Insights from a single-site study on female adolescent and young adult oncofertility documentation

Cancer rates among adolescents and young adults (AYAs) have steadily increased. As survival improves, infertility risk from cancer treatment is a survivorship concern. Guidelines emphasize timely oncofertility counseling. However, clinical documentation remains inconsistent, limiting appropriate care coordination. This single-site study explored oncofertility documentation in the electronic medical record (EMR) for female AYAs at a single center in the United States.

We conducted a retrospective chart review of 30 females aged 18-39 (2018-2020) who desired or were unsure about fertility consultation. Data abstraction captured documentation of fertility preservation (FP) discussions, referrals, timing, provider type, and psychosocial care. Descriptive statistics summarized trends.

Participants averaged 29.7 years (range 20-39). Most were White (80%), 66.7% had no children at diagnosis, and 73.3% desired future children. Breast cancer was the most common diagnosis (20%). Treatments included surgery (53.3%), hormone therapy (30%), radiation (23.3%), and chemotherapy (20%). Over half (56.7%) had no documentation of an FP discussion. When present, oncologists documented 46.2% of discussions. Referrals to reproductive specialists appeared in 40% of charts, and psychosocial support in 46.7%. Documentation varied by provider and EMR location.

This single-site retrospective chart review identified variability in documentation of oncofertility discussions, referrals, and psychosocial care across providers and EMR locations. Larger, multi-site studies are needed to validate these findings and inform equitable documentation strategies.