Counting the costs of treatment: the reproductive and gynaecological consequences of adjuvant therapy in young women with breast cancer

Prevalence of preterm, low birthweight, and small for gestational age delivery after breast cancer diagnosis: a population-based study

BACKGROUND

Black-white disparities in breast cancer incidence rates and birth outcomes raise concerns about potential disparities in the reproductive health of premenopausal breast cancer survivors. We examined the prevalence of preterm birth (PTB), low birthweight (LBW), and small for gestational age (SGA) by breast cancer history and effect modification by race.

METHODS

We analyzed linked North Carolina birth records and Central Cancer Registry files from 1990 to 2009 (n = 2,325,229). We used multivariable negative log-binomial regression to calculate prevalence ratios (PRs) and 95% confidence intervals (CIs) for the association between breast cancer history and PTB, LBW, and SGA.

RESULTS

Of 1,912,269 eligible births, 512 births were to mothers with a previous breast cancer diagnosis history. Average age at breast cancer diagnosis was 31.8 years (SD = 4.7). Mean time from diagnosis to delivery was 3.3 years (SD = 2.8). After multivariable adjustment, the PR was 1.67 (95% CI, 1.42-1.97) for PTB, 1.50 (95% CI, 1.23-1.84) for LBW, and 1.30 (95% CI, 1.05-1.61) for SGA comparing women with a breast cancer history to the general population. Among black mothers, the PRs associated with breast cancer history for PTB, LBW, and SGA were 1.31 (95% CI, 1.00-1.72), 1.49 (95% CI, 1.14-1.94), and 1.44 (95% CI, 1.11-1.87), respectively. The corresponding PRs among white mothers were 2.06 (95% CI, 1.67-2.54), 1.53 (95% CI, 1.12-2.08), and 1.10 (95% CI, 0.77-1.58), respectively. The interaction between breast cancer history and race was statistically significant for associations with PTB, but not for LBW or SGA.

CONCLUSIONS

In our data, women with a breast cancer history were at higher risk of delivering a PTB, LBW, or SGA infant, especially if they received chemotherapy or gave birth within 2 years of their breast cancer diagnosis date.

Outcomes of an uncertainty management intervention in younger African American and Caucasian breast cancer survivors

PURPOSE/OBJECTIVES

To determine whether breast cancer survivors (BCSs) who received an uncertainty management intervention, compared to an attention control condition, would have less uncertainty, better uncertainty management, fewer breast cancer-specific concerns, and more positive psychological outcomes.

DESIGN

A 2 × 2 randomized block, repeated-measures design, with data collected at baseline and two other points postintervention, as well as a few days before or after either a mammogram or oncologist visit.

SETTING

Rural and urban clinical and community settings.

SAMPLE

313 female BCSs aged 50 or younger; 117 African Americans and 196 Caucasians.

METHODS

Participants were blocked on ethnicity and randomly assigned to intervention or control. The intervention, consisting of a scripted CD and a guide booklet, was supplemented by four scripted, 20-minute weekly training calls conducted by nurse interventionists. The control group received the four scripted, 20-minute weekly training calls.

MAIN RESEARCH VARIABLES

Uncertainty in illness, uncertainty management, breast cancer-specific concerns, and positive psychological outcomes.

FINDINGS

BCSs who received the intervention reported reductions in uncertainty and significant improvements in behavioral and cognitive coping strategies to manage uncertainty, self-efficacy, and sexual dysfunction.

CONCLUSIONS

The intervention was effective as delivered in managing uncertainties related to being a younger BCS.

IMPLICATIONS FOR NURSING

The intervention can realistically be applied in practice because of its efficient and cost-effective nature requiring minimal direct caregiver involvement. The intervention allows survivors who are having a particular survival issue at any given point in time to access information, resources, and management strategies.

KNOWLEDGE TRANSLATION

Materials tested in CD and guide booklet format could be translated into online format for survivors to access as issues arise during increasingly lengthy survivorship periods. Materials could be downloaded to a variety of electronic devices, fitting with the information needs and management styles of younger BCSs.

Characteristics of breast cancer patients who experience menopausal transition due to treatment

OBJECTIVE

To identify patient-related and treatment-related factors associated significantly with climacteric symptoms in young patients who experience menopausal transition due to adjuvant treatment for breast cancer.

METHODS

This cross-sectional study used questionnaire data collected to screen breast cancer patients for participation in a multicenter trial on the efficacy of supportive interventions for treatment-induced menopausal symptoms. The screening instrument included questions on sociodemographics, menopausal history and current menopausal status and symptoms, treatment history and lifestyle factors. Univariate and multivariate analyses were used to identify factors associated significantly with two major menopausal symptoms, hot flushes/night sweats and vaginal dryness.

RESULTS

In total, 435 patients were included in this study. Hot flushes/night sweats exhibited a significant, negative association with education and a significant positive association with alcohol consumption, and having been treated with the combination of chemotherapy and hormonal therapy. Vaginal dryness was positively associated with combined treatment with chemotherapy and hormonal therapy.

CONCLUSIONS

Menopausal symptoms among young breast cancer patients who experience menopausal transition due to adjuvant treatment are associated with a number of sociodemographic, lifestyle and treatment-related factors. Carefully designed interventions to prevent or alleviate these symptoms should take these factors into account.

Utility of a Web-Based Breast Cancer Predictive Algorithm for Adjuvant Chemotherapeutic Decision Making in a Multidisciplinary Oncology Center

PURPOSE

Adjuvant drug therapy can extend survival for breast cancer patients, but the balance between costs and benefits may be difficult to estimate. Software programs have been developed for this purpose and recently have become available online. Here, we describe our experience using a web-based program to support adjuvant decision making at a multidisciplinary breast cancer Tumor Board in a university-affiliated oncology center.

PATIENTS AND METHODS

One hundred two adjuvant breast cancer cases were discussed by the Tumor Board over a four-month period, with a provisional treatment plan being formulated after each discussion. Program data predicting 10-year risks and benefits were shared with board members after each provisional plan and any change in recommendation was recorded. A user survey was conducted to assess the perceived strengths and weaknesses of the program.

RESULTS

Treatment decisions were changed in 12.7 percent of cases (13/102) after consideration of data from the program. Most of these (76.9 percent) were node-negative ER-positive cases, with the most common reason for change being a lower-than-expected added survival benefit from less intensive chemotherapy regimens (ACx4 or CMF; 81.8 percent). In certain recurrent scenarios, the program was perceived to have limitations that led to retention of the original management plan despite data that might otherwise have favored different treatment. On completion of the study period, clinicians' attitudes to the program ranged from enthusiasm to caution.

CONCLUSION

Although not replacing clinical judgement, these findings support the value of this web-based program as a decision making adjunct that can help clinicians to separate risk and benefit, compare the added value of different therapeutic interventions in a given clinical context, and present more balanced information about treatment options to patients.

Ovarian function and childbearing issues in breast cancer survivors

The increasing number of breast cancer survivors makes the issues of ovarian dysfunction and childbearing ability more and more relevant for the quality of life of these patients. The incidence of ovarian dysfunction is related to patient age, the specific agents used and the total dose administered, especially the dose of alkylating agents such as cyclophosphamide. Amenorrhea rates following combination chemotherapy consisting of cyclophosphamide + methotrexate + 5-flurouracil (CMF regimen) range from 21 to 71% in women aged 40 years and younger, and from 40 to 100% in older ones. In most series anthracycline-based adjuvant chemotherapy regimens appear to have a lower incidence of amenorrhea, which is probably due to the lower cumulative cyclophosphamide dose administered compared with that given in the CMF regimen. Few data are currently available regarding ovarian function in women treated with taxane-based chemotherapy. In a recent retrospective study on 191 patients, the amenorrhea rate was 64% for women who received doxorubicin + cyclophosphamide (AC regimen) followed by a taxane, compared with 55% (p = 0.05) for those treated with AC alone. Forty percent of women aged 40 years or younger resumed menstruation, whereas the amenorrhea was more likely to be irreversible in older women; however, the addition of a taxane did not change the reversibility rate. Ovarian reserve can be tested with serum assays of follicle-stimulating hormone, inhibin B, estradiol and anti-Müllerian hormone, as well as by ultrasound assessment of antral follicle count. A review of literature data failed to show that a subsequent pregnancy increases the risk of recurrence and death in breast cancer survivors, and some series have even detected longer survival for patients who get pregnant after breast cancer treatment. This apparent survival benefit, probably due to a selection bias called the 'healthy mother effect', suggests that breast cancer survivors who subsequently conceive are a self-selecting group of women with better prognosis. The little available information appears to show no increase in the incidence of prematurity, stillbirth or congenital malformations in their babies. In conclusion, future pregnancy is a viable option for a woman treated for early-stage breast cancer and does not appear to be detrimental to either the mother or her offspring.

Menopausal-type symptoms in young breast cancer survivors

BACKGROUND

There has been little previous information available about menopausal-type symptoms in very young breast cancer survivors.

METHODS

In collaboration with the Young Survival Coalition, we conducted an Internet-based survey of women with a history of breast cancer diagnosed at age 40 years or younger using items derived from the Breast Cancer Prevention Trial symptom checklist.

RESULTS

A total of 371 respondents were eligible for analysis. Mean age at diagnosis was 32.8 years and mean age at follow-up 36.2 years; 89% of women received chemotherapy, 49% tamoxifen, 15% ovarian suppression, 4% aromatase inhibitors. At the time of survey, 37% were taking tamoxifen and 9% ovarian suppression. Excluding women on ovarian suppression, 77% of women were premenopausal at follow-up. Many women reported bothersome menopausal-type symptoms. In particular, 46% of women reported hot flashes and 39% reported dyspareunia. In a linear regression model of symptom scores, current ovarian suppression, postmenopausal status, baseline anxiety before the diagnosis, pregnancy after the diagnosis, prior chemotherapy, and lower perceived financial status were associated with more bothersome symptoms.

CONCLUSION

A substantial number of young breast cancer survivors experience bothersome menopausal symptoms. While the women who responded to our survey may represent a select group of survivors, these findings may have important implications for treatment decision making and long-term quality of life of young women with breast cancer.

Fertility preservation in young women undergoing breast cancer therapy

Breast cancer accounts for one third of all neoplasms seen in reproductive-age women and affects tens of thousands of women each year in that age group. The adjuvant chemotherapy regimens used for the treatment commonly affect fertility and cause premature ovarian failure. There have been recent advances in the field of fertility preservation, which can allow many of these breast cancer survivors to have children in the future. The most established option is embryo cryopreservation; oocyte cryopreservation can be considered in single women. Both of these approaches require approximately 2 weeks of ovarian stimulation beginning with the onset of the patient's menstrual cycle. Thus, it is crucial that these patients are referred to appropriate assisted reproduction centers as soon as they are diagnosed with breast cancer. Recently developed ovarian stimulation protocols using tamoxifen and letrozole can be used to increase the margin of safety in these patients. When and if a breast cancer patient does not have time to undergo ovarian stimulation prior to chemotherapy, ovarian cryopreservation for future autotransplantation can be offered as the last resort. The benefit of ovarian protection by gonadotropin-releasing hormone analogues is unproven and unlikely, and thus this treatment should not be offered as the sole method of fertility preservation.

Conserving fertility in the management of gynaecological cancers

The quality of cancer treatment is judged by both morbidity and mortality. Patients benefit if morbidity is reduced without compromising mortality. This applies particularly for women who develop gynaecological malignancy during their childbearing years where curative treatment also renders them infertile. This study reviews the increasing role of fertility-sparing surgery in such women. A literature search was undertaken using PubMed, entering the terms endometrial cancer, cervical cancer and ovarian cancer in conjunction with the terms fertility and fertility sparing. Each relevant identified paper was reviewed, references checked and results collated to provide an evidence-based summary of fertility-sparing treatments for gynaecological malignancy. Fertility-sparing surgery is appropriate in many circumstances, and all doctors who advise young women with gynaecological malignancy should be aware of these possibilities. However, data are relatively sparse in many situations, and careful counselling and balanced guidance are essential if patients are to understand the full implications of their choices.

Fertility in female cancer survivors: pathophysiology, preservation and the role of ovarian reserve testing

The improved long-term survival of adolescents and young women treated for cancer has resulted in an increased focus on the effects of chemotherapy on ovarian function and its preservation. These women may seek advice and treatment regarding their reproductive status, including ways of preserving their fertility and preventing a premature menopause--factors that can have a profound impact on their quality of life. This article comprehensively reviews ovarian reserve testing (ORT) in general. Special emphasis is placed on patients with cancer, including the pathophysiology of gonadal damage following chemotherapy, fertility preservation and the potential role of ORT. Baseline parameters of ovarian reserve [FSH LH, estradiol, inhibin B and anti-Mullerian hormone (AMH)] have not yet performed sufficiently well in predicting poor outcome in assisted reproduction, but biochemical markers of ovarian reserve appear to be better than chronological age. Inhibin B and AMH show potential for future use. Dynamic testing appears to show much promise, especially stimulated levels of inhibin B and estradiol. The most promising tests of ovarian reserve are the biophysical markers, where total antral follicle count was found to be most discriminatory followed by ovarian volume. Combination of biochemical, biophysical and clinical markers of ovarian reserve may also improve predictive capacity. However, there is a lack of data pertinent to ORT in cancer. As yet there is no single clinically useful test to predict ovarian reserve accurately. Patients with cancer represent a distinct cohort who have particular concerns about their future fertility and the possibility of a premature menopause, they can benefit greatly from knowledge of their functional ovarian reserve. Large, prospective, randomized, adequately controlled studies specific to different geographical areas are required in a control population of comparable reproductive age to determine the potential role of ORT in clinical practice.