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      Patterns of Referral for Fertility Preservation Among Female Adolescents and Young Adults with Breast Cancer: A Population-Based Study

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          Abstract

          Purpose: To assess the fertility preservation (FP) referral rates and patterns of newly diagnosed breast cancer in female adolescent and young adult (AYA) patients.

          Methods: Women aged 15–39 years with newly diagnosed breast cancer in Ontario from 2000 to 2017 were identified using the Ontario Cancer Registry. Exclusion criteria included prior sterilizing procedure, health insurance ineligibility, and prior infertility or cancer diagnosis. Women with a gynecology consult between cancer diagnosis and chemotherapy commencement with the billed infertility diagnostic code (ICD-9 628) were used as a surrogate for FP referral. The effect of age, parity, year of cancer diagnosis, staging, income, region, neighborhood marginalization, and rurality on referral status was investigated.

          Results: A total of 4452 patients aged 15–39 with newly diagnosed breast cancer met the inclusion criteria. Of these women, 178 (4.0%) were referred to a gynecologist with a billing code of infertility between cancer diagnosis and initiation of chemotherapy. Older patients, prior parity, and advanced disease were inversely correlated with referrals. Referral rates also varied regionally: patients treated in the south-east and south-west Local Health Integration Networks (LHINs) had the highest probability of referral, and patients covered by north LHINs had the lowest (central LHIN as reference). General surgeons accounted for 36.5% of all referrals, the highest percentage of all specialists. Referral rates significantly increased over time from 0.4% in 2000 to 10.7% in 2016.

          Conclusion: FP referral rates remain low and continue to be influenced by patient demographics and prognosis. These findings highlight the need for further interdisciplinary coordination in addressing the fertility concerns of AYA with newly diagnosed breast cancers.

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          Most cited references33

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          The effects of radiotherapy and chemotherapy on female reproduction.

          High dose chemotherapy and radiotherapy have radically increased long-term survival of young cancer patients, but major side effects of these treatments are ovarian failure and infertility. Knowledge of the risks and probabilities of ovarian failure caused by treatment is crucial for patients and physicians in order to make informed choices that will best serve patients' interests. This review presents data on ovarian damage and failure following exposure to radiotherapy, chemotherapy and ablative therapy. The risk is evaluated from the published literature according to patient's age, treatment protocol and also according to the diagnosis of some common malignancies. Many of these patients will not be sterilized immediately following treatment, but will suffer from premature menopause. In order to prevent sterilization, ovarian transposition before pelvic irradiation is mandatory. Besides cryopreservation of ovarian tissue and embryos before administration of chemotherapy, the possible protective effect of pituitary-ovarian down-regulation is discussed. The mechanism of primordial follicles damage induced by radio/chemotherapy is presented as well as the role of apoptosis signalling pathways underlying destruction. Increased knowledge of these mechanisms could help to identify potential effective inhibitors that can block the path of primordial follicles destruction and reduce ovarian failure rate.
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            Development of the Canadian Marginalization Index: a new tool for the study of inequality.

            Area-based measures of socio-economic status are increasingly used in population health research. Based on previous research and theory, the Canadian Marginalization Index (CAN-Marg) was created to reflect four dimensions of marginalization: residential instability, material deprivation, dependency and ethnic concentration. The objective of this paper was threefold: to describe CAN-Marg; to illustrate its stability across geographic area and time; and to describe its association with health and behavioural problems. CAN-Marg was created at the dissemination area (DA) and census tract level for census years 2001 and 2006, using factor analysis. Descriptions of 18 health and behavioural problems were selected using individual-level data from the Canadian Community Health Survey (CCHS) 3.1 and 2007/08. CAN-Marg quintiles created at the DA level (2006) were assigned to individual CCHS records. Multilevel logistic regression modeling was conducted to examine associations between marginalization and CCHS health and behavioural problems. The index demonstrated marked stability across time and geographic area. Each of the four dimensions showed strong and significant associations with the selected health and behavioural problems, and these associations differed depending on which of the dimensions of marginalization was examined. CAN-Marg is a census-based, empirically derived and theoretically informed tool designed to reflect a broader conceptualization of Canadian marginalization.
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              Physician referral for fertility preservation in oncology patients: a national study of practice behaviors.

              Cancer survival rates are improving, and the focus is moving toward quality survival. Fertility is a key aspect of quality of life for cancer patients of childbearing age. Although cancer treatment may impair fertility, some patients may benefit from referral to a specialist before treatment. However, the majority of studies examining patient recall of discussion and referral for fertility preservation (FP) show that less than half receive this information. This study examined the referral practices of oncologists in the United States. This study examined oncologists' referral practice patterns for FP among US physicians using the American Medical Association Physician Masterfile database. A 53-item survey was administered via mail and Internet to a stratified random sample of US physicians. Forty-seven percent of respondents routinely refer cancer patients of childbearing age to a reproductive endocrinologist. Referrals were more likely among female physicians (P = .004), those with favorable attitudes (P = .043), and those whose patients routinely ask about FP (odds ratio = 2.09; 95% CI, 1.31 to 3.33). Less than half of US physicians are following the guidelines from the American Society of Clinical Oncology, which suggest that all patients of childbearing age should be informed about FP.
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                Author and article information

                Journal
                J Adolesc Young Adult Oncol
                J Adolesc Young Adult Oncol
                jayao
                Journal of Adolescent and Young Adult Oncology
                Mary Ann Liebert, Inc., publishers (140 Huguenot Street, 3rd FloorNew Rochelle, NY 10801USA )
                2156-5333
                2156-535X
                01 April 2019
                05 April 2019
                05 April 2019
                : 8
                : 2
                : 197-204
                Affiliations
                [ 1 ]Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Queen's University, Kingston, Canada.
                [ 2 ]Division of Reproductive Endocrinology and Infertility, University of British Columbia, Vancouver, Canada.
                [ 3 ]Institute for Clinical Evaluative Sciences, Queen's University, Kingston, Canada.
                [ 4 ]Department of Family Medicine, Centre for Health Services and Policy Research, Queen's University, Institute for Clinical Evaluative Sciences, Kingston, Canada.
                [ 5 ]Department of Population, Family, and Reproductive Health, Bloomberg School of Public Health, Baltimore, Maryland.
                Author notes
                [*]Address correspondence to: Ann Korkidakis, MD, MPH, Division of Reproductive Endocrinology and Infertility, University of British Columbia, D402-4500 Oak Street, Vancouver, BC V6H 3N1, Canada a.korkidakis@ 123456alumni.ubc.ca
                [*]Maria P. Velez, MD, PhD, Department of Obstetrics and Gynecology, Queen's University, Kingston General Hospital, Victory 4, 76 Stuart Street, Kingston, ON K7L 2V7, Canada maria.velez@ 123456queensu.ca
                Article
                10.1089/jayao.2018.0102
                10.1089/jayao.2018.0102
                6479234
                30676852
                27e8d066-0793-43b4-8c37-5e6958aee07b
                © Ann Korkidakis et al. 2019; Published by Mary Ann Liebert, Inc.

                This Open Access article is distributed under the terms of the Creative Commons License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Page count
                Figures: 2, Tables: 4, References: 46, Pages: 8
                Categories
                Original Articles

                oncofertility,fertility preservation,breast cancer,premature ovarian insufficiency

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