One of the aspects of cancer treatment I have become intimately aware of since my own experience with leukemia, is the collateral damage of all of the treatments patients undergo. Second cancers, heart disease, neuropathy and leukemia are often mentioned the most, but there is another pressing issue that often gets less attention: infertility.
Not that long ago, most women had their children in their twenties. Now, with the luxury of contraception and with the addition of successful assisted reproductive technology (ART), women are able to decide to not have children until they are in their thirties or forties. This means we are seeing more women diagnosed with premenopausal breast cancer who have not yet had children. Fertility after cancer treatment affects people with all different types of cancers. But it is especially complicated in breast cancer, where treatments may include ovarian suppression for women with hormone-sensitive tumors or the recommendation of a preventative removal of the ovaries for women who carry a BRCA1 or BRCA2 mutation.
Pamela Munster, an oncologist at the University of California, San Francisco Helen Diller Family Comprehensive Cancer Center addressed all of these issues in a comprehensive review of both the problems and the options published on June 17 in Oncology. [http://www.cancernetwork.com/breast-cancer/content/article/10165/2145852]
As she points out, the NSBAP B30 study [http://www.nsabp.pitt.edu/B-30.asp] found that women whose periods stopped during chemotherapy and did not start again were less likely to have a recurrence or die from breast cancer, even if their tumors were estrogen negative. Another study, the International Breast Cancer Study Group Trial VIII [http://www.ncbi.nlm.nih.gov/pubmed/21325445] suggested that adding goserelin (Zoladex) to the chemotherapy regimen standard at the time the study was conducted (CMF) increased survival. In addition, recent studies have shown that 10 years of tamoxifen (the hormone therapy used to treat premenopausal women who don’t take a drug to stop ovarian functioning) is better than five. And since women taking tamoxifen are discouraged from getting pregnant (the drug can cause birth defects), this finding extends the time after a breast cancer diagnosis when women is advised against getting pregnant.
This conflict between better overall survival through ovarian suppression and the desire to have children is a hard trade off. Luckily, women can now take advantage of assisted reproductive technologies that allow them to freeze eggs or embryos, so that they can try to get pregnant after their treatment is over. But for women to have this option, we need to make sure that oncologists discuss fertility with their patients and refer those interested in having children to a reproductive endocrinologist before they start their cancer treatment. It is also important for those of us who talk to women who are newly diagnosed—as I know many of you do—to pass on this information. Another excellent source of information and support is Fertile Hope [http://www.fertilehope.org/], now a program of the Livestrong Foundation. (They may be able to offer financial assistance as well.)
It’s wonderful that cancer doesn’t have to end the dream of having a child. But the need for women to make these choices highlights the limitations and complications of treatments, even when they are successful. It all brings me back to my mantra: We need to find the cause and end breast cancer.