Breast cancer & Fertility. Do we provide good information?

M Fastrez, C Houba 27 – 4 – 13

CHU St Pierre Réseau IRIS

University of Brussels

We have no conflict of interest to disclose.

Summary

• Introduction: epidemiology • Effects of breast cancer treatment on fertility

– Surgery – Radiotherapy – Systemic therapy:

• chemotherapy • hormonal treatment

• Fertility sparing options • Breast cancer & pregnancy • Importance of information • Family Hope

Increasing number of women surviving breast cancer

Berry DA et al. New Engl J Med 2005

• 10 000 women/year in Belgium are diagnosed with BC (1)

• 1/20 is less than 40 (1)

• Data from the US (2): – young BC survivors have minor (73%) and major

(39%) concerns about treatment-induced infertility

– ½ felt that their fertility concerns were sufficiently addressed

(1) National cancer registry, Belgium, 2008 (2) Partridge AH et al. J Clin Oncol. 2004 Oct 15;22(20):4174-83

Effect of breast-conserving surgery on QOL

Waljee et al. JCO 2008.

Effect of breast-conserving surgery on QOL

Waljee et al. JCO 2008. Effect on fertility?

Surgery for prevention of BC

• BSO recommended to BRCA-mutation carriers by the age of 40

Encourage early maternity

• Bilateral salpingectomy may reduce ovarian cancer risk, no effect on BC risk

• Other prevention strategies: – Early screening (clinical examination, mammography,

MRI) from the age of 25

– Chemoprevention: tamoxifen reduces risk of BC by 62% in BRCA-2 mutation carriers

ACOG Practice Bulletin No. 103. Gynecol Obstet 2009

Radiotherapy effects

• After adjuvant chemotherapy

• No gonadotoxicity

Precaution principle: abdominal head apron

• Fertility strategies:

– Possibility to stimulated ovaries during the radiotherapy

– Use of aromatase inhibitors

– Chemotherapy after radiotherapy

Buchholtz et al.Lancet 2011

Effect of chemotherapy

Chemotherapy-induced premature menopause

Is directly correlated to:

• Agents used

• Total dose delivered

• Patient’s age

High cumulative doses of alkylant

agents > 35 years high probability of premature menopause

=

Major concern for young women with BC and influence therapeutic decision & treatment adherence

F Cardoso et al. Eur J Cancer 2012

Chemotherapy-induced infertility

• Is directly correlated with premature menopause

• Toxic effect of CT: – On primordial ovarian oocyte pool infertility

– Granulosa cells irregular cycles

• Infertility is not always associated with amenorrhea

Fertility sparing options must be discussed

with the patient before treatment!

Hormonal treatment effects

• 2/3 of women less than 40

• 5 years Tamoxifen

• GNRH agonists not recommended

untill new data

Oncological consequence: Reduced mortality by 40 %

Fertility consequence: 5 years delay before conception

Stop tamoxifen ealier –For good prognosis tumors

–Wash out 3 months

–Start again Tamoxifen after pregnancy

How to preserve

• Gold standard: Embryo vitrification

• New promising technique: Oocyte vitrification (1)

• Experimental protocoles: Ovarian tissue autotransplantation (2)

• Future:

– Complete IV follicule growth (3) – New oocytes from oogonial stem cells (4)

Oncological view: ensure the best recovery rate Fertility view: ensure the best pregnancy rate

They need to work closely ASRM Guidelines 2013

(1) Cobo et al. Fertil Steril. 2013 Mar 28 (2) Demeestere et al. Obstet Gynecol Int. 2012;2012:695041 (3) Telfer et al. IVI Seviila 2013

(4) Dori et al. Reprod Sci 20(1):7-15 (2013)

• Other parenthood options – Eggs donation – Adoption

Pregnancy after breast cancer

• Should not be discouraged

• Individual risk should be discussed

• No consensus about the delay

Azim HA Jr et al. Eur J Cancer. 2011

Pregnancy after breast cancer

• Delay ≥ 2 years for patients with high risk of relapse

• Early interruption of adjuvant therapy risk of recurrence

• Ovarian stimulation remains debatable

Azim HA Jr et al. Eur J Cancer. 2011

Management of BC during pregnancy

• Pregnancy shouldn’t be aborted because of BC

• Standard management according to stage of pregnancy

• Management in a multidisciplinary team

• Neonatal morbidity < prematurity no induced delivery before 37 weeks

Amant F et al. Eur J Cancer 2010

Being pregnant doesn’t seem to affect overall survival if treatment is completed (*)

(*) Amant F et al. JCO 2013

Why is information important?

For patients

• <10% young (before 40 y.o.) patients with breast cancer will have a child (1)

• 50% of them want to have a child (1)

• 50% have the feeling that their concern about fertility was addressed adequately(2)

• No increase of death if pregnancy after breast cancer (3, 4)

Also patients between 40 and 45

(1) Mueller BA et al. Cancer 2003 Sep 15;98(6):1131-40.

(2) Partridge AH et al. J Clin Oncol. 2004 Oct 15;22(20):4174-83

(3) Ives A et al. BMJ. 2007 Jan 27;334(7586):194.

(4) Largillier et al. Cancer 2009 Nov 15;115(22):5155-65. doi: 10.1002/cncr.24608

Why is it difficult ?

• For the oncologist – They forgot 8% of patients are less than 40 Not a frequent case, no well established timetable care – Not enough time

• During consultation • Before the adjuvant therapy

– Not the good moment – No great familiarity with prognosis and fertility preservation options – No rapid links with a fertility consultation – Poor compliance

• For the patient – increased psychological distress – Ethical choice sometimes difficult, they need support from partner, close

friends, parents, gynecologist, and family doctor

Tool to provide good information at the good moment for patients and health care providers

Fertility sparing options amoung women with breast cancer

Importance of information

How to inform?

• In 2012, the Fondation Roi Baudouin and the Fonds Pink Ribbon support creation of a national web site with the purpose to inform women diagnosed with breast cancer about fertility sparing treatment options

www.family-hope.be (online 1/10/2013)

• 7 belgian universities involved: ULB, VUB, UCL, KUL, ULG, UGent, UAntwerp

Aims of the Family Hope project

• To provide information in all 3 national languages to all belgian patients and/or her families

• To bring all belgian university centers together into the same oncofertility consortium

• To develop a network of reference

www.family-hope.be (online 1/10/2013)