While cancer death rates have declined substantially in recent years, this progress is being overshadowed by a rising and unexplained incidence of cancer in individuals younger than 50 years, especially women.1 Approximately 89,000 adolescents and young adults (AYAs) aged 15 to 39 years are diagnosed with cancer each year in the United States, representing about 5% of all new cancer diagnoses.2,3
As curative treatments continue to improve outcomes for AYAs, attention is increasingly turning to survivorship issues—chief among them, preserving fertility. However, the likelihood of infertility is not uniform.4-9 A useful framework categorizes infertility risk factors into 3 domains: patient-related, treatment-related, and emerging or uncertain risks (Figure 1).6
Evidence from the literature has shown that the psychological impact of potential infertility weighs heavily on all reproductive-age cancer survivors, with knock-on effects on treatment decisions and long-term quality of life.4,5,10,11 These burdens are further intensified by inequities in access to fertility preservation (FP) services, which disproportionately affect patients of color and those with limited socioeconomic resources.4-9
Despite known infertility risks from curative cancer treatments and the fact that more than 80% of young cancer patients want children in the future, fertility counseling before treatment remains inconsistent.12,13 Moreover, discussion rates were not consistently associated with whether fertility-sparing treatment was ultimately used.13 This shortfall profoundly impacts patients wishing to retain the option to have a family.
Within this gap, patient navigation has emerged as a critical intervention. Navigators span a wide spectrum—from licensed clinical professionals to trained nonclinically trained professionals—each addressing barriers across the cancer continuum.
Navigators span a wide spectrum— from licensed clinical professionals to trained nonclinically trained professionals—each addressing barriers across the cancer continuum.
Here, we focus on the clinical patient navigator (PN): a licensed healthcare professional—typically, a registered nurse, nurse practitioner (NP), or licensed clinical social worker—with oncology-specific expertise.5,12,14,15 But FP involves ethically complex decisions that require coordination across specialties, navigation of evolving technologies, and interpretation of insurance and legal frameworks—tasks that exceed the scope of most generalist roles.6,9,15
Moreover, AYA patients face disproportionately high unmet needs in this domain, including inconsistent counseling and limited access to FP services.2,9,13
This is where a clinical PN, the oncofertility patient navigator (OPN), can advocate for reproductive health, guiding patients from diagnosis through FP decisions. Though not yet formally codified, OPNs play a vital role in bridging oncology and reproductive care.12,14-16
Evidence from a 14-year retrospective study at a single academic center supports that even in settings where a full-time OPN is not feasible, training an existing clinician to assume this role—partially or in tandem with other responsibilities—can significantly improve access to FP services and streamline care coordination.14
Importantly, emerging models of care increasingly leverage telehealth to expand access to reproductive counseling and FP services, particularly in underserved or resource-limited settings. For example, the Telehealth Oncofertility Care intervention demonstrated improved delivery of fertility care to pediatric, adolescent, and young adult cancer survivors through a stepped-wedge randomized trial.17 In addition, decision-support tools developed by the Oncofertility Consortium and international models of care underscore the value of integrating virtual platforms to support timely, patient-centered fertility discussions.18,19
For the distinct needs of AYAs with cancer (15-39 years, and possibly into early 40s), FP represents a unique and time-sensitive challenge. Unlike older adults, AYAs are at the nascent stage of family planning, and lifesaving treatment poses a risk to their future reproductive potential. The necessity of expedited cancer treatment also creates a narrow time window, sometimes days, for FP intervention.6 The urgency is compounded by the vulnerability of developing reproductive systems to cancer treatment, underscoring why prompt counseling and access to oncofertility care is vital to mitigating the long-term impact of cancer care on having children.6,9
Yet, many AYA cancer patients are unaware that FP is even an option, highlighting a critical gap in communication and education at the time of diagnosis.2 When FP is not feasible before treatment, some patients—particularly those who strongly desire having biological children—may opt for less gonadotoxic treatment regimens when clinically appropriate. These decisions, made in collaboration with their medical team, reflect the deeply personal and psychosocial dimensions of fertility and family building that are integral to comprehensive cancer care for AYAs.20
However, the ability to make such informed decisions is often hindered by a range of individual and systemic barriers. On a personal level, AYA patients may feel emotionally overwhelmed and face financial concerns, lack of time before treatment initiation, limited knowledge about FP, uncertainty about future parenthood, or simply not knowing who to talk to about fertility concerns.13,21
These individual challenges are further compounded by systemic issues—such as fragmented care delivery, inconsistent training among healthcare providers, and poor integration between oncology and reproductive health services.13,21 In many clinical settings, there is no standardized pathway for initiating FP discussions or referrals, leaving patients without timely or adequate guidance. As a result, opportunities for FP may be missed entirely, or patients may be left to navigate complex decisions without the support they need.
This flies in the face of established and updated guidelines from major organizations, including the American Society for Reproductive Medicine and ASCO, emphasizing the need for evaluating and counseling patients about reproductive risks at diagnosis and during survivorship. Many patients still do not receive adequate information or referrals from any healthcare professional for FP.6,8,21,22
Per key FP guidelines, counseling should be an ongoing, patient-centered dialogue that begins at diagnosis and continues throughout treatment and survivorship. It should not be treated as a one-time intervention.6,8,17 Patients who are interested in or uncertain about FP should be referred to reproductive specialists as early as possible, ideally before the initiation of cancer-directed therapy.6
For individuals assigned male at birth who have reached puberty, sperm cryopreservation should be offered as the first-line FP method (Figure 2).6 If ejaculation is not possible, testicular sperm extraction is an established alternative.6 Testicular tissue cryopreservation remains investigational for prepubertal males and should only be offered under institutional review board–approved clinical trial protocols.6,8 Patients should be informed that sperm collected shortly after the start or completion of cancer therapy may carry a higher risk of genetic damage, compared with waiting 6 to 12 months posttreatment.8 Those interested in or unsure about FP should be referred to a fertility specialist, such as a reproductive endocrinologist and infertility (REI) expert.6,8
For individuals assigned female at birth who have reached puberty, established FP options include embryo and oocyte cryopreservation, ovarian tissue cryopreservation, ovarian transposition, and conservative gynecologic surgery (Figure 2).6 In vitro maturation of oocytes is an emerging method that may be considered in select cases.6 FP after treatment may be cautiously considered in survivors who did not preserve gametes beforehand or who require additional material to meet family-building goals, but only if ovarian reserve is adequate and after thorough counseling about uncertain outcomes and potential risks.6,8
Gonadotropin-releasing hormone agonists are considered experimental for FP due to inconsistent efficacy. They should not replace established methods but may be offered as adjunctive therapy for individuals with breast cancer or those with no other approved FP options, particularly when urgent treatment precludes other interventions.6,8
The primary function of the OPN is to serve as an educator, liaison, and patient advocate. This individual collaborates with members of an interprofessional team to help children and AYA cancer survivors understand FP challenges and options. The OPN educates patients and families on the impact of cancer treatments on fertility, consultation expectations, preservation timelines, associated costs, and available support services.22,23
Such discussions must be framed within the context of what the patient and their family already know. OPNs also assess the health literacy levels of patients and families to guide education and discussions in a patient-centered, accessible manner (Figure 3).15 The OPN then explains the FP process, outlines what to expect, and presents available options. The goal is for patients and families to feel informed and empowered to proceed in whatever manner they choose and feel is appropriate at that point in time.21
To address informational and decisional barriers, OPNs provide tailored, evidence-based resources, such as those developed by the Oncofertility Consortium and published in the Journal of Oncology Navigation & Survivorship.18,23 These include:
Despite the importance of FP counseling, it may not always be feasible to conduct in-depth sessions with all patients of reproductive potential. For example, pediatric patients with hematologic malignancies often require immediate treatment, leaving little time for FP interventions. Research suggests that in-depth FP counseling may be more appropriate after initial diagnosis, but before relapse, in high-risk patients.5,27
Expanding patient navigation programs across healthcare systems is not merely an enhancement—it is a clinical imperative. FP remains a critical yet inconsistently addressed component of cancer care, particularly for AYA patients. Despite clear professional guidelines, many patients still face systemic barriers, including fragmented care, provider knowledge gaps, financial constraints, and implicit biases, that disproportionately affect patients of color, those with lower socioeconomic status, and individuals in rural or underserved areas.
Within this landscape, clinical PNs play a pivotal role in bridging gaps in care. A specialized subset of these professionals, the OPN, focuses specifically on guiding patients through the complex, time-sensitive, and emotionally charged decisions surrounding FP. OPNs serve as educators, advocates, and care coordinators, ensuring that patients receive timely, equitable, and informed support.
While cancer diagnoses are typically made in hospital or oncology settings, family practice clinical NPs also fulfill critical roles across the care continuum. They often serve as the first point of contact in community-based settings and maintain long-term relationships with patients during survivorship. NPs are well-positioned to reinforce or revisit fertility discussions that may have been rushed or overlooked during the acute diagnostic phase. They can assess reproductive health, refer to fertility specialists, and support family-building goals posttreatment. In rural or underserved areas, NPs can also serve as first-line educators and advocates, especially when also trained as OPNs.
As emphasized by the Academy of Oncology Nurse & Patient Navigators, successful navigation programs are built on institutional commitment, interprofessional collaboration, and a deep understanding of patient needs. NPs or other healthcare professionals trained as OPNs can lead these efforts—streamlining care coordination, addressing disparities, and advocating for policy change.
Ultimately, integrating oncofertility navigation into standard oncology care is not just about improving outcomes—it is about restoring agency and hope. By empowering patients with knowledge, dismantling systemic barriers, and ensuring access to FP, OPNs—especially those led by family practice clinical NPs—safeguard the future of young cancer survivors. Their work affirms that survivorship includes not only life after cancer, but also the possibility of life beyond it.
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