Reports From the Field

Fertility and Fertility Preservation: Scripts to Support Oncology Nurses in Discussions with Adolescent and Young Adult Patients


 

References

From the Moffitt Cancer Center, Tampa, FL (Dr. Vadaparampil, Ms. Bowman, Ms. Sehovic, Dr. Quinn), Memorial Sloan Kettering Cancer Center, New York, NY (Ms. Kelvin), and Edward Via College of Osteopathic Medicine, Auburn, AL (Ms. Murphy).

Abstract

  • Objective: To describe a script-based approach to assist oncology nurses in fertility discussions with their adolescent and young adult (AYA) patients.
  • Methods: Scripts were developed by a team that included experts in fertility and reproductive health, health education, health communication, and clinical care of AYA patients. Individual scripts for females, males, and survivors were created and accompanied by a flyer and frequently asked questions sheet. The script and supplementary materials were then vetted by oncology nurses who participated in the Educating Nurses about Reproductive Health Issues in Cancer Healthcare (ENRICH) training program.
  • Results: The scripts were rated as helpful and socially appropriate with minor concerns noted about awkward wording and medical jargon.
  • Conclusion: The updated scripts provide one approach for nurses to become more adept at discussing the topic of infertility and FP with AYA oncology patients and survivors.

In the United States, over 70,000 adolescents and young adults (AYAs) are diagnosed with cancer each year [1,2]. Treatments are available that are associated with improved survival for these cancers. Unfortunately, cancer treatment may significantly impact AYA survivors’ future fertility. Infertility or premature ovarian failure can occur during or after cancer treatment (eg, chemotherapy, radiation) for females, and males may be temporarily or permanently azoospermic [3]. There are a number of established methods of fertility preservation (FP) that are available; these include oocyte and embryo cryopreservation and ovarian transposition for females and sperm banking for males [3]. Experimental options for males include testicular tissue freezing and for females ovarian tissue cryopreservation.

The American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network [4,5] recommend discussing FP with patients of reproductive age, ideally before initiation of treatment. In 2013, ASCO updated guidelines extending the responsibility for discussion and referral for FP beyond the medical oncologist to explicitly include other physician specialties, nurses, and allied health care professionals in the oncology care setting [3]. However, multiple publications, including patient surveys and interviews, physician surveys, and medical record abstraction studies suggest these discussions do not consistently take place. In an analysis of 156 practice groups submitting data as part of ASCO's Quality Oncology Practice Initiative, only ~15%–20% of practices routinely discussed infertility risks and FP options [6]. A recent review of medical charts of patients aged 18–45 treated in 2011 at 1 of 4 large U.S. cancer care institutions found that documentation of discussions for infertility risk was 26%, 24% for FP option discussion, and 13% for fertility specialist referral [7].

Oncology nurses play a key role in patients’ care and, compared to other health care providers, are more likely to have multiple interactions with patients prior to the initiation of treatment [8]. They are often attuned to the medical and psychosocial needs of the patient and family and can advocate for their needs and desires [9]. However, existing research finds few oncology nurses discuss this topic with AYA patients. Studies examining barriers have identified factors that may hinder discussions about infertility and FP with AYA oncology patients. These barriers include lack of knowledge about cancer related infertility and available FP procedures; access to reproductive endocrinologists or sperm banking clinics; time constraints in busy clinics and concerns about delaying treatment; discomforts discussing reproductive health; patient’s ability to afford FP; bias about the suitability of FP for young or unpartnered or LGBT patients or those with a poor prognosis; and personal religious or moral values about the use of assisted reproductive technologies [10–15].

Equipping nurses with content-specific communication may overcome some of the barriers described. A method often used in nursing education and communication interventions is scripting [16–18]. Scripting provides precise key words that ensure consistency in the message, no matter the messenger [19]. This paper reports on the development and refinement of a series of scripts to guide discussions about FP for male and female AYA patients and survivors.

Script Development

In 2003 Studer developed the AIDET (Acknowledge, Introduce, Duration, Explanation, and Thank you) model of communication for health professionals [19]. AIDET is an effective tool in facilitating communication practices among nurses and physicians in adult and pediatric settings [20–24]. The AIDET model was adapted by our team to develop AIDED: Assess, Introduce, Decide, Explain, and Discuss, a script-based approach to assist oncology nurses in fertility discussions with their AYA patients. Our team included experts in fertility and reproductive health, health education, health communication, as well as clinical and psychosocial care of AYA patients.

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