Controversies in preservation of ovary function and fertility in patients with breast cancer

Japan Society of Clinical Oncology Clinical Practice Guidelines 2017 for fertility preservation in childhood, adolescent, and young adult cancer patients: part 2

The Japan Society of Clinical Oncology (JSCO) published the "JSCO Clinical Practice Guidelines 2017 for Fertility Preservation in Childhood, Adolescent, and Young Adult Cancer Patients" in 2017. This was the first guideline in cancer reproductive medicine in Japan. In the field of cancer reproductive medicine, close cooperation between an oncologist and a physician for reproductive medicine is important from before treatment initiation until long after treatment. The guideline takes into consideration disease specificity and provides opinions from the perspective of oncologists and specialists in reproductive medicine that are in line with the current state of the Japanese medical system. It is intended to serve as a reference for medical staff in both fields regarding the availability of fertility preservation therapy before the start of cancer treatment. Appropriate use of this guideline makes it easier to determine whether fertility preservation therapy is feasible and, ultimately, to improve survivorship in childhood, adolescent, and young adult cancer patients. In this article (Part 2), we describe details by organ/system and also for pediatric cancer.

Oocyte and embryo cryopreservation before gonadotoxic treatments: Principles of safe ovarian stimulation, a systematic review

OBJECTIVE

Review the safety of fertility preservation through ovarian stimulation with oocyte or embryo cryopreservation, including cycle and medication options.

EVIDENCE REVIEW

A systematic review of peer-reviewed sources revealed 2 applicable randomized control trials and 60 cohort studies as well as 20 additional expert opinions or reviews.

RESULTS

The capacity for future family building is important for the majority of reproductive age people, despite life-altering medical or oncologic diagnosis. Modern fertility preservation generates a high rate of oocyte yield while utilizing protocols that can be started at multiple points in the menstrual cycle and suppressing supra-physiologic levels of estrogen. Finally, more than one quarter of fertility preservation patients will return to later utilize fertility services.

CONCLUSION

For most patients, fertility preservation can safely be pursued and completed within 2 weeks without affecting disease severity or long-term survival.

GnRHa for Ovarian Protection and the Association between AMH and Ovarian Function during Adjuvant Chemotherapy for Breast Cancer

Background: Chemotherapy impairs ovarian function in premenopausal breast cancer patients. Many breast cancer patients experience menopause earlier and therefore lose their reproductive abilities. The protective effect of gonadotropin-releasing hormone agonist (GnRha) upon the ovary is clearly apparent for hormone receptor (HR) negative patients, although the available data is not consistent for the patient body as a whole when considered regardless of HR status. It is also unknown whether levels of Anti-Mullerian Hormone (AMH) can reflect the influence of chemotherapy upon the ovary.

Methods: We randomly assigned 98 premenopausal breast cancer patients regardless HR-positive or -negative to receive either standard chemotherapy with GnRHa (GnRHa group) or standard chemotherapy without GnRHa (control group). Our primary end point was ovarian failure rate (OVF) at 1 year. In addition, we observed the change of AMH level during chemotherapy and the association between AMH and OVF.

Results: OVF was significantly lower (44.7%) in the GnRHa group than in the control group (80.6%; P=0.002). Median AMH levels were significantly higher before chemotherapy when compared to after 1/2cycles of chemotherapy, both in the GnRHa group (1.86ng/ml vs 0.12ng/ml; P=0.000) and in the control group (1.57ng/ml vs 0.10ng/ml; P=0.000). OVF was 91.3% in the AMH baseline level <1.1ng/ml group and 63.5% in the AMH baseline level >1.1ng/ml group (P=0.013).

Conclusion: Data showed that GnRHa may have a protective effect on young breast cancer patients regardless of HR during chemotherapy. AMH could reflect changes of OVF during chemotherapy and predict OVF after chemotherapy.

[Fertility preservation in women of the childbearing age: Indications and strategies]

Advances on cryopreservation techniques now allow considering oocyte, embryo or ovarian tissue freezing for female fertility preservation. Originally developed for patients suffering from cancer, fertility preservation has rapidly invaded others medical fields, and represents now the standard of care for all young patient diagnosed with a disease that could impair fertility or having to receive possibly gonadotoxic treatment. As a result, autoimmune diseases, some genetic pathologies or iterative pelvic surgeries, at risk of premature ovarian failure, have become common indications of fertility preservation. In addition, the social egg freezing aiming at preventing the age-related fertility decline is still debated in France, although authorized in numerous countries. This review will discuss the different strategies of fertility preservation in young girls and women of reproductive age, regarding different medical or non-medical indications.

Prevention of Early Menopause Study (POEMS): is it possible to preserve ovarian function by gonadotropin releasing hormone analogs (GnRHa)?

INTRODUCTION

The effect of GnRHa in the preservation of ovarian function during a modern chemotherapy is still under discussion.

MATERIAL AND METHOD

In this News and Views article, we discuss the benefits and weaknesses of the recently presented POEMS.

RESULTS

The POEM study demonstrated an increased resumption of ovarian function and pregnancy rate after using GnRHa. GnRHa in HR-negative patients led to a significant increase in disease free and overall survival, with those effects being inexplicable. Weaknesses of the trial were prematurely close due to lack of recruitment, a drop-out rate of 38 % during follow-up and definition of hormone receptor negativity by <10 % positive stained cells.

CONCLUSION

Even after POEMS, there is no additional clarity regarding preservation of ovarian function during chemotherapy by GnRHa.

[Vitrification: Principles and results]

Sperm and embryos cryopreservation is a commonly applied technique for several years. Recently authorized in France, vitrification tends to replace gradually the conventional technique of slow freezing, so upsetting the practices in the management of patients. It allows from now on the cryopreservation of oocytes and opens new perspectives in egg donation either still in fertility preservation. This review thus attempted to examine the contribution of vitrification in the freezing of oocytes and human embryos at various stages of development. If obviously vitrification appears as the current method of choice for the cryopreservation of oocytes as well as blastocysts, the results are less cut as regards embryos to early stages. No increase in adverse obstetric and perinatal outcomes in children conceived from vitrified oocytes or embryos is noted in the literature.

Fertility preservation and breast cancer: a review

Breast cancer is the most common malignancy in women, and its incidence increases with age, with the majority of patients diagnosed after menopause. However, in 15–25% of cases, patients are premenopausal at the time of diagnosis, and about 7% of them are below the age of 40. Therefore, a considerable amount of young women are diagnosed with breast cancer during their reproductive life. Within this group, most cancer cases require cytotoxic chemotherapy and/or hormone therapy, which are responsible for a decrease in the patients’ reproductive function, along with their age. The efficacy of such treatments, among other factors, has led to a high five-year-survival rate, which results in an increasing number of young women who survive breast cancer before having fulfilled their reproductive wishes, especially considering the current trend to delay pregnancy until the late 30s or early 40s in developed countries. The combination of these factors justifies the importance of fertility preservation and reproductive counselling at the time of breast cancer diagnosis in young women.

A wide range of fertility preservation techniques has been developed, such as ovarian suppression, oocyte and embryo cryopreservation, immature oocyte retrieval and in vitro maturation, and ovarian tissue cryopreservation.

Early counselling and referral of these patients to fertility specialists are fundamental factors in order to maximise their chances of pregnancy. This review aims to update the knowledge about the influence of breast cancer in fertility, the influence of pregnancy and fertility preservation techniques in breast cancer patients and assessment of ovarian reserve for a better treatment choice. A special section dedicated to BRCA-mutation carriers has been included because of their specific features.

A comprehensive literature search has been conducted, including publications from the last five years.

Is symptom-oriented follow-up still up to date?

The main objective of following patients after the primary treatment of breast cancer is the detection of potentially curable events, particularly the detection of local recurrences and contralateral breast cancer. Additionally, medical counseling on therapies, psychosocial aspects, side effects of therapies, and lifestyle interventions is important to improve the quality of life. There is an ongoing discussion about whether early detection of asymptomatic metastasis could improve the course of disease. Today, the follow-up is still symptom-orientated. Intensified imaging and laboratory check-ups have not been beneficial for the patients' survival. A follow-up in the first 2-3 years is recommended every 3 months. Because of the decreasing incidence of recurrence from year 4, 6-monthly screening intervals are recommended. The screening should include a history, physical examination, and a consultation. Routine diagnostic imaging - except for mammography/ultrasound - is not indicated in asymptomatic patients. Innovative therapies for patients with metastatic breast cancer have been introduced. Therefore, measures of an intensified follow-up could change in the future as novel endocrine combination or targeted therapies in molecular subtypes could significantly improve the survival in early detected metastasis. In the future, more individualized follow-up programs are conceivable. However, this idea is so far not supported by the available data.

Effect of leuprolide acetate on ovarian function after cyclophosphamide-doxorubicin-based chemotherapy in premenopausal patients with breast cancer: results from a phase II randomized trial

Previous studies provided inconclusive evidence for the effectiveness of gonadotropin-releasing hormone analogue on ovarian function protection against chemotherapy-induced genotoxicity in premenopausal patients. This study was designed to examine the efficacy of leuprolide acetate on ovarian function preservation in patients with breast cancer. A total of 220 patients were recruited in this prospective clinical trial and were assigned randomly to receive cyclophosphamide-doxorubicin-based chemotherapy only or chemotherapy plus leuprolide acetate. Resumption of menses or premenopausal levels of both follicle-stimulating hormone (FSH) and estradiol (E2) within 12 months after the end of chemotherapy were considered as effective ovarian preservation. A total of 183 patients were considered evaluable (94 in chemotherapy-only group and 89 in chemotherapy plus leuprolide acetate group). At the end of follow-up, 27 patients in chemotherapy group and 15 in chemotherapy plus leuprolide acetate group resumed menses; seven patients in chemotherapy group and 14 in chemotherapy plus leuprolide acetate group restored premenopausal levels of FSH and E2. The median time to resume menses was 9.2 months for patients in chemotherapy plus leuprolide acetate group and was not reached in chemotherapy-only group. In addition, our results demonstrated that age and chemotherapy doses made no significant difference in the occurrence of premature menopause. The leuprolide acetate treatment simultaneously with cyclophosphamide-doxorubicin-based chemotherapy reduced the risk of developing premature menopause in premenopausal patients with breast cancer.

Fertility outcome of breast cancer and Hodgkin's lymphoma female survivors: a growing clinical challenge for gynecologists and oncologists

The issue of taking into consideration future fertility in young women with breast cancer and Hodgkin's lymphoma [HL] will become more and more common and represent a growing clinical challenge for gynecologists and oncologists. The present paper will review literature data on the attempts of preventing chemotherapy-induced ovarian damage in these women and on their fertility outcome. Gonadotropin-releasing hormone [Gn-RH] agonists have been widely investigated as agents able to prevent ovarian failure in animal models and in humans. The majority of the studies on women with breast cancer and HL have shown a protective effect of Gn-RH agonists. A recent meta-analysis of five randomized trials, including 528 premenopausal breast cancer patients, revealed that relative risk [RR] of developing premature ovarian failure within one year was 0.40 (95% confidence interval [CI] = 0.21-0.75) for the women who received Gn-RH agonists with chemotherapy compared to those who received chemotherapy alone. However, the concurrent administration of Gn-RH agonists during chemotherapy appeared to have no effect on spontaneous pregnancy rates. Limited information are available about pregnancies in breast cancer and HL survivors, but the current literature appears to show no apparent increase in pregnancy complications, spontaneous abortions, or congenital abnormalities compared to general obstetric population.

Incidence of chemotherapy-induced amenorrhea in premenopausal women treated with adjuvant FOLFOX for colorectal cancer

BACKGROUND

Studies indicate that the incidence of young women diagnosed with colorectal cancer is rising, thus there is an increasing number of female colorectal cancer survivors of premenopausal and child-bearing age. Adjuvant FOLFOX (5-fluorouracil, leucovorin, and oxaliplatin) chemotherapy is the most widely used standard treatment for stage III and high-risk stage II colon cancer. We evaluated the incidence of FOLFOX-induced amenorrhea in women age 50 and younger treated with adjuvant therapy for colorectal cancer.

PATIENTS AND METHODS

A search of pharmacy records identified 119 women age 50 or younger who received adjuvant FOLFOX chemotherapy at Memorial Sloan-Kettering for stage II or III colorectal cancer from January 2002 and January 2011. Eligible patients were mailed an anonymous questionnaire. The returned surveys were reviewed and the results tallied.

RESULTS

Seventy-three patients returned the questionnaire. Twenty-four patients were excluded from analysis: 19 were treated with pelvic radiotherapy, 2 patients had undergone bilateral oophorectomy, 2 had a hysterectomy, and 1 stopped menstruating before diagnosis. Forty-nine patient responses were analyzed. In total, 41% (n = 20) experienced amenorrhea during chemotherapy. Sixteen percent had persistent amenorrhea 1 year after completion of chemotherapy. The incidence of amenorrhea during chemotherapy trended higher in patients aged older than 40 compared with patients aged 40 and younger (59% vs. 31% [P = .075]). There was no statistically significant difference in persistent amenorrhea between the 2 age groups (24% vs. 13%; P = .42).

CONCLUSION

In this retrospective series, there appears to be a trend toward FOLFOX induced amenorrhea during chemotherapy increasing with age. Twenty-four percent of women older than the age of 40 were found to have persistent amenorrhea after FOLFOX therapy. Because of the small sample size, the study is underpowered to detect a statistically significant difference between older and younger patients. Prospective studies are planned to further characterize the effect of FOLFOX on early menopause and fertility.

Physicians' knowledge, attitude, and behavior regarding fertility issues for young breast cancer patients: a national survey for breast care specialists

BACKGROUND

Fertility is one of the key aspects of quality of life for breast cancer patients of childbearing age. The objective of this study was to describe fertility-related practice for young breast cancer patients in Japan and to identify healthcare provider factors that contribute to physicians' behavior towards fertility preservation.

METHODS

A cross-sectional survey was developed in order for Japanese breast cancer specialists (n = 843) to self-evaluate their knowledge, attitude, and behavior regarding fertility preservation. Survey items included questions regarding knowledge of and attitude toward fertility issues in cancer patients, fertility-related practice, potential barriers for the discussion of fertility with patients, and responding physicians' socio-demographic background.

RESULTS

Four hundred and thirty-four (52%) breast oncologists responded to the survey. Female and younger oncologists (age less than 50 years) had significantly higher probability of referring patients to reproductive specialists. Physicians who had better knowledge score and positive attitudes toward fertility preservation were more likely to discuss potential fertility issues with cancer patients. This was significantly associated with consultation and referral to reproduction specialists when encountering fertility issues with cancer patients. Risk of recurrence, lack of collaborating reproductive specialists, and time constraints in the clinic were identified as major barriers to discussion of fertility preservation with breast cancer patients.

CONCLUSION

Female and younger physicians as well as physicians working in a multidisciplinary environment had positive attitudes and behavior towards fertility preservation in breast cancer patients. The development of comprehensive and interdisciplinary programs for healthcare providers is necessary to meet the expectations and fertility needs of breast cancer patients.

Major clinical research advances in gynecologic cancer in 2011

The annual review of 2011 comprised 11 themes of major research achievements in gynecologic oncology including breast cancer. A potential paradigm shift in the management of ovarian cancer was reviewed through comprehensive genomic analyses and a tumor-specific new intraoperative fluorescence imaging technique using folate receptor-α targeted agent, which is expected to improve intraoperative staging and more radical cytoreduction. In addition, updates of bevacizumab and poly (ADP-ribose) polymerase inhibitors, risk-reducing salpingo-oophorectomy, and risk evaluation of pelvic mass were discussed. Regarding cervical cancer, this review covered new findings on human papillomavirus vaccines and human papillomavirus tests as well as the current status of clinical trials on locally advanced cervical cancer. The promising role of sentinel lymph node biopsy in the management of early stage endometrial cancer was followed by two notable clinical researches on: exemestane, an aromatase inhibitor, for the prevention of breast cancer and eribulin, a non-taxane microtubule dynamics inhibitor for the treatment of metastatic breast cancer. Lastly, in premenopausal women with breast cancer, the effect of gonadotropin-releasing hormone analogue on the occurrence of chemotherapy-induced early menopause was discussed.

Pregnancy after treatment of breast cancer in young women does not adversely affect the prognosis

We assessed whether pregnancy after breast cancer in patients younger than 36 years of age affects the prognosis. Of 115 women with breast cancer followed for a mean of 6 years, 18 became pregnant (median time between diagnosis and the first pregnancy 44.5 months). Voluntary interruption of pregnancy was decided by 8 (44.4%) women. Significant differences in prognostic factors between pregnant and non-pregnant women were not observed. Pregnant women showed a lower frequency of positive estrogen receptors (41%) than non-pregnant (64%) (P=0.06). At 5 years of follow-up, 100% of women in the pregnant group and 80% in the non-pregnant group were alive. The percentages of disease-free women were 94% and 64%, respectively (P=0.009). Breast cancer patients presented a high number of unwanted pregnancies. Pregnancy after breast cancer not only did not adversely affect prognosis of the neoplasm but also may have a protective effect.

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.

Management of early invasive breast cancer in very young women (<35 years)

BACKGROUND

To give an overview about current treatment recommendations and special problems concerning the management of women <35 years with early breast cancer.

METHODS

We performed a selective systematic literature review. We discussed with reference to key studies and meta-analyses, current standards of care, and controversies regarding patient management.

RESULTS

Breast cancer in patients younger than 35 years is rare but associated with an unsatisfactory prognosis. Local treatment should not differ from general guidelines, but awareness of the high risk of local recurrence must be maintained. Adjuvant polychemotherapy is almost always indicated, standard endocrine therapy is tamoxifen. Before the start of systemic therapy, the patient must be offered different types of fertility preservation. Pregnancy related breast cancer is not associated with a worse prognosis, but with delayed diagnosis. Therefore, every suspicious lesion in the breast or axilla must be imaged and biopsied. The optimal time to delay pregnancy following the diagnosis is unknown. Hormonal contraceptives are contraindicated after breast cancer. Every woman <35 years diagnosed with breast cancer should be offered genetic counseling.

CONCLUSION

The management of breast cancer in very young women requires a multidisciplinary team to find the optimal treatment and to solve their specific problems.

Effect of luteinizing hormone-releasing hormone agonist on ovarian function after modern adjuvant breast cancer chemotherapy: the GBG 37 ZORO study

PURPOSE

Observational studies suggested that luteinizing hormone-releasing hormone agonists (LHRHa) might prevent premature ovarian failure resulting from adjuvant chemotherapy in premenopausal patients. We aimed to test the efficacy of ovarian function preservation with the LHRHa goserelin in patients with breast cancer.

PATIENTS AND METHODS

In a prospective, randomized, open-label, controlled multicenter study, 60 patients younger than age 46 years with hormone-insensitive breast cancer were allocated to receive anthracycline/cyclophosphamide (with or without taxane) -based neoadjuvant chemotherapy with or without goserelin. The first goserelin injection was administered at least 2 weeks before the first chemotherapy cycle, continuing at 3.6 mg subcutaneously every 4 weeks until the end of the last cycle. The primary objective was the reappearance of normal ovarian function, defined as two consecutive menstrual periods within 21 to 35 days at 6 months after end of chemotherapy.

RESULTS

Fifty-three patients (88.3%) experienced temporary amenorrhea (93.3% with v 83.3% without goserelin). No significant difference was observed regarding the reappearance of menstruation at 6 months after chemotherapy (70.0% with v 56.7% without goserelin; difference of 13.3%; 95% CI, -10.85 to 37.45; P = .284). All but one evaluable patient reported regular menses at 2 years after chemotherapy. Time to restoration of menstruation was 6.8 months (95% CI, 5.2 to 8.4) with goserelin and 6.1 months (95% CI, 5.3 to 6.8) without goserelin (P = .304). Chemotherapy resulted in a decreased ovarian reserve measured by inhibin B and anti-Müllerian hormone during follow-up, supporting the other findings.

CONCLUSION

Premenopausal patients with breast cancer receiving goserelin simultaneously with modern neoadjuvant chemotherapy did not experience statistically significantly less amenorrhea 6 months after end of chemotherapy compared with those receiving chemotherapy alone.

Breast cancer and fertility preservation

OBJECTIVE

To review the benefits of adjuvant systemic therapy given to women with breast cancer of reproductive age, its effects on fertility, and options for fertility preservation.

DESIGN

Publications relevant to fertility preservation and breast cancer were identified through a PubMed database search.

CONCLUSION(S)

Most women who develop invasive breast cancer under age 40 will be advised to undergo adjuvant chemotherapy with or without extended antihormonal therapy to reduce the risk of recurrence and death from breast cancer. Adjuvant chemotherapy particularly with alkylating agents such as cyclophosphamide is gonadotoxic and markedly accelerates the rate of age-related ovarian follicle loss. Although loss of fertility is an important issue for young cancer survivors, there is often little discussion about fertility preservation before initiation of adjuvant therapy. Greater familiarity with prognosis and effects of different types of adjuvant therapy on the part of infertility specialists and fertility preservation options such cryopreservation of embryos, oocytes, and ovarian tissue on the part of oncologists would facilitate these discussions. Establishment of rapid fertility consultation links within cancer survivorship programs can help ensure that every young woman who is likely to undergo gonadotoxic cancer treatment is counseled about the effects of therapy and options available to her to increase the likelihood of childbearing after cancer treatment.

Incidence of chemotherapy-induced amenorrhea associated with epirubicin, docetaxel and navelbine in younger breast cancer patients

BACKGROUND

The rates of chemotherapy-induced amenorrhea (CIA) associated with docetaxel-based regimens reported by previous studies are discordant. For navelbine-based chemotherapies, rates of CIA have seldom been reported.

METHODS

Of 170 premenopausal patients recruited between January 2003 and September 2008, 78 were treated with fluorouracil plus epirubicin and cyclophosphamide (FEC), 66 were treated with docetaxel plus epirubicin (TE), and 26 were treated with navelbine plus epirubicin (NE). Patient follow-up was carried up every 3-4 months during the first year, then every 9-12 months during subsequent years.

RESULTS

In univariate analysis, the rates of CIA were 44.87% for the FEC regimen, 30.30% for the TE regimen and 23.08% for the NE regimen (P = 0.068). Significant differences in the rates of CIA were not found between the FEC and TE treatment groups (P > 0.05), but were found between the FEC and NE treatment groups (P < 0.05). Furthermore, no significant differences were found between the TE and NE regimens (P > 0.05). Tamoxifen use was a significant predictor for CIA (P = 0.001), and age was also a significant predictor (P < 0.001). In multivariate analysis, age (P < 0.001), the type of chemotherapy regimens (P = 0.009) and tamoxifen use (P = 0.003) were all significant predictors.

CONCLUSIONS

Age and administration of tamoxifen were found to be significant predictive factors of CIA, whereas docetaxel and navelbine based regimens were not associated with higher rates of CIA than epirubicin-based regimen.

Menopausal symptoms among breast cancer patients 6 months after diagnosis: a report from the Shanghai Breast Cancer Survival Study

OBJECTIVE

The aim of this study was to estimate the prevalence of menopausal symptoms in relation to treatment modalities in Asian women treated for breast cancer.

METHODS

A population-based cohort of 5,023 Chinese women aged 25 to 70 years with primary stage 0 to III breast cancer was identified from a population-based tumor registry and enrolled in the study approximately 6 months after diagnosis. Participants were asked about the occurrence of specific menopausal symptoms. Associations between these symptoms and breast cancer treatments were evaluated by stratified, multivariate logistic regression.

RESULTS

Among women with a recent diagnosis of breast cancer, 67.2% of premenopausal women and 46.3% of postmenopausal women experienced at least one menopausal symptom, namely, hot flashes, night sweats, and/or vaginal dryness. Symptom prevalence among postmenopausal women decreased progressively with age at diagnosis (63.3% for women aged 51-55 y, 51.5% for women aged 56-60 y, and 34.4% for women aged >65 y; P < 0.01). Overall, the highest prevalence of most symptoms occurred in women aged 46 to 55 years (P < 0.01). Chemotherapy was positively associated with the occurrence of any symptom and with each individual symptom, mainly in premenopausal women (adjusted odds ratio [OR] range, 2.2-3.3; P < 0.05 for all). Tamoxifen use and immunotherapy were associated with having any symptom and with each individual symptom, regardless of menopause status (adjusted OR range, 1.5-1.8 and 1.3-1.5, respectively; P < 0.05 for all). Women treated before menopause were at particularly high risk of experiencing two or more symptoms after chemotherapy (OR, 1.77; 95% CI, 1.54-4.98; P interaction = 0.05) compared with postmenopausal women.

CONCLUSIONS

Menopausal symptoms are prevalent among Chinese women recently treated for primary breast cancer. These symptoms are associated with age and menopause status at the time of diagnosis, as well as with the type of treatment received.

Cancer and fertility preservation: fertility preservation in breast cancer patients

Aggressive chemotherapy has improved the life expectancy for reproductive-age women with breast cancer, but it often causes infertility or premature ovarian failure due to destruction of the ovarian reserve. Many questions concerning fertility preservation in breast cancer patients remain unanswered – for example, whether fertility preservation methods interfere with chemotherapy, and whether subsequent pregnancy has negative effects on the prognosis. Fertility preservation is a critical factor in decision-making for younger breast cancer patients, however, and clinicians should address this. The present article reviews the incidence of chemotherapy-induced amenorrhea, and discusses fertility-preservation options and the prognosis for patients who become pregnant after breast cancer.