CRNP Clearview Cancer Institute Huntsville, Alabama, United States
BACKGROUND Fertility preservation is a major concern of adolescents and young adults (AYAs, age 15-39) with cancer. Multiple professional organizations recommend guidelines for addressing fertility with prompt referral if indicated. However, a gap remains in practice to address the potential impact of gonadotoxic cancer treatment on fertility. Advanced practice providers (APPs), a software developer, and the quality director at a private, community oncology practice designed and led an initiative to improve fertility preservation concordant with National Comprehensive Cancer Network (NCCN) guidelines. APPs educated the multidisciplinary team on fertility preservation, created a standard practice to identify candidates, conduct needs assessments, counsel, educate and refer AYAs with cancer.
METHODS The project team met with a local reproductive endocrinologist to learn more about fertility preservation, time frames for patient care, and expedited referral processes for AYA patients. This meeting along with NCCN guidelines established the framework for identification, documentation, and referral process. To identify AYAs for fertility preservation discussion, an initial review of current new patient referral activities and data points was conducted by the project team. With assistance from the software developer, an automated report was created to identify patients based on age, oncology referral, and new patient appointment status. A weekly list was generated and stored on an internal SharePoint site for manual distribution to APPs by secure email. As a result of stakeholder feedback, this process has been refined to include automated report identification alongside secure email automation which notifies APPs daily, thereby reducing the likelihood of unidentified patients.
RESULTS From the eight-month pilot period, 133 AYAs were identified as eligible for fertility preservation discussions and/or referrals. During this time, 20 patients (15%) accepted referrals for fertility preservation consultation with a reproductive endocrinologist. These referrals represent at least a 150% increase in referrals when compared to the calendar years 2020 and 2021. In comparing average referrals per month, the pilot period revealed an increase of over 250%. Of the remaining identified patients, 18% declined referral and 67% were ineligible for referral due to factors such as diagnosis other than cancer, previously addressed fertility needs, or sterility. In addition, < 1% of eligible patients were placed on ovarian suppression protocol per provider discretion.
CONCLUSIONS An APP-driven fertility preservation initiative mitigated an unmet need in the AYA population in the community setting. APPs are uniquely positioned to minimize long term effects of cancer care in fertility for this underserved population. Through automated identification, APPs were able to facilitate counseling and referrals with over a two-fold increase during a pilot period.
RECOMMENDATIONS Implementing a fertility preservation program as the standard of care within community practice should be a mainstay of care among the AYA population to provide comprehensive, quality care. Inefficiencies identified during process development facilitated changes throughout the pilot. The inclusion of automated reports and notifications is integral in the success of patient identification to ensure prompt counseling and referral driven by the APPs.
