A Geospatial Analysis of Disparities in Access to Oncofertility Services

Abstract

ImportanceFertility preservation (FP), including oocyte and embryo cryopreservation prior to gonadotoxic therapy, is an urgent and essential component of comprehensive cancer care. Geographic proximity to a center offering FP is a critical component of ensuring equitable access for people with cancer desiring future fertility.ObjectiveTo characterize the distribution of centers offering FP services in the US, quantify the number of self-identified reproductive-age female individuals living outside of geographically accessible areas, and investigate the association between geographic access and state FP mandates.Design, Setting, and ParticipantsThis cross-sectional analysis calculated 2-hour travel time isochrone maps for each center based on latitude and longitude coordinates. Population-based geospatial analysis in the US was used in this study. Fertility clinics identified through the 2018 Centers for Disease Control and Prevention Fertility Clinic Success Rates Report were defined as oncofertility centers by meeting 4 criteria: (1) offered oocyte and embryo cryopreservation, (2) performed at least 1 FP cycle in 2018, (3) served people without partners, and (4) had an accredited laboratory. County-level data were obtained from the 2020 US Census, with the primary at-risk population identified as reproductive-age female individuals aged 15 years to 44 years. The analysis was performed from 2021 to 2022.ExposuresLocation outside of 2-hour travel time isochrone of an oncofertility center.Main Outcomes and MeasuresOncofertility centers were compared with centers not meeting criteria and were classified by US region, state FP mandate status, number of assisted reproductive technology cycles performed, and number of FP cycles performed. The number and percentage of at-risk patients, defined as those living outside of accessible service areas by state, were identified.ResultsAmong 456 Centers for Disease Control and Prevention–reporting fertility clinics, 86 (18.9%) did not meet the criteria as an oncofertility center. A total of 3.63 million (5.70%) reproductive-age female individuals lack geographic access to an oncofertility center. States with FP mandates have the highest rates of eligible female patients with geographic access (98.54%), while states without active or pending legislation have the lowest rates (79.57%). The greatest disparities in geographic access to care are most concentrated in the Mountain West and West North Central regions.Conclusions and RelevancePatients face numerous barriers to comprehensive cancer care, including a lack of geographic access to centers capable of offering FP services. This cross-sectional study identified disparities in geographic access and potential opportunities for strategic expansion.

Patient Location and Disparities in Access to Fertility Preservation for Women With Gynecologic or Breast Cancer

“…Prior studies have demonstrated geographic disparities in cancer care and access to ART. [23][24][25] A recent study by Peipert et al 26 used geospatial modeling to assess the distribution of oncofertility centers in the United States and found that 3.63 million reproductive-aged females lack access to oncofertility services and that states with fertility-preservation mandates have the highest rates of eligible female patients with geographic access. Our study supports and builds on this prior research by being the first to evaluate geospatial predictors of fertility-sparing treatment in addition to ART use and using health indices to predict the use of fertility-sparing treatment or ART.…”

“…Additionally, legislation for state-mandated fertility preservation appears to be another means of decreasing geographic disparities. 26 Telemedicine has also demonstrated its potential to bridge geographical gaps and provide remote access to specialized care as well as reduce wait times to see specialists and may have benefits in both rural and urban settings. 29 Finally, the relative weights of the California Healthy Places Index domains provide additional insight into the types of interventions that may be most effective.…”

Fertility concerns and treatment decision‐making among national sample of young women with breast cancer

“…Since then, access and options to fertility preservation have evolved favorably in the U.S., including the emergence of state‐based fertility preservation insurance mandates 36 . However, a significant number of barriers to accessing oncofertility care remain, including lack of financial or geographic access, 37 lack of information and referral, and personal fear or uncertainty regarding fertility presentation. While we were unable to evaluate specific reasons for non‐utilization in our analysis, we believe that medical insurance coverage and cost of the procedures were factors that may have discouraged patients from pursuing these procedures, as demonstrated in prior studies 38 .…”

The Status of Fertility Preservation (FP) Insurance Mandates and Their Impact on Utilization and Access to Care

“…Of note, FP insurance mandates may have the potential to reduce disparities in geographic access to oncofertility care. Peipert et al demonstrated that patients in states with FP legislation had higher geographic access to oncofertility centers compared to states without FP legislation, as defined by the percentage of patients within a 2 h travel time to a center [38]. Although research is needed to elucidate the contributing factors underlying this association, the authors posit that FP insurance mandates could create an economic incentive for an increase in oncofertility centers.…”