Perceived and Objective Fertility Risk Among Female Survivors of Adolescent and Young Adult Cancer

Importance: Fertility is important to many survivors of adolescent and young adult (AYA) cancer, yet data on this population's fertility perceptions and their alignment with objective infertility risk are scant. Objective: To assess whether estimated treatment gonadotoxicity and posttreatment menstrual pattern are associated with higher infertility risk perception. Design, Setting, and Participants: This retrospective cohort study included female young adult survivors of cancer diagnosed between ages 15 and 39 years were recruited between March 25, 2015, and September 24, 2018, from 2 state cancer registries, social media, and clinician referrals to participate in a study of posttreatment ovarian function. Data analysis occurred between March 1 and September 1, 2022. Exposures: Participants reported their menstrual pattern. Estimated treatment gonadotoxicity was ascertained through medical record review. Main Outcomes and Measures: Participants reported infertility risk perception and were categorized as increased risk (feeling less fertile or unable to become pregnant) or no increased risk (feeling more or as fertile) compared with female individuals their age. Objective infertility risk was determined by estimated gonadotoxicity, menstrual pattern, and ovarian reserve testing of self-collected dried blood spots. Multivariable logistic regression identified factors associated with perceived infertility and underestimation or overestimation of infertility risk. Results: This study included 785 female participants with a mean (SD) age of 33.2 (4.8) years at enrollment and 25.9 (5.7) years at diagnosis. Most participants self-identified their race and ethnicity as White (585 74.5%) and non-Hispanic (628 78.7%). Most participants (483 61.5%) perceived a higher risk of infertility compared with female participants their age. Prior exposure to moderate- or high-gonadotoxicity treatments was associated with higher odds of perceiving increased infertility risk compared with exposure to low-gonadotoxicity treatments (adjusted odds ratio AOR, 2.73 95% CI, 1.87-3.97 and 15.39 95% CI, 5.52-42.96, respectively). Amenorrhea and irregular cycles were associated with higher odds of perceiving increased infertility risk (AOR, 3.98 95% CI, 2.13-7.41 and 1.69 95% CI, 1.19-2.40, respectively). Perceived infertility risk had minimal agreement with objective risk (κ = 0.19). Multiparity (AOR, 4.17 95% CI, 2.61-6.64) was associated with increased odds of underestimation, while older age (AOR, 0.94 95% CI, 0.89-0.98), endocrine comorbidity (AOR, 0.35 95% CI, 0.18-0.69), and prior infertility (AOR, 0.16 95% CI, 0.07-0.38) were associated with lower odds of underestimation. Multiparity (AOR, 0.48 95% CI, 0.27-0.86), breast cancer (AOR, 0.38 95% CI, 0.20-0.73), and skin cancer (AOR, 0.24 95% CI, 0.11-0.51) were associated with lower odds of overestimation. Conclusions and Relevance: In this cohort study, survivors of AYA cancer had high rates of perceiving increased infertility risk but frequently overestimated or underestimated their risk. These findings suggest that counseling on infertility risk throughout survivorship may reduce misalignment between perceptions and actual risk, decrease fertility-related psychological distress, and inform family planning decisions.