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Best Practices in breast cancer – October 2017 Vol 8

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Fertility

Addressing Fertility Concerns for Young Women with Breast Cancer

Catherine Klein, MBA, BSN, RN, CBCN, OCN, ONN-CG
Breast Center Nurse Navigator
Johns Hopkins Breast Center,
Baltimore, MD 

Addressing Fertility Concerns for Young Women with Breast CancerThere are about 3.6 million breast cancer survivors in the United States.1 Most breast cancers are found in women aged ≥50 years, but breast cancer does affect younger women. Although breast cancer in young women is less common, more than 250,000 survivors living today were diagnosed when aged <40 years.2,3 Breast cancer is the most common cancer in women aged <50.4

A breast cancer diagnosis can be difficult for women of any age, but young women can have unique needs that make this experience more complex. Young women are usually starting or completing their families, working toward professional goals, and surrounded by healthy young friends. Compared with older women, younger women generally face more aggressive cancers often requiring chemotherapy.2,3 Although younger women diagnosed with breast cancer can expect long-term survival because of advances in treatments, the quality of their lives may be hampered by side effects such as premature menopause and infertility.5 Young women will likely experience a longer period of survivorship, making fertility an important long-term quality-of-life issue.

Breast cancer treatments such as chemotherapy or hormonal therapy can cause temporary or permanent infertility. Premature ovarian failure and reduced ovarian reserve can be impacted by the chemotherapy agents used, cumulative doses received, and the women’s age at the time of treatment.6,7 The incidence of permanent amenorrhea following systemic therapy for breast cancer ranges from 33% to 76%.8,9 Many young women are delaying the time until their first pregnancy, so the potential risks for infertility can be greater. In addition, for women with hormone receptor-positive breast cancers, the recommendation of 5 to 10 years of endocrine therapy can push many women past the reproductive age.10,11

The potential impact cancer treatment has on future ability to conceive can be a source of distress for women of childbearing age. Chemotherapy-induced infertility is a major concern for many cancer survivors because of the impact on sense of self-fulfillment and female identity.12,13 Findings also show that concerns about fertility are present for the majority of premenopausal women regardless of their age and extent of disease.14,15 Fertility concerns have also been shown to influence treatment decision-making.10,14 It is important to address the possibility of treatment-related infertility to balance cancer-fighting treatments with fertility-preserving options.

After a diagnosis of breast cancer, young women are confronted with many difficult fertility decisions to make, and often in a short period. The American Society of Clinical Oncology recommends fertility discussions and referral to reproductive specialists as soon as possible and before cancer treatment begins.10 Most established methods, such as embryo and oocyte cryopreservation, may require several weeks to complete, which can potentially delay therapy. Timely referral enables earlier initiation of cryopreservation and the potential for multiple fertility preservation cycles. Women who can undergo multiple cycles may have an advantage because of a larger number of oocytes or embryos cryopreserved.16 Delayed referrals to fertility specialists can result in missed opportunities and the limitation of fertility preservation options.

As with any medical intervention, patients need to be informed about the possible risks associated with breast cancer treatment to make informed decisions regarding their care. Informed patients experience greater emotional and physical well-being,11,17 better quality of life, and improved satisfaction with care.11,18 However, advising young women on their individual risk for infertility at the time of diagnosis can be challenging. The overall treatment plan may not yet be known because key pieces of clinical information may be pending. BRCA mutation carriers have a diminished ovarian reserve and may be more prone to chemotherapy-induced infertility.19 The use of tumor genomic assay testing has helped to distinguish patients with estrogen receptor–positive, HER2-negative cancers benefiting from chemotherapy and is generally done after breast cancer surgery. Relaying results of subsequent testing, discussing how it impacts treatment, and reviewing any implications on future fertility will help to improve patient knowledge and informed decision-making.

A woman’s decision to pursue fertility preservation can be complex and based on a number of individual factors. Women who are pregnant at the time of diagnosis may not be able to undergo fertility preservation before starting treatment. Genetic testing results may also impact the decision for future fertility because of fears of passing on a mutation. Women who are single or do not have a male partner may not have the opportunity to do embryo preservation. Financial concerns due to lack of insurance or inadequate coverage for fertility preservation may also influence a young woman’s decision. Understanding the dynamics of the situation and perceptions of the patient can help guide interventions to address fertility concerns.

Discussions regarding fertility often occur at a highly stressful time following a breast cancer diagnosis. The patient may focus more on life conservation and see fertility preservation as a secondary concern. The confrontation with mortality and fears of recurrence can impact patient decision-making.17 Fear of exposure to estrogen limits access to embryo or oocyte cryopreservation; however, the use of aromatase inhibitors in ovarian stimulation protocols has increased the margin of safety.20 Young women may also have concerns about future pregnancy as an increased risk for recurrence.14 Studies have not shown a negative impact of subsequent conception on breast cancer survivors’ prognoses, particularly their risk for recurrence or death. Available evidence suggests that pregnancy after breast cancer does not increase a woman’s risk of recurrence and may grant a protective effect.6,21 Overall, fertility preservation has not been shown to increase risk or diminish the chance of successful cancer treatment.10

Navigators are uniquely positioned to help bridge a young woman’s survivorship goals with treatment goals in order to safeguard hope. Through facilitating discussions about patient goals and preferences beyond cancer treatment, navigators can help identify fertility-related concerns. As members of the multidisciplinary team, navigators can facilitate a dialogue between patients and providers and provide education and resources to support informed decision-making on fertility preservation. These discussions can also make young women aware of alternatives, including surrogacy and adoption, for those who decide not to pursue fertility preservation.

Navigators help to optimize fertility options by promoting timely access and identifying barriers to care. After a breast cancer diagnosis, young women may have limited time to make decisions regarding future fertility and fertility preservation. Overseeing care coordination to medical oncology, genetic counselors, and reproductive specialists can avoid delays and provide time for patients to discuss overall risks and available options. Medical costs can often create barriers to fertility preservation. Navigators play a pivotal role in connecting patients with resources. Referrals to assistance programs like LIVESTRONG, certain pharmaceutical companies, or connecting with a financial counselor at the fertility center can help alleviate some of the financial stress.

A new diagnosis and the need to make decisions quickly regarding future fertility can cause distress for young women with breast cancer. For some women fertility preservation may not be an option, and the risk to future pregnancies can be emotionally overwhelming. Young women may experience a wide variety of feelings such as anxiety, anger, depression, worry, or grief. Providing psychosocial support for young women who desire future pregnancy is important to help them work through distress. Linking patients to appropriate psychosocial health services such as counseling, social worker, or therapists specialized in fertility issues can help improve quality of life for young women undergoing breast cancer treatment.

Young breast cancer survivors have a unique set of survivorship needs. Cancer treatment can challenge patient goals impacting long-term quality of life. Risks to fertility can be a source of distress for women of childbearing age. Addressing fertility concerns can be a complex process that encompasses the multidisciplinary team. Navigators are fundamental in optimizing this experience for young survivors by providing advocacy, education, resources, and support.

References

  1. American Cancer Society. Cancer Treatment & Survivorship Facts & Figures 2016-2017. Atlanta, GA: American Cancer Society; 2016.
  2. Anders CK, Fan C, Parker JS, et al. Breast carcinomas arising at a young age: unique biology or a surrogate for aggressive intrinsic subtypes? J Clin Oncol. 2011;29:e18-e20.
  3. Anders CK, Hsu DS, Broadwater G, et al. Young age at diagnosis correlates with worse prognosis and defines a subset of breast cancers with shared patterns of gene expression. J Clin Oncol. 2008;26:3324-3330.
  4. Jemal A, Siegel R, Xu J, et al. Cancer statistics, 2010. CA Cancer J Clin. 2010;60:277-300.
  5. Ganz PA, Greendale GA, Petersen L, et al. Breast cancer in younger women: reproductive and late health effects of treatment. J Clin Oncol. 2003;21:4184-4193.
  6. Ives A, Saunders C, Bulsara M, et al. Pregnancy after breast cancer: population based study. BMJ. 2007;334:194.
  7. Duffy CM, Allen SM, Clark MA. Discussions regarding reproductive health for young women with breast cancer undergoing chemotherapy. J Clin Oncol. 2005;23:766-773.
  8. Tham YL, Sexton K, Weiss H, et al. The rates of chemotherapy-induced amenorrhea in patients treated with adjuvant doxorubicin and cyclophosphamide followed by a taxane. Am J Clin Oncol. 2007;30:126-132.
  9. Hulvat CM, Jeruss JS. Maintaining fertility in young women with breast cancer. Curr Treat Options Oncol. 2009;10:308-317.
  10. Loren AW, Mangu PB, Beck LN, et al. Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013;31:2500-2510.
  11. Peate M, Smith SK, Pye V, et al. Assessing the usefulness and acceptability of a low health literacy online decision aid about reproductive choices for younger women with breast cancer: the aLLIAnCE pilot study protocol. Pilot Feasibility Stud. 2017;3:31.
  12. Dagan E, Modiano-Gattegno S, Birenbaum-Carmeli D. “My choice”: breast cancer patients recollect doctors fertility preservation recommendations. Support Care Cancer. 2017;25:2421-2428.
  13. Dryden A, Ussher JM, Perz J. Young women’s construction of their post-cancer fertility. Psychol Health. 2014;29:1341-1360.
  14. Partridge AH, Gelber S, Peppercorn J, et al. Web-based survey of fertility issues in young women with breast cancer. J Clin Oncol. 2004;22:4174-4183.
  15. Reyna C, Lee MC. Breast cancer in young women: special considerations in multidisciplinary care. J Multidiscip Healthc. 2014;7:419-429.
  16. Lee S, Ozkavukcu S, Heytens E, et al. Value of early referral to fertility preservation in young women with breast cancer. J Clin Oncol. 2010;28:4683-4686.
  17. Fernandes-Taylor S, Adesoye T, Bloom JR. Managing psychosocial issues faced by young women with breast cancer at the time of diagnosis and during active treatment. Curr Opin Support Palliat Care. 2015;9:279-284.
  18. Peate M, Meiser B, Cheah BC, et al. Making hard choices easier: a prospective, multicentre study to assess the efficacy of a fertility-related decision aid in young women with early-stage breast cancer. Br J Cancer. 2012;106:1053-1061.
  19. Titus S, Li F, Stobezki R, et al. Impairment of BRCA1-related DNA double-strand break repair leads to ovarian aging in mice and humans. Sci Transl Med. 2013;5:172ra21.
  20. Sonmezer M, Oktay K. Fertility preservation in young women undergoing breast cancer therapy. Oncologist. 2006;11:422-434.
  21. Pagani O, Partridge A, Korde L, et al. Pregnancy after breast cancer: if you wish, ma’am. Breast Cancer Res Treat. 2011;129:309-317.

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