Physical and mental health correlates of pregnancy following breast cancer

Psychological Aspects of Pregnancy and Lactation in Patients with Breast Cancer

Young breast cancer patients face numerous challenges during the cancer trajectory. As in the last decade, women tend to delay pregnancies to a later time in life, and clinicians are often faced with young breast cancer patients who want to start a family or complete it. Becoming a mother is a delicate developmental process in which the woman redefines and restructures her identity as she gets prepared for her new role and responsibilities. When there is a history of cancer or cancer diagnosis is communicated during the pregnancy, fears, worries, and concerns emerge and specific support may be necessary. Follow-ups during the post-partum period are also recommended as lactation issues should not be overlooked. In this chapter, we analyze the psychological aspects of cancer survivors and women with pregnancy-associated breast cancer, and the management of these issues.

Mortality of Pregnancy Following Breast Cancer Diagnoses in Taiwanese Women

BACKGROUND

This work examined the association between pregnancy after breast cancer (BC) diagnosis and total mortality in Taiwanese patients with BC.

MATERIALS AND METHODS

The Taiwan Cancer Registry, National Health Insurance database, and Taiwan National Death Certificate database were reviewed. Patients who became pregnant after being diagnosed with BC were selected (n = 249). Four nonpregnant patients with BC were selected and matched to every pregnant patient with BC by age at diagnosis, year at diagnosis, and propensity score based on disease stage, tumor size, node involvement, and histological grade. The disease-free time interval for the selected control needed to have been longer than the time interval between the cancer diagnosis and pregnancy for the index case. Follow-up was calculated from the pregnancy date of the index case to the date of death or December 31, 2014, whichever came first. Cox proportional hazards models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

After adjusting for age, year at BC diagnosis, stage, positive nodes, and hormone therapy, patients with BC who became pregnant after their cancer diagnosis had lower total mortality than did the comparison group (HR = 0.44, 95% CI = 0.23-0.84), including that of estrogen receptor-positive patients (HR = 0.23, 95% CI = 0.07-0.77). The inverse association was more pronounced for those who became pregnant more than 3 years after diagnosis (HR = 0.19, 95% CI = 0.05-0.78).

CONCLUSION

Our nationwide retrospective analysis revealed that pregnancy after BC diagnosis was associated with lower mortality than that of nonpregnant patients with BC at a similar age, year at diagnosis, and clinical characteristics.

IMPLICATIONS FOR PRACTICE

This article provides high-level evidence based on an Asian population for pregnancy counseling after a breast cancer diagnosis, including for patients with estrogen receptor-positive cancers. The study also revealed the optimal time for patients who would like to become pregnant after breast cancer.

Motherhood during or after breast cancer diagnosis: A qualitative study

OBJECTIVE

Little is known about the process of becoming a mother in women who experienced a breast cancer diagnosis (BC). In this qualitative study, we investigated maternal representations in pregnant women with experience of BC and those with no oncological history.

METHODS

A total of 38 women were recruited, 19 women who experienced a BC diagnosis and 19 who had not. To explore maternal representations, semi-structured interviews were conducted and analysed through thematic analysis.

RESULTS

Four main themes were identified: fears and worries, meaning of motherhood, mother-foetus relationship and partner support. Across themes, differences between primiparous and multiparous are reported. Women with gestational breast cancer (GBC) described fear for their own and their child's survival. Women with previous BC recall contrasting emotions. All women with experience of BC perceived breastfeeding as fundamental and inability to do so provoked worry. Relationship with the partner was considered central, while healthy women were projected towards the future triadic relationship.

CONCLUSIONS

Finding a mental space during pregnancy for the representation of the future child could be hard for women with GBC. Dissimilarities in the experience of motherhood in cancer patients provide insight into psychological aspects that should be taken into account in clinical practice.

Safety of pregnancy after surgical treatment for breast cancer: a meta-analysis

PURPOSE

Because of the rising trend of delayed pregnancies, more and more women remain nulliparous at the diagnosis of breast cancer, and approximately 71% of them desire to conceive after breast cancer treatment. Advances in breast cancer screening have made early diagnosis of breast cancer possible, and many patients have the opportunity to be treated by surgery. In this study, we conducted a meta-analysis to evaluate the effect of pregnancy on patient survival and prognosis after surgical treatment for breast cancer.

METHODS

An electronic search was performed in MEDLINE (PubMed), EMBASE, and Web of Science to identify potentially eligible studies published before August 2013. Both fixed-effect and random-effect models were used to calculate the pooled relative risk (PRR). The Q test and I(2) statistics were used to assess the heterogeneity among the studies.

RESULTS

A total of 5 studies were included in our meta-analysis. Five hundred fifty-four patients who become pregnant after surgical treatment for breast cancer were compared with a control group of 2354 patients for overall survival (OS). Our analysis demonstrated that pregnancy after surgical treatment for breast cancer had a significant beneficial effect on OS (PRR, 0.78; 95% confidence interval, 0.64-0.95). The disease-free survival outcome also favored patients in the pregnancy group (PRR, 0.87; 95% confidence interval, 0.71-1.08).

CONCLUSIONS

This meta-analysis indicates that pregnancy after surgical treatment does not increase the risk of breast cancer recurrence and may actually improve OS.

Chemotherapy for gynaecological malignancies and fertility preservation

Infertility is an increasingly important issue for patients surviving cancer. Significant improvements in cancer management have led to greater numbers of patients living healthy and fulfilling lives for many years after a diagnosis of cancer, and the ability to bear children is a major component of well-being. Infertility is particularly challenging in gynaecological cancer, where multiple treatment modalities are often employed. Surgery may involve the removal of reproductive organs and subsequent chemotherapy may also lead to infertility. Mitigation of this through the use of cryopreservation of embryos, oocytes or ovarian tissue before chemotherapy may enable subsequent pregnancy in the patient or a surrogate mother. Suppression of ovarian function during chemotherapy is less well established, but promises a reduction in infertility without the risks associated with surgery. Similarly, evolving chemotherapy regimens with replacement of alkylating agents will reduce the incidence of infertility. With a combination of these techniques, an increasing proportion of patients may be able to conceive after completion of treatment, and there is no evidence of an increase in congenital abnormalities. This review discusses chemotherapy-induced infertility, interventions and success rates, and demonstrates that individualisation of management is required for optimum outcome.

Pregnancy after Breast Cancer: Myths and Facts

Most young breast cancer survivors consider reproductive issues to be of great importance, but many questions remain undervalued and unanswered. Overall, available data support the safety and feasibility of pregnancy and breastfeeding after breast cancer. The accuracy of the evidence is however limited by: i) the retrospective and frequently incomplete population-based nature of the data, ii) data not representing the entire population, iii) patient-related effects, iv) underpowered sample size, and v) lack of control for biological factors and risk determinants. We review the available evidence in light of these limitations which outline the need for prospective data collection and focused priority research.

Quality of life, fertility concerns, and behavioral health outcomes in younger breast cancer survivors: a systematic review

BACKGROUND

Breast cancer is the most common cancer in women younger than age 50 years. Cancer treatments in younger women may cause premature menopause, infertility, and negative psychosocial effects. In this systematic review, we examined three key domains of functioning that are particularly relevant for younger breast cancer survivors: health-related quality of life (QOL), menopausal symptoms and fertility concerns, and behavioral health outcomes.

METHODS

We conducted a literature review using PubMed and secondary sources and examined 840 articles published between January 1990 and July 2010. Inclusion criteria for articles were 1) published in English after 1989; 2) exclusively analyzed female breast cancer survivors aged 50 years or younger or premenopausal at diagnosis, with baseline characteristics and/or quantitative or descriptive analyses for this age group; 3) investigated QOL (health-related QOL including physical functioning and mental health, depression, and anxiety), menopause- or fertility-related concerns, and weight gain or physical activity-related behavioral health outcomes. Data were extracted using a standardized table collecting the purpose, design, population, and results of each study. Extracted data were reviewed for accuracy by two investigators and presented as descriptive tables.

RESULTS

A total of 28 articles met the inclusion criteria (15 cross-sectional studies, eight longitudinal studies, and five randomized trials). Regarding data review, no discordance between investigators was noted. Standardized measures of QOL and depressive symptoms identified worse outcomes as being more frequent or severe in breast cancer survivors aged 50 years or younger when compared with the general age-matched population of women without cancer and to older women (aged >50 years) with breast cancer. Concerns about premature menopause, menopausal symptoms, and infertility were common in younger women (aged ≤ 50 years) and had a role in the level of distress after treatment. Weight gain and physical inactivity were common health outcomes in younger women.

CONCLUSIONS

Younger women with breast cancer were found to experience distinct psychosocial and menopause-related concerns, weight gain, and physical inactivity. A need for more longitudinal research, including efforts at intervention to manage these symptoms and adverse health outcomes, remains.

Motherhood after breast cancer: searching for la dolce vita

Advances in the field of adjuvant therapy in breast cancer have led to significant improvements in breast cancer survival. This has resulted in a progressive decline in breast cancer-related mortality, such that in 2010 there were estimated to be 400,000 breast cancer survivors under the age of 40 in the USA. Hence, enquiry into the feasibility of fertility preservation, subsequent pregnancy and breastfeeding is increasingly encountered. Fertility counseling remains suboptimal in breast cancer clinics, and there is a wide perception that pregnancy could worsen the prognosis of young breast cancer survivors, despite the lack of evidence supporting this notion. In addition, fertility preservation by means of embryo or oocyte cryopreservation requires ovarian stimulation, which is associated with a significant rise in estradiol levels and might delay initiation of therapy. All these factors, and others, have influenced the quality of fertility counseling offered to young breast cancer patients. In this article, we will critically analyze the available clinical and biological evidence on the safety and feasibility of pregnancy and breastfeeding following breast cancer. In addition, we will discuss the different fertility-preservation techniques available for these patients.

Depressive symptoms among young breast cancer survivors: the importance of reproductive concerns

Breast cancer diagnosis and treatment can negatively impact fertility in premenopausal women and influence reproductive planning. This study investigates whether concerns about reproduction after breast cancer treatment were associated with long-term depressive symptoms. Participants include 131 women diagnosed with early-stage breast cancer at age 40 or younger participating in the Women's Healthy Eating and Living (WHEL) Survivorship Study. Participants were enrolled an average of 1.5 years postdiagnosis and depressive symptoms were monitored 6 times throughout the average additional 10 year follow-up period. Detailed recall of reproductive concerns after treatment was collected an average of 12 years postdiagnosis. Multilevel regression was used to evaluate whether mean long-term depressive symptoms differed as a function of reproductive concerns and significant covariates. Multilevel regression identified greater recalled reproductive concerns as an independent predictor of consistent depressive symptoms after controlling for both social support and physical health (B = 0.02, SE = 0.01, P = 0.04). In bivariate analyses, being nulliparous at diagnosis and reporting treatment-related ovarian damage were both strongly associated with higher reproductive concerns and with depressive symptoms. Reported reproductive concerns after breast cancer treatment were a significant contributor to consistent depressive symptoms. Younger survivors would benefit from additional information and support related to reproductive issues.