Participant demographics
Participants were aged between 32 and 49 years and had received a diagnosis of breast cancer between the years 2016 and 2023 (Table 1).
Three (3) predominant themes emerged from the analysis of the data: (1) limited knowledge and awareness regarding FP options; (2) barriers to effective FP discussions and uptake and (3) promoting factors for FP (Table 2). In the paragraphs below, each principal theme is further explained by a set of subthemes to enhance the understanding of the overarching concepts.
Theme 1: limited knowledge and awareness regarding FP options
Most women 10 out of 15 in this study indicated a lack of awareness regarding FP, although they were receiving cancer treatment at a tertiary healthcare facility, some of whom had been diagnosed as far back as 2016. FP did not seem to be a well-recognized medical procedure among this sub-group of women. Two participants had only gained knowledge about FP for the first time, through interacting with the study research assistants during the cross-sectional phase of the research:
If not for you guys [researchers] educating me on the topic, I wouldn’t have had a fair idea of what it was. (Participant 11)
The last time I came to Korle Bu it was explained to me by your research, I wouldn’t have known anything about it (Participant 8).
Three participants as illustrated below, pointed out that their knowledge of FP originated from non-medical sources including via reading a book or hearsay.
Um, I know that they can freeze your eggs. Yeah. That I know. I read it. (Participant 13)
There is a madam, it seems she is a survivor. She was saying that there is another lady who told her of something like that. But as for me I haven’t heard of anybody talking about it. (Participant 3)
I don’t know if it was a movie I heard it from. I just know I’ve heard people have that conversation. (Patient participant)
While the above discussion highlights a potential lack of awareness of FP among women receiving treatment, two participants explained that as part of standard medical procedure the attending healthcare professional had discussed FP, prior to breast cancer treatment.
Before treatment, they (health professionals) lay these issues before you, either they have injections and medications … that will protect your eggs (Participantt 2).
They told me that before chemo, they can remove and store some of a woman’s eggs and then put it back after treatment. And if that’s not what you want, they have some injections they will be giving you for you to get pregnant (Participantt 12).
It emerged that patient education on fertility preservation was not standard or routine practice. What’s more is that in some cases there appeared to be no clarity about the discussions and the decisions that followed FP education. Two patient’s highlight this communication gap:
When I was in Korle-Bu, they came round and said they can help you get pregnant after treatment but I haven’t heard anything else (Participantt 14).
Before I started treatment, one guy explained all that (FP) to me. But I didn’t see that happen so I wouldn’t know if my eggs were taken or if I was injected … but I don’t know (Participantt 15).
Theme 2: barriers to effective FP discussions and uptake
Participant accounts reveal several barriers to effective FP discussions and uptake, these are discussed in more detail in the sections below:
Subtheme 2.1: Doctors non-disclosure of FP options
A significant barrier to FP uptake was the failure of healthcare providers to communicate information or sufficient information regarding FP options. As already described above, the discussions of FP were not held or were conducted in a poor manner. Expressing displeasure about not being informed about reproductive choices, two women said:
None of this (FP) was mentioned to me before my treatment began oh…They didn’t inform us so we know our options and the decisions to take, they waited for us to undergo treatment first (Participant 12).
If I knew that there was a way to solve that … like the issue of freezing your eggs before you go for the chemotherapy, I would have gone for that. Um, I haven’t spoken with anybody who has actually said anything concerning that (Participant 13).
Inferring from the narratives above, failing to communicate FP options did a disservice to participants who may have been willing to explore FP options.
Subtheme 2.2: Patients fertility history or parity
Patients attempted to reason why FP was not discussed by the medical provider, after a diagnosis of breast cancer. They recalled their interaction with the attending health professional:
The doctor first asked me how many children I had, to which I answered four. If I had told him I had no children, maybe he would have taken time to explain that to me, but because I told him I had children, he did not say anything else. (Participant 9)
I think if I had said no, I am not done, I’m not yet done having children, they would have probably introduced the subject. But the question was, are you, you know, how many children do you intend to have anymore? No. Okay. Then they move on to the next thing. (Participantt 10)
Having a satisfying number of children seemed good reason for why some women lacked interest in pursuing FP options:
As for me I have some children that’s why I didn’t give it much thought. (Patient 4)
If the person is also old and doesn’t need more children, then it may not be necessary for the person to do it. (Participant 8)
It is important to recognize that fertility-related concerns may vary, at the time of diagnosis. For one participant who was pregnant, fertility concerns were centred on the potential outcome of a current pregnancy rather than future reproductive choices, “ I was pregnant during diagnosis, so the conversation did not focus so much on how would you give birth. I was more concerned if the pregnancy will still hold” (Participant 1).
Subtheme 2.3: The burden of cancer care versus fertility needs
As illustrated above, for majority of the (9 out of 15) women, the immediate health concerns of cancer seemed to overshadow considerations for future fertility. Participants indicated that oncological care consumed their entire focus, against this backdrop FP seemed secondary. Describing the overwhelming nature of living with a breast cancer diagnosis and concerns about survival, one participant explained “It affects you, you don’t know your chances of survival (Patient 1, Another explained further “When you are diagnosed with the cancer, all you are thinking about is to cure, you know, to save your life, sort of. Uh-huh. So, that one (FP) becomes a secondary matter” (Participant 4).
Ongoing treatment of cancer seems intense, on this account the women in this study projected and feared that FP procedures would add an additional layer of stress and thus discourage patronage. Weary of their own histories of cancer surgery and the burden experienced, two participants reflected:
Just like my reason for saying that I am tired of surgery, there may be others who may also be afraid like that. (Participant 3)
There are too many surgeries involved. Do you think some women will agree if you tell somebody that aside the surgery they’ll undergo as part of the cancer treatment, there are other surgeries they would have to undergo if they wish to have children after the treatment? (Participant 9)
Viewing the introduction of FP as burdensome, one patient shares how it could potentially affect adherence to treatment:
It’s a lot dealing with cancer from my perspective, it’s a lot it’s heavy so if we have to add fertility and it has to be done in a way ahh, it won’t… it won’t burden the person. You see, some people are there, immediately they hear all these things then, a lot of people stop coming for treatment because the things to are too much. (Participant 10)
Finding balance between cancer care treatment and fertility needs seemed crucial for women to accept FP treatment.
Subtheme 4: Financial cost or affordability
The cost of FP was viewed as a limiting factor to FP uptake, by women in this study:
Someone may want to do it but because there is no money the person may say that I won’t do it because I do not have money. (Participant 3)
If I had that money, I would have made them take all my eggs. But that procedure involves money (Participant).
The participants in this study viewed that the financial burden of undergoing an extra procedure, in addition to what is already required for breast cancer treatment, may deter patients from considering FP.
You just imagine paying for chemo and then paying for the preservation process after. It’ll be too expensive. (Participant 15)
You also know how costly the cancer treatment itself is. And so, I believe a lot of women would want to go through the egg freezing process if it weren’t for how expensive the entire procedure is. (Participant 11)
Subtheme 5: Little awareness and evidence in support of FP success
The women indicated they had no previous encounter with someone who had undergone the FP process:
I haven’t heard anyone say they’ve been through FP before. (Participant 15)
I don’t know anyone with breast cancer who has done this procedure. (Participant 2)
The narrative was the same for patient 3 who added that personal success stories about FP could significantly influence decision-making for those contemplating FP.
This is something that isn’t already in existence, so it won’t be easy for people to do it. But for others as well, unless someone has experienced it and tells them how it is like. Then maybe the person may be able to convince them to accept. But for someone who hasn’t done it before or someone who hasn’t witnessed it, it will be very difficult for them to accept. (Participant 3)
For such interested women, patient 3 believed first-hand accounts would be crucial in encouraging their acceptance of FP.
Subtheme 6: Religious barriers
Highlighting the importance of religion, Participant 3 perceived that one’s religious beliefs could serve as a deterrent to FP uptake, she noted:
Someone’s belief can prevent them because you know that in Ghana, we have a lot of religions, so someone’s beliefs can prevent them. (Participant 3)
Someone’s church, maybe the person may say that this is the church I go to and so I cannot do such a thing. (Participant 4)
Conversely, participants 13 and 12 opined that religion was not a barrier to the uptake of FP
I don’t see culture coming in. Maybe religion, some of the religions, yeah, might not, I don’t see too much of it coming in. (Participant13)
Since it’s something that can help women, I don’t think religion would really cause a hindrance. (Participant 12)
Theme 3: promoting factors for FP
Factors proposed to promote the uptake for FP were awareness creation, talking about its benefit, and the provision of financial support.
Subtheme 3.1: Awarenesscreation
The patients’ suggested public health and patient educative counselling were the best ways to create awareness about FP. Participant 1 suggested this education should be done right before breast cancer treatment is started perhaps to give the women a chance to fully consider all the resources available to them.
During the time that erm, we are going to start treatment, it should be something spoken of and we should be open to them that you know chemo can do so – so and so to your system. So, these are the things we think would increase your chances of having children by preserving your eggs. These must be said to patients before they start treatment. I think, with this, they will have an option to choose whether to preserve their eggs or not to. (Participant 1)
Education is key. Like they should make us aware that these options are there. (Participant 5)
The doctor can inform them that their eggs can be removed and stored so that they can later be fertilized with their husband’s sperm and implanted in them. If they agree to it, fine. And if they don’t agree to it, they should be left alone. (Participants 9)
Participants advised that FP awareness should be created, and accurate and reliable information about FP provided. They also cautioned that the information should be communicated in a way that is not overwhelming:
So, it hasn’t been,… err there hasn’t been a lot of education on the FP. So, I think it’s good if it’s introduced well you know, but you know,… slowly and not; go and do it!, it seems a lot for them….(Participant 10).
Erm I suggest that someone going through cancer treatment should be given the right information and educated on this topic. Because someone might have no problem financing the procedure but they may not have been educated on that so they would not get the chance to make that decision. At least with me, I got educated on it by you guys. So, I think more education on the preservation would really help. (Participant 11)
I think it should be emphasized more, you know, for people to be aware of so many options they can have during or after treatment, so, it should be popular but it’s not popular. It’s not something out there. (Participant 1).
Patient 13 hinted that there should be a professional on the medical team solely responsible for FP counselling:
Adding a reproductive person as part of the team for the chemo treatment session such that, if someone comes and the person is still in the reproductive age, maybe the person can go through some counselling with the person, you know.
Subtheme 3.2: The perceived benefit of future fertility
As revealed in the patients’ narratives, education that lays emphasis on the perceived benefits of FP would be key for successful uptake.
If I am told these are the things you can do to increase your chances of having children after treatment, of course I’ll go for it. (Participant 1)
Also, 10 out of 15 believed that FP held a lot of promise for women diagnosed with breast cancer, particularly young ones who have no child.
I think it is good… if you will be treated and can be given medication that will protect your eggs. For example, maybe the person is young … if this option is here … then I think that it is good. (Participant 2)
As for me I have some children that’s why I didn’t give it much thought. But for those who have the illness but do not have children, that procedure will have been good for them (Participant 4).
Someone may be young, hasn’t given birth before or married before and this befalls the person, then it is advisable for that the person so that the person can get children when she marries. So, it is very good. (Participant 8)
Subtheme 3.3: Financial relief
Women suggested that the government could assist by providing financial aid to support women going through breast cancer treatment. As illustrated below participants believed that women would accept FP if they are supported financially. Others also requested that the government reduce the cost instead of absolving all of it.
Ok. For me, I think financial because if they make it less expensive or erm the government can help_ let me say government – either make it less expensive or the government can help by subsidizing the fees they have to pay. If it’s possible, they can put it on health insurance for those who want to give birth after treatment, because the treatment itself is expensive. (Participant 5)
If the National Health Insurance Scheme can cover some of the cost of the FP process women wouldn’t have to pay so much for the process. (Participant 11)
I don’t know if the government or hospital can help with that. I think the government should help us out with that. (Participant 12)
What I can say is that, the government should help with the cost of the process. Because it’s not easy at all, the cost involved in chemo and the FP process as well. (Participant 15)
According to the participants’ narratives, FP awareness creation, support from government and highlighting the benefits of FP from previous beneficiaries may promote the uptake of FP in Ghana.