were independently associated with parenthood project. Cancer stage at diagnosis and evolution did not modify this project.
Conclusions
Two years after cancer diagnosis when fertility has been preserved, motives against parenthood project tend to be similar among cancer survivors and in the general population. Survivors who reported a reduction in financial resources were less likely to have a parenthood project. Targeted support is needed to help them to face financial consequences of the disease.
Keywords: Adult, Age Distribution, Aged, Cross-Sectional Studies, European Continental Ancestry Group, Female, Fertility, physiology, France, Humans, Intention, Male, Middle Aged, Neoplasms, psychology, Questionnaires, Reproductive Behavior, Risk Factors, Sex Distribution, Socioeconomic Factors, Survivors, psychology, statistics & numerical data, Young Adult
Keywords: cancer, oncology, cancer survivors, parenthood, procreational intentions, socio-economic status, national survey
INTRODUCTION
With the increased frequency of delayed childbearing in developed countries, many adult cancer survivors may not have completed their family at the time of cancer occurrence. Previous studies on psychosocial consequences of a cancer occurring before or during reproduction years, have shown that parenthood is a main concern among young survivors [1]. Parenthood after cancer is not exceptional, but, according to a recent survey, it is reduced by about 25% for first births and 36% for higher-order births compared with the general population [2]. Of course, fertility is frequently impaired by cancer itself and/or its treatment [3], but infertility related to cancer treatment may not be the only barrier to parenthood after cancer. Cancer survivors may fear that pregnancy will result in cancer recurrence, that the child will not be healthy, or that they will not live long enough to see their child grow up [4–6]. Financial difficulties, cancer family history or fear of the responsibility may also affect child desire [1]. On the contrary, cancer experience may improve skills and pleasure of parenting, help to regain health and femininity, and decrease death anxiety [7]. Surveys among survivors suggested that the wish to have a child is generally not influenced by cancer occurrence [1] and could even increase among childless survivors [4]. However, previous research has mainly focused on parenthood rates of cancer survivors [2,8–10] or in motivation for parenthood after breast cancer [1]. Less is known about parenthood projects in other cancer sites [4,5] and, to our knowledge, there is no survey on child project in a fertile representative population of cancer survivors.
The first aim of this study was to determine the rates of parenthood projects among men and women with a preserved fertility two years after a cancer diagnosis in a national representative sample of French cancer survivors. The second aim was to identify factors associated with parenthood project, opposing cancer-related factors to socio-demographic factors usually associated with parenting in healthy individuals.
METHODS
Study population
In 2004, a French national cross-sectional survey was initiated to investigate living conditions of adult cancer patients two years after cancer diagnosis [11]. Patients were randomly selected in the Long Duration Disease File of the National Health Insurance Fund. Eligible patients were all those included in this file between September and October 2002 for a diagnosis of biopsy-proven primary cancer, aged over 18 years at diagnosis, still alive two years after diagnosis, not hospitalised at the time of the survey and with a valid address. Of the 6,957 eligible cancer patients, 4,270 agreed to participate (response rate: 64.1%).
Data collection
Telephone interviews were conducted with consenting patients between November 2004 and January 2005 to collect sociodemographic data, data on disease history, and health status at the time of the interview. For ethical concerns, the question about the potential parenthood project (“Do you plan to have a child or more children?”) was asked only to patients who reported having a preserved fertility [12]. Medical characteristics (cancer localisation, stage and evolution) were collected by advisory physicians of the National Health Insurance Fund. Coping with cancer was assessed using the ‘Mental Adjustment to Cancer scale’ (MAC), a 21-item self-report questionnaire measuring three possible responses to cancer: fighting spirit, helpless/hopelessness, and anxious preoccupation [13]. Health-related quality of life was assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) [14].
Patients
For the purpose of the analyses on reproductive issues, an upper age limit was fixed at 44 years for women and 70 years for men. The study sample included 969 two-year cancer survivors who reported having preserved fertility: 178 of 282 women (63.1%) and 791 of 1,137 men (69.6%) included [12].
Statistical analyses
Because parenthood theme concerned different age classes in males and females, description of parenthood projects rates among age groups were first stratified according to gender.
Secondly, as plan to have a(nother) child among older men was a rare event, factors associated with such plan were only assessed in 20–44 years old men and women together. Main socio-demographic factors (age, previous children, and gender) were first entered in a multiple logistic regression model. Then, the contribution of factors associated with cancer was assessed using adjusted odds ratios.
RESULTS
Parenthood project according to gender
Among the 969 fertile two-year cancer survivors with preserved fertility, 959 (99%) responded to the question about parenthood project. Of the 175 fertile women less than 45 years old, 46 (26.3%) planned to have a child or more children. This project was more frequent in younger women (71.1% of women 20–34 years old vs. 18.5% of 35–39 years old vs. 5.3% of 40–44 years old; p<0.001), but is still present in the oldest women (until 43 years old). Of the 784 fertile men less than 71 years old, 48 (6.1%) planned to have a child or another child. Such plan decreased with age (77.8% of men 20–34 years old vs. 45.5% of 35–39 years old vs. 8.3% of 40–44 years old vs. 2.9% of 45–49 years old vs. 0.9% of >49 years old; p<0.001) but remained in some of the oldest survivors (until 70 years old).
Factors associated with parenthood project among 20–44 years old survivors (men and women together) (Table)
Table.
Factors associated with parenthood project in French adult cancer survivors.
| Parenthood project | Adjusted OR* | (95%CI) | Adjusted P value | ||||
|---|---|---|---|---|---|---|---|
| No | Yes | ||||||
| n | % | n | % | ||||
| Gender | |||||||
| Male | 42 | 51.2 | 40 | 48.8 | 2.3 | (1.0 to 5.2) | 0.039 |
| Female | 129 | 73.7 | 46 | 26.3 | 1 | ||
| Age | <0.001 | ||||||
| 20–34 | 21 | 25.9 | 60 | 74.1 | 25.3 | (9.0 to 71.3) | <0.001 |
| 35–39 | 56 | 73.7 | 20 | 26.3 | 6.0 | (2.1 to 17.4) | 0.001 |
| 40–44 | 94 | 94.0 | 6 | 6.0 | 1 | ||
| Previous child | <0.001 | ||||||
| 0 | 21 | 30.9 | 47 | 69.1 | 12.9 | (5.1 to 32.3) | <0.001 |
| 1 | 27 | 50.9 | 26 | 49.1 | 8.1 | (3.2 to 20.4) | <0.001 |
| 2 and more | 123 | 90.4 | 13 | 9.6 | 1 | ||
| Education | 0.048 | ||||||
| < high school | 81 | 77.1 | 24 | 22.9 | 1 | ||
| high school graduate | 40 | 64.5 | 22 | 35.5 | 1.5 | (0.5 to 3.9) | 0.451 |
| > high school | 50 | 55.6 | 40 | 44.4 | 3.1 | (1.3 to 7.8) | 0.015 |
| Financial resources | |||||||
| Stable/increased | 117 | 64.6 | 64 | 35.4 | 2.4 | (1.0 to 5.7) | 0.050 |
| Reduced | 54 | 72.0 | 21 | 28.0 | 1 | ||
| Couple relationship | 0.306 | ||||||
| No | 22 | 48.9 | 23 | 51.1 | 1 | ||
| Stable | 116 | 72.5 | 44 | 27.5 | 3.0 | (0.9 to 10.1) | 0.083 |
| Deteriorated/separation | 28 | 70.0 | 12 | 30.0 | 2.9 | (0.6 to 13.3) | 0.163 |
| New | 5 | 41.7 | 7 | 58.3 | 4.2 | (0.6 to 26.8) | 0.134 |
| Cancer site | 0.324 | ||||||
| Breast | 63 | 87.5 | 9 | 12.5 | 0.6 | (0.2 to 2.2) | 0.440 |
| Thyroid | 26 | 54.2 | 22 | 45.8 | 2.4 | (0.8 to 7.8) | 0.130 |
| Melanoma | 15 | 62.5 | 9 | 37.5 | 1.8 | (0.4 to 8.0) | 0.422 |
| Testicular | 8 | 40.0 | 12 | 60.0 | 1.4 | (0.3 to 7.0) | 0.679 |
| Lymphoma | 9 | 42.9 | 12 | 57.1 | 2.6 | (0.6 to 11.1) | 0.190 |
| Leukaemia | 8 | 57.1 | 6 | 42.9 | 1.3 | (0.2 to 7.1) | 0.768 |
| Other** | 42 | 72.4 | 16 | 27.6 | 1 | ||
| Troublesome sequelae | |||||||
| Yes | 26 | 83.9 | 5 | 16.1 | 0.4 | (0.1 to 1.6) | 0.199 |
| No | 143 | 63.8 | 81 | 36.2 | 1 | ||
| Specialized psychological support at time of survey | 0.316 | ||||||
| No. not wanted | 133 | 65.2 | 71 | 34.8 | 1 | ||
| No. but wished | 23 | 79.3 | 6 | 20.7 | 0.4 | (0.1 to 1.3) | 0.129 |
| Yes | 15 | 62.5 | 9 | 37.5 | 0.9 | (0.2 to 3.6) | 0.915 |
| Mean | SD | Mean | SD | ||||
| Prognosis index*** | 62.1 | 20.2 | 58.8 | 21.1 | 1.00 | (0.98 to 1.02) | 0.751 |
| SF-36 Physical Component Summary | 47.3 | 9.0 | 48.8 | 8.6 | 1.02 | (0.98 to 1.07) | 0.287 |
| SF-36 Mental Component Summary | 42.6 | 11.0 | 45.8 | 9.8 | 1.02 | (0.99 to 1.06) | 0.175 |
| MAC21 Fighting Spirit (FS) | 54.4 | 9.7 | 55.9 | 9.5 | 1.04 | (1.00 to 1.08) | 0.069 |
| MAC21 Hopelessness/Helplessness (HH) | 50.4 | 13.4 | 46.9 | 9.3 | 0.97 | (0.93 to 1.00) | 0.067 |
| MAC21 Anxious Preoccupation (AP) | 46.4 | 8.8 | 44.3 | 8.5 | 0.97 | (0.93 to 1.01) | 0.165 |
CI = confidence interval.
adjusted odds ratio (systematic adjustment on gender, age and previous child).
upper aerodigestive tract (10), renal (9), digestive (8), genital (7), sarcoma (6), brain (5), connective and soft tissue (4), lung (3), eye (3), endocrine (1), multiple myeloma (1), skin (1).
based on national 5-year relative survival weighted by stage (solid tumours), spread (Hodgkin’s disease), or grade (other lymphomas) at diagnosis (range: 0–100).
Eighty-six (33.5%) of the 257 fertile survivors aged 20–44 years (average age = 36.7 +/− 5.8) had a parenthood project. This project was more frequent in male, youngest and childless patients.
After adjustment for age, previous children, and gender, only a lower education level and a reduction of financial resources were independently associated with lack of parenthood project. Mostly, this reduction of financial resources was reported by survivors as directly related to cancer occurrence (78.7%). Moreover, a stable couple relationship, a fighting spirit and a low feeling of hopelessness/helplessness were marginally associated with parenthood project. No relation was found (not reported) between parenthood project and current employment status (p=0.14), family financial resources (p=0.24), and negative sexual consequences of cancer (p=0.33).
Parenthood project was independent of cancer site, cancer prognosis index, and report of troublesome sequelae, but also (not reported) of cancer stage at diagnosis (localised, regional, distant tumour; p=0.92), treatment (surgery, radiotherapy, chemotherapy, hormonotherapy: p=0.26; p=0.52; p=0.59; p=0.14, respectively), and disease evolution 2 years later (remission, stability, relapse; p=0.94). Moreover, survivors who stated that their family members had an increased risk of cancer occurrence had also similar rates of children project (not reported; p=0.12).
DISCUSSION
The desire for children among cancer survivors is still poorly documented. Among survivors having preserved fertility, parenthood project is frequent and influenced by a reduction of financial resources.
In our survey, one third of the 20–44 years French fertile cancer survivors, 2 years after a cancer diagnosis, had a parenthood project. Schover et al [4] in a small sample of American cancer survivors and Heard et al [15] in a representative sample of French HIV-infected patients reported similar rates of parenthood project. As expected, parenthood project was more frequent in younger cancer survivors. However, our survey showed that child project remained in oldest survivors, suggesting that detailed information about infertility risk related to cancer treatment should be provided to all treated patients, irrespective of their age [12]. The great persistence of parenthood project in fertile survivors suggests that the important reduction of parenthood probability in cancer survivors compared with the general population [2,9,10] is mainly related to fertility impairment. Moreover, in premenopausal women, despite preserved fertility and a strong child desire, long-term hormonal therapies may lead to delay pregnancies for years, until parenthood became impossible. For example, premenopausal women with localised breast cancer should be informed that early conception, six months after completing their treatment would not reduce survival [16]. More generally, a greater attention should be given to the preservation of fertility in patients with cancer. New methods of fertility preservation and treatment modifications can help to preserve fertility without compromising cancer care [17].
The main predictors of parenthood projects were age, gender and previous children, as already described in parenthood rates [2,8,18]. However, if post cancer reproduction rate is known to be strongly associated with the type, extent and treatment of the malignancy [8], none of the variables measuring objective or perceived health status were associated with parenthood project in our survey. Such a low impact of clinical conditions on child desire is consistent with results of previous surveys carried out in HIV patients [15] or in breast cancer women [1]. The only major negative impact of cancer on child project is indirect, through income reduction. This argument against parenthood is not specific to cancer. Financial restraints are common arguments against parenthood in the general population [19,20].
If in our results, couple relationship was not associated with parenthood project, youngest adult cancer survivors with parenthood projects that have not started to live in couple may experience difficulties to get married or enter a union such as childhood cancer patients [21] and have their child project compromised by lack of partner. Future studies with larger sample of young adult cancer survivors may answer this question.
Our study has a few limitations. First, fertility assessment was based on patients’ self report. However, for the evaluation of parenthood project, self-perception of fertility could be as relevant as real fertility. Second, our sample included only a few survivors of cancer sites like leukaemia, lymphoma or testicular cancer. The subrepresentation of these cancer sites is not related to a selection bias but is directly related to consequences of cancer treatment on fertility. So our sample is representative of French fertile cancer survivors 2 years after diagnosis.
Finally, our results show that cancer characteristics do not deeply affect parenthood project in fertile survivors, and that, 2 years after a cancer diagnosis, motives against parenthood project tend to be similar among cancer survivors and in the general population. Of course, more efforts should be done to improve fertility preservation before cancer treatment, but once ‘patients’ have become ‘survivors’, targeted support is also needed to help them to face financial consequences of the disease.
Acknowledgments
This survey was initiated by the “Direction de la recherche, des études, de l’évaluation et des statistiques” (DREES) and was additionally supported by the “Ligue Nationale contre le Cancer”. This work was made possible by the involvement and the support of the “Caisse Nationale de l’Assurance Maladie des Travailleurs Salariés” (CNAMTS), the “Mutualité sociale agricole” (MSA), the “Régime social des indépendants” (RSI). We are indebted to the advisory physicians of the National Health Insurance Fund who participated actively in the present study. We also thank the members of the ALD Cancer Study Group* (“Groupe d’étude ALD Cancer”) for their contribution and Pr Michel Dorval for kindly reviewing this manuscript.
Footnotes
The ALD Cancer Study Group (“Groupe d’étude ALD Cancer”)
Guy-Robert AULELEY (Caisse Nationale du RSI, Paris), Pascal AUQUIER (Université de la Méditerranée, Marseille), Philippe BATAILLE (Université Lille 3, Lille), Nicole BERTIN (CNAMTS, Paris), Frédéric BOUSQUET (HAS, Paris), Anne-Chantal BRAUD† (Institut Paoli-Calmettes, Marseille), Chantal CASES (IRDES, Paris), Sandrine CAYROU (Psychologue, Toulouse), Claire COMPAGNON (Conseil en santé, Paris), Paul DICKES (Université Nancy 2 - GRAPCO - LABPSYLOR, Nancy), Pascale GROSCLAUDE (Registre du cancer du Tarn, Albi), Anne-Gaëlle LE CORROLLER-SORIANO (Inserm U379, Marseille), Laëtitia MALAVOLTI (Inserm U379, Marseille), Catherine MERMILLIOD (DREES, Paris), Jean-Paul MOATTI (Université de la Méditerranée - Inserm U379, Marseille), Nora MOUMJID-FERDJAOUI (GRESAC - Université Lyon 1, Lyon), Marie-Claude MOUQUET (DREES, Paris), Lucile OLIER (DREES, Paris), Frédérique ROUSSEAU (Institut Paoli-Calmettes, Marseille), Gérard SALEM (INCa, Boulogne-Billancourt), Christine SCARAMOZZINO (Ligue Nationale contre le Cancer, Paris), Florence SUZAN (Institut de veille sanitaire, Saint-Maurice), Vincent VAN BOCKSTAEL (CCMSA, Paris), Alain WEILL (CNAMTS, Paris).
References
- 1.Braun M, Hasson-Ohayon I, Perry S, et al. Motivation for giving birth after breast cancer. Psychooncology. 2005;14:282–296. doi: 10.1002/pon.844. [DOI] [PubMed] [Google Scholar]
- 2.Syse A, Kravdal O, Tretli S. Parenthood after cancer - a population-based study. Psychooncology. 2007;16:920–927. doi: 10.1002/pon.1154. [DOI] [PubMed] [Google Scholar]
- 3.Lee SJ, Schover LR, Partridge AH, et al. American Society of Clinical Oncology Recommendations on Fertility Preservation in Cancer Patients. J Clin Oncol. 2006;24:2917–2931. doi: 10.1200/JCO.2006.06.5888. [DOI] [PubMed] [Google Scholar]
- 4.Schover LR, Rybicki LA, Martin BA, et al. Having children after cancer. A pilot survey of survivors’ attitudes and experiences. Cancer. 1999;86:697–709. doi: 10.1002/(SICI)1097-0142(19990815)86:4<697::AID-CNCR20>3.0.CO;2-J. [DOI] [PubMed] [Google Scholar]
- 5.Schover LR, Brey K, Lichtin A, et al. Knowledge and experience regarding cancer, infertility, and sperm banking in younger male survivors. J Clin Oncol. 2002;20:1880–1889. doi: 10.1200/JCO.2002.07.175. [DOI] [PubMed] [Google Scholar]
- 6.Reinmuth S, Liebeskind AK, Wickmann L, et al. Having children after surviving cancer in childhood or adolescence - results of a Berlin survey. Klin Padiatr. 2008;220:159–165. doi: 10.1055/s-2008-1073143. [DOI] [PubMed] [Google Scholar]
- 7.Eisinger F, Noizet A. Breast cancer and pregnancy: decision making and the point of view of the mother. Bull Cancer. 2002;89:755–757. [PubMed] [Google Scholar]
- 8.Cvancarova M, Samuelsen SO, Magelssen H, et al. Reproduction rates after cancer treatment: experience from the Norwegian radium hospital. J Clin Oncol. 2009;27:334–343. doi: 10.1200/JCO.2007.15.3130. [DOI] [PubMed] [Google Scholar]
- 9.Madanat LM, Malila N, Dyba T, et al. Probability of parenthood after early onset cancer: A population-based study. Int J Cancer. 2008;123:2891–2898. doi: 10.1002/ijc.23842. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Magelssen H, Melve KK, Skjaerven R, et al. Parenthood probability and pregnancy outcome in patients with a cancer diagnosis during adolescence and young adulthood. Hum Reprod. 2008;23:178–186. doi: 10.1093/humrep/dem362. [DOI] [PubMed] [Google Scholar]
- 11.Le Corroller-Soriano AG, Malavolti L, Mermilliod C, et al. Les Conditions de vie des patients atteints du cancer deux ans après le diagnostic. DREES Etudes et Résultats. 2006;486:1–12. [Google Scholar]
- 12.Mancini J, Rey D, Preau M, et al. Infertility induced by cancer treatment: inappropriate or no information provided to majority of French survivors of cancer. Fertil Steril. 2007;90:1616–1625. doi: 10.1016/j.fertnstert.2007.08.064. [DOI] [PubMed] [Google Scholar]
- 13.Cayrou S, Dickes P, Gauvain-Piquard A, et al. The mental adjustment to cancer (MAC) scale: French replication and assessment of positive and negative adjustment dimensions. Psychooncology. 2003;12:8–23. doi: 10.1002/pon.634. [DOI] [PubMed] [Google Scholar]
- 14.Leplege A, Ecosse E, Verdier A, et al. The French SF-36 Health Survey: translation, cultural adaptation and preliminary psychometric evaluation. J Clin Epidemiol. 1998;51:1013–1023. doi: 10.1016/S0895-4356(98)00093-6. [DOI] [PubMed] [Google Scholar]
- 15.Heard I, Sitta R, Lert F. Reproductive choice in men and women living with HIV: evidence from a large representative sample of outpatients attending French hospitals (ANRS-EN12-VESPA Study) Aids. 2007;21 (Suppl 1):S77–82. doi: 10.1097/01.aids.0000255089.44297.6f. [DOI] [PubMed] [Google Scholar]
- 16.Ives A, Saunders C, Bulsara M, et al. Pregnancy after breast cancer: population based study. Bmj. 2007;334:194. doi: 10.1136/bmj.39035.667176.55. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Jeruss JS, Woodruff TK. Preservation of fertility in patients with cancer. N Engl J Med. 2009;360:902–911. doi: 10.1056/NEJMra0801454. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Fossa SD, Magelssen H, Melve K, et al. Parenthood in survivors after adulthood cancer and perinatal health in their offspring: a preliminary report. J Natl Cancer Inst Monogr. 2005:77–82. doi: 10.1093/jncimonographs/lgi019. [DOI] [PubMed] [Google Scholar]
- 19.Stobel-Richter Y, Beutel ME, Finck C, et al. The ‘wish to have a child’, childlessness and infertility in Germany. Hum Reprod. 2005;20:2850–2857. doi: 10.1093/humrep/dei121. [DOI] [PubMed] [Google Scholar]
- 20.Kravdal Ø. The impact of individual and aggregate unemployment on fertility in Norway. Demographic Research. 2002;6:263–294. doi: 10.4054/DemRes.2002.6.10. [DOI] [Google Scholar]
- 21.Felder-Puig R, Formann AK, Mildner A, et al. Quality of life and psychosocial adjustment of young patients after treatment of bone cancer. Cancer. 1998;83:69–75. doi: 10.1002/(SICI)1097-0142(19980701)83:1<69::AID-CNCR10>3.0.CO;2-A. [DOI] [PubMed] [Google Scholar]