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Fertility Clinic Referral for Breast Cancer Patients: The Sooner the Better
by Dr. Ellen Warner, MD, M.Sc., FRCPC, FACP
Contrary to long-held myths, we now know from well-designed studies that:
- Newly diagnosed breast cancer patients don’t just care about surviving breast cancer. They also want to have normal lives once their treatment is over and retaining the ability to get pregnant is at the top of their agenda. This is more of an issue now than it was several decades ago because, since women today tend to delay childbearing, many young breast cancer patients haven’t even started let alone completed their families.
- Getting pregnant after a breast cancer diagnosis, whether it ends in miscarriage or a healthy live birth, is safe even for patients with hormone sensitive (ER+) tumors.
This is excellent news for our young breast cancer patients. But things are not so simple. Chemotherapy damages the ovaries and probably shortens a woman’s natural fertility span by 5 to 10 years. Tamoxifen, which is often prescribed for at least 5 years, doesn’t damage the ovaries but it does cause fetal malformations so women must not get pregnant while taking the drug. Since fertility drops with age, delaying pregnancy to take several years of tamoxifen means a greater risk of infertility.
Fortunately, there are now excellent fertility preservation options for women who need chemotherapy and/or tamoxifen but want to maximize their chance of having one or more babies in the future. Women in stable relationships can have embryos (fertilized eggs) frozen while single women can freeze unfertilized eggs. While both procedures require a brief period of hormonal stimulation to enable the harvesting of multiple eggs, studies to date show no evidence of an increase in cancer recurrence rates. Fertility preservation takes several weeks, must be completed before chemotherapy or tamoxifen is started and may require difficult personal and financial decisions for some women. Consequently, the earlier a woman is referred to a fertility specialist (ideally right after her breast cancer diagnosis), the more time she’ll have to make these decisions and the less likely it is that her cancer treatment will have to be delayed.
Discussion of fertility issues with all newly diagnosed breast cancer patients of reproductive age and early referral to a fertility clinic, if appropriate, has been strongly recommended by the American Society of Clinical Oncology. Unfortunately, however, the majority of young breast cancer patients are not getting the opportunity to have fertility preservation. Barriers include lack of information for oncologists and patients, and lack of access to fertility clinics.
In Canada, the new CKN Oncofertility Referral Network is a most welcome solution to these issues. From our experience at our cancer centre with PYNK: Breast Cancer Program for Young Women, we have discovered that by disseminating fertility information to oncologists and patients, and with close co-operation between oncologists and fertility specialists, we can ensure that every patient (for whom fertility preservation is appropriate) receives a timely referral to a fertility clinic. Thanks to the CKN Oncofertility Referral Network, young breast cancer patients across Canada will have the same opportunity.
Dr. Warner is a medical oncologist and Professor of Medicine at the University of Toronto who has been at the Odette Cancer Centre since 1993, where her practice and research have been devoted to breast cancer. In 1994, she created a program for hereditary breast and ovarian cancer patients, which introduced genetic counseling and testing to the Odette Cancer Centre. Related research includes the determination of mutation prevalence in patient subgroups, gene-environment interactions and the development of validated educational materials for patients and physicians. Since 1997, she has led a study to explore the role of magnetic resonance imaging (MRI) in screening women with an inherited predisposition to develop breast cancer which has helped make annual MRI surveillance the standard of care for this very high risk population. Over the last few years she has created PYNK: Breast Cancer Program for Young Women, an interdisciplinary clinical and research program for young breast cancer patients which was officially launched in 2008. This program, the only one of its kind in Canada, addresses the unique tumour biology as well as the special medical and psychosocial needs of this population.