Pregnancy after breast cancer: case report and review of the literature

Fertility preservation and monitoring in adult patients diagnosed with lymphoma: consensus-based practical recommendations by the Fondazione Italiana Linfomi & Società Italiana della Riproduzione Umana

Introduction

Fertility preservation (FP) and monitoring has considerable relevance in the multidisciplinary approach to cancer patients. In these consensus-based practical recommendations, the scientific societies Fondazione Italiana Linfomi (FIL) and Società Italiana della Riproduzione Umana (SIRU) reviewed the main aspects and identified the optimal paths which aim to preserve and monitor fertility in patients diagnosed with lymphoma at the different phases of the disease and during long-term survivorship.

Methods

For the Panel, eleven experts were selected for their expertise in research and clinical practice on onco-fertility and lymphoma. The Panel's activity was supervised by a chairman. A series of rank-ordering key questions were proposed according to their clinical relevance and discussed among the Panel, focusing on patients diagnosed with non-Hodgkin's lymphomas and Hodgkin lymphoma. Agreement among all the Panelists on the content and terminology of the statements was evaluated by a web-based questionnaire according to the Delphi methodology.

Results

From the literature review a total of 78 questions or sentences, divided into the 6 areas of interest, were identified. By applying the Gwet's AC, k was: Section 1: 0,934 (Very good); Section 2: 0,958 (Very good); Section 3: 0,863 (Very good); Section 4: 0,649 (Good); Section 5: 0,936 (Very good); Section 6 raw agreement 100%. Two rounds of Delphi allowed to provide the maximum agreement. All statements were newly discussed in a round robin way and confirmed for the drafting of the final recommendations.

Discussion

These recommendations would be useful for onco-hematologists, gynecologists, urologists, and general practice physicians who take care of young lymphoma patients to guarantee an evidence-based oncofertility assessment and treatment during the oncologic pathway.

Extended adverse effects of cyclophosphamide on mouse ovarian function

PURPOSE

Most patients with cancer undergo multiple administrations of anticancer drugs during treatment, resulting in chronic impairment of their reproductive health. As improved treatment options increase cancer survival, it has become increasingly important to address fertility issues in cancer survivors. In this study, we examined the pathophysiological effects of multiple exposures to cyclophosphamide (Cy) on the ovaries of mice and their underlying molecular mechanism.

METHODS

Female C57BL/6 mice were intraperitoneally injected with 100 mg/kg Cy six times over 2 weeks; 4 weeks later, the mice were sacrificed and their ovaries, sera, and oocytes were collected for histological observation, measurement of anti-Müllerian hormone levels, and assessment of oocyte quantity and quality in response to hormonal stimulation. Gene expression changes in Cy-treated ovaries were examined by microarray and bioinformatics analyses.

RESULTS

After repeated Cy exposure, the anti-Müllerian hormone level was decreased, and follicle loss and impairments in the quality of oocyte were irreversible. The expression levels of genes involved in folliculogenesis, oogenesis, and zona pellucida glycoprotein transcription displayed sustained alterations in Cy-exposed ovaries even after 4 weeks.

CONCLUSION

The adverse effects of Cy on ovarian function and oocytes remained even after chemotherapy was complete. Therefore, strategies to prevent ovarian damage or restore ovarian function after treatment are required to safeguard the fertility of young cancer survivors.

Samul-tang ameliorates oocyte damage due to cyclophosphamide-induced chronic ovarian dysfunction in mice

Samul-tang (SM), a traditional herbal medicine, has been used to treat menstrual irregularities and infertility in women. However, the cellular and molecular mechanisms underlying the effects of SM remain elusive. We investigated the potential protective effect of SM against chronic ovarian dysfunction and used bioinformatics analysis to identify its underlying mechanism in a mouse model of cyclophosphamide (CP)-induced diminished ovarian reserve. Female C57BL/6 mice were intraperitoneally injected with CP three times a week, followed by oral administration of distilled water (CP group) or SM (CP + SM group) for 4 weeks. Four weeks later, the effect of SM was assessed by ovarian tissue histological analysis, steroid hormone measurement, oocyte quality, and mRNA and microRNA microarray analysis in the ovaries. Although SM administration did not prevent CP-induced follicle loss in mice, the quality of oocytes was better in CP + SM mice than in CP mice. Gene expression analysis revealed that the expression of fertilisation- and ovarian follicle development-related genes was altered by CP treatment but normalized after SM administration. Further bioinformatics analysis showed possible interactions between differentially expressed mRNAs and microRNAs. Therefore, we demonstrated the protective effects of SM on ovarian function and oocyte maturation against CP-induced damage via multiple epigenetic mechanisms.

Breast cancer in young women: special considerations in multidisciplinary care

Breast cancer is one of the most prevalent cancers in females, and 5%-7% of breast cancer cases occur in women under 40 years of age. Breast cancer in the young has gained increased attention with an attempt to improve diagnosis and prognosis. Young patients tend to have different epidemiology, presenting with later stages and more aggressive phenotypes. Diagnostic imaging is also more difficult in this age group. Multidisciplinary care generally encompasses surgeons, medical oncologists, radiation oncologists, radiologists, and social workers. Other special considerations include reconstruction options, fertility, genetics, and psychosocial issues. These concerns enlarge the already diverse multidisciplinary team to incorporate new expertise, such as reproductive specialists and genetic counselors. This review encompasses an overview of the current multimodal treatment regimens and the unique challenges in treating this special population. Integration of diagnosis, treatment, and quality of life issues should be addressed and understood by each member in the interdisciplinary team in order to optimize outcomes.

Matching methods to create paired survival data based on an exposure occurring over time: a simulation study with application to breast cancer

Background

Paired survival data are often used in clinical research to assess the prognostic effect of an exposure. Matching generates correlated censored data expecting that the paired subjects just differ from the exposure. Creating pairs when the exposure is an event occurring over time could be tricky. We applied a commonly used method, Method 1, which creates pairs a posteriori and propose an alternative method, Method 2, which creates pairs in “real-time”. We used two semi-parametric models devoted to correlated censored data to estimate the average effect of the exposure HR¯(t): the Holt and Prentice (HP), and the Lee Wei and Amato (LWA) models. Contrary to the HP, the LWA allowed adjustment for the matching covariates (LWA_a) and for an interaction (LWA_i) between exposure and covariates (assimilated to prognostic profiles). The aim of our study was to compare the performances of each model according to the two matching methods.

Methods

Extensive simulations were conducted. We simulated cohort data sets on which we applied the two matching methods, the HP and the LWA. We used our conclusions to assess the prognostic effect of subsequent pregnancy after treatment for breast cancer in a female cohort treated and followed up in eight french hospitals.

Results

In terms of bias and RMSE, Method 2 performed better than Method 1 in designing the pairs, and LWA_a was the best model for all the situations except when there was an interaction between exposure and covariates, for which LWA_i was more appropriate. On our real data set, we found opposite effects of pregnancy according to the six prognostic profiles, but none were statistically significant. We probably lacked statistical power or reached the limits of our approach. The pairs’ censoring options chosen for combination Method 2 - LWA had to be compared with others.

Conclusions

Correlated censored data designing by Method 2 seemed to be the most pertinent method to create pairs, when the criterion, which characterized the pair, was an exposure occurring over time. In such a setting, the LWA was the most appropriate model.

Childbearing attitudes and decisions of young breast cancer survivors: a systematic review

BACKGROUND

Young breast cancer survivors often need to deal with adverse effects of treatments on fertility and complex reproductive decisions. In this systematic review, we highlight what is known about childbearing and parenthood attitudes and decisions of young breast cancer survivors from their own perspective.

METHODS

We conducted manual and electronic searches on Pubmed, PsychInf and CINAHL databases for articles, published in English between 1 January 1990 and 31 October 2012, that assessed childbearing, pregnancy and parenthood attitudes/decisions of female breast cancer survivors (premenopausal and/or <50 years old). Eligible articles were classified into quantitative studies, qualitative studies and mixed methods studies. Data from each study were individually extracted by all the authors, and standardized tables were created and discussed to ensure congruence of the information extracted.

RESULTS

Of the 493 publications identified in PubMed (results are presented for PubMed searches as the other databases did not yield any new relevant papers), 8 met the inclusion criteria, in addition to 2 publications retrieved manually. A total of 10 studies provided information on pregnancy and parenthood attitudes and decisions, in addition to risks and benefits of childbearing after breast cancer. Survivors had mixed attitudes towards the issue. Fear associated with future pregnancy was reported, namely the risk of cancer recurrence. However, for many survivors, pregnancy and parenthood can represent normalcy, happiness and life fulfilment.

CONCLUSIONS

Childbearing after breast cancer is an important issue for survivors. Future larger and prospective studies should be implemented to increase certainty of conclusions of current research. Clinicians may benefit from a deeper understanding of the importance of pregnancy and parenthood to survivors in order to provide the needed educational and psychosocial support services, overcome misinformation and better assist women with their fertility-related decisions.

Pregnancy despite ovarian insufficiency in a patient with breast cancer

Future fertility is a concern for many young breast cancer survivors. Secondary amenorrhea occurs frequently during or soon after oncologic treatment. Return of menstruation and serum biomarkers are not absolute predictors of future fertility. We report a case of a 28 year old gravida 0 with recurrent Stage IIB invasive ductal breast carcinoma who managed to conceive twice despite showing clinical and biochemical signs of decreased ovarian reserve following treatment with chemotherapy and radiation. This case illustrates the potential for fertility in a patient with breast cancer despite chemotherapy-related amenorrhea and undetectable anti-Müllerian hormone levels. It exemplifies the imprecise nature of all clinical tests used to predict future fertility in breast cancer patients post-treatment. It should remind all providers to be careful in basing recommendations for childbearing on these surrogate endpoints.

Embryo banking between induction and consolidation chemotherapy in women with leukemia

OBJECTIVE

To report the results of controlled ovarian hyperstimulation (COH) after long-acting GnRH agonist (GnRH-a) and chemotherapy for the purposes of embryo cryopreservation.

DESIGN

Case report.

SETTING

University medical center.

PATIENT(S)

Two premenopausal women with acute myelogenous leukemia with recent treatment with GnRH-a and induction chemotherapy for hematopoietic cell transplantation (HCT).

INTERVENTION(S)

COH with embryo cryopreservation.

MAIN OUTCOME MEASURE(S)

Numbers of oocytes and embryos cryopreserved.

RESULT(S)

Both patients responded to gonadotropin stimulation and cryopreserved embryos.

CONCLUSION(S)

Women who have received recent long-acting GnRH-a and chemotherapy may respond to gonadotropin stimulation. The option of embryo banking can be offered to leukemia patients who are preparing for HCT.