Pregnancy after breast cancer: if you wish, ma’am

Motherhood on a precarious path: Pregnancy following breast carcinoma - Case report

Women of childbearing age frequently express a desire for pregnancy even after a diagnosis of breast cancer and after undergoing treatment. The average age of primiparous women is rising and gynecologists and oncologists are faced with inquiries about pursuing childbearing after the diagnosis of breast cancer. We present a case of a 39 year old women who came to our clinic in 39th week of gestation, gave vaginal birth to a vigorous neonatus and underwent into dyspnea just two hours after the delivery. She voluntarily disclosed her advanced stage of breast cancer diagnosis, as she feared it could lead to the termination of her pregnancy. After she was released from the hospital, she did not attend any follow-up appointments at our clinic, hence we have no knowledge whether she contacted her oncologist or the outcome of her primary disease.

[Live birth rates after breast cancer among women who desired a child]

INTRODUCTION

In France, the breast cancer is the most common cancer among women under the age of 40. From 38 to 70% of women have not fulfilled their parental plans at the time of diagnosis. The gonadotoxicity of the treatments and the follicular physiological decline linked to age can become an obstacle to this project.

METHODS

Among the patients, 386 were treated for breast cancer at the Centre Georges-François-Leclerc in Dijon between January 2011 and December 2018 were identified. 192 patients aged under 39 met the inclusion criteria. We excluded metastatic cancers, cancer in situ and pregnant patients at diagnosis. A total of 124 patients agreed to participate in the study. The included patients filled out a self-questionnaire. Data were collected from the patient's electronic medical. The primary endpoint of this study was the live birth rate.

RESULT

Among women who desired a child after breast cancer, the overall rate of live births was 36.2 % (21/58). Most achieved pregnancies were spontaneous (90.5 %). No factor was significantly associated with the absence of obtaining birth. Fertility was preserved by oocyte cryopreservation in 13.8 % of patients (17/124). The median time to conception in patients who received chemotherapy was 8 months [1.0-60.0] vs 2 months [1.0-7.0] in women who did not receive chemotherapy.

DISCUSSION

The non-negligible proportion of live births following spontaneous pregnancy after breast cancer allows us to be reassuring for patients. However, the emergence of new chemotherapy protocols whose consequences on long-term gonadotoxicity are still not well known requires further studies and prompts the promotion of fertility preservation as a precautionary measure.

Obstetric and Neonatal Outcomes 1 or More Years After a Diagnosis of Breast Cancer

OBJECTIVE

To evaluate obstetric and neonatal outcomes of the first live birth conceived 1 or more years after breast cancer diagnosis.

METHODS

We performed a population-based study to compare live births between women with a history of breast cancer (case group) and matched women with no cancer history (control group). Individuals in the case and control groups were identified using linked data from the California Cancer Registry and California Office of Statewide Health Planning and Development data sets. Individuals in the case group were diagnosed with stage I-III breast cancer at age 18-45 years between January 1, 2000, and December 31, 2012, and conceived 12 or more months after breast cancer diagnosis. Individuals in the control group were covariate-matched women without a history of breast cancer who delivered during 2000-2012. The primary outcome was preterm birth at less than 37 weeks of gestation. Secondary outcomes were preterm birth at less than 32 weeks of gestation, small for gestational age (SGA), cesarean delivery, severe maternal morbidity, and neonatal morbidity. Subgroup analyses were used to assess the effect of time from initial treatment to fertilization and receipt of additional adjuvant therapy before pregnancy on outcomes of interest.

RESULTS

Of 30,021 women aged 18-45 years diagnosed with stage I-III breast cancer during 2000-2012, 553 met the study inclusion criteria. Those with a history of breast cancer and matched women in the control group had similar odds of preterm birth at less than 37 weeks of gestation (odds ratio [OR], 1.29; 95% CI 0.95-1.74), preterm birth at less than 32 weeks of gestation (OR 0.77; 95% CI 0.34-1.79), delivering an SGA neonate (less than the 5th percentile: OR 0.60; 95% CI 0.35-1.03; less than the 10th percentile: OR 0.94; 95% CI 0.68-1.30), and experiencing severe maternal morbidity (OR 1.61; 95% CI 0.74-3.50). Patients with a history of breast cancer had higher odds of undergoing cesarean delivery (OR 1.25; 95% CI 1.03-1.53); however, their offspring did not have increased odds of neonatal morbidity compared with women in the control group (OR 1.15; 95% CI 0.81-1.62).

CONCLUSION

Breast cancer 1 or more years before fertilization was not strongly associated with obstetric and neonatal complications.

Obstetric complications at time of delivery amongst breast cancer survivors: A population-based cohort study

PURPOSE

Our aim was to determine whether breast cancer survivors are at increased risk of obstetric and maternal complications at time of delivery.

METHODS

The USA 'National Inpatient Sample' database was queried for hospitalizations associated with deliveries, between 2015 and 2018. The incidence of maternal and fetal complications was compared between women with, and without, a personal history of breast cancer.

RESULTS

Of the 2,103,216 birth related admissions, 617 (0.03%) of the women were breast cancer survivors, with the proportion increasing over time (from 0.02% in 2015 to 0.04% in 2018). Breast cancer survivors had a higher socioeconomic status (p < 0.001) and were significantly older compared to other mothers (34 vs. 28 years, p < 0.001). Additionally, they were more likely to suffer from preexisting chronic diseases including cardiopulmonary disease and diabetes mellitus, and had a higher incidence of multiple gestation (4.4% vs. 1.6%) [OR 2.7, 95% CI 1.9-4.0, p < 0.001]. The incidence of acute adverse events at time of delivery including fetal distress, preterm labor, cesarean section and maternal infection was higher amongst the breast cancer survivors. On multivariate analysis age, ethnic group, comorbidities, multiple gestations, and a previous breast cancer diagnosis, but not cancer treatment, were associated with an increased risk of an obstetric adverse event.

CONCLUSION

Breast cancer survivors have more comorbidities and are at increased risk of acute obstetrical complications at time of delivery. Further studies are required to validate these findings, and evaluate the ability of interventions to improve obstetrical outcomes amongst breast cancer survivors.

The impact of young age at diagnosis (age <40 years) on prognosis varies by breast cancer subtype: A U.S. SEER database analysis

Purpose

Women under 40 years old are at increased risk for developing human epidermal growth factor receptor 2 (HER2) positive or triple negative subtype and more advanced breast cancer, yet young age itself has also historically been an independent prognostic factor.

Methods

Using the Surveillance, Epidemiology, and End Results (SEER) Program, we examined data for 271,173 women with stage I-III breast cancer between 2010 and 2015. Using Fine and Gray regression models to account for competing risks, we examined the risk of breast cancer-specific death by age and clinical subtypes, considering grade, hormone receptor (HR) and HER2 status, adjusting for demographic, clinical and treatment variables.

Results

Of 271,173 women eligible for analysis, 14,109 were <40 years of age. Women under 40 years old were more likely to be non-white, uninsured, and to have higher stage, higher grade, HER2-positive and triple-negative subtype disease (all, p < 0.001). Compared to women ages 40–60, women ages <40 had higher breast cancer mortality (hazard ratio, 1.8; 95% confidence interval (CI) 1.6–1.9) in unadjusted analysis. In models controlling for demographic, clinical and treatment factors, young age was significantly associated with an increased risk of breast cancer mortality among women with HR-positive, lower grade disease (hazard ratio 1.7; 95% CI 1.4–2.1) but not for women with high grade/HR-positive, HER2-positive, or triple-negative disease. Women age >75 had increased breast cancer mortality in all subtypes.

Conclusion

With modern clinical subtyping, age under 40 remains independently associated with worse outcomes in 30 months follow-up only in HR-positive, lower grade disease.

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Young women present with more advanced and aggressive types of breast cancer.

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Young age is not an independent prognostic factor in HER2+ breast cancer or TNBC.

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Young age is independently associated with poor outcomes in HR+/lower grade disease.

Ovarian tissue cryopreservation in a patient with breast cancer during pregnancy: a case report

BACKGROUND

Fertility preservation using ovarian tissue cryopreservation (OTC) in patients with certain diseases, especially those needing chemo- or radiotherapy, is becoming routine in various Western countries. Our hospital is the first and until now the only centre in China to use this method. The question of whether treatment of breast cancer during pregnancy (PrBC) should be similar to non-pregnant young patients with breast cancer is controversial. To our knowledge, this is the first report worldwide to use OTC as fertility preservation for PrBC.

CASE PRESENTATION

During the 29th week of pregnancy, a 24-year-old woman underwent needle aspiration cytology of a left breast tumour. Ultrasound and cytology revealed BI-RADS 4a grade. Oncologists recommended termination of the pregnancy. Caesarean section was performed at week 32, and ovarian tissue samples were collected for OTC to preserve fertility and ovarian endocrine function. Twenty-three ovarian cortex slices were cryopreserved. It is estimated that 13,000 follicles were cryopreserved. Breast nodules and sentinel lymph node biopsy suggested invasive micropapillary carcinoma. Neoadjuvant chemotherapy was started within 1 week after diagnosis. After six courses of neoadjuvant chemotherapy, targeted drug therapy and goserelin acetate, left mastectomy and left axillary lymph node dissection were performed. In total, 23 doses of radiotherapy, eight trastuzumab targeted therapy treatments, and 17 pertuzumab + trastuzumab double targeted therapy treatments were performed after breast cancer surgery. Until now, more than 2 years after delivery, the ovarian function still is good, and no signs of a negative impact of OTC have been observed. Goserelin acetate injections, administered every 28 days, are planned to last for the next 5 years. In addition, endocrine therapy with anastrozole was started after breast cancer surgery and also is scheduled for 5 years.

CONCLUSION

OTC for fertility preservation in patients with PrBC does not delay breast surgery, radiotherapy or chemotherapy, which is essential for effective treatment of breast cancer. We assess this method as a promising fertility preservation method which was used here for the first time worldwide in a patient who developed breast cancer during pregnancy.

Case Report: Young Adults With Breast Cancer: A Case Series of Fertility Preservation Management and Literature Review

Breast cancer comprised at least 21.8% of the overall cancer among young adult (YA) women and became the leading cancer in this group in Japan, with 50% adolescent and YAs being diagnosed and 15–44-year-old women showing excellent 5-year survival. Surgical-chemoradiation therapy often results in excellent survivorship with an increased incidence of treatment-induced subfertility. Therefore, adding fertility preservation (FP) to the primary cancer treatment is necessary. Herein, we reported a series of cases of YA women with breast cancer who opted for FP, where their option was tailored accordingly. To date, the selection of oocytes, embryos and ovarian tissue is widely available as an FP treatment. PGT could reduce the risk of BRCA mutation transmission amongst BRCA carriers before pregnancy planning. Otherwise, gonadotropin-releasing hormone analog has no gonadoprotective effect and thus should not be considered as an FP option.

Pregnancy after breast cancer: Results from a prospective cohort of young women with breast cancer

BACKGROUND

Many young women with newly diagnosed breast cancer are interested in future pregnancies. Prospective data regarding fertility interest and reproductive patterns after diagnosis are needed to counsel patients.

METHODS

The Young Women's Breast Cancer Study is a multicenter, prospective cohort of women who were diagnosed with breast cancer at age ≤40 years between 2006 and 2016. Women complete surveys at baseline, every 6 months for 3 years, then annually. Here, the authors describe fertility interest and pregnancies within 5 years of diagnosis for women with stage 0 through III breast cancer.

RESULTS

Of 1026 eligible participants, 368 (36%) reported interest in future biologic children at least once within 5 years after diagnosis, including 16% at 5 years after diagnosis. Among 130 women who attempted to become pregnant, 90 (69.2%) conceived; and, among 896 women who did not attempt to conceive, 18 (2.0%) became pregnant, with a total of 152 pregnancies resulting in 91 live births. Factors associated with pregnancy included younger versus older age at diagnosis (aged ≤30 vs 36-40 years: odds ratio [OR], 6.63; 95% CI, 3.18-13.83; P < .0001; aged 31-35 vs 36-40 years: OR, 5.86; 95% CI, 3.37-10.17; P < .0001) and being nulliparous versus parous (OR, 2.66; 95% CI, 1.56-4.53; P = .001). The receipt of endocrine therapy versus no endocrine therapy (OR, 0.35; 95% CI, 0.20-0.59; P = .001) was inversely associated with pregnancy.

CONCLUSIONS

Many women remain interested in future fertility in the 4 years after a breast cancer diagnosis, indicating that longitudinal fertility discussions are needed. Although a minority of those interested in having children attempted to become pregnant in the first 5 years, most who attempted to conceive did so and had live births.

Pregnancy in Breast Cancer Survivors

Safety of pregnancy occurring after breast cancer treatment has been studied largely, but it is still debatable. These studies have generally showed that overall and disease-free survival in breast cancer survivors with subsequent pregnancy is not less than those without future pregnancy . Also, breast cancer survivors treated with chemotherapy , radiation therapy, or both had no increased risk of congenital anomalies, single gene disorders, or chromosomal syndromes in their offspring. However, it appears that the incidence of preterm labor, low birth weight, and fetal anomalies is higher in these cases.These issues as well as safe time interval from breast cancer treatment to pregnancy , safe contraceptive method after breast cancer, counseling about pregnancy in survivors, and how to follow up the patient for breast cancer recurrence during pregnancy are discussed in this chapter.

ESO-ESMO 4th International Consensus Guidelines for Breast Cancer in Young Women (BCY4)

The 4th International Consensus Conference for Breast Cancer in Young Women (BCY4) took place in October 2018, in Lugano, Switzerland, organized by the European School of Oncology (ESO) and the European Society of Medical Oncology (ESMO). Consensus recommendations for the management of breast cancer in young women were updated from BCY3 with incorporation of new evidence to inform the guidelines. Areas of research priorities were also identified. This article summarizes the ESO-ESMO international consensus recommendations, which are also endorsed by the European Society of Breast Specialists (EUSOMA).

State of the Art in Fertility Preservation for Female Patients Prior to Oncologic Therapies

Quality of life improvement stands as one of the main goals of the medical sciences. Increasing cancer survival rates associated with better early detection and extended therapeutic options led to the specific modeling of patients’ choices, comprising aspects of reproductive life that correlated with the evolution of modern society, and requires better assessment. Of these, fertility preservation and ovarian function conservation for pre-menopause female oncologic patients pose a contemporary challenge due to procreation age advance in evolved societies and to the growing expectations regarding cancer treatment. Progress made in cell and tissue-freezing technologies brought hope and shed new light on the onco-fertility field. Additionally, crossing roads with general fertility and senescence studies proved highly beneficial due to the enlarged scope and better synergies and funding. We here strive to bring attention to this domain of care and to sensitize all medical specialties towards a more cohesive approach and to better communication among caregivers and patients.

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.

Counseling young women with early breast cancer on fertility preservation

PURPOSE

Women with early-stage breast cancer may still have a future child wish, while chemotherapy may impair fertility. To pursue on fertility preservation shortly after breast cancer diagnosis is complex. This review holds a critical reflection on all topics that need to be counseled to give them the opportunity to make a well-informed decision before starting any oncological treatment.

METHODS

A comprehensive literature review was performed on papers published in English language on breast cancer in young women, risk of chemotherapy-induced infertility, fertility preservation techniques, impact of possible mutation carriership, and future pregnancy outcome.

RESULTS

Below 40 years of age, the risk of permanent chemotherapy-induced ovarian function failure is approximately 20%, where taxanes do not significantly add to this risk. Overall, 23% of reported women who performed fertility preservation by cryopreserving oocytes or embryos returned for embryo transfer. Of these, 40% gave live birth. Both fertility preservation in women diagnosed with breast cancer and pregnancy after treatment seem safe with respect to breast cancer survival. Women who have a genetic predisposition for breast cancer like BRCA gene mutation should also be informed about the possibility of pre-implantation genetic diagnosis.

CONCLUSIONS

Women with an early stage of breast cancer and a possible future child wish should be referred to an expertise center in breast cancer, fertility preservation, and genetics in this complex decision-making process, shortly after diagnosis.

Reproductive Outcomes After a Childhood and Adolescent Young Adult Cancer Diagnosis in Female Cancer Survivors: A Systematic Review and Meta-analysis

Improvements in cancer therapy for childhood and adolescent and young adult (AYA) survivors have increased in excess of 80% among pediatric patients and in excess of 85% among AYA cancer patients. Our research group explored the late effects consequences of cancer treatment on pregnancy and birth outcomes subsequent to a childhood (0-14 years) or AYA (15-25 years) diagnosis of cancer in female cancer survivors. Embase and Medline databases were searched. There were 17 review (n = 10 matched and n = 7 unmatched) studies that met the inclusion criteria. Subanalyses were conducted on 10 matched studies. The median age for all studies for patients at diagnosis and birth was 11 and 27 years, respectively. In matched cohort studies, female childhood and AYA cancer patients, who received chemotherapy alone, had a pooled estimated rate of 18% of experiencing a live birth compared with 10% of females who received radiotherapy alone and subsequently had a live birth. Females who received surgery alone reported higher pooled estimated rates of 44% for a live birth. For matched retrospective review studies, 79% (n = 973) of women experienced a live birth, of which 22% of these babies were born preterm. This meta-analysis found lower birth rates for survivors. Access to fertility-related information and discussions around fertility preservation options and oncofertility psychosocial support should be offered to all cancer patients and their families before starting cancer treatment.

Controversies in Breastfeeding

When addressing the compatibility of breastfeeding with certain maternal conditions, we need to differentiate between "contraindication" and "obstacle." Failure to distinguish between the two confuses new mothers and their families, and engenders misconceptions about breastfeeding advice by health professionals. Health conditions that may simply impede the initiation and duration of breastfeeding are often wrongly referred to as true contraindications to breastfeed, under the assumption that they might harm the health of the mother and/or that of the nursing infant. Here, we discuss several topics, including breast surgery, prolactinoma, concurrent new pregnancy, hormonal contraception, and use of medications and contrast agents, that continue to raise controversy. While most conditions appear to be compatible with breastfeeding, the major determinants of a woman's final choice of whether to nurse her infant or not are the attitude of health professionals and the state of mind of being an informed mother.

Fertility Rates in Young Korean Breast Cancer Patients Treated with Gonadotropin-Releasing Hormone and Chemotherapy

PURPOSE

Gonadotropin-releasing hormone (GnRH) agonists have been used with adjuvant chemotherapy to protect ovarian function. However, there are no data on the actual pregnancy rates among young breast cancer patients receiving GnRH agonists and concurrent chemotherapy in Korea.

METHODS

Among patients who underwent surgery from January 2002 to April 2012, premenopausal patients aged between 20 and 40 years were included in the analysis. We retrospectively reviewed clinicopathologic features (e.g., age, obstetric and menstruation history), recurrence, and survival status. The rate of resumption of menstruation was calculated in all patients. In the married group, pregnancy and delivery rates were also recorded.

RESULTS

Among 101 patients, 19 were lost to follow-up and 82 were eligible for the analysis. Among them, 31 were married, 10 of 51 got married, and 41 remained unmarried through the follow-up period. Among the married patients, 15 became pregnant and gave birth to 19 babies, whereas 26 did not become pregnant. The pregnancy rate in the married group was 50.0% (15/30). Three of 15 pregnancies (20.0%) were multiparous. Most of the delivered babies were healthy and 80.0% of patients had no problems breastfeeding (12/15). More than half the patients in all groups recovered menstrual status within 12 months.

CONCLUSION

Fifty percent of young breast cancer patients who attempted pregnancy succeeded in pregnancy after adjuvant chemotherapy and GnRH agonists. Further studies that include control groups are required to confirm whether the use of GnRH agonists improves pregnancy.

Impact of prior breast cancer on mode of delivery and pregnancy-associated disorders: a retrospective analysis of subsequent pregnancy outcomes

PURPOSE

The aim of this paper is to analyze the impact of prior breast cancer (BC) on mode of delivery and pregnancy-associated disorders.

METHODS

A database from 262 German gynecological practices including 289,712 women between the ages of 18 and 45 with documented pregnancies between 2000 and 2014 was used to search for patients with a history of BC up to 10 years prior to pregnancy. A total of 165 patients with a history of BC were found and matched with 165 patients without a history of any cancer (1:1) by age, physician, obesity, and documented referral to a fertility center up to 12 months before the index pregnancy. The impact of prior BC on the mode of delivery and pregnancy-associated disorders was analyzed using Cox regression models.

RESULTS

The mean maternal age at first visit was 34.6 years in both groups. The early and late pregnancy loss was significantly reduced (17.7 versus 29.9%, OR 0.50) and delivery of a live-born child more frequent (82.3 versus 70.1%, OR 2.00) in women who had had BC than in controls. Furthermore, preterm contractions without preterm birth were less frequent in women with BC compared to controls (9.2 versus 18.9%, OR 0.43). No significant differences were found for other pregnancy complications, such as suspected fetal growth restriction, genito-urinary infections, fetal malpresentation, gestational diabetes, pre-eclampsia, or breastfeeding issues.

CONCLUSIONS

Based on the decreased rate of early and late pregnancy loss and the absence of significant differences in most documented pregnancy-associated disorders, women with the previous BC can be assured of the possibility of a good outcome on a subsequent pregnancy.

Impact of tamoxifen therapy on fertility in breast cancer survivors

OBJECTIVE

To determine whether tamoxifen use is associated with decreased ovarian reserve and decreased likelihood of having a child after a breast cancer diagnosis, using data from the Furthering Understanding of Cancer, Health, and Survivorship in Adult (FUCHSIA) Women Study.

DESIGN

Population-based cohort study.

SETTING

Not applicable.

PATIENT(S)

Three hundred ninety-seven female breast cancer survivors aged 22-45 years whose cancer was diagnosed between ages 20 and 35 years and who were at least 2 years after diagnosis; 108 survivors also participated in a clinic visit.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Time to first child after cancer diagnosis, clinical measures of ovarian reserve (antimüllerian hormone [AMH] and antral follicle count [AFC]) after cancer.

RESULT(S)

Women who had ever used tamoxifen were substantially less likely to have a child after the breast cancer diagnosis (hazard ratio [HR] 0.29; 95% confidence interval [CI], 0.16, 0.54) than women who had never used tamoxifen. After adjusting for age at diagnosis, exposure to an alkylating agent, and race, the HR was 0.25 (95% CI, 0.14, 0.47). However, after adjusting for potential confounders, women who had used tamoxifen had an estimated geometric mean AMH level 2.47 times higher (95% CI, 1.08, 5.65) than women who had never taken tamoxifen. Antral follicle count was also higher in the tamoxifen group compared with the tamoxifen nonusers when adjusted for the same variables (risk ratio 1.21; 95% CI, 0.84, 1.73).

CONCLUSION(S)

Breast cancer survivors who had used tamoxifen were less likely to have a child after breast cancer diagnosis compared with survivors who never used tamoxifen. However, tamoxifen users did not have decreased ovarian reserve compared with the tamoxifen nonusers.

Breast Cancer in Young Women: Research Priorities. A Report of the Young Survival Coalition Research Think Tank Meeting

Breast cancer in young women is a significant issue-7% of all female breast cancer is diagnosed in women under 40 years of age. Young women with breast cancer (YWBC) face significant and unique challenges, including a higher likelihood of biologically aggressive disease and metastatic disease at diagnosis, leading to poorer prognosis, more aggressive treatment and long-term treatment-related toxicities, and unique psychosocial concerns. This article summarizes the Young Survival Coalition (YSC) Research Think Tank Meeting, held in Arlington, Virginia, in February 2013, and presents the process that led to YSC's priorities for YWBC research. The meeting's participants focused on six broad categories of investigation in which additional advancements in research on YWBC are crucial: risk factors; treatment; fertility; pregnancy-associated breast cancer; quality of life and survivorship; and metastasis. Several key themes emerged from this meeting. Researchers and advocates felt that a large-scale data registry focused on YWBC is necessary to collect quality information to guide future research for YWBC. This database should include clinical data, genomic profiling of primary tumor and metastatic sites, and an increased focus on fertility and pregnancy following breast cancer treatment. The participants also felt that more must be done to elucidate how and why YWBC develop more aggressive tumors, and to what degree treatment should be modified for young women. The discussions summarized here led to the formulation of YSC's Research Agenda, published in May 2014.

Considerations for the Treatment of Young Patients with Breast Cancer

Breast cancer in the young patient, generally defined as younger than 40 years, is a rare but important problem. In the US, over 24,000 women under age 45 are diagnosed with breast cancer each year and nearly 2,500 young women die annually of the disease. This review is intended to address issues specific to caring for the young breast cancer patient including diagnosis, genetic counseling, tumor biology, surgery, and potential for development of contralateral breast cancer. Additionally, there are psychosocial considerations unique to this age group which should be addressed as part of a comprehensive, multi-disciplinary team approach including discussions about fertility, sexual function, behavioral health, and quality of life.

Oncofertility Knowledge, Attitudes, and Practices of Canadian Breast Surgeons

BACKGROUND

Guidelines recommend that oncologists discuss treatment-related fertility issues with young cancer patients as early as possible after diagnosis and, if appropriate, expedite referral for fertility preservation (FP). This study sought to determine the attitudes and practices of Canadian breast surgeons regarding fertility issues, as well as barriers to and facilitators of fertility discussion and referrals.

METHODS

Semistructured telephone interviews were conducted with 28 site lead surgeons (SLSs) at 28 (97 %) of 29 centers (25 % cancer centers, 64 % teaching hospitals) across Canada participating in RUBY, a pan-Canadian research program for young women with breast cancer. In addition, 56 (65 %) of 86 of their surgical colleagues (non-site lead surgeons [NSLSs]) completed an online survey of their oncofertility knowledge, attitudes, and practices.

RESULTS

Of the 28 SLSs (43 % male, 36 % in practice <10 years), 46 % had inadequate oncofertility knowledge, 25 % discussed fertility only if mentioned by the patient, 21 % believed fertility discussion and referral were the mandate of the medical oncologist, and 45 % did not know of an FP center in their area. More than 80 % of the NSLSs (54 % male, 30 % in practice <10 years) were unfamiliar with oocyte or embryo cryopreservation; 36 % never or rarely discussed fertility issues; and 51 % thought referral to a fertility specialist was not their responsibility.

CONCLUSIONS

Oncofertility knowledge was low among the SLSs, especially the NSLSs, and barriers to referral were identified. An oncofertility knowledge translation intervention specifically for breast surgeons is being developed to increase surgeon knowledge and awareness of oncofertility issues and referral.

The Modern Landscape of Endocrine Therapy for Premenopausal Women with Breast Cancer

The optimal endocrine therapy for premenopausal women with early and advanced breast cancer still remains an important and controversial issue. For over 30 years, tamoxifen has been the gold standard in the adjuvant setting. New therapeutic options, such as the addition of ovarian function suppression to oral endocrine therapy (either tamoxifen or aromatase inhibitors), can improve outcomes over tamoxifen alone in well-selected patients. Treatment duration has also been revisited, and extended therapy is becoming a new standard of care, especially in high-risk patients. Endocrine therapy for advanced disease still represents a challenge and a research priority. New drugs and combinations able to overcome endocrine resistance are at the horizon, and their role in premenopausal women should be better elucidated. Side effects and quality of life (including family planning considerations) play an important role in treatment selection and in the patients' treatment adherence and should always be discussed before start of treatment. The paper will specifically focus on how to integrate all new treatment options in the current armamentarium of endocrine therapy of premenopausal women, with the aim of best fine-tuning treatment selections according to the individual risk/benefit evaluation.

Systematic review of effects of pregnancy on breast and abdominal contour after TRAM/DIEP breast reconstruction in breast cancer survivors

Transverse rectus abdominis myocutaneous (TRAM) and its derivatives are the most commonly performed autologous breast reconstruction procedures. These procedures were not recommended in the past for those who planned for subsequent childbearing because of the transposition of portions of the abdominal wall during the procedure into the anatomic position of the breast, implying possible adverse effects over the contour of these manipulated areas during pregnancy and delivery. We conducted a systematic review to assess the literature on esthetic or functional consequences of childbearing over the breast and abdomen after these procedures in patients that were affected by breast cancer. A comprehensive literature search in databases and citation indexes was conducted from February 2014 to April 2015. Any paper on pregnancy after breast reconstruction by TRAM or its derivatives and modifications, written in English or French, were included. The search results underwent a first screening to exclude duplicate and irrelevant papers. Full texts were then reviewed as to the criteria for inclusion, and data were extracted into data extraction forms from eligible papers. The initial search yielded 5132 articles. After screening and review, overall 17 papers met all criteria for inclusion in this review. Our work revealed that uneventful pregnancy and delivery can be anticipated in breast cancer survivors who had undergone breast reconstruction via TRAM or its derivatives with minor negative effects on either the breast or the abdomen.

Outcome of patients with pregnancy during or after breast cancer: a review of the recent literature

BACKGROUND

An increasing number of young women are delaying childbearing; hence, more are diagnosed with breast cancer (bca) before having a family. No clear recommendations are currently available for counselling such a population on the safety of carrying a pregnancy during bca or becoming pregnant after treatment for bca.

METHODS

Using a Web-based search of PubMed we reviewed the recent literature about bca and pregnancy. Our objective was to report outcomes for patients diagnosed with bca during pregnancy, comparing them with outcomes for non-pregnant women, and to evaluate prognosis in women diagnosed with and treated for bca who subsequently became pregnant.

RESULTS

"Pregnancy and bca" should be divided into two entities. Pregnancy-associated bca tends to be more aggressive and advanced in stage at diagnosis than bca in control groups; hence, it has a poorer prognosis. With respect to pregnancy after bca, there is, despite the bias in reported studies and meta-analyses, no clear evidence for a different or worse disease outcome in bca patients who become pregnant after treatment compared with those who do not.

CONCLUSIONS

Pregnancy-associated bca should be treated as aggressively as and according to the standards applicable in nonpregnant women; pregnancy after bca does not jeopardize outcome. The guidelines addressing risks connected to pregnancy and bca lack a high level of evidence for better counselling young women about pregnancy considerations and preventing unnecessary abortions. Ideally, evidence from large prospective randomized trials would set better guidelines, and yet the complexity of such studies limits their feasibility.

Pregnancy after breast cancer: Are young patients willing to participate in clinical studies?

Young patients with breast cancer (BC) are often concerned about treatment-induced infertility and express maternity desire. Conception after BC does not seem to affect outcome, but information in estrogen-receptor positive (ER+) disease is not definitive. From September 2012-March 2013, 212 evaluable patients with ER+ early BC, <37 years at diagnosis, from 5 regions (Europe/US/Canada/Middle-East/Australia) answered a survey about fertility concerns, maternity desire and interest in a study of endocrine therapy (ET) interruption to allow pregnancy. Overall, 37% of respondents were interested in the study; younger patients (≤30 years) reported higher interest (57%). Motivation in younger patients treated >30 months was higher (83%) than in older women (14%), interest was independent of age in patients treated for ≤30 months. A prospective study in this patient population seems relevant and feasible. The International-Breast-Cancer-Study-Group (IBCSG), within the Breast-International-Group (BIG) - North-American-Breast-Cancer-Groups (NABCG) collaboration, is launching a study (POSITIVE) addressing ET interruption to allow pregnancy.

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.

Tamoxifen co-administration during controlled ovarian hyperstimulation for in vitro fertilization in breast cancer patients increases the safety of fertility-preservation treatment strategies

OBJECTIVE

To evaluate the safety and efficacy of tamoxifen co-administration during conventional controlled ovarian hyperstimulation (COH) protocols for a fertility-preservation IVF cycle in breast cancer patients.

DESIGN

Two groups: retrospective descriptive cohort study and prospective study.

SETTING

Breast cancer oncology and fertility-preservation centers in a tertiary hospital.

PATIENT(S)

Two groups of breast cancer patients: premenopausal patients treated with adjuvant tamoxifen; and patients undergoing in vitro fertilization (IVF) for fertility preservation.

INTERVENTION(S)

Fertility-preservation cycles, tamoxifen co-administration during conventional IVF.

MAIN OUTCOME MEASURE(S)

Endocrine records, and IVF results.

RESULT(S)

Estradiol (E2) levels were chronically high (mean 2663 pmol/L, maximum: 10,000 pmol/L) in 38 of 46 breast cancer patients treated with adjuvant tamoxifen. Co-administration of tamoxifen (48 cycles) during conventional IVF or without tamoxifen (26 cycles), using either the long gonadotropin-releasing hormone-agonist or-antagonist protocols, resulted, respectively, in a mean of 12.65 and 10.2 oocytes retrieved, and 8.5 and 6.4 embryos cryopreserved. Average peak E2 levels were 6,924 pmol/L and 5,093 pmol/L, respectively, but long-term recurrence risk (up to 10 years) was not increased.

CONCLUSION(S)

In breast cancer patients, co-administration of tamoxifen during conventional COH for fertility preservation does not interfere with IVF results. The high serum E2 levels during COH should be considered safe, as it simulates the high prevalence of persistently high serum E2 levels in premenopausal breast cancer patients safely treated with adjuvant tamoxifen.

Factors associated with pregnancy attempts among female young adult cancer survivors

PURPOSE

Little is known about pregnancy attempts among female young cancer survivors (YCS). We sought to determine fertility preservation (FP), demographic, cancer, and reproductive characteristics associated with pregnancy attempts after cancer.

METHODS

We recruited 251 female YCS (ages 18-44) to complete a survey on reproductive health outcomes. We used log-binomial regression models to estimate relative risks (RR) for characteristics associated with pregnancy attempts.

RESULTS

For the entire cohort, median time since cancer diagnosis was 2.4 years (interquartile range 4.0). Fifty-two YCS (21%) attempted pregnancy after cancer diagnosis. In unadjusted analyses, lack of FP therapy prior to cancer treatment, older age, partnered relationship, higher income, no history of stem cell or bone marrow transplant, and longer duration of survivorship were significantly associated with pregnancy attempts. In multivariable analyses, YCS who did not undergo FP therapy were more than twice as likely to attempt pregnancy as those who did undergo FP therapy (RR 2.4, 95% confidence interval (CI) 1.3, 4.3). Partnered status (RR 7.1, 95% CI 2.5, 20.2) and >2 years since cancer diagnosis (RR 2.3, 95% CI 1.3, 4.1) were also significantly associated with attempts.

CONCLUSIONS

In YCS, milestones including partnered relationships and longer duration of cancer survivorship are important to attempting pregnancy. A novel, inverse association between FP therapy and pregnancy attempts warrants further study.

IMPLICATIONS FOR CANCER SURVIVORS

Pregnancy attempts after cancer were more likely after attaining both social- and cancer-related milestones. As these milestones require time, YCS should be made aware of their potential for concomitant, premature loss of fertility in order to preserve their range of fertility options.

First international consensus guidelines for breast cancer in young women (BCY1)

The 1st International Consensus Conference for Breast Cancer in Young Women (BCY1) took place in November 2012, in Dublin, Ireland organized by the European School of Oncology (ESO). Consensus recommendations for management of breast cancer in young women were developed and areas of research priorities were identified. This manuscript summarizes these international consensus recommendations, which are also endorsed by the European Society of Breast Specialists (EUSOMA).

Current evidence supporting fertility and pregnancy among young survivors of breast cancer

Approximately 6% of invasive breast cancer is diagnosed in women younger than age 40 of age childbearing potential. Cancer-directed therapies can cause hormonal and anatomical changes that negatively affect the reproductive potential of young survivors of breast cancer. Recent national guidelines on fertility preservation are widely available. However, gaps in care exist in the interdisciplinary evidence-based management of young survivors of breast cancer with fertility and parenting concerns after cancer treatment.

Chemotherapy-induced amenorrhea in patients with breast cancer with a BRCA1 or BRCA2 mutation

PURPOSE

To determine the likelihood of long-term amenorrhea after treatment with chemotherapy in women with breast cancer who carry a BRCA1 or BRCA2 mutation.

PATIENTS AND METHODS

We conducted a multicenter survey of 1,954 young women with a BRCA1 or BRCA2 mutation who were treated for breast cancer. We included premenopausal women who were diagnosed with invasive breast cancer between 26 and 47 years of age. We determined the age of onset of amenorrhea after breast cancer for women who were and were not treated with chemotherapy, alone or with tamoxifen. We considered chemotherapy-induced amenorrhea to have occurred when the patient experienced ≥ 2 years of amenorrhea, commencing within 2 years of initiating chemotherapy, with no resumption of menses.

RESULTS

Of the 1,426 women who received chemotherapy, 35% experienced long-term amenorrhea. Of the 528 women who did not receive chemotherapy, 5.3% developed long-term amenorrhea. The probabilities of chemotherapy-induced amenorrhea were 7.2% for women diagnosed before age 30 years, 33% for women age 31 to 44 years, and 79% for women diagnosed after age 45 years (P trend < .001). The probability of induced amenorrhea was higher for women who received tamoxifen than for those who did not (52% v 29%; P < .001).

CONCLUSION

Age at treatment and use of tamoxifen are important predictors of chemotherapy-induced amenorrhea in women who carry a BRCA1 or BRCA2 mutation. The risk of induced long-term amenorrhea does not seem to be greater among mutation carriers than among women who do not carry a mutation.

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.

Fertility counseling of young breast cancer patients

Approximately 6% of women with breast cancer are diagnosed before the age of 40. Young age is an independent predictor of adverse outcome and most young breast cancer patients receive systemic treatment with chemotherapy, hormonal therapy or both. The loss or impairment of fertility is a potential side effect of antineoplastic treatments. Due to the rising trend to delaying pregnancy in life, an increasing proportion of young cancer patients who are yet to have a pregnancy will face the problem of iatrogenic menopause in the future. The incidence of anticancer-treatment-related ovarian failure depends on the type of chemotherapy regimen administered, the use of tamoxifen and the age of patients. It rises with increasing age, in the range of 22-61% and 61-97% in women aged <40 years and >40 years respectively. Although there is a clear trend to increasing incidence of ovarian failure with the rise in aging, there may be a small proportion of patients who became amenorrhoeic despite the very young age, thus indicating that also individual factors still unknown may affect the probability of treatment-related ovarian failure. A prompt referral of patients to reproductive counseling and a multidisciplinary team including Oncology and Reproductive Units are essential to face the management of fertility issues in cancer patients. Fertility counseling should include a detailed description of all the available techniques to preserve fertility. The main available fertility preservation techniques, standard and experimental, for young breast cancer patients include: temporary ovarian suppression during chemotherapy with gonadotropin-releasing hormone analogues, embryo cryopreservation, cryopreservation of oocytes and cryopreservation of ovarian tissue. Research efforts are still necessary to improve the efficacy and safety of the available fertility preservation strategies as well as an efficient collaboration between oncologists and gynecologists is necessary to improve patients' access to the strategies themselves.

Much more than a gene: hereditary breast and ovarian cancer, reproductive choices and family life

This article presents the results of a study that investigates the way in which carriers of a mutation on the BRCA1 or the BRCA2 gene, associated with a high risk of breast and ovarian cancer, make their reproductive decisions. Using semi-structured interviews, the study explored the way in which these persons reflected on the acceptability of taking the risk of transmitting this mutation to the next generation, the arguments they used in favor or against taking that risk, and in the light of these arguments, their opinion on the acceptability of preimplantation genetic diagnosis (PGD) as a reproductive option. The findings suggest that when carriers are planning to have a(nother) child, they are mainly concerned by the risk of transmitting 'much more than a gene': essentially painful experiences not only with respect to health, such as undergoing cancer surveillance or combatting one's own illness, but also with regards to family life, such as witnessing the illness and death of a close relative, encountering difficulties in finding a partner or reconsidering one's plans to have a family. As for opinions concerning the acceptability of PGD as a reproductive option, opinions about personal recourse were varied but all expressed the understanding that PGD should be made available to those persons who consider it their best option.

Prognostic impact of pregnancy after breast cancer according to estrogen receptor status: a multicenter retrospective study

PURPOSE

We questioned the impact of pregnancy on disease-free survival (DFS) in women with history of breast cancer (BC) according to estrogen receptor (ER) status.

PATIENTS AND METHODS

A multicenter, retrospective cohort study in which patients who became pregnant any time after BC were matched (1:3) to patients with BC with similar ER, nodal status, adjuvant therapy, age, and year of diagnosis. To adjust for guaranteed time bias, each nonpregnant patient had to have a disease-free interval at least equal to the time elapsing between BC diagnosis and date of conception of the matched pregnant one. The primary objective was DFS in patients with ER-positive BC. DFS in the ER-negative cohort, whole population, and overall survival (OS) were secondary objectives. Subgroup analyses included DFS according to pregnancy outcome and BC-pregnancy interval. With a two-sided α = 5% and β = 20%, 645 ER-positive patients were required to detect a hazard ratio (HR) = 0.65.

RESULTS

A total of 333 pregnant patients and 874 matched nonpregnant patients were analyzed, of whom 686 patients had an ER-positive disease. No difference in DFS was observed between pregnant and nonpregnant patients in the ER-positive (HR = 0.91; 95% CI, 0.67 to 1.24, P = .55) or the ER-negative (HR = 0.75; 95% CI, 0.51 to 1.08, P = .12) cohorts. However, the pregnant group had better OS (HR = 0.72; 95% CI, 0.54 to 0.97, P = .03), with no interaction according to ER status (P = .11). Pregnancy outcome and BC-pregnancy interval did not seem to impact the risk of relapse.

CONCLUSION

Pregnancy after ER-positive BC does not seem to reduce the risk of BC recurrence.