Cancer Treatment and Fertility: by Marie Ennis O'Connor

With the support of Prof. Donal Brennan in the Mater Hospital and UCD, this month we are very fortunate to be joined for a talk by Prof Martha Hickey, Head of the Gynaecological Research Centre as the University of Melbourne and Royal Women’s Hospital, Victoria, Australia, a world expert in supporting women with reproductive symptoms associated with cancer treatment.

Symptoms such as induced menopause, loss of fertility and psychosexual issues are common for women being treated for cancer and they pose a big burden for them and their loved ones. Many researchers will be unfamiliar with these effects and consequences of treatment so we are very grateful to Marie Ennis O’Connor, a patient advocate, who has penned a description of the impact of cancer treatment on her fertility and thoughts and advice for other women that might be facing these challenges.

While breast cancer is still primarily a disease of older women (only approximately 25% of cases occur in women younger than 50 years), the absolute number of younger women diagnosed with breast cancer has steadily increased in recent years.

The good news is that in the last decade the mortality rate from breast cancer has steadily declined, with the greatest gains among younger women. However, although younger women are surviving longer because of advancement in treatments, studies suggest that adaptation and quality of life after breast cancer is more difficult for them.

Quality of Life (QoL) is a person's sense of well-being that stems from satisfaction or dissatisfaction with aspects of life that are important to him/her. For many young women with breast cancer, the ability to have children is a prime consideration in their quality of life after treatment. The use of chemotherapy and endocrine therapies in the treatment of premenopausal women carries with it reproductive implications that must be considered. Interventions to preserve fertility generally need to be accessed before chemotherapy, but many women do not receive information regarding these options in a timely fashion.

I know this from personal experience. In my early thirties I was diagnosed with breast cancer but I wasn’t given any fertility-related information. I only found out about it on the Internet late one night when I had already started chemotherapy. It was extremely distressing to find out this way. It’s a conversation that I should have had with my oncologist before I started treatment. If I had known then what I know now about the impact of breast cancer on my future fertility, I would have made different choices at the time. Today I share my story in the hope that if you are reading this as a young woman who has just received a diagnosis of breast cancer, you will know there are things you can do to retain your fertility.

Back in 2004, the year in which I was diagnosed, a group of researchers surveyed 657 members of the Young Survival Coalition (YSC), a breast cancer patient advocacy group, on their attitudes about fertility. 57% of patients reported being very concerned about becoming infertile, regardless of their age or stage of disease, while 29% said concern about infertility influenced their decisions about treatment. The researchers highlighted the need for more data on the impact of treatment on fertility, as well as the development of new approaches to preserving fertility in women treated for breast cancer.

Fast forward to a 2012 study which concluded that receiving specialized counselling about reproductive loss and pursuing fertility preservation is associated with less regret and greater quality of life for survivors. And yet “few patients are exposed to this potential benefit.”

It dismays me that all these years later, there’s still a real need to educate young patients regarding fertility issues and a need for more research directed at preserving fertility. Guidelines presented by the American Society of Clinical Oncology (ASCO), American Society of Reproductive Medicine (ASRM), and National Comprehensive Cancer Network (NCCN) all state that premenopausal women diagnosed with breast cancer should be informed about the potential impacts of treatment on their fertility and should be given the opportunity for a fertility referral in a timely fashion.

How Does Cancer Treatment Affect Fertility?

Infertility can be a side-effect in young women having cancer treatment because of the sensitivity of a woman’s eggs to anti-cancer drugs. The effect of treatment on fertility depends on your type of cancer, where it is, your age, gender, the type of cancer treatment you undergo and your response to treatment. Some breast cancer therapies may cause women to stop menstruating, either temporarily or permanently, and women who continue to have normal menstrual cycles may go through menopause earlier or may be less fertile following chemotherapy. In addition, while standard hormone-based cancer therapies do not typically cause permanent infertility, they often require years of treatment during which women are advised not to become pregnant.

What Are Your Fertility Options?

Standard fertility preservation options like embryo and egg freezing can offer an opportunity to save fertility for patients who have the time and resources to undergo ovarian stimulation and retrieval. Ovarian tissue freezing—a procedure that removes and freezes ovarian tissue for later use could offer an alternative for women who can’t undergo egg freezing for medical reasons. While egg and embryo freezing can take weeks to complete, an ovarian tissue freezing procedure can be done quickly. The procedure, which is still considered experimental, may be a promising option for the future, but far more research is needed to prove its success.

Is It Safe To Get Pregnant After Breast Cancer?

If you are fertile after your treatment finishes, there is no evidence to suggest that getting pregnant increases your risk of your cancer returning. However, most women are advised to wait at least 2 to 3 years after a breast cancer diagnosis before becoming pregnant. Because the risk of cancer recurrence is higher earlier in survivorship, waiting to get pregnant is a way to prevent the difficult situation of finding a cancer recurrence early in pregnancy.

Other Parenting Options

If fertility treatments aren’t a good choice for you, there are other ways to have a family after breast cancer, such as surrogacy and adoption. Today, more adoption agencies are open to helping cancer survivors have a family. Your oncologist can support your application by writing a letter which outlines your cancer type, stage, treatment plan, and expected prognosis.

Which Questions Should You Ask Your Oncology Team?

Before beginning cancer treatment, multiple decisions need to be made in a short amount of time which can lead to additional stressors. However, it is important to talk to your medical team before you start treatment about the possible effects it may have on your fertility. Having a clearer understanding of your personal fertility risks and treatment options will help you make more informed decisions about your health care.

Some questions you might ask before undergoing treatment are:

• Will my cancer treatments affect my fertility?
• Is my infertility likely to be temporary or permanent?
• Can anything be done to preserve my fertility before my treatment begins?
• Will any of the options to preserve my fertility interfere with my cancer treatment?
• Can you refer me to a fertility specialist before treatment?

Some questions to ask after treatment are:

• How will I know if I am fertile after treatment?
• How long will it take for my periods to return?
• How long should I wait after treatment to become pregnant?
• If I become infertile, what are my parenthood options?

Being diagnosed as a young woman with breast cancer brings its own unique challenges. Today, more women than ever survive breast cancer, only to confront the long-term effects of treatment on their fertility. While at the time of diagnosis, the focus is understandably on having your life saved, this can sometimes mean that issues such as fertility get overlooked. It’s important that you know you have a right to get your fertility-related questions answered, and this may mean you may need to advocate for yourself and your reproductive future. For many young women, preserving their fertility before starting treatment represents not just surviving the disease, but going on to live a fulfilling life.