This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.
As cancer treatments continue to improve, it is increasingly important that women of reproductive age have an opportunity to decide whether they want to undergo fertility preservation treatments to try to protect their ability to have a child after cancer. Clinical practice guidelines recommend that providers offer fertility counseling to all young women with cancer; however, as few as 12% of women recall discussing fertility preservation. The long-term goal of this program is to develop an interactive web-based patient decision aid to improve awareness, access, knowledge, and decision making for all young women with cancer. The International Patient Decision Aid Standards collaboration recommends a formal decision-making needs assessment to inform and guide the design of understandable, meaningful, and usable patient decision aid interventions.
This study aims to assess providers’ and survivors’ fertility preservation decision-making experiences, unmet needs, and initial design preferences to inform the development of a web-based patient decision aid.
Semistructured interviews and an ad hoc focus group assessed current decision-making experiences, unmet needs, and recommendations for a patient decision aid. Two researchers coded and analyzed the transcripts using NVivo (QSR International). A stakeholder advisory panel guided the study and interpretation of results.
A total of 51 participants participated in 46 interviews (18 providers and 28 survivors) and 1 ad hoc focus group (7 survivors). The primary themes included the importance of fertility decisions for survivorship, the existence of significant but potentially modifiable barriers to optimal decision making, and a strong support for developing a carefully designed patient decision aid website. Providers reported needing an intervention that could quickly raise awareness and facilitate timely referrals. Survivors reported needing understandable information and help with managing uncertainty, costs, and pressures. Design recommendations included providing tailored information (eg, by age and cancer type), optional interactive features, and multimedia delivery at multiple time points, preferably outside the consultation.
Decision making about fertility preservation is an important step in providing high-quality comprehensive cancer care and a priority for many survivors’ optimal quality of life. Decision support interventions are needed to address gaps in care and help women quickly navigate toward an informed, values-congruent decision. Survivors and providers support developing a patient decision aid website to make information directly available to women outside of the consultation and to provide self-tailored content according to women’s clinical characteristics and their information-seeking and deliberative styles.
With cancer survival rates exceeding 75% for young adults, it is increasingly important to minimize the negative effects of treatment, such as infertility, to protect survivors’ long-term quality of life. Infertility ranks fifth on the World Health Organization’s list of serious disabilities, and multiple studies show that cancer-related infertility causes distress and regret that persist long term, even in survivors with otherwise positive mental health status [
Several previous studies have explored barriers to fertility preservation discussions, referrals, and treatment [
Patient decision aids are tools that complement clinical consultations by providing up-to-date, plain language descriptions of the options as well as theory- and evidence-based approaches to help patients engage in decision making [
In Australia [
As a key step in the systematic development of a patient decision aid, the International Patient Decision Aid Standards (IPDAS) Collaboration recommends a formal assessment of all stakeholders’ decision-making needs and perspectives to ensure that the decision aid will be effective, meaningful, usable, and sustainable [
Following the Decisional Needs Assessment approach [
The Ottawa Decision Support Framework (
The Ottawa Decision Support Framework.
To address the specific aims, this study used semistructured cognitive interviews and an ad hoc semistructured focus group.
The International Patient Decision Aid Standards Collaboration model for systematic development of a patient decision aid.
The principal investigator (TLW) purposefully invited oncology providers at the institution representing a variety of professional roles (surgeons, advance practice providers, etc), clinical expertise, experience, and sociodemographic characteristics. To recruit survivors, the research team distributed flyers in the waiting areas and lobbies throughout the MD Anderson Cancer Center and community clinics and invited survivors in person after their appointments at the Oncofertility Clinic. Over the past 10 years, the racial and ethnic distribution of survivors seen at the Oncofertility Clinic included 65% White, 11.6% Black, 10.5% Asian, 5.7% other, and 22.5% Hispanic individuals (7.2% declined to respond). Eligible survivors included English-speaking 18- to 45-year-old females diagnosed with cancer within the previous 5 years who received a potentially fertility-damaging treatment (eg, chemotherapy, radiation, or surgery on a reproductive organ). In the context of this sensitive survivorship topic, it is important to note that
Following the Decisional Needs Assessment Workbook [
While analyzing the cognitive interview transcripts, the research team observed that participants had introduced ideas that merited further exploration, including a variety of factors that drove their decisions (ie, their
Interviews were coded and analyzed using the coding process by Strauss and Corbin [
Interview findings were summarized using an initial word frequency analysis, followed by keywords in context analysis to identify primary themes and subthemes. There were not sufficient distributions for subgroup analyses; however, exemplary quotes were purposively selected across age and parity subgroups. The research team also compared and contrasted interview transcripts to identify potential missing items or misconceptions that could be addressed in a patient decision aid. As the focus group was conducted to clarify specific points and obtain initial reactions to existing materials, the transcript was analyzed descriptively and the results were summarized in terms of notable points and recommendations that could inform the future design and user testing studies. All findings and interpretations were shared with the stakeholder advisory panel to confirm meaningful interpretations.
All 51 individuals who were recruited in person agreed to participate, including 18 oncology providers and 33 female cancer survivors. None of the women responded solely to public flyers. Interview recruitment continued until data saturation (n=46, including 18 providers and 28 survivors). The follow-up focus group reengaged 2 survivors from the interviews and 5 additional survivors (n=7).
Providers’ characteristics (n=18).
Characteristic | Value | ||
|
|||
|
Medical oncology | 1 (6) | |
|
Surgical oncology | 1 (6) | |
|
Radiation oncology | 4 (22) | |
|
Pediatric oncology | 2 (11) | |
|
Gynecological oncology | 3 (17) | |
|
Lymphoma or myeloma | 3 (17) | |
|
Leukemia | 2 (11) | |
|
Stem cell transplant | 2 (11) | |
Years in practice, median (range) | 9 (3-18) | ||
Female, n (%) | 13 (72) | ||
|
|||
|
White | 8 (45) | |
|
Black | 2 (11) | |
|
Asian | 6 (33) | |
|
Other | 2 (11) | |
Ethnicity (Hispanic), n (%) | 2 (11) | ||
|
|||
|
Attending physician | 13 (72) | |
|
Advanced practice provider | 5 (28) |
Survivors’ characteristics (n=33).
Characteristic | Value | ||
|
|||
|
Breast | 11 (33) | |
|
Ovarian, cervical, or vaginal | 5 (15) | |
|
Lymphoma or leukemia | 14 (42) | |
|
Other | 3 (9) | |
Age (years), median (range) | 32 (20-45) | ||
Years since diagnosis, mean (range) | 2.1 (0-5) | ||
Female, n (%) | 33 (100) | ||
|
|||
|
White | 25 (76) | |
|
Black | 4 (12) | |
|
Asian | 3 (9) | |
|
Other | 1 (3) | |
Ethnicity (Hispanic), n (%) | 5 (15) | ||
|
|||
|
Some college | 7 (21) | |
|
Associate degree | 4 (12) | |
|
Bachelor’s degree | 15 (46) | |
|
Master’s degree | 6 (18) | |
|
Professional degree | 1 (3) | |
|
|||
|
Single | 10 (30) | |
|
In a relationship | 14 (42) | |
|
Married | 7 (21) | |
|
Divorced | 1 (3) | |
|
Other | 1 (3) | |
Nulliparous at diagnosis, n (%) | 30 (90) | ||
Completed fertility preservation therapy, n (%) | 18 (55) |
Interviews and the focus group lasted 1 hour each and were conducted in private rooms at the cancer center. Across all participants, 3 primary themes emerged: (1) fertility preservation decisions are important for survivorship, (2) significant but potentially modifiable barriers to decision making exist, and (3) support exists for a carefully designed fertility preservation patient decision aid. Within the primary themes, 10 subthemes emerged from the 74 unique codes. The following sections describe providers’ and survivors’ comments by subtheme and provide exemplary quotes.
All participants emphasized the importance of fertility decisions, both for cancer treatment and for long-term survivorship. A total of 3 subthemes were identified (
“It is really about [having] that conversation. I’ve learned from survivors, that they are: ‘I didn’t know, nobody told me. I have this question mark. I feel like this is cancer all over again.’ It is incertitude that is really...the most burdensome.” (Provider 17, leukemia nurse practitioner)
“...if this is going to be a long-term cure, we need to look at the whole picture and stop just treating the one aspect of their life. Empowering patients themselves to ask about their risk of infertility I think is really important.” (Provider 4, gynecological oncologist)
“It was just so amazing to know that I still had a shred of hope. The past few weeks with chemo have been hard, but knowing that I have something in the future to look forward to gets me through it. I’m not sure it would have been this easy if I didn’t have that embryo, because I feel like, ‘What’s the point, it is not like I can have kids.’ That embryo is just the icing on the cake. It made everything so much easier.” (Survivor 1, 22 years old, White, in a relationship)
“We thought that there was no chance for us anymore. Then they gave us this information today about possible IVF...even if we are not overly concerned about getting pregnant, it is nice to know we still have that option.” (Survivor 28, 33 years old, Hispanic, single)
“They need...a decision aid that says, ‘[Protecting your fertility] is an option. These are all the different options that you have. You can choose to say No. You can choose all these different routes.’” (Provider 16, breast medical oncologist)
“I did see [the fertility specialist], and she told me there were all these other options...Just hearing the options made me feel better. I never heard options from anyone until I came here.” (Survivor 25, 22 years old, White, in a relationship)
“For me, [a key recommendation] is ‘make sure you know all your options.’ To me the worst decision we can make is not fully understanding what all of our options are at the time.” (Survivor 6, 35 years old, White, single)
“Even that person who is, OK, well, no. I’ll just take my chances, and I’m not talking to anybody - I guess my fear is that they don’t really understand what I’m saying or what they have been told, that this will probably affect their ability to have children in the future.” (Provider 3, gynecological oncologist)
“[I recommend fertility preservation counseling] even if you are not totally certain where your life is going at the moment. I would say, while you have those resources and options available...because you may feel very differently in 5 years. I know, for me, I didn’t want kids 5 years ago and now I am kind of open to the possibility.” (Survivor 2, 32 years old, White, single)
“I was in a relationship, but I kept postponing things, thinking, ‘35 and then I’ll start thinking about kids.’ But it is one of those things that you are not 100% sure if you can plan it.” (Survivor, 37 years old, White, single)
All participants also reported that decision-making barriers still exist, and 4 subthemes emerged (
“Those are questions that are really best for...the reproductive [endocrinologist].” (Provider 7, radiation oncologist)
“[I am] reasonably satisfied [with my fertility preservation knowledge]. I’m not an expert in that area...I provide some general counseling [and tell patients], ‘I certainly can’t deliver [personalized risks and rates of fertility preservation outcomes], but I’m pretty sure that [the reproductive endocrinologist] can.’” (Provider 16, breast medical oncologist)
“The thing is, they didn’t tell me anything about it [chemotherapy affecting infertility], so I couldn’t say yes or no. Now I’m learning about all of this, that chemotherapy can affect it.” (Survivor 32, 23 years old, Black, in a relationship)
“I had no idea. They didn’t tell me when I was diagnosed that this might cause problems having kids. Nobody told me that. It is still new to me. They didn’t tell me until a couple of months ago. That is why I am doing everything I can. I have been wanting kids since I was 9...always, always, always.” (Survivor 19, 21 years old, White, single)
“[Patients] come in on Monday, have tests on Tuesday and Wednesday, and by Friday we are starting treatment. There are times when you have to start that same day.” (Provider 10, gynecological oncologist)
“...to go from chemo directly to fertility within that one hour is too much. So if there was...online resources [for fertility preservation education], that would help.” (Provider 16, breast medical oncologist)
“I would say generally, less than 5 minutes. That would be my usual conversation.” (Provider 1, medical oncologist)
“It was incredibly frustrating, because...there is not a direct path to get them a referral...your ovarian reserve declines, but we don’t really have a mechanism to actually test that routinely in patients and counsel patients with their true fertility potential.” (Provider 1, medical oncologist)
“...you have cancer, and that’s hard enough. But then to be told that you have to make a decision right now, because we can’t delay it...[The doctor] says I can’t even think about it one night.” (Survivor 30, 33 years old, White, married)
“The barriers would probably be insurance. That is maybe number one; that is 100%.” (Provider 8, radiation oncologist)
“Payment is a barrier for women but I think the ones that really want to pursue it, we find options for them.” (Provider 5, nurse practitioner)
“...what I have been researching really has been around funding,...the cost factor, because I know that this is something that I want to do. However, [the cost] is my roadblock.” (Survivor 3, 39 years old, Black, single)
“I was going to go through with the egg preservation...but then, like I said, once I saw the prices and everything, I was, as much as I want to do this, I think I have to accept if for what it is right now. And later on get over that when it comes...” (Survivor 25, 23 years old, Black, in a relationship)
“I have over time learned...not to stereotype and pitch the whole thing based on ethnicity and religion...just say that these are personal decisions based on your own morals and religion, your previous experience, and your family’s experience.” (Provider 15, gynecological oncologist)
“I guess more than anything, being mindful that there is not one cookie cutter approach, that every situation is so different.” (Provider 1, medical oncologist)
Most providers also discussed awareness, time, and cost barriers to decision making and added the need for additional education about the ASCO guidelines, updated risks of newer procedures, and the time or processes needed for fertility preservation. Many providers also discussed the need for information tailored to cancer type but viewed their role as introducing the topic and facilitating referrals to a reproductive endocrinologist for personalized decision counseling. A majority of providers expressed a need for practical support to identify appropriate women and facilitate the process (eg, navigating timely referrals and planning for the future). Notably, all oncologists reported feeling comfortable introducing treatment-related infertility; however, a few providers who expressed higher levels of knowledge and comfort also reported discussing decisions with patients more often and in greater detail.
Over half of the providers discussed the relevance of patients’ demographic characteristics (particularly age, culture, spiritual beliefs, and potential resources) for introducing the topic appropriately; however, they cautioned against making assumptions, noting that many women or families make unique decisions and find additional resources (eg, family contributions and fundraising). Seven providers brought up scenarios in which they initially felt it might be okay not to offer a fertility preservation decision aid (eg, noncurative treatment plan, single women, older age, multiple children already, low socioeconomic status, and religion). However, they quickly provided examples of exceptions (eg, a family who wants to freeze their dying daughters’ eggs or embryos and remarried mothers who strongly want more children) and emphasized offering information equally yet compassionately to all women.
All participants supported the use of a fertility preservation patient decision aid, provided it was carefully designed to overcome the barriers. Three subthemes arose in their recommendations: provide tailorable content, use appropriate and inclusive language, and design multiple delivery formats and routes (
“The 18- to 22-year-olds may be different than the 30 year-old because the parents are going to be watching more. Split it up between minors and non-minors.” (Provider 16, breast medical oncologist)
“[Tailor by] solid versus liquid tumor, because that would be different.” (Provider 1, medical oncologist)
“It would be really cool if you [could] put in a patient’s age, history, results,...then it brings up their algorithm, including the known statistics about a given cancer and what their outcomes potentially are. That would help the patient and the provider.” (Provider 3, gynecological oncologist)
“I like details. I am going to click on that and get every detail possible. I’m like that. I think to grab someone’s attention, something general, but then when you click on it, a bunch of details on that one topic.” (Survivor 2, 21 years old, White, single)
“I think they [patient stories] are helpful, because it shows that other people have gone through the same thing and how they came to their decisions.” (Survivor 33, 24 years old, White, in a relationship)
“Some countries like Qatar, have reproductive medicine and it is not a big deal (shipping international can be a barrier), but for Kuwait, Saudi Arabia, UAE, etc, it may be a big issue. Sometimes women cannot get married if they are infertile.” (Provider 6, pediatric nurse practitioner)
“...particularly Orthodox Jewish populations and having families is very important to them. While they don’t talk about sex overtly, they are very interested in finding way to preserve fertility because that is so important to their religion. If they have concerns, it typically goes through the Rabbi.” (Provider 10, gynecologic oncologist)
“...with Arabic women, many of them are virgins, so doing a transvaginal ultrasound or a transvaginal procedure becomes an issue. I had one patient that declined because she wouldn’t do that.” (Provider 15, gynecological oncologist)
“We only found one company [that]...was open to same sex adoptions.” (Survivor 10, 31 years old, White, in a relationship)
“[New patients] need to hear it two or three different ways because they are not processing a lot in those first three visits (other than chemo and surgery).” (Provider 1, medical oncologist)
“It could be part of the nursing intake (Are they 45 or under? Make sure you give them the fertility information to watch). I would involve nurses and midlevels.” (Provider 16, breast medical oncologist)
“We have different education backgrounds, so sometimes people can interpret a flowchart better than others, and people might relate better to the story of this person that went through it.” (Provider 17, nurse practitioner)
“The nurses have that way of going, ‘What else is going on?’ I think that is the perfect time to say, ‘OK, you may not be thinking about it, but these are some of the things that you may want to consider and ask.’” (Provider 1, medical oncologist)
“The simplest thing would be if there was one piece of paper that I could just hand them and say, ‘You can go to this website and explore this decision aid, and we can discuss it next time.’ And offer periodic [group] discussions.” (Provider 9, radiation oncologist)
“I use the [institution] website for a lot, so it is handy that it has the mobile application, and the desktop. Although they look a little bit different, they are pretty much the same. For simplicity, it is nice to have it optimized for the mobile device.” (Survivor 30, 33 years old, White, married)
“To be honest, probably because of my age, no. I don’t like those stupid movies...I think it has to do with the fact that I have grown up and been taught to be a strong independent woman. I don’t feel like I need to lean on those types of things.” (Survivor 11, 22 years old, White, in a relationship)
Survivors’ recommendations focused on the content and ability to select the level of information and support needed. Their recommendations varied from brief introductory overviews (leaving the majority of the information for the fertility consultation) to detailed comparison charts and suggestions for addressing uncertainty, managing emotions, and navigating the financial process. The majority of survivors recommended having a way to select only their relevant options to minimize information overload. They also requested implicit decision guidance (eg, examples and testimonials about decision making) and inclusion of multiple lifestyles, cultures, and beliefs.
Providers recommended a tool that presented options tailored to clinical factors, such as age and cancer type. They also recommended providing explicit decision-making activities (eg, value clarification exercises and preference elicitation) to assist in identifying who may benefit from a referral for fertility counseling. Several providers mentioned the need for low health literacy and culturally appropriate language, and many providers cited examples of the importance of virginity and fertility in many cultures.
The majority of recommendations in both groups focused on delivery. Both survivors and providers recommended offering a patient-facing decision aid at multiple time points using multiple media, with an emphasis on viewing outside the consultation. Suggestions included providing an initial handout, booklet, or email at the first and/or second visit after diagnosis that contained a URL link to an institutionally supported website, viewable on a computer, tablet, or phone. Survivors also suggested having a nurse or a peer volunteer personally recommend the decision aid to emphasize the importance of fertility and distinguish it among the many handouts received at diagnosis. Both groups supported offering a website to allow women to view it when optimal. Notably, providers recommended web delivery to address diagnostic consultation time limitations and to enable patients to self-refer to a fertility specialist. Survivors recommended web delivery to address information overload and coping barriers. A few survivors also mentioned wanting to revisit the information after cancer treatment.
In addition to the primary themes, a few individuals raised the following four points, which the stakeholder panel recommended reporting to inform decision counseling. One provider noted the importance of clearly discussing alternative family-building options, including acknowledging the potential challenges for cancer survivors considering surrogacy or adoption. Two survivors recommended including testimonials from women at various stages of cancer treatment and survivorship. Two others mentioned addressing their partners’ preferences and support. A pediatric oncologist noted the communication barriers for young adults and their parents and suggested a pediatric version of a patient decision aid that offers tangible support:
[Tell patients:] We will help [you] talk to your mom. There are resources...our social worker may be able to help. We will talk to the oncologist.
Participants in the ad hoc focus group confirmed and clarified the findings of the individual interviews and deepened explanations. There was unanimous agreement that fertility should be explained as early as possible. Survivors particularly commented on needing time to make the transition from initial awareness and comprehension to delving into the potential costs, insurance processes, ethical considerations, and future decisions. A few women reiterated needing to acknowledge that the "new normal" may include uncertainty when making decisions.
Women related several examples of feeling rushed, unaware, or pressured, which led to unanswered questions and unspoken preferences, with continued feelings of regret and sadness. Several mentioned feelings of reliving the trauma as survivors and "not being able to own that decision." Several comments were made regarding the need to include fertility preservation in their financial planning and acknowledging resources other than insurance, such as foundations, family contributions, and social fundraising.
During the review of the cancer center’s patient information handouts, existing decision aid materials from other countries [
Focus group participants also brought up additional topics that they thought should be included in decision support materials, such as how to be your own personal champion, resolve family conflict or pressure, engage your partner in this decision, and have someone come with you to take notes and raise questions:
I kind of grieved it when I was first diagnosed with cancer, and for 7 years, kind of held my breath. [My husband] came into my life, and there was a real sad time after about a year of marriage where I was having to face it again.
I was told [that I had cancer] on a Wednesday, by Thursday I was getting my port, and Friday and Saturday I started my treatment. All I was thinking at that time was, “Okay, do what you need to do.” So my sister was there and she said, “Wait, wait, hold on, we have to discuss this. There are other options.”
My mom and my boyfriend at the time were just, “We want you to be okay.” But I wanted to have my own baby...one doctor kind of yelled at me, “You need to just survive it!” I said, “If I survive, I want to be able to have babies!”
Overall, providers and survivors emphasized the importance of fertility preservation decision making for high-quality comprehensive cancer care. Both groups acknowledged existing barriers, such as awareness, time, and costs, and proposed potential solutions. All participants strongly supported offering women a website so that they could review the material at home. They recommended providing a lay language overview, interactive features to self-tailor (eg, by cancer type), guidance in decision making about seeking or accepting a fertility referral, and links to facilitate referrals and access financing programs. They noted the value of a patient decision aid for engaging women in the initial decision and the potential for this engagement and empowerment to improve hope during the treatment process and decrease downstream regret.
These results confirm the results of previous studies regarding the multilevel challenges to providing high-quality fertility preservation counseling [
This study adds to the literature user-generated design recommendations, such as providing understandable medical information; explicitly addressing uncertainty; and helping personalize the information by providing estimates of costs, descriptions of the treatment or recovery processes, values clarification exercises, and example stories modeling decision making [
Notably, providers and survivors expressed a need for clear cost information. Providers stated that they rarely discussed costs, whereas survivors stated that costs played a significant role in their decision—either they assumed their insurance would not cover the treatments or the fertility counseling or they could not locate cost information in time to make an informed decision. The pressure to make these decisions with incomplete cost information may be forcing women to forego fertility counseling and fertility preservation treatments they need and desire. This suboptimal decision process may, in turn, compound long-term decisional regret because of a sense of unnecessary loss [
Consistent with the distributions of survivors seen at the Oncofertility Clinic, this study recruited 24% non-White and 15% Hispanic women. However, a larger question remains as to whether these distributions represent optimal equitable care. Previous studies document variations in utilization of fertility preservation by race and gender and note a variety of barriers, including awareness, access, and insurance coverage [
These results emphasize that fertility preservation decisions are as unique as the women who face them and support the ethical imperative of the guidelines to offer fertility counseling to all women who are interested or unsure [
Providers and survivors were recruited from a comprehensive cancer with a reproductive endocrinologist; decision support needs may differ for community clinics that refer to private fertility centers. The focus group may have increased reflexivity; however, it allowed us to confirm data interpretations and explore emergent questions. For ethical reasons, we chose to interview survivors instead of newly diagnosed patients, but their wisdom provided an additional benefit—they generated a list of common
Providers and patients continue to report unmet needs regarding timely access to fertility preservation education and decision support. Survivors emphasize the importance of explicitly addressing fertility preservation early to allow them time to make decisions and plan financially. Providers emphasize designing tools to facilitate timely information and appropriate referrals and to improve adherence to guidelines. Both women and providers supported the development of a patient decision aid website to address these challenges and recommended interactive, self-tailoring features. Providing an accessible, tailored, and meaningful patient decision aid may increase awareness, decision making, and referrals; reduce regret; and improve long-term survivorship outcomes.
Survivor and provider interview guides.
Focus group discussion guide.
American Society of Clinical Oncology
frequently asked question
International Patient Decision Aid Standards
The authors would like to thank the providers and women who shared their experiences and provided valuable insights to guide the design of fertility preservation decision support programs for women with cancer. The authors also appreciate the support of their colleagues at MD Anderson Cancer Center: Gary Chisholm (MS), Department of Gynecologic Oncology and Reproductive Medicine; Colleen Gallagher (PhD, MA, LSW), Integrated Ethics; and the clinical and administrative staff of the Department of Gynecologic Oncology and Reproductive Medicine. This work was supported by a grant from the University of Texas MD Anderson Cancer Center Duncan Family Institute for Cancer Prevention and Risk Assessment. The statements presented in this work are solely the responsibility of the authors and do not necessarily represent the views of the University of Texas MD Anderson Cancer Center or the Duncan Family Institute for Cancer Prevention and Risk Assessment.
None declared.