To meet fertility-specific Quality Oncology Practice Initiative (QOPI) standards for young breast cancer patients, a novel EHR (electronic health record) template was incorporated into a new patient note form. A retrospective chart review identified 112 patients, 56 prior and 56 following template initiations. Documentation of fertility discussion was 7% (4/56) prior and 91% (51/56) following implementation. Fertility discussions improved from 40% (2/5) to 100% (4/4). The fertility preservation template improved breast cancer patient fertility discussion documentation. EHR fertility-specific templates could be implemented in other cancer populations as fertility preservation discussions improve the quality of life in cancer survivors.
 

• Breast cancer
• Fertility preservation
• Discussion
• Prompt

Hasija N, Hawamdeh R, Katragadda L, Schmit J, Daily K, et al. (2017) Utilization of the Electronic Health Record as a Novel Method to Improve Fertility Discussion and Documentation among Young Breast Cancer Patients. JSM Invitro Fertil 2(1): 1010.

FP: Fertility Preservation; ASCO: American Society of Clinical Oncology; FD: Fertility Discussions.

Numerous studies have documented the lack of communication about potential threats to fertility or options for FP between physicians and newly diagnosed cancer patients of childbearing age. The ASCO published fertility-specific guidelines, which were updated and reaffirmed in 2013 [1,2]. Oncologists and other providers have the task of discussing potential threats to fertility in patients of reproductive age resulting from various treatments at the earliest possible opportunity as part of the informed consent process. Documentation of FD has been suboptimal. In a recent study only 26% of women had documented FD in their medical record [3]. Another study in breast cancer patients under age 40, noted FD were documented in 55% of patients, with only 52% of patients recalling the discussion[4].

For young women with breast cancer, concerns about future reproductive health such as early menopause can have lingering effects well into survivorship [5]. Individuals with cancer have reported a need for information about fertility [6,7], with the importance of FD ranking second only to discussions about mortality for some patients [8]. Studies report fertility issues are particularly important to the 5-7% of breast cancer patients less than 40 years of age. However, in a web-based survey of fertility issues in 657 young breast cancer survivors, 57% recalled having substantial concern at diagnosis about becoming infertile after treatment[9].

There are many established and readily available methods for preservation of fertility, including embryo cryopreservation and oocyte cryopreservation. Ovarian tissue cryopreservation remains experimental at this time [1,2]. The utilization of these FP procedures requires recommendation and counseling by a health care provider, typically a reproductive endocrinologist. However, oncologists should also be knowledgeable of these options and make referrals to reproductive specialists when appropriate. Many strategies to improve patient access to FD and FP include the provision of written materials [10] and web-based decision aids [11,12]. Barriers that remain include the limited time or urgency to initiate cancer treatments, concerns about high estradiol levels related to ovarian stimulation, lack of financial resources and insurance coverage for procedures such as oocyte freezing, lack of perceived access to reproductive specialists, and a failure initiate a conversation concerning fertility and reproductive issues [13]. The ASCO QOPI guidelines measure two indicators: documentation of a discussion about the risk of infertility associated with chemotherapy in patients of reproductive age and discussion of FP options or referral to fertility specialists [13].

A retrospective chart review on QOPI measures in the care of breast cancer patients indicated that only 11% (0-20%) of charts documented FP. Menopausal status, another QOPI indicator, was only documented in 49% of cases [14]. The ASCO Survivorship Committee emphasizes the importance of longterm effects in cancer care. This is especially important in young breast cancer patients for whom reproductive and fertility can be long term issues [15]. There is evidence that not only is providers unaware of the ASCO FP guidelines, but they are reluctant to initiate conversations pertaining to fertility. A national survey of oncologists by Quinn et al found that fewer than 25% reported routinely referring patients for FP and only 38% reported knowledge of the ASCO guidelines [16]. Furthermore, recently published rates of documentation at four cancer centers among 231 patients ages 18 to 45 years with primary breast, leukemia/ lymphoma, sarcoma or testicular cancer diagnoses found that only 26% documented infertility risk, 24% documented the discussion of options of FP and 13% documented referrals to a fertility specialist [3]. Women with breast cancer, women in general, Hispanic/Latino patients, and those who already had children were provided with the least amount of information and had the fewest discussions about fertility options [5]. A recent study reported participation in QOPI correlated with improvement in measures of clinical performance, however, the quality measure of documentation of infertility risk and FP counseling still remained low[17].

Current evidence reveals a significant need to improve the documentation of discussions about FP between oncologists and their patients, especially in the vulnerable breast cancer population3 . Methods to enhance FP discussions among providers and cancer patients include educational seminars, online training modules, clinical prompting discussion tool, patient education brochures, and most effectively, use of a full time on-site clinical navigator [12,18-21]. Our institution has utilized all of these methods with limited success and lacks dedicated navigator funding so we sought a new method to enhance FP documentation and discussion. With mandated use of EHRs, we viewed this as an opportunity to consider a new and innovative method of promoting, ensuring, and documenting the FP discussion in breast cancer patients. Templates allow customization of questions and mandate answers prior to chart closure. We hypothesized that creating a fertility-specific template in the EHR including pertinent questions would serve as a prompt to discussions about FP and also would increase the documentation among patients with newly diagnosed breast cancer.

The study was IRB approved. In this pilot study, we selected a sample patient population of new breast cancer patients in the outpatient medical oncology clinic from June 2014 to April 2015. All female breast cancer patients were included. As standard protocol, all new patient encounters were documented using a standardized new breast cancer patient template. Based on the ASCO 2013 guidelines, we selected questions to identify patients who would most benefit from FP discussions, specifically those of reproductive age undergoing therapies which may adversely affect future fertility. Questions were designed to prompt a subsequent referral to reproductive endocrinology. In November 2014, we implemented a “Fertility Counseling” section into the established consult note template in EPIC EHR®. The following questions were added: (1) Is this patient 13 to 44 years old? (2) Is this patient being considered for chemotherapy, brain radiation and/or pelvic radiation? (3) If the answers to #1 and #2 were yes, was the risk of infertility and fertility preservation discussed, and if no, then document reason why; and (4) Was a referral made to reproductive endocrinology and infertility specialists?

A retrospective chart review was performed of patients’ medical records to include age, race, number of children, diagnosis, and treatments discussed. Each medical record was reviewed and relevant data regarding fertility was extracted for each patient. We evaluated whether the new template was used and recorded any comments. Comparisons between the pre- and post-template groups were made for the primary outcome of documentation of FP. Subset analysis compared groups according to demographic data including number of children and race. Data were summarized using descriptive statistics. The two sample test of proportions was conducted to analyze the difference in fertility discussion in the target population before and after the template, with the significance level set at p< 0.05.

A total of 112 patient charts were reviewed. 56 patients were seen prior to the template initiation in November 2014 and 56 were seen following template initiation. Patient characteristics are listed in Table (1). Only 9 of 112 patients (8%) were in the reproductive age range of 13 to 44 years old. Target population characteristics are listed in Table (2). The majority of patients were Caucasian (83%). There was no significant difference in template initiation based on patients having prior children. The template was used in 51 of 56 patients in the post-template initiation group (91%). Documentation of FP discussion prior to template initiation was 7% (4 of 56). After implementation, documentation rates of the total population improved to 91%. Among the target population, fertility discussion improved from 40% (2 of 5) to 100% (4 of 4) with a trend towards significance with p=0.0578.

The QOPI guidelines and the ASCO Clinical Oncology Breast Cancer Survivorship Care Guidelines emphasize the importance of fertility and reproductive health documentation and discussion for optimal care [14]. Integration of a FP counseling section into an established EHR template was a successful new method to ensure the documentation of FP discussions in young breast cancer patients. At institutions with broad-based EHR’s, the template within the oncology record allowed assurance that FD occurred, documentation was present regarding the discussion, and there was an option of immediate referral to a reproductive specialist. As the onus of discussion and documentation is most frequently on the medical oncologist, the use of this template has the potential to improve documentation and prompt discussions of this important topic. Attempts using many other methods including web-based materials, written information, clinical prompting discussion tools, and an onsite navigator [10-12,19-21], have been made to improve the discussion and documentation. EHR fertility-specific templates offers a unique opportunity to implement in any cancer population, a fertility preservation and discussion prompt to improve quality of cancer care and survivorship.

According to verbal feedback, providers were able to answer questions without difficulty and found the template easy to use. One problem encountered was initial reluctance by a limited number of providers to answering the questions, as this would increase documentation requirements in an already busy outpatient medical oncology practice. We suspect an additional source of hesitancy may be providers were not comfortable with the diverse options for FP, as was seen previously in the Quinn 2007 [22] study. Our template resolves this potential barrier while still fulfilling the spirit of the ASCO and QOPI guidelines by not requiring detailed discussion outside the usual knowledge base and scope of practice of a medical oncologist. Physicians need only inform patients there is a risk to future fertility, there are options to increase the chance that fertility is preserved, and offer a referral to a reproductive endocrinologist.

Retrospective evidence has shown that whether patients were fearful of infertility in nulliparous state, multiparous state or even if ambivalent about their future reproductive needs, each group benefitted from FD[16]. Our template may remind a provider to initiate this discussion or consult a reproductive endocrinologist in the busy clinic setting. As Klapper highlighted, in order to meet national standards, a streamlined process is needed to enable FD in clinic [3]. Given the overall positive feedback and significant results of our study, the changes to our institution template were left in place. Based in our results, our institutional lymphoma and gynecologic oncology groups have added this additional fertility section into their respective oncology templates.

There were limitations to the study. First, we had a very small sample size, especially of our target population. We found that the population of interest represented only a small minority (8%) of the total women seen for new breast cancer consultations during our study time period. Restricting the FP template to only target age women would address the concern regarding increased documentation effort and time requirements. Second, we implemented this template in a cancer type with a higher postmenopausal population. The patient population of other cancer types specifically lymphoma, sarcomas and testicular cancers would include more of our target population. However, we felt it was important to test the accuracy and utility of the template in a group which had sufficient new patient visits in a shorter interval. We plan on conducting a follow up study in the future using the template, powered to show a difference in a larger target population.

The impact of breast cancer and related treatments on fertility was being inadequately addressed in this group of patients at our institution. The use of the template easily improved the discussion of this important aspect of quality oncology care as documentation is instantaneous and referrals are automatic. We propose that in addition to the template, focused education for providers regarding the options and updates in FP is vital to the open comprehensive patient education. Ideally, a multidisciplinary team including psychosocial providers along with certified reproductive specialists would allow optimal care of reproductive age patients by addressing specific risks, rates of success, and issues of cost and timeliness of interventions, which can be a source of great emotional and financial distress for vulnerable patients. The most reliable method to ensure patients get this information seems to be a FP navigator, but not all programs have the funding and institutional support for that program[21].

As EHRs are now a national standard, this FP template can be easily incorporated into multiple provider clinical practices so this discussion becomes a routine component of cancer care for any new oncology patient. All reproductive age cancer patients deserve having a fertility discussion, a well-established method to improve patient satisfaction with their cancer care and survivorship [23-25]. Offering the highest quality breast cancer care includes a discussion about fertility preservation, and our template increases adherence to QOPI measures and ASCO guidelines.

Table 1: All Patients.

Table 2: Target Population.

1. Lee SJ, Schover LR, Partridge AH, Pasquale Patrizio, Wallace WH, Karen Hagerty, et al. American Society of Clinical Oncology recommendations on fertility preservation in cancer patients. J ClinOncol. 2006; 24: 1-15.

2. Loren AW, Mangu PB, Beck LB, Brennan L, Magdalinski AJ, Partridge AH, et al. Fertility preservation for patients with cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. J ClinOncol. 2013; 31: 2500-2510.

3. Quinn GP, Block RG, Clayman ML, Joanne Kelvin, Arvey SR, Ji-Hyun Lee, et al. If you did not document it, it did not happen: rates of documentation of discussion of infertility risk in adolescent and young adult oncology patients’ medical records. J OncolPract. 2015; 11: 137- 144.

4. Banerjee R, Tsiapali E. Occurrence and recall rates of fertility discussions with young breast cancer patients. Support Care Center. 2016; 24: 163-171.

5. Hill KA, Nadler T, Mandel R, Burlein-Hall S, Librach C, Glass K, et al. Experience of Young Women Diagnosed With Breast Cancer Who Undergo Fertility Preservation Consultation. Clinical Breast Cancer. 2012; 12: 127-132.

6. Tschudin S, Bitzer J. Psychological aspects of fertility preservation in men and women affected by cancer and other life-threatening diseases. Human Reproduction Update. 2009; 15: 587-597.

7. Dryden A, Ussher J, Perz J. Young women’s construction of their post-cancer fertility. Psychology and Health. 2014; 29: 1341-1360.

8. Loscalzo MJ, Clark KL. The psychosocial context of cancer-related infertility. Cancer Treatment and Research. 2007; 138: 180-190.

9. Partridge AH, Gelber S, Peppercorn J, Sampson E, Knudsen K, Laufer M, et al. Web-based survey of fertility issues in young women with breast cancer. J ClinOncol. 2004; 22: 4174-4183.

10. Garvelink MM, TerKuile MM, Louwe LA, Hilders CG, Stiggelbout AMA. Delphi consensus study among patients and clinicians in the Netherlands on the procedure of informing breast cancer patients about fertility preservation. ActaOncol. 2012; 51: 1062-1069.

11. Peate M, Meiser B, Cheah BC, Saunders C, Butow P, Thewes B, et al. Making hard choices easier: a prospective, multicenter study to assess the efficacy of a fertility-related decision aid in young women with early-stage breast cancer. Br Cancer. 2012; 106: 1053-1061.

12. Gonçalves V, Quinn GP. Review of fertility preservation issues for young women with breast cancer. Human Fertility. 2016; 19: 152-165.

13. Neuss MN, Desch CE, McNiff KK, Eisenberg PD, Gesme DH, Jacobson JO, et al. A process for measuring the quality of cancer care. The Quality Oncology Practice Initiative. J ClinOncol. 2005; 23: 6233-6239.

14. Gray JE, Laronga C, Siegel EM, Lee JH, Fulp WJ, Fletcher M, et al. Degree of Variability in Performance on Breast Cancer Quality Indicators: Findings from the Florida Initiative for Quality Cancer Care. Am SocClinOncol. 2011; 7: 247-251.

15. Runowicz CD, Leach CR, Henry NL, Henry KS, Mackey HT, CowensAlvarado RL, et al. American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline. J ClinOncol. 2016; 34: 611-635.

16. Quinn G, Vadaparampil ST, Jacobsen P, Lee J, Lancaster J, Bepler G, et al. National survey of physicians practice patterns: Fertility preservation and cancer patients. J ClinOncol. 2009; 27: 485.

17. Neuss MN, Malin JL, Chan S, Kadlubek PJ, Adams JL, Jacobson JO, et al. Measuring the improving quality of outpatient care in medical oncology practices in the United States. J ClinOncol. 2013; 31: 1471- 1477.

18. Forman EJ, Anders CK, Behera MA. Pilot survey of Oncologists regarding treatment-related infertility and fertility preservation in female cancer patients. J Reprod Med. 2009; 54: 203-207.

19. Murphy D, Knapp CA, Sawczyn KK, Vadaparampil ST, Rhoton-Vlasak A, Quinn GP. Lessons Learned: Feasibility of a Discussion Priming Tool to Increase Fertility Risk Discussion Among Adolescent Oncology Families. The Qualitative Report. 2016; 21: 16-25.

20. Quinn GP, Vadaparampil T, Gwede CK, Reinecke JD, Mason TM, Silva S. Developing a referral system for fertility preservation among patients with newly diagnosed cancer. 2011; 9: 1219-1225.

21. Srikanthan A, Amir E, Warner E. Does a dedicated program for young breast cancer patients affect the likelihood of fertility preservation discussion and referral? The Breast. 2016; 27: 22-26.

22. Quinn GP, Vadaparampil T, Gwede CK, Miree C, King LM, Clayton HB, et al. Discussion of fertility preservation with newly diagnosed patients: Oncologists’ views. J Cancer Surviv. 2007; 1: 146-155.

23. Shah MS, Letourneau JM, Niemasik EE, Bleil M, McCulloch C. The Role of In-depth Reproductive Health Counseling in Addressing Reproductive Health Concerns in Female Survivors of Non-gynecologic Cancers. J PsychosocOncol. 2016; 34: 305-317.

24. Deshpande NA, Braun IM, Meyer FL. Impact of fertility preservation counseling and treatment on psychological outcomes among women with cancer: A systematic review. Cancer. 2015; 121: 3938-3847.

25. Baysal Ö, Bastings L, Beerendonk CC, Postma SA, IntHout J, Verhaak CM, et al. Decision-making in female fertility preservation is balancing the expected burden of fertility preservation treatment and the wish to conceive. Hum Reprod. 2015; 30: 1625-1634.