女性癌症患者常未被告知生育力受损风险

波士顿——据国际生殖学会联盟（IFFS）与美国生殖医学会（ASRM）联合会议上报告的一项研究，对1,282名各类癌症的女性生存者的调查显示，只有不足半数被确诊为癌症的育龄女性与其医生讨论癌症疗法（化疗或放疗）对生育能力的潜在影响，而被转诊至生育专家者更是少之又少。

在这项研究中，亚特兰大市埃默里大学罗林斯公共卫生学院的助理教授Penelope P. Howards博士及其同事检索了乔治亚州癌症登记处的资料，识别并采访了于20~35岁时初次确诊为癌症的女性。采访的问题包括受访者的生育史、是否与医生讨论过癌症疗法会如何影响其生育能力、以及是否收到过向生育学专家转诊的通知。研究队列由在1990~2009年间被确诊的女患者构成，女性得到生育能力方面建议的几率因癌症类型和常规疗法而异。例如，70%的宫颈癌女患者称会与医生讨论生育能力问题，而常规通过手术处置的癌症（例如黑色素瘤和甲状腺癌）患者被告知生育能力可能受损的几率最低。只有60%的子宫癌患者和42%的卵巢癌患者被告知治疗对生育能力的影响，尽管她们患的是生殖系统的癌症。在研究中最常见的癌症类型——乳腺癌女患者中，仅有44%的患者称得到生育能力忠告。在确诊时至少已有一个子女的女性被告知的几率低于没有子女的女性（分别为42%和50%），20~24岁之间的女性被告知生育能力可能受损的几率低于30多岁的女性。据Howards博士推测，肿瘤科医生可能认为年轻癌症患者恢复生育机能的时间比临近更年期的女性长，故需要忠告的几率较低，另外，他们可能观察到因癌症治疗而停经的年轻女性最终可能恢复行经，因此错误地认为恢复行经意味着整个生殖系统完全恢复健康。在报告称进行过生育能力讨论的女性中，有33%的人说讨论由其本人发起，44%的人说讨论由其肿瘤科医生提出，23%的人说由其他人发起。

能显著预测女性被告知不孕不育问题的几率较低的因素包括：在确诊时已生育子女（校正后比值比[aOR]为1.7）；在确诊时较年轻（aOR为1.5）；为非裔美国人（与白种人相比，aOR为1.2）；不接受化疗或放疗（aOR为3.1）。在那些进行过生育能力讨论的女性当中，仅有6%的有子女女性及19%的无子女女性被转诊到生育专家。未参与此项研究的研究者田纳西州查塔努加市厄兰格卫生系统的泌尿科医生AnandShridharani称这一问题并不仅限于女性，据其观察，对于确诊为癌症的男性，在采用放疗、化疗或手术等可能影响其生育能力状况的疗法之前，进行有关生育能力的讨论者并不多见。

此研究收到了尤尼斯·肯尼迪·施莱佛美国国家儿童健康与人类发育研究所提供的资助。Howards博士和Shridharani博士报告称无相关披露。

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By: NEIL OSTERWEIL, Internal Medicine News Digital Network

BOSTON – Less than half of all women of child-bearing age who are diagnosed with cancer discuss with their physicians the potential effects of cancer therapy on fertility, and even fewer are referred to reproductive specialists, investigators reported at the conjoint meeting of the International Federation of Fertility Societies and the American Society for Reproductive Medicine.

A survey of 1,282 female survivors of various cancers showed that more than 50% did not have a discussion with their oncologists about the possible deleterious effects of chemotherapy or radiation on fertility, and few patients received referrals to reproductive specialists, said Penelope P. Howards, Ph.D., assistant professor of epidemiology at Emory University’s Rollins School of Public Health in Atlanta.

"In our cohort, which was women who were diagnosed between 1990 and 2009, a large proportion is not getting the message about how treatments may affect their fertility," Dr. Howards said in an interview.

The likelihood that women would have been counseled about fertility varied by the type of cancer and by the typical treatment approach. For example, nearly 70% of women with cervical cancer said they had talked about fertility with their physicians, whereas women with cancers more typically managed by surgery – such as melanoma and thyroid cancer – were the least likely to be informed about potentially compromised fertility.

Only 60% of women with uterine cancers and 42% of women with ovarian cancers were told about the effects of treatment on fertility, despite having cancers of the reproductive system. Among women with breast cancer, the most common cancer type represented in the study, only 44% said they received fertility counseling.

Women who had at least one child by the time of diagnosis were less likely to be counseled than were women with no children (42% vs. 50%, respectively), and women aged 20-24 years were less likely to be informed about potentially compromised fertility than were women in their 30s, the investigators found.

Dr. Howards speculated that oncologists may assume that younger cancer patients are less likely to need counseling because they have a longer time to recover reproductive function than women who are approaching the age of menopause. Additionally, they may observe that young women who are rendered amenorrheic by cancer treatment may eventually resume menses, and wrongly assume that a return to menstruation indicates a return to full reproductive health.

Of those women who reported having a fertility discussion, 33% said they had initiated it themselves, 44% said that their oncologists had brought it up, and 23% said someone else initiated the discussion.

Dr. Howards and her colleagues searched the Georgia Cancer Registry to identify and interview women with a first diagnosis of cancer between the ages of 20 and 35 years. The interviews included questions about their reproductive histories, whether they had discussed with a clinician how cancer therapies might affect their fertility, and whether they had received a referral to a fertility specialist.

Factors that significantly predicted which women would be less likely to be counseled about infertility included having a child at diagnosis (adjusted odds ratio, 1.7), younger age at diagnosis (aOR, 1.5), being African American vs. white (aOR, 1.2), and not receiving chemotherapy or radiation (aOR, 3.1).

Of those women who did have a fertility discussion, only 6% of those with a child and 19% of those without children were referred to a fertility specialist.

An investigator who was not involved in the study said that the problem is not limited to women.

"With regard to men who get a diagnosis of cancer, we have seen that the discussion about their fertility status is not often had prior to getting a therapy that would affect their fertility status, such as chemotherapy, radiotherapy, or surgery," said Dr. AnandShridharani, a urologist at the Erlanger Health System in Chattanooga, Tenn.

The study was supported by a grant from the Eunice Kennedy Shriver National Institute for Child Health and Development. Dr. Howards and Dr. Shridharani reported having no relevant disclosures.