NCCN Continuing Education
Target Audience: This journal article is designed to meet the educational needs of oncologists, nurses, pharmacists, and other healthcare professionals who manage patients with cancer.
Accreditation Statements
In support of improving patient care, National Comprehensive Cancer Network (NCCN) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physicians: NCCN designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Nurses: NCCN designates this educational activity for a maximum of 1.0 contact hour.
Pharmacists: NCCN designates this knowledge-based continuing education activity for 1.0 contact hour (0.1 CEUs) of continuing education credit. UAN: JA4008196-0000-24-013-H01-P
PAs: NCCN has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.0 AAPA Category 1 CME credit. Approval is valid until December 10, 2025. PAs should only claim credit commensurate with the extent of their participation.
All clinicians completing this activity will be issued a certificate of participation. To participate in this journal CE activity: (1) review the educational content; (2) take the posttest with a 66% minimum passing score and complete the evaluation at https://education.nccn.org/node/94885; and (3) view/print certificate.
Pharmacists: You must complete the posttest and evaluation within 30 days of the activity. Continuing pharmacy education credit is reported to the CPE Monitor once you have completed the posttest and evaluation and claimed your credits. Before completing these requirements, be sure your NCCN profile has been updated with your NAPB e-profile ID and date of birth. Your credit cannot be reported without this information. If you have any questions, please email education@nccn.org.
Release date: December 10, 2024; Expiration date: December 10, 2025
Learning Objectives:
Upon completion of this activity, participants will be able to:
Integrate into professional practice the updates to the NCCN Guidelines for Survivorship
Describe the rationale behind the decision-making process for developing the NCCN Guidelines for Survivorship
Disclosure of Relevant Financial Relationships
None of the planners for this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
Individuals Who Provided Content Development and/or Authorship Assistance:
The faculty listed below have no relevant financial relationship(s) with ineligible companies to disclose.
Andrew T. Day, MD, MPH, Panel Vice Chair
K. Scott Baker, MD, MS, Panel Member
Christine Hill-Kayser, MD, Panel Member
Nita Lee, MD, MPH, Panel Member
Nicole McMillian, MS, CHES, Senior Guidelines Coordinator, NCCN
Deborah Freedman-Cass, PhD, Senior Manager, Guidelines Processes, NCCN
The faculty listed below have the following relevant financial relationship(s) with ineligible companies to disclose. All of the relevant financial relationships listed for these individuals have been mitigated.
Tara Sanft, MD, Panel Chair, has disclosed receiving honoraria from Biotheranostics.
Mindy Goldman, MD, Panel Member, has disclosed serving as an Officer, Director, or any other fiduciary role for Midi Health.
Kathi Mooney, RN, PhD, Panel Member, has disclosed receiving consulting fees from Reimagine Care.
Halle Moore, MD, Panel Member, has disclosed receiving grant/research support from AstraZeneca Pharmaceuticals LP, Daiichi-Sankyo Co., Pfizer Inc., Roche/Genentech, SeaGen, and Sermonix Pharmaceuticals.
Amye Tevaarwerk, MD, Panel Member, has disclosed receiving consulting fees from Tempus.
To view disclosures of external relationships for the NCCN Guidelines panel, go to NCCN.org/guidelines/guidelines-panels-and-disclosure/disclosure-panels
This activity is supported by educational grants from AstraZeneca; Bristol Myers Squibb; Janssen Biotech, Inc., administered by Janssen Scientific Affairs, LLC; and Seagen. This activity is supported by a medical education grant from Exelixis, Inc. This activity is supported by an independent educational grant from Merck & Co., Inc., Rahway, NJ, USA.
Overview
There were an estimated 18 million cancer survivors in the United States in 2022, with this number predicted to surpass 22 million by 2030.1 This growing population often experiences physical and/or psychosocial late and/or long-term effects of cancer and its treatment.2 Psychological effects, including anxiety, depression, trauma, and distress, can result from the fear of recurrence or death or occur secondary to physical side effects or social/practical issues surrounding employment, finances, and health insurance.3–6 Physical effects of cancer stem from the disease itself and the treatment received (eg, bowel and urinary dysfunction after radiation to the pelvis).7,8 Other common physical side effects include pain, fatigue, cognitive dysfunction, lymphedema, premature menopause/infertility, and sexual dysfunction.2,9–16
The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Survivorship are intended to aid health care professionals who work with survivors of adult-onset cancer. The NCCN Survivorship Panel comprises a multidisciplinary group of experts that includes different types of oncologists, a cancer survivor/patient advocate, and experts in bone marrow transplantation, gynecology, urology, cardiology, neurology, primary care, supportive care, psychology, psychiatry, nutrition, nursing, and epidemiology. This article summarizes the NCCN Survivorship Panel’s most recent recommendations regarding sexual health and fertility concerns.
Sexual Health
Concerns about sexual function are common in cancer survivors.2 Cancer treatment, especially hormonal therapy with induced menopause and surgical and/or radiation therapy directed toward the pelvis or head and neck, can impair sexual function.2 Therefore, sexual dysfunction may be especially common in certain populations of cancer survivors. For example, patients treated for colorectal or prostate cancer may experience erectile dysfunction (ED), and those treated for breast or gynecologic cancers may experience vaginal dryness and dyspareunia.17–23 In addition, 24% to 100% of head and neck cancer survivors reported a negative effect of head and neck cancer on their sexuality.24,25 Other populations that are likely to experience sexual dysfunction include female survivors of anal or colorectal cancer and gay and bisexual men who engage in receptive anal sex after treatment for prostate, anal, or colorectal cancer.21,26–29 The causes of sexual dysfunction in these populations include pain, physical barriers, decreased libido, changes in emotional functioning, fatigue, and body image distress.21,26–30 In addition, depression and anxiety, which are common in survivors, can contribute to decreased sexual desire and function.31 It is also important to note that individuals with past trauma are more likely to experience sexual dysfunction, although data in cancer populations are lacking.32
Sexual dysfunction can cause increased distress and have a significant negative impact on quality of life.33,34 Effective strategies for treating sexual dysfunction exist, making discussions related to sexual health a critical part of survivorship care. However, sexual function is often not discussed with survivors, for reasons including a lack of training of health care professionals, discomfort among providers and/or survivors with the topic, survivors’ perception of discomfort from the provider, and insufficient time during visits for discussion.33,35–38
There is strong panel consensus that all adult cancer survivors, regardless of gender identity and sexual orientation, should be asked about their sexual function at regular intervals, by inquiring about any concerns or distress regarding sexual function, sexual activity, sexual relationships, or sex life.
Sexual Function in Gender-Diverse Survivors
Gender-diverse individuals include those who are transgender, nonbinary, agender, intersex, and gender queer. Unfortunately, there is a lack of research regarding sexual function following cancer treatment in this population.39,40 The panel therefore developed the recommendations within these NCCN Guidelines for cisgender survivors based on the availability of data, but the panel believes they should be followed for gender-diverse survivors as applicable, with involvement of appropriate health care specialists. The panel notes that studies on the unique sexual health issues faced by gender-diverse cancer survivors are greatly needed.
Sexual Function in Cisgender Women
Sexual problems related to sexual desire, arousal, orgasm, and pain are common after cancer treatment and vary with cancer site and treatment modalities.15,41–47 For example, survivors of cervical cancer who were treated with radiotherapy had worse sexual functioning scores (for arousal, lubrication, orgasm, pain, and satisfaction) than those treated with surgery, whose sexual functioning was similar to that of age- and race-matched noncancer controls.46 A systematic review of sexual functioning in cervical cancer survivors found similar results, except that no differences in orgasm/satisfaction were observed.48 Chemotherapy seems to be linked to sexual dysfunction in breast cancer survivors, possibly related to the prevalence of chemotherapy-induced menopause in this population.42,47 Furthermore, body image changes after cancer treatment can affect sexual health.49
Sexual dysfunction is often multifactorial in nature. Therefore, the panel consensus is that treatment requires a multidimensional plan that addresses the underlying issues, which can be physiologic (eg, menopause, illness), psychologic (eg, anxiety, depression), disease- or medication-induced, and interpersonal. Treatments depend on the type of sexual dysfunction and may include both over-the-counter and prescription options, as well as pelvic physical therapy and integrative therapies. Referrals to specialists (ie, psychotherapy, sexual/couples counseling, gynecologic care, sexual health specialist) should be made if appropriate and available (see Figure 1). For sexual concerns that may be related to menopause (eg, vaginal dryness, discomfort, discharge, pain), menopausal hormone therapy can lead to improvements in sexual function (see section on “Hormone-Related Symptoms” in the full version of these guidelines, available at NCCN.org).
SSH-2. NCCN Clinical Practice Guidelines in Oncology for Survivorship, Version 2.2024.
Citation: Journal of the National Comprehensive Cancer Network 22, 10; 10.6004/jnccn.2024.0062
Integrative therapies, such as yoga and meditation, may be helpful for survivors with sexual dysfunction because they can help alleviate associated symptoms like anxiety that can impact sexual functioning.50,51 In addition, cognitive behavioral therapy (CBT) has been shown to be effective at improving sexual functioning in breast cancer survivors.52 Vaginal moisturizers, gels, and oils can help alleviate symptoms such as vaginal dryness and sexual pain, although data on these over-the-counter products are limited.53,54 Topical anesthetics may help with vaginal pain, as shown in a study in 46 breast cancer survivors that found that application of lidocaine to the vulvar vestibule before vaginal penetration improved dyspareunia.55
Many survivors with sexual dysfunction may have associated pelvic floor dysfunction, which can be treated with pelvic physical therapy (ie, pelvic floor muscle training). Alleviating pelvic floor dysfunction may improve sexual pain, arousal, lubrication, orgasm, and satisfaction. In fact, a small study of 34 survivors of gynecologic cancers found that pelvic floor training significantly improved sexual function.56 Vaginal dilators are an option for survivors with pain during sexual activity and those with vaginal stenosis from pelvic radiation. Although evidence for the effectiveness of dilators is limited,57 they may be useful for increasing vaginal depth and accommodation and may allow a survivor to discover what hurts and what does not in a nonsexual setting.
Several topical prescription medications can also be considered for survivors with sexual dysfunction. Vaginal estrogen is the most effective treatment for vaginal dryness leading to sexual dysfunction and has been shown to be effective in treating itching, discomfort, and painful intercourse in postmenopausal individuals.58–60 A study in 76 postmenopausal survivors of hormone receptor (HR)–positive breast cancer receiving aromatase inhibitor (AI) therapy found that intravaginal testosterone cream or an estradiol-releasing vaginal ring were safe and improved vaginal atrophy and sexual function.61 Furthermore, a large cohort study of almost 50,000 patients with breast cancer followed for up to 20 years showed no evidence that there was a higher risk of breast cancer–specific mortality in those using vaginal estrogen.62 Vaginal androgens (ie, DHEA, also known as prasterone) can also be considered for vaginal dryness or pain with sexual activity. Several studies have shown DHEA to be effective at reducing dyspareunia in postmenopausal individuals.63–67 However, a systematic review and meta-analysis published in 2015 concluded that it is uncertain whether vaginal DHEA improves vaginal dryness.68 A randomized controlled trial of 464 survivors of breast or gynecologic cancer showed that vaginal DHEA led to significant improvements in sexual desire, arousal, pain, and overall sexual function, although a plain moisturizer also improved symptoms.69 Overall, safety data for the use of androgen-based therapy in survivors of hormonally mediated cancers are limited. The panel notes that DHEA should be used with caution in survivors receiving AI therapy, because vaginal DHEA increases levels of circulating androgens,70 which have the potential to impact AI activity. Overall, the safety of vaginal hormones has not been firmly established in survivors of estrogen-dependent cancers. Therefore, first-line vaginal therapy for survivors of estrogen-sensitive cancers should be over-the-counter options.
Ospemifene, an FDA-approved selective estrogen receptor modulator (SERM), has been studied in several large trials of individuals with postmenopausal vulvar and vaginal atrophy and was found to effectively treat vaginal dryness and dyspareunia.71–73 Data in the survivor population, however, are very limited. One prospective study, in which 52 survivors of stage I–IIA cervical cancer with vulvovaginal atrophy were treated with ospemifene, found improvements in vaginal health and function, sexual activity, body image, sexual enjoyment, global health status, and emotional and social functioning.74 The panel recommends consideration of ospemifene as an option for dyspareunia in survivors without a history of estrogen-dependent cancers.
Meta-analyses have shown that flibanserin, an FDA-approved medication used to treat acquired, generalized hypoactive sexual desire disorder (HSDD) in premenopausal women, results in approximately 1 additional satisfying sexual event every 2 months in premenopausal individuals.75,76 Preliminary results from a small study of 37 survivors with breast cancer receiving adjuvant endocrine therapy showed that flibanserin may also be effective in this population.77 Although it is not FDA-approved for use in postmenopausal individuals, some data suggest that it can be effective and safe in the postmenopausal setting as well.78,79
Another FDA-approved drug, bremelanotide, is an option for premenopausal individuals with low sexual desire. Safety and efficacy of bremelanotide in premenopausal individuals with HSDD was evaluated in 2 phase III, randomized, double-blind, placebo-controlled, multicenter clinical trials.80 Participants in the bremelanotide groups experienced a statistically significant increase in sexual desire and a statistically significant reduction in distress related to low sexual desire compared with placebo. Bremelanotide has not been studied in cancer survivors, but the panel believes it may be an appropriate option for some survivors with HSDD.
Other options for survivors with low or lack of desire, libido, or intimacy include off-label use of bupropion and buspirone. These drugs have been studied in a few trials involving noncancer populations.81–84 Despite limited safety and efficacy data, the panel agrees that these drugs may be considered as options for survivors with HSDD.
Currently, the panel does not recommend the use of oral phosphodiesterase type 5 inhibitors (PDE5i) for sexual dysfunction in cisgender females because of the limited data regarding their effectiveness. Although thought to increase pelvic blood flow to the clitoris and vagina,85,86 PDE5i showed contradictory results in randomized clinical trials of various noncancer populations of women being treated for sexual arousal disorder.87–93 In addition, the panel does not currently recommend the use of vaginal laser therapy for the treatment of vaginal dryness and other genitourinary symptoms in postmenopausal individuals.94 Some trials have shown a benefit of laser therapy in improving symptoms of genitourinary syndrome of menopause in cancer survivors, but data on the overall safety and effectiveness of these types of devices in cancer populations are limited.95–98 Furthermore, the FDA has not cleared or approved for marketing any energy-based devices for the treatment of menopausal symptoms and notes that the safety and effectiveness of these devices for these types of treatments have not been established. Therefore, although preliminary data look promising, the panel notes that additional studies in cancer survivors are needed before this type of treatment is recommended.
Sexual Function in Cisgender Men
ED, or the inability to achieve or maintain an erection firm enough for satisfactory sexual intercourse, is common after cancer treatment. For example, the reported prevalence of ED in survivors of colorectal cancer ranges from 45% to 75%, and it has been reported in up to 90% of prostate cancer survivors.17–20 ED may have a psychologic component, but is most often physiologic and iatrogenic, because cancer therapy can damage blood vessels, leading to a reduction in blood circulation to the penis and/or damage to the autonomic nervous system. In the case of surgery, ED may be immediately evident; in the case of radiation treatments, presentations can be delayed. Cancer treatment can also cause hypogonadism, resulting in decreased libido and sexual function.99 Cancer therapies can also cause a variety of ejaculatory dysfunctions (eg, premature, absent, or delayed ejaculation, or climacturia) or problems with orgasm (eg, less intensity, difficulty achieving, accompanying pain).100–103
The panel’s consensus is that treatment of sexual dysfunction requires a multidimensional treatment plan that addresses the underlying issues, as guided by the specific type of problem. Referrals to specialists (ie, psychotherapy, sexual/couples counseling, urology, sexual health specialist) should be made if appropriate and available (see Figure 2).
SSH-3. NCCN Clinical Practice Guidelines in Oncology for Survivorship, Version 2.2024.
Citation: Journal of the National Comprehensive Cancer Network 22, 10; 10.6004/jnccn.2024.0062
PDE5i treatment has been shown to improve the symptoms of ED and be well tolerated.104,105 Many studies have also shown the efficacy and tolerability of PDE5i for treating ED in patients with cancer and survivors.106–108 Importantly, PDE5i are contraindicated in patients taking oral nitrates, because together they can lead to a dangerous decrease in blood pressure.109,110 The timing and dose of on-demand PDE5i should be started conservatively, and it should be titrated to the maximum dose as needed.111 Survivors on PDE5is should be monitored periodically for efficacy, side effects, and any significant change in health status. In addition to on-demand PDE5i treatment, studies have shown that daily, low-dose treatment with these drugs can be effective.112–115
Testosterone therapy may relieve symptoms of ED, problems with ejaculation, or problems with orgasm for survivors with hypogonadism.116–118 The addition of testosterone to PDE5i therapy in individuals with low serum testosterone levels may also improve ED.119–124 Testosterone therapy should not be used if contraindicated by the primary oncologic diagnosis (eg, prostate cancer on active surveillance, prostate cancer on androgen deprivation therapy [ADT]). Furthermore, the panel cautions that exogenous testosterone therapy should not be prescribed to those who are currently trying to conceive because it can cause short-term suppression of sperm production.125 Although evidence is conflicting, testosterone may also have a long-term impact on spermatogenesis, which should be discussed with those interested in future fertility.125
Treatment for sexual dysfunction should include risk factor modification, such as smoking cessation, weight loss, increasing physical activity, and avoiding excess alcohol consumption. Several trials have shown that such lifestyle modifications can improve erectile and sexual function.126–129 In fact, one study found that PDE5i treatment combined with an aerobic activity program was more effective than PDE5i treatment alone in 60 patients with ED.130 However, evidence for these effects in patients with cancer and survivors is lacking.
Treatment of psychosocial problems, with referral to sex and couples therapy as appropriate, can also alleviate symptoms of sexual dysfunction.131–135 Small studies in survivors of prostate cancer suggest that these approaches can be helpful in the survivorship population as well.136,137
Although evidence in the general population is limited, studies in prostate cancer survivors suggest that pelvic physical therapy (ie, pelvic floor muscle training) may improve sexual function in this population.138,139 Vibratory therapy may reduce problems with premature ejaculation, and cabergoline, a dopamine agonist, has been shown to have subjective improvement in orgasm.140,141 Other options to treat problems with ejaculation include a psychological evaluation and use of selective serotonin reuptake inhibitors (SSRIs) or on-demand clomipramine, although data in cancer populations are lacking.102,103
The panel would like survivors and clinicians to be aware that “restorative or regenerative” therapies for ED (eg, low-intensity shock wave therapy, stem cell therapy, platelet-rich plasma) are being widely advertised in the United States, but, as of the time of publication, none of these treatments has been approved or cleared by the FDA for the treatment of ED. These therapies are being administered in cash-only practices. The Sexual Medicine Society of North America (SMSNA) also recommends against the use of restorative therapy in routine clinical practice, citing an absence of robust clinical trial data supporting their efficacy.142
Fertility
Cancer treatments, particularly chemotherapy and radiation, can be gonadotoxic and can result in impaired fertility.143 Premenopausal cancer survivors who received chemotherapy may experience transient or permanent menopause, dependent on the age of the patient and the type of chemotherapy.144–146 For example, 33% to 73% of premenopausal patients treated for breast cancer become perimenopausal or postmenopausal after treatment.147 However, clinicians and survivors should not assume that an amenorrheic survivor is infertile, because menses may resume. A discussion regarding the need for contraception may be needed, because the incidence of unplanned pregnancies is approximately 3 times higher in cancer survivors than in the general population.148
Cancer treatment can also cause low sperm counts (oligospermia), an absence of sperm (azoospermia), and diminished sperm quality, and can have effects on erection and ejaculation.149,150 In one study of survivors treated for testicular cancer between 1979 and 1999, 67.1% of those who attempted to impregnate their partners succeeded, compared with 91.2% before treatment.151 Radiation was more detrimental to fertility than chemotherapy. More recent data showed that only 56.5% of posttreatment testicular cancer survivors successfully impregnated their partners.152
Fortunately, fertility preservation techniques can be effective and are widely available.16,143,153 In addition, radiation planning techniques can be used to spare or minimize dose to reproductive organs and thus minimize the impact of radiation on fertility.154 For survivors in their reproductive years, fertility preservation is of crucial importance and should be an integral part of their cancer care.16,155–157 Importantly, the population of survivors of reproductive age is expanding, as the incidence of cancer in individuals aged <50 years of age has increased over the last decade.158 In fact, >56,000 people were diagnosed with cancer before the age of 49 years in the United States. in 2019.158
Unfortunately, however, there are barriers to fertility preservation in patients with cancer, including those at the patient level (eg, concerns about delaying cancer treatment), the clinician level (eg, limited knowledge, training, and confidence; discomfort with the topic), and the system level (eg, lack of insurance coverage; scarcity of fertility resources; absence of standardized referral mechanisms).159,160 Rates of counseling on the infertility risks of chemotherapy in patients of reproductive age was only 44% in a large cross-sectional study, and range from 34% to 70% in other studies.161,162
Fertility preservation procedures such as oocyte, embryo, or ovarian tissue cryopreservation and sperm banking before treatment are the most effective way to preserve fertility (see the NCCN Guidelines for Adolescent and Young Adult Oncology at NCCN.org for more information on pretreatment fertility preservation). In addition, limited evidence suggests that luteinizing hormone–releasing hormone (LHRH) agonists and antagonists given during chemotherapy may help preserve ovarian function and thus lead to improved fertility.163 Therefore, the panel recommends that goals regarding fertility and the risks of treatment-induced infertility should be discussed with all reproductive-aged survivors at the time of cancer diagnosis and before cancer treatment is initiated. Available options for fertility preservation should be discussed and/or referrals made to the appropriate specialists for those patients wishing to preserve fertility prior to initiation of cancer treatment (see Figure 3).
SF-1. NCCN Clinical Practice Guidelines in Oncology for Survivorship, Version 2.2024.
Citation: Journal of the National Comprehensive Cancer Network 22, 10; 10.6004/jnccn.2024.0062
These conversations should be performed by a multidisciplinary team that can include oncologists, reproductive endocrinologists and urologists, and reproductive surgeons with fertility preservation training.153 The panel also recommends ongoing collaboration between specialists. Conversations surrounding fertility, especially for younger survivors, can have a strong emotional impact, and there may be concerns about the cost of fertility preservation or the transmission of heritable diseases. Therefore, mental health professionals, ethicists, genetic counselors, and financial counselors may also be needed to assist survivors in the decision-making process about fertility preservation.16,153
Addressing Fertility After Cancer Treatment
A survey of 484 cancer survivors who wanted to have children before treatment showed that the majority maintained that desire 3 to 7 years posttreatment, but approximately one-third of respondents reported difficulty conceiving.164 Furthermore, an unfulfilled desire to have children was associated with poorer mental health.
Survivors and clinicians should be aware that there are approaches that can be undertaken after cancer treatment to aid in fertility for those who did not receive fertility preservation before treatment. For example, some evidence suggests that ovarian tissue cryopreservation and oophorectomy after aggressive cancer treatment can result in viable tissue and live births following transplantation, and testicular sperm extraction and intracytoplasmic sperm injection are methods that can help posttreatment survivors with minimal sperm achieve pregnancy.162 Furthermore, pregnancy is usually considered safe for survivors and their offspring posttreatment, although the majority of data are in those treated for breast cancer.165 Similarly, although there can be mutagenic effects of chemotherapy and radiation on sperm and the data on the safety of conception during or shortly after cancer treatment are limited, conception post–cancer treatment can result in healthy offspring.166,167
Therefore, it is important for clinicians caring for survivors to be aware that fertility issues should be discussed in the survivorship phase, despite whether they were addressed prior to treatment. The panel recommends that posttreatment survivors interested in fertility should be assessed by a fertility specialist (see Figure 3).
Conclusions
Sexual health and fertility are important issues for many cancer survivors. The NCCN Guidelines for Survivorship provide workup, treatment, and follow-up recommendations for survivors with concerns regarding their sexual health and outline central principles of fertility for cancer survivors based on consensus and a review of the evidence. Effective strategies exist for treating sexual dysfunction and for addressing fertility in posttreatment survivors even if it was not addressed prior to cancer treatment. Despite barriers to discussing these issues with survivors, clinicians should prioritize open conversations to ensure that survivors get the care they need.
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