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Reply: Comment on ‘Fertility preservation in cancer survivors: a national survey of oncologists’ current knowledge, practice and attitudes’ – Oncologists must not allow personal attitudes to influence discussions on fertility preservation for cancer survivors

Sir,

We are pleased that our research has provoked debate in this important area. We would like to thank Young et al (2013) for their positive and constructive comments on our work, and take this opportunity to respond to some of the points they raise in their letter. Young et al (2013) question our finding that 97% of oncologists ‘discuss fertility issues with their patients’ and contrast this with their own work which demonstrates unmet patient information needs, especially in the area of fertility and sexuality.

In relation to our own findings, the disparity can be understood in a number of ways. First, our sample of oncologists is self-selected, and may have higher than average interest in fertility issues (and therefore, willingness to discuss these as part of their clinical practice) as evidenced by their participation in our survey. Second, the finding pertains to self-report rather than actual clinical behaviours that we did not measure, i.e., rather than 97% of oncologists discussing these issues, 97% of oncologists reported that they are discussing these issues. Third, even if 97% of these oncologists said they would discuss fertility with patients, it is difficult to know if that means that fertility is discussed with all appropriate patients. Too often it seems that distress or seeming lack of interest from the patients is interpreted as a reason not to discuss these difficult issues. It would be useful to conduct studies into the actual clinical practice and communication of oncologists. However, it is important to bear in mind here the inherent difficulty in capturing adequately the content of highly emotionally charged two-way conversations. Research on communication in this area has repeatedly pointed to the fact that the information that was actually imparted may be very different from the perceptions of what was said and heard (Fischer and Ereaut, 2012). The important learning point here may then not only be to ask oncologists to discuss fertility in more detail, but also to provide oncologists with further training in communication skills to allow them to navigate the patients’ cognitive processing bias at this emotionally charged time.

In this context, we welcome Young et al’s discussion of holistic needs assessments (HNAs) and how they can facilitate information sharing. We also agree that clinical judgment about patient’s needs should not be clouded by personal assumptions. However, while HNAs and other care planning tools may aid information sharing, it may not only be the content of information sharing but also the process which needs further attention. Bracketing off one’s own assumptions and personal values is difficult and requires time and practice. It is worth pointing out that allowing clinicians the time and space to reflect upon their decision making and ways in which their own assumptions guide their approach to patients may be equally valuable, and lead to more compassionate care (Bar-Sela et al, 2012; Goodrich, 2012).

Finally, we fully support Young et al’s call to include discussions about fertility, early menopause and sexuality in the whole trajectory of cancer care. In order for this to realistically be possible alongside all the other important medical and contextual issues to be discussed, we need to allow health-care professionals a reflective space in which they can think about their own pressures and anxieties about discussing these difficult topics, be it time pressures, fear of emotional overload or worry that they cannot come up with feasible solutions.

We would agree with Young et al (2013) that timely information is crucial. We would also agree that Macmillan Cancer Care provides some of the most up-to-date, comprehensive and sensitively written cancer information available in the United Kingdom and would also wish to encourage oncologists and nurse specialists to share these materials with their patients. However, we feel that attention to those factors facilitating good communication are equally important. We ought to turn our attention to improving clinical communication, we owe it to patients and health-care professionals alike.

References

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Correspondence to E Adams.

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Adams, E., Hill, E. & Watson, E. Reply: Comment on ‘Fertility preservation in cancer survivors: a national survey of oncologists’ current knowledge, practice and attitudes’ – Oncologists must not allow personal attitudes to influence discussions on fertility preservation for cancer survivors. Br J Cancer 109, 2021–2022 (2013). https://doi.org/10.1038/bjc.2013.460

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