Health equity in fertility specialty care among cancer survivors

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1 Project Summary 2 For many reproductive-age cancer survivors, access to safe and effective methods for fertility preservation is 3 an essential but often elusive path to creating a family. As more women delay childbirth, and greater numbers 4 of women are not reaching their desired family size at the time of cancer diagnosis, fertility concerns have 5 become increasingly relevant. Although the appropriateness of fertility treatment varies by clinical and patient 6 factors, cancer survivors are more likely to require assisted reproductive technologies (ARTs) at a younger age 7 and may have lower chances of conceiving. Methods to achieve fertility goals using ARTs are important to 8 cancer survivors in two distinct settings, either at cancer diagnosis for fertility preservation or after completing 9 cancer treatment. For many survivors, factors at the individual (e.g., race/ethnicity, insurance status), 10 neighborhood (e.g., household income, education, geographic access to ART clinics), and policy levels create 11 substantial barriers to accessing these methods. Therefore, as fertility options for cancer survivors become 12 more common and successful, a potential new area for health care disparity has emerged. In addition, unequal 13 insurance coverage for fertility preservation and the use of ARTs after cancer treatment further magnifies the 14 disparities for medically underserved survivors. Most women who receive ARTs pay out-of-pocket for their 15 treatment, making this option prohibitively expensive for those with limited financial resources. The overall 16 objective of our study is to answer two distinct questions: 1. What are the sources and extent of disparities in 17 fertility preservation, access to ARTs, and live births among cancer survivors? 2. Does improving access to 18 ARTs mitigate these disparities? We will evaluate how dimensions of social disparities arising from individual- 19 level, neighborhood-level (social determinants measured at census tract), and policy-level (state insurance 20 mandates) factors affect access to and use of ARTs and live births. Specifically, we aim to 1) investigate 21 individual-, neighborhood-, and policy-level factors associated with fertility preservation; 2) investigate 22 individual-, neighborhood-, and policy-level factors associated with ART use after completion of cancer 23 treatment; and 3) quantify the contribution of individual-, neighborhood-, policy-level factors to live birth rates 24 after cancer, and whether live birth rates after cancer will be lower in medically underserved populations and 25 partially mediated by ART use. Creation of a family is a basic human right, and ensuring equitable access to 26 oncofertility services for all populations is key to addressing cancer care disparities for reproductive-age cancer 27 survivors. The deleterious effects of cancer treatments on fertility among medically underserved cancer 28 survivors has emerged as an important area of widening disparity in health care. Study findings should reveal 29 the mechanisms underlying disparities in access to ARTs and could be used by policymakers to improve 30 access to ARTs for vulnerable populations.