Purpose: Oncofertility care at cancer diagnosis remains under-implemented across oncology and fertility care settings, with limited tools to scale up effective implementation strategies. Using implementation science theory, we systematically assessed factors that influence oncofertility care implementation and map scalable strategies, particularly electronic health record (EHR)-enabled ones, that fit adult and pediatric oncology care contexts.Methods: Using purposeful sampling, we recruited healthcare providers and female, reproductiveaged survivors of adolescent and young adult cancers (AYA survivors) from a comprehensive cancer center and a freestanding children's hospital to semi-structured interviews and focus groups. Using thematic analysis combining inductive codes with deductive codes using the Consolidated Framework for Implementation Research (CFIR), we characterized barriers and facilitators to care and designed responsive strategies. Two coders independently coded each transcript.Results: We recruited 19 oncology and fertility providers and 9 cancer survivors. We identified barriers and facilitators to oncofertility care in the CFIR domains of individual, inner setting, outer setting, and process, allowing us to conceptualize oncofertility care to encompass three core components (screening, referral, and fertility preservation counseling) and map five strategies to these components that fit an adult and a children's context and bridge oncology and fertility practices. The strategies were screening using a best practice advisory, referral order, telehealth fertility counseling, provider audit and feedback, and provider education. All but provider education were EHR tools with embedded efficiencies.Conclusions: An implementation science approach systematically assessed oncofertility care and mapped strategies to provide a theory-based approach and scalable EHR tools to support wider dissemination.
Background: Durable palliation of advanced lung cancer is a common objective for radiation oncologists.However, there is no consensus on how to deliver the radiation course. Herein we report our experience of using split course radiotherapy and our assessment of outcomes based on planning from three-dimensional (3D) simulation before each treatment course.Methods: All lung cancer patients from 2006-2020 were identified. Of these, 52 patients received a split course treatment of 50-60 Gy in 18-25 fractions intended to provide durable palliation for disease not amenable to curative therapy. Treatment involved 3D planning with repeat computed tomography (CT) simulation prior to the second course. Survival and symptomatic response were analyzed via chart review. We categorized rapid responders versus non-rapid responders from the initial radiation course based on ≥30% gross tumor volume (GTV) reduction at the second CT simulation. We evaluated the impact of response on overall survival and palliative response.Results: Among our cohort treated with split course palliative radiotherapy, 33 (63%) had a rapid response to initial treatment. There was no difference in survival between groups [hazard ratio (HR) =1.30, P=0.47].There was no significant difference in palliative response rates between rapid and non-rapid responders.On multivariable analysis, only female sex (HR =0.26, P<0.01) and receipt of systemic therapy following radiotherapy (HR =0.19, P<0.01) were associated with improved survival.Conclusions: There is currently significant practice pattern variability for palliative lung radiotherapy.Split course palliative radiation of 50-60 Gy in 18-25 fractions represents an option to consider for patients with advanced lung cancer who do not undergo definitive therapy and may benefit from a higher dose regimen. Our retrospective review suggests that rapid tumor response in a split course model does not predict survival or symptomatic response. Prospective studies are needed to further define which lung cancer patients may benefit from higher dose regimens.
MATERIALS AND METHODS: TNB adolescents and their cisgender siblings participated in a one-time, one-on-one semi-structured interview and survey. Interview data was coded to develop themes that then guided analysis of the survey data. To assess the fertility attitudes of TNB and their cisgender siblings, a modified version of the Transgender Youth Fertility Attitudes Questionnaire (TYFAQ) was utilized. Possible answers to the TYFAQ survey included ''agree,'' ''maybe,'' or ''disagree.'' Outcomes were treated as ordinal and associations were analyzed using the Mann-Whitney U test.RESULTS: A total of 40 participants were included in the analysis (29 TNB adolescents, 11 cisgender siblings). Four major themes were noted when comparing the two groups: 1) the role of gender identity and gender dysphoria 2) desire for future economic and social stability 3) perceived personal reproductive potential 4) future partner's gamete compatibility. TNB adolescents were more likely to say they would consider adoption someday (93% vs 54%, p ¼ .0068). Cisgender adolescents were more likely than TNB adolescents to say it is important to have biological children (65.5% vs 27%, p ¼ 0.05). Cisgender boys were more likely to feel pressured by their family to have biological children than their transmasculine TNB peers (20% vs 0%, ¼ 0.04). In comparing heterosexual adolescents to those who identify as lesbian, gay, bisexual, or queer (LGBQ), heterosexual adolescents were more likely to say it is important to have biological children in the future (77% vs 18%, p¼0.0023). Among TNB adolescents, those currently using gender-affirming hormones were less likely to think their feelings about children might change in the future (p ¼ 0.029). TNB adolescents with a prior diagnosis of gender dysphoria were more likely to say they wanted to have kids someday (71% vs 37%, p ¼ 0.003) and less likely to say their family would be sad if they did not have biological children (0% vs 25%, p ¼ 0.03). TNB adolescents who endorsed parental support were more likely to say it is not important to have biological children in the future (72% vs 25%, p ¼ 0.05), and those that that do not participate in a support group were more likely to say their parents would be disappointed if they did not have biological children (25% vs 0%, p ¼ 0.003).CONCLUSIONS: Sexual orientation and gender identity are important factors to consider when assessing an adolescent's desire for future family building. TGN youth, on average, express lower desires for biological children when compared to their cisgender siblings, which is influenced by their experience with dysphoria and perception of community support. These factors should be considered when counseling adolescents on their future fertility and family building options.
Purpose: Oncofertility care for pediatric, adolescent, and young adult cancer patients remains under-implemented across adult and pediatric oncology settings. We pilot tested an electronic health record (EHR)-enabled multi-component oncofertility intervention (including screening, referral, and fertility consult) in an adult academic oncology program and systematically assessed intervention fit to pediatric and community oncology programs. Methods: Using surveys (n=33), audits (n=143), and interviews (n=21) guided by implementation science frameworks, we pilot tested the EHR-enabled intervention for oncofertility care in young cancer patients at an adult oncology program and evaluated implementation outcomes. We interviewed healthcare providers from seven regional oncology and fertility programs about intervention fit to their clinical contexts. Results: We recruited 33 healthcare providers from an adult oncology setting and 15 healthcare providers from seven additional oncology and fertility settings. At the adult oncology setting, the intervention was found to be appropriate, acceptable, and feasible and improved the screening of fertility needs (from 30% pre- to 51% post-intervention), yet some patients did not receive appropriate referrals to fertility consults. Providers across all settings suggested content and context modifications, such as adding options to the intervention or allowing the screening component to pop up at a second visit, to improve and adapt the intervention to better fit their clinical care contexts. Conclusions: We found that the EHR-enabled intervention increased the rate of goal-concordant oncofertility care delivery at an adult oncology program. We also identified facilitators, barriers, and needed adaptations to the intervention required for implementation and scaling up across diverse oncology settings.
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