February 19, 2025
Integrating Training in Sexual and Reproductive Health Into Hematology/Oncology Fellowship Programs

There is a new call for a paradigm shift when it comes to addressing sexual and reproductive health (SRH) concerns in routine cancer care. A recent survey sent to all program directors (PDs) of adult hematology/oncology fellowship programs in the United States found that training in SRH, particularly in sexual health, is lacking in hematology/oncology fellowship programs.1 The authors of the study are calling for integrated comprehensive training in SRH into fellowship programs. 

The survey, which included 114 PDs, showed that nationally there is a heavy reliance on informal instruction methods, potentially leading to inconsistent and inadequate patient education. “I think the main thing that needs to be studied next is how we can best change the status quo to offer feasible and effective training within hematology/oncology fellowship programs on sexual and reproductive health for patients diagnosed with cancer,” said study author Jennifer Barsky Reese, PhD, of the Cancer Prevention and Control Program at Fox Chase Cancer Center, Philadelphia, Pennsylvania.

Dr Reese and colleagues are currently developing a tool to improve training for future hematologists in how to deliver care regarding SRH. However, there are other possibilities on the horizon that could move the needle on these efforts. “Some institutions already have clinicians who have obtained specialized training in sexual health or fertility in cancer. These institutions could provide support and resources to develop educational materials, which could then be provided to hematology and oncology departments to offer to patients,” she noted. 

The study showed that limited training is a significant barrier, and only 49% of programs offer formal instruction on sexual health. Only 37% of programs address safe sex practices. Formal training for fertility was offered at 75% programs. “One thing that surprised us was how commonly programs seemed to be relying on informal training methods, including direct clinical exposure, as the primary means of training fellows in sexual and reproductive health. Unfortunately, there is good reason to think that informal training methods, which can often be idiosyncratic and thus missing key information, are likely an insufficient substitute for formal training methods,” Dr Reese said.

Informal training in SRH relied primarily on webinars and journal clubs. Dr Reese said being able to develop programs that could address the noted education gaps could help lead to improved care and better patient outcomes. “We know from many years of research and from speaking with patients diagnosed with cancer as well as with hematologists and oncologists that sexual and reproductive health are often left out of discussion during routine clinic visits,” she explained. “However, we had not seen any formal surveys conducted of adult hematology/oncology fellowship programs in the United States. that could give a clear picture for how sexual and reproductive health are covered during fellowship programs.”

The researchers identified all the hematology/oncology fellowship programs in the U.S. through the American Medical Association Residency and Fellowship Database website. The response rate obtained was 65%, which was highly beneficial. “A 65% response rate is very good and tells us that we can feel confident that our findings are quite applicable more generally to programs in the United States,” said Dr Reese.

Clinicians within cancer institutions, who are aware of sexual and reproductive health specialists, could help to cull a list of these specialists to use as referral sources so that hematologists/oncologists could begin to address these issues with their patients, Dr Reese stated. “Additionally, in this study, we found that a common barrier to offering training in sexual and reproductive health within hematology/oncology fellowships is the simple fact that these topics are not required, and therefore are omitted.,” she said. 

There is a need to rethink this issue because sexual and reproductive health are important to cancer survivors’ health and well-being. Dr Reese explained it is time to shift the mindsets of program directors and others who are responsible for assembling curricula toward the importance of including these topics within hematology/oncology fellowship as a required component.

Vivek Patel, MD, who is an assistant professor of medicine in the Department of Hematology/Oncology at Vanderbilt University, Nashville, Tennessee, said when it comes to training about sexual health it is not a time issue, just less of a priority in fellowship programs. “I think the training is highly lacking. This study validates what we were all thinking. We need to do much more,” Dr Patel said. “This is really an important issue and it needs to be addressed by all the stakeholders.”

Unfortunately, there is good reason to think that informal training methods, which can often be idiosyncratic and thus missing key information, are likely an insufficient substitute for formal training methods.

Alisha Tolani, MD, a clinical fellow in Reproductive Endocrinology and Infertility and a board-certified Obstetrician-Gynecologist at the University of California, San Francisco, said cancer rates are continuing to rise in our population, including cancers affecting adolescent and young adult populations. Per the American Cancer Society, there are approximately 2 million new cancer diagnoses anticipated in 2024, compared to approximately 600,000 deaths per year.2 

“As the death rates from cancer decline and patients achieve remission, patients desire to lead normal sexual and reproductive lives. Cancer treatment can impact both male and female sexual and reproductive function,” said Dr Tolani. For women, chemotherapy, surgery, and radiation treatments can cause infertility, vaginal stenosis, and atrophy and premature menopause.3,4 The hormonal changes associated with premature menopause have sexual and broader health implications that physicians need to be well-trained to treat, Dr Tolani noted.

Currently, discussing sexual health is much more acceptable than it was in decades past. Dr Tolani said physicians need to meet patients’ needs by understanding the impact cancer treatments pose to sexual health.4 In her practice, she sees patients with varying stages, some at the time of cancer diagnosis prior to starting treatment. “This is the ideal time to meet with the patient, as we can work with the patients’ oncologists to figure out what fertility preservation options are safe and offer the patient options. Some fertility preservation options are time sensitive and have to be pursued prior to starting treatment, so timing can be very critical,” she said. 

The most common scenario is that patients either never receive counseling about these issues or are provided incorrect information about their sexual health and fertility.1 Only a small minority of patients get referred. “The literature supports this, as we know that up to 50-90% of patients who are eligible for fertility counseling are not referred to fertility specialists,” said Dr Tolani.

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