Helping Patients to Make Informed Decisions About Fertility Preservation

Studies show that young women diagnosed with breast cancer are not routinely receiving information about fertility preservation (FP) before their anticancer therapy begins, posing a missed opportunity for healthcare practitioners to provide women with options for improving their chances for a future pregnancy.

Combination chemotherapy regimens involving an alkylating drug can result in the equivalent of a reduction of 10 years in a patient’s ovarian reserve; although most women under age 35 years resume menses after treatment, they remain at risk for premature ovarian failure. Adjuvant therapy with tamoxifen also will delay efforts to conceive, and women with BRCA mutations may have a slightly earlier average age of menopause.

Despite this, “fertility preservation is a very feasible for young women with breast cancer,” said Leslie R. Schover, PhD, in a presentation at the recent Miami Breast Cancer Conference.

No Increased Risk of Recurrence

Studies show that pregnancy is not a risk factor for recurrence, and a number of reasonably large ones, said Schover, point to a “healthy mother” effect: “Women who do have a child after breast cancer treatment, tend to have, if anything, longer overall and disease-free survival.” Schover is a professor in the Department of Behavioral Science, Department of Gynecologic Oncology and Reproductive Medicine, at the University of Texas MD Anderson Cancer Center in Houston.

Concerns also have been raised about safety for women with breast cancer undergoing ovarian stimulation before treatment. Again, said Schover, although she would like to see larger studies with longer follow-up, current research has not suggested an association between assisted reproductive technology and cancer recurrence.

She added that there are IVF protocols which minimize estrogen exposure: for example, combining letrozole with follicle-stimulating hormone, or adding a GnRH agonist to trigger ovulation. Such methods, she said, also “make it less likely that these young fertile women will go into ovarian hyperstimulation and a medical crisis that could delay their chemotherapy.” Ovarian stimulation cycles can now be initiated anytime in the menstrual cycle, Shover noted, and many women are able to have two cycles before beginning their cancer treatment.

As a result, she recommends that referrals to reproductive endocrinology and infertility (REI) specialists be made early for women considering FP.

“Even if you’re not sure yet what her treatment plan is going to be, the earlier she knows her options and can consider them, the more she will be able to complete a couple of cycles and preserve more eggs or embryos,” said Schover.

Avoiding “Decision Regret”

Surveys show that less than 50% of oncologists routinely refer women for fertility preservation.^1,2 Schover urged practitioners to make the time to discuss FP options, despite the barriers to such consultations which researchers have identified, including a lack of time in a busy clinic, lack of knowledge about the options, and not having an easy way to refer patients for consultation, as well as a reluctance by some oncologists to mention FP to certain women, for example, those who already have children, those with a poor prognosis, or those who the provider feels will have difficulty affording it.

Nevertheless, initiating FP discussions will lower the likelihood of women experiencing “decision regret” and help to alleviate emotional distress, said Schover, citing her 2012 study of 240 women surveyed 10 years after cancer, 77 of whom had been unable to fulfill their wish for a child and who were significantly more distressed than other survivors.³ In another study of 560 women at risk of infertility, researchers found significant emotional benefits were derived from having an FP consultation and proceeding with FP, though the numbers were small: only 5% (n = 45) consulted with a fertility specialist and 4% (n = 36) proceeded with FP.⁴

Clinicians need to be mindful of the need for patients to make rapid decisions about FP at an already stressful time for them, but it’s important to at least bring up the issue and engage oncology team members in counseling and/or refer women directly to an REI specialist. Optimally, Schover said, this would entail having multidisciplinary care available on site—including a nurse practitioner or physician assistant in the clinic who can help to identify FP risks and refer patients for counseling—along with a referral network that includes trained mental health professionals and genetic counselors.

“This is a long-term issue that has a real impact on women’s lives,” stressed Schover. “Having the opportunity to consider the choice is something many women feel grateful for—even if they decide it’s not for them.”

References

• Forman EJ, Anders CK, Behera MA. A nationwide survey of oncologists regarding treatment-related infertility and fertility perseveration in female cancer patients. Fertil Steril. 2010;94(5):1652- 1656.
• Quinn GP, Vadaparampil ST, Lee JH, et al. Physician referral for fertility preservation in oncology patients: a national study of practice behaviors. J Clin Oncol. 2009;27(35):5952-5957.
• Canada AL, Schover LR. The psychosocial impact of interrupted childbearing in long-term female cancer survivors. Psychooncology. 2012;21(2):134-143.
• Letourneau JM, Ebbel EE, Katz PP, et al. Pretreatment fertility counseling and fertility preservation improve quality of life in reproductive age women with cancer. Cancer. 2012;118(6):1710-1717.