Gonadotoxic therapies, such as chemotherapy, used to treat breast cancer can have harmful effects on fertility- they destroy ovarian follicles, or women's reserve of ova, resulting in amenorrhea and/or early menopause. Additionally, many endocrine therapies used to treat breast cancer have indirect effects on fertility, often impairing ovulatory and endometrial function.
Approximately 11% of women diagnosed with breast cancer are under age 45, and one of the largest predictors of infertility after cancer treatment in women is age: 5% of women diagnosed with cancer at age 30, 32% of women diagnosed at age 35, and 80% of women diagnosed at age 40 are infertile after cancer treatment. Women under age 45 have unique survivorship concerns- including the risk of infertility due to cancer treatment.
Current guidelines from both the American Society of Clinical Oncology (ASCO) and the American Society for Reproductive Medicine (ASRM) recommend discussing the impact of cancer treatment on fertility and fertility preservation options with all reproductive-aged patients. These discussions need to take place as early as possible following a cancer diagnosis so there is time to consider all fertility preservation options.
It is unknown how many women in the United States are at risk for loss of fertility following breast cancer treatment. A recently published article by Trivers et al. (2014) in The Oncologist, estimated the number of breast cancer survivors in the U.S. at risk of infertility for whom fertility preservation education is necessary. Trivers et al. (2014) also estimated the number of at-risk survivors who may desire pregnancy and therefore may benefit from a more in-depth fertility preservation consultation as well.
The study combined data from several different sources:
- National Program of Cancer Registries (NPCR)
- National Cancer Institute’s (NCI’s) Surveillance, Epidemiology, and End Results (SEER) program
- NPCR's 2004 Breast and Prostate Cancer Data Quality and Patterns of Care (PoC) study
- 2006-2010 National Survey of Family Growth (NSFG)
In the cancer registry data, an average of 20,308 women with breast cancer aged <45 years were diagnosed annually. Based on estimates from PoC data, almost all of these survivors (97%, 19,416 women) were hormone receptor positive or received chemotherapy and would be at risk for infertility. These women should receive information about the impact of treatments on fertility. Estimates based on NSFG data suggest approximately half of these survivors (9,569 women) might want children and could benefit from fertility counseling and fertility preservation.
Trivers et al. (2014) conducted the first study determining that nearly all young women diagnosed with early stage breast cancer will receive therapy and treatment that puts them at risk for infertility, and approximately half of at-risk survivors may be interested in having children in the future. Therefore health care providers should discuss the potential impact of cancer treatment on fertility with all reproductive-aged patients diagnosed with cancer and refer them to a fertility specialist before cancer treatment begins.
Unfortunately, barriers exist which prevent young women diagnosed with early stage breast cancer from receiving the needed information regarding their future fertility. Many survivors have reported not receiving information about how cancer treatment effects fertility and/or available fertility preservation options. Nevertheless, health care providers have a critical role in discussing potential risk of infertility in the context of treatment decision making and determining the patient’s interest in having children. Additionally, financial constraints make it difficult for women to proceed with fertility preservation procedures. Cancer survivors should have access to and coverage for fertility preservation services given the risk of potential infertility and the subsequent quality-of-life implications. The American Medical Association (AMA) recently released a policy supporting coverage by all insurance companies of fertility preservation techniques for cancer patients requiring treatment that may result in infertility.
In conclusion, Trivers et al. (2014) data showed the importance of and the need for fertility preservation consultations and access to oncofertility specialists among almost all young women diagnosed with breast cancer.