Too few women with invasive breast cancer are informed of the risk of hypofertility after chemotherapy. However, this risk can be prevented by offering gamete preservation by a specialized team. We believe that if more women were informed about gamete preservation, more of them would accept it. The primary objective is to describe each step of the oncofertility care pathway from provision of information to gamete preservation. The secondary objective is to estimate the impact of not receiving information by determining the proportion of women who would have undergone gamete preservation if they had been informed. 575 women aged 18–40 years treated with chemotherapy for breast cancer between 2012 and 2017 in the Ouest-Occitanie region (~3 million inhabitants) were included. We first constructed a multivariate predictive model to determine the parameters influencing the uptake of the offer of gamete preservation among women who were informed and then applied it to the population of uninformed women. Only 39% of women were informed of the risks of hypofertility related to chemotherapy and 11% ultimately received gamete preservation. If all had been informed of the risk, our model predicted an increase in gamete preservation of 15.35% in the youngest women (<30 years), 22.88% in women aged between 30 and 35 years and zero in those aged ≥36 years. We did not find any association with the European Deprivation Index (EDI). Oncologists should be aware of the need to inform patients aged ≤ 35 years about gamete preservation. If all received such information, the impact in terms of gamete preservation would likely be major. Life-Course Epidemiology and Social Inequalities in Health Volume 11 - 2023 | https://doi.org/10.3389/fpubh.2023.1129198 Introduction: Too few women with invasive breast cancer are informed of the risk of hypofertility after chemotherapy this risk can be prevented by offering gamete preservation by a specialized team We believe that if more women were informed about gamete preservation Objectives: The primary objective is to describe each step of the oncofertility care pathway from provision of information to gamete preservation The secondary objective is to estimate the impact of not receiving information by determining the proportion of women who would have undergone gamete preservation if they had been informed Method: 575 women aged 18–40 years treated with chemotherapy for breast cancer between 2012 and 2017 in the Ouest-Occitanie region (~3 million inhabitants) were included We first constructed a multivariate predictive model to determine the parameters influencing the uptake of the offer of gamete preservation among women who were informed and then applied it to the population of uninformed women Results: Only 39% of women were informed of the risks of hypofertility related to chemotherapy and 11% ultimately received gamete preservation our model predicted an increase in gamete preservation of 15.35% in the youngest women (<30 years) 22.88% in women aged between 30 and 35 years and zero in those aged ≥36 years We did not find any association with the European Deprivation Index (EDI) Conclusion: Oncologists should be aware of the need to inform patients aged ≤ 35 years about gamete preservation the impact in terms of gamete preservation would likely be major These figures are far removed from the potential number of beneficiaries thus highlighting the need to improve the access to gamete preservation The pathway leading to gamete preservation therefore requires perfect coordination between the oncology team and the gynecologist specialized in fertility at each step Most studies until now have described either the transmission of information to patients and access to the oncofertility consultation or the frequency of gamete preservation Few studies have examined the entire pathway of breast cancer patients from the announcement of the personalized care plan to the actual preservation of gametes in order to assess the attrition of cohorts at the different steps of the pathway The main objective of this study is to describe the oncofertility care pathway at each step from providing information to gamete preservation in a cohort of women with invasive breast cancer representative of the general population The secondary objective is to estimate the impact of not being informed about this issue by determining the proportion of women who would have decided to benefit from gamete preservation if they had been informed about it The same person collected the data from the medical records of all the health centers in the region 917235V1) was obtained from the National Commission for Informatics and Liberties (CNIL) to create the database The gamete preservation pathway comprises the following steps: (1) information on the risk of hypofertility given by the oncologist, (2) offer of consultation with a specialized gynecologist, (3) oncofertility consultation, (4) offer of gamete preservation, depending on the woman's ovarian reserve and not only on her acceptance, and finally, and (5) gamete preservation if the patient so wishes (Figure 2) We sought to establish the proportion of women completing each step of this process Patient's trajectory to fertility preservation Bold: cumulative number of cases or percentage Narrow: conditional number of cases or percentage Example: step2 FPC proposal: 227 women (39%) were informed of the risks associated with chemotherapy Fertility presevation consultation was offered to 184 women (81%) and not offerred to 43 (19%) These 43 women were excluded from the process and added to the 348 who had not been informed At the end of the second step 391 women were excluded (68%) We considered that a woman had been informed and the consultation offered if this was mentioned in the report of the announcement consultation For the oncofertility consultation and gamete preservation we consulted the oncofertility centers of the region whose data were cross-referenced with our cohort The information on the preservation proposal was found in the oncofertility consultation reports We studied the main factors associated with gamete preservation found in the literature: - Gender-specific factors such as age at diagnosis (divided into three classes: [18–29]; [30–35]; [36–40]), parity (into three classes: 0; 1; >1), marital status at diagnosis, family history of breast cancer (present or not), and social conditions as assessed by the European Deprivation Index (EDI) (8) - Carcinologic characteristics: year of primary diagnosis (in two time periods: [2012–2013] and [2014–2017]) and neoadjuvant chemotherapy administered (yes/no) - Factors related to the care pathway: type of institution that initiated the medical treatment: university hospital All analyses were done using STATA software (StataCorp LP we constructed a multivariate stepwise predictive model It confirms that women aged ≥ 36 years were the least informed Proportion of positive decisions at different steps of the pathway by age Our model for predicting gamete preservation on the basis that the subject was informed included the following variables: age and parity at diagnosis, gender of oncologist, and time of diagnosis (Supplementary Appendix 1). This model had a sensitivity of 70.91%, a specificity of 83.05%, a positive predictive value of 66.10% and a negative predictive value of 85.96% (Supplementary Appendix 2) (Table 2) Missed opportunity estimation related to the lack of access to initial information When applied to the group of women who were not informed the model predicted that if all patients had been informed 52.6% of those aged < 30 years and 18.8% of those aged between 30 and 35 years would have accepted the offer of gamete preservation whereas no women aged ≥ 36 years would have received it This represents an increase in gamete preservation of 15.35% in the youngest women (age < 30 years) 22.88% in those of intermediate age (30–35 years) and zero for those with age at diagnosis ≥36 years Our study is one of the few to provide a comprehensive view of the oncofertility care pathway in women aged ≤ 40 years with invasive breast cancer, from the transmission of information by the oncologist about the risk of chemo-induced hypofertility to gamete preservation. While the uptake of the offer of gamete preservation increased from 2012 to 2017, thus confirming the results of other studies (10, 11) For each step of the oncofertility pathway, we calculated not only a cumulative percentage from the beginning but also a percentage of women who had reached the previous step (Figure 2). The step at which there were the most exclusions was step 1, i.e., information from the oncology team (Figures 2, 3) since only 39% of women were informed of the risk of post-chemotherapy hypofertility our results also show significant exclusions at subsequent steps marital status did not appear to be correlated with receiving gamete preservation after adjustment for age and number of children patients' choices may also depend on other more subjective factors such as the way in which the risks of hypofertility are presented to them and their belief in being able to become pregnant after treatment Another limitation of our study is that we were not able to investigate the nature of the information that the women received and the way in which it was transmitted We found (Figure 3) an age gradient for the successive steps of the process where the woman's choice is not expressed (i.e. proposal for consultation and proposal for preservation): the older the women were the less they were informed or offered interventions when women were able to express themselves because they were informed this age gradient disappeared for those over 30 years of age The first two steps (information and consultation) differ from the offer of gamete preservation in that they do not depend on the technical feasibility of preservation The age gradient observed in these first two steps may be explained by an a priori selection made by the oncologists on the basis of the age and/or parity of their patients Findings on the uptake of the offer of a specialist consultation and gamete preservation steps where women's choice is expressed suggest that this selection was greater in women over 35 years of age since they were proportionally more numerous in participating in the following steps In the PREFER study conducted in Italy between 2012 and 2020 evaluating the reasons for acceptance or refusal of gamete preservation in patients with breast cancer, Blondeaux et al. (18) showed that although 95% of 159 women aged ≤ 40 years were concerned about the problem of post-chemotherapy hypofertility after receiving information only 34% accepted the offer of an oncofertility consultation but this percentage increased to 69% (=158/227) when only informed women were considered This difference is probably due to the fact that the PREFER study was an interventional study in which all women received systematic and standardized information information was probably given mainly to the youngest and/or most motivated women and varied according to the doctors giving it and/or the health centers in which it was given 80 (26%) had a fertility discussion with a physician 55 (18% of the total sample) had a fertility consultation 39% of women had a fertility discussion and 27% had a fertility consultation among the 55 patients who had a consultation 17 (or 5.6% of the total number) received gamete preservation the American study also included the results of women who received potential protection by a GnRH agonist alone or in addition to an oncofertility consultation we constructed the model on one population (informed women) and then applied it to another (uninformed women) which may have differed from the first in terms of characteristics that we did not include in our study yet the model assumes that the information was not associated with characteristics that were not studied Our choice of variables to build the model was based on data in the literature and the possibility of collecting them Other parameters might therefore explain the choice of preservation with more precision the desire to become a parent or the quality of the information given We may also have underestimated the proportion of women informed it was sometimes difficult to trace the transmission of information by the oncologist When this information was noted down in the patients' files we assumed that the doctor had discussed eventual fertility problems related to chemotherapy information may have been given but not recorded as such either because the physician forgot to report it in the consultation report or because it was recorded in another document to which we did not have access unlike the information given to the patient the existence of a consultation could be ascertained since we cross-referenced our files with those of the only two fertility centers in the region Another limitation is that our study concerns only one region, while recommendations concerning the oncofertility care pathway laid down in the French Cancer Plans apply nationally (22) our findings are likely generalizable to the rest of France since oncofertility is one of the themes of this national cancer plan and is approached similarly nationwide The decision whether to embark upon the oncofertility care pathway must be made via a caring explanatory discussion between the physician and the patient. The patient must be allowed to express her wishes and expectations (desire for pregnancy, benefit/risk ratio) so that the final decision is acceptable and accepted by both the patient and the physician, as expressed by Habermas in his analysis of the ethics of discussion (25) While the amount of information transmitted can be objectively quantified it is the quality of that information and the way in which it is understood by the patient that should take of place Our results therefore call for further reflection on these ethical issues our results lead us to reflect more deeply on issues such as health information The raw data supporting the conclusions of this article will be made available by the authors All authors contributed to the article and approved the submitted version The authors thank all the participating centers They also thank Oum-Sack E and Gosset A for data collection and data management We also thank the French league against cancer The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2023.1129198/full#supplementary-material Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update 2. 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