Risk of menopause during the first year after breast cancer diagnosis

Patterns, Predictors, and Prognostic Implication of Treatment-Related Amenorrhea in Patients With Breast Cancer

Background

Treatment-related amenorrhea (TRA) is a common side effect of treatment in premenopausal patients with breast cancer, with important consequences for patient counseling and management. Its occurrence and potential influence on survival outcomes remain active areas of investigation. This study aimed to evaluate the incidence, risk factors, and prognostic significance of TRA in patients with breast cancer.

Methods

This is a retrospective cohort study. Patients were interviewed during and after chemotherapy to assess their menstrual status. Sociodemographic, clinical, and treatment data of patients were also collected. TRA was classified into early amenorrhea (EA) and late amenorrhea (LA) based on the duration of amenorrhea. Univariable and multivariable logistic regression were used to identify risk factors of EA and LA. Kaplan-Meier curves and Cox proportional hazards analyses were used to investigate the impact of EA and LA on 3-year overall survival (OS).

Results

There were 81 patients who were eligible for the final analysis. Of these subjects, 14 (17.3%) developed no amenorrhea, 67 (82.7%) developed EA, and 45 (55.6%) developed LA. We did not find any significant independent risk factor for EA. Age > 45 years (odds ratio (OR): 4.00; confidence interval (CI): 1.23 - 13.01; P = 0.021) and the usage of hormonal therapy (OR: 4.96; CI: 1.58 - 15.53; P = 0.006) independently significantly increase the risk of LA, whereas a metastatic disease status decreased the risk (OR: 0.20; CI: 0.04 - 0.90; P = 0.036). Both EA (hazard ratio (HR) = 0.262, CI: 0.105 - 0.653; P = 0.002) and LA (HR = 0.234, CI: 0.091 - 0.604; P = 0.001) were associated with an improved 3-year OS rate.

Conclusions

Age > 45 years and the usage of hormonal therapy are risk factors for LA, while metastatic disease was associated with a decreased risk. Both EA and LA had a significant association with favorable 3-year OS. These findings enable clinicians to provide personalized guidance, tailor treatment strategies, and improve the outcomes of premenopausal patients with breast cancer. Standardization of how TRA is defined and assessed in future studies is essential to improve comparability and enhance the understanding of its clinical implications.

Boric Acid Protects the Uterus and Fallopian Tubes from Cyclophosphamide-Induced Toxicity in a Rat Model

Background/Objectives: Cyclophosphamide (CP) is widely used for treating various cancers and autoimmune diseases, but it causes damage to reproductive organs due to oxidative stress (OS) and inflammation. Boric acid (BA) has antioxidant properties that may help reduce OS, which is critical for preserving uterine functionality, particularly for cancer patients considering pregnancy after cryopreservation. This study aimed to determine whether BA could diminish CP-induced toxicity in the uterus and fallopian tubes (FT) using CP-induced toxicity in a rat model. Methods: Forty female Wistar rats, aged 18-20 weeks, were divided into four groups as follows: control, oral BA (OBR), CP, and CP plus OBR (CP + OBR). The toxicity was induced in the CP and CP + OBR groups with an initial dose of 200 mg/kg CP, followed by 8 mg/kg daily for 14 days. Rats in the OBR and CP + OBR groups received 20 mg/kg/day of BA. After the 16-day experiment, tissues were collected for analysis. Results: Histopathological and immunohistochemical assessments of IL-6 and HIF-1α expressions were used to evaluate inflammation and OS. The control, OBR, and CP + OBR groups maintained normal tissue features, while the CP group showed epithelial cell shedding, vacuolization, degenerative endometrial glands, lymphocyte infiltration, and reduced collagen fiber density. Elevated HIF-1α and IL-6 expressions in the uterus and FT indicated significant OS and inflammation. Conclusions: The study concluded that BA supplementation in CP-treated rats effectively reduced CP-induced uterine and FT damage, suggesting the potential protective role of BA in managing CP-associated toxicity.

Patient-Related Awareness of Impact of Cancer-Directed Therapy on Fertility in Young Women Diagnosed of Breast Cancer

Nita S. Nair Chemotherapeutic agents used in the treatment of breast cancer (BC) adversely impact growing ovarian follicles and can induce permanent premature ovarian failure or reduce ovarian reserve in younger women. As treatments result in improved survival of BC patients, young survivors face quality of life (QOL) issues, including treatment-related infertility. We conducted a survey to evaluate awareness among patients regarding the impact of cancer-directed therapy on fertility and available options of fertility preservation (FP). We interviewed 350 women with BC under 40 years of age at the start of treatment, of which 321 (91.70%) were in varying stages of follow-up, 8 women (2.30%) were scheduled to start treatment, and 21 (6.00%) women were under treatment. All received chemotherapy or hormone therapy with or without ovarian suppression. Of the 350 women who responded to the survey, 321 (91.70%) women were on follow-up, 8 (2.30%) women were due to start treatment, and 21 (6%) women were on treatment. The median age at diagnosis was 35 years, with 12.9% of women aged less than 30 years, 15 (4.28%) were unmarried, 31 (8.85%) were nulliparous, and 98 (28%) had one child. Overall, 271 (77.42%) women were aware (at the start of treatment) of impact of therapy on fertility, but only 48/271(17.71%) women were aware of the options of FP. In this cohort, 94/350 (26.85%) women felt FP was a priority, 64/350 (18.28%) women perceived their family as incomplete, and 17/64 (26.56%) women were willing to consider invasive reproductive assistance (IRA). Reasons for refusal for IRA included cost, risk of relapse, and delay of treatment. There was an association between being unmarried ( p  = 0.00), having an incomplete family (0.00), considering more children ( p  = 0.00) and willingness to consider IRA. FP is a priority for women treated for BC and an important QOL domain that needs to be addressed at the start of treatment We found a high level of awareness of impact of cancer-directed therapy to fertility in this cohort, but low awareness and acceptance for options for FP.

Measuring serum oestrogen levels in breast cancer survivors using vaginal oestrogens: a systematic review

PURPOSE

Vaginal oestrogens can be used to treat genitourinary symptoms in women with early breast cancer. Studies evaluating vaginal oestrogens have commonly measured serum oestrogen levels as a surrogate marker of safety, but methods vary. We sought to summarise the data on serum oestrogen measurement in women with breast cancer using vaginal oestrogens to better understand the methods, levels and reliability.

METHODS

We searched Medline, Embase, CENTRAL, SCOPUS and CINAHL from inception to October 2023 for clinical studies where serum oestrogen was measured in women with a history of early breast cancer using vaginal oestrogens. Studies with a reported testing methodology were included.

RESULTS

Nine studies met the inclusion criteria for this systematic review. Methods used to measure oestradiol and oestriol in selected studies included mass spectrometry and immunoassays; several studies used more than one with variable concordance. Mass spectrometry detected oestradiol levels down to a lower limit between 1.0 pg/mL and 3.0 pg/mL. Immunoassays such as ELISA (enzyme-linked immunosorbent assay), ECLIA (enhanced chemiluminiscence immunoassay) and RIA (radioimmunoassay) had lower detection limits ranging between 0.8 pg/mL and 10 pg/mL. Studies were heterogeneous in testing techniques used, timing of testing, and the population including with subsequent varying results in the effect on oestrogens reported.

CONCLUSIONS

Adopting consistent and standardised methods of measuring oestrogens in clinical trials involving women with early breast cancer on vaginal oestrogens is critical. Serum oestrogens are used as a surrogate marker of safety in this population, and good-quality data are necessary to enable clinicians and patients to feel confident in prescribing and taking vaginal oestrogens. Mass spectrometry, although more expensive, gives more reliable results when dealing with very low levels of oestrogens often found in women on aromatase inhibitors, compared to immunoassays.

Fertility preservation in patients undergoing gonadotoxic treatments: a Canadian Fertility and Andrology Society clinical practice guideline

The management of young patients with cancer presents several unique challenges. In general, these patients are ill prepared for the diagnosis and the impact on their fertility. With the improved survival for all tumour types and stages, the need for adequate fertility counselling and a multidisciplinary approach in the reproductive care of these patients is paramount. Recent advances in cryopreservation techniques allow for the banking of spermatozoa, oocytes, embryos and ovarian tissue without compromising survival. This Canadian Fertility and Andrology Society (CFAS) guideline outlines the current understanding of social and medical issues associated with oncofertility, and the medical and surgical technologies available to optimize future fertility.

Vasomotor symptoms and management of women undergoing treatment for breast cancer: literature review with focus on the therapeutic potential of cytoplasmic pollen extract

OBJECTIVE

Effective management of vasomotor symptoms (VMS) in patients undergoing treatment for breast cancer (BC) represents a critical but frequent unmet need. This review summarizes the epidemiology, pathophysiology, and clinical features of VMS in patients with BC and provides a synopsis of the complementary and alternative medicine (CAM) approaches in relieving VMS with a focus on purified cytoplasm of pollen (PCP).

METHODS

The literature on VMS epidemiology, pathophysiology, clinical burden, and CAM treatment in healthy women and patients with BC was reviewed.

RESULTS

VMS are common in patients with BC undergoing hormonal treatment and negatively impact quality of life, leading to treatment discontinuation in up to 25% of patients with detrimental impact on risk of BC recurrence and overall survival. CAM approaches to treat VMS in patients with BC include vitamin E, phytoestrogens, and black cohosh, even if there is a lack of solid evidence to guide clinicians in the choice of treatment. PCP, obtained according to standards of good manufacturing practice, has a definite pharmacological mechanism of action, is devoid of estrogen activity, and has shown clinical efficacy on menopause-associated symptoms with a favorable safety profile and high compliance. As such, it appears to represent a valid management option to improve quality of life in patients with pre- and postmenopausal BC.

CONCLUSIONS

Physicians should actively investigate the presence and impact of VMS in patients receiving therapy for BC. Additional and appropriately sized randomized clinical trials are needed to provide clear evidence on how to best meet the needs of patients with BC suffering from menopause-associated symptoms.

Factors Associated with Sleep Disorder among Korean Cancer Survivors: A Cross-Sectional Study

BACKGROUND

The factors associated with sleep disorder are controversial. This study aimed to evaluate the prevalence of sleep disorder and the factors associated with sleep disorder among Korean adult cancer survivors.

METHODS

In this cross-sectional study, we collected data on sleep problems as outcome variables, and sociodemographic and clinical information as predictor variables from cancer survivors at two university-affiliated hospitals. Sleep disorder was defined as "a difficulty in sleep initiation or sleep maintenance at least 3 times a week that started after a cancer diagnosis." Multiple logistic regression analysis was performed with odds ratios (OR) and 95% confidence intervals (95% CI) to evaluate the factors associated with sleep disorder.

RESULTS

The participants were 1,893 Korean cancer survivors (mean age, 58.1 years; females 68.0%). The prevalence of sleep disorder among male and female cancer survivors were 16.5% and 20.3%, respectively. An increase of age by 1-year was associated with a 1.04 (95% CI, 1.01-1.07; P=0.011) times higher risk of sleep disorder in males, while an inverse association was found in females. In female survivors, high fear of cancer recurrence (FCR), high anxiety, menopause, and high EuroQol Visual Analog Scale were associated with 1.45 (95% CI, 1.06-1.98; P=0.020), 1.78 (95% CI, 1.25-2.55; P=0.002), 1.70 (95% CI, 1.08-2.67; P=0.022), and 0.59 (95% CI, 0.43-0.82; P=0.002) times higher risk of sleep disorder, respectively. In male survivors, living with a spouse/or partner was associated with 57% (95% CI, 0.20-0.95; P=0.036) lower risk of sleep disorder. Analyses of cancer sites showed that the factors associated with sleep disorder varied across cancer sites.

CONCLUSION

One-fifth of adult cancer survivors had sleep disorder. Age, menopausal status, FCR, anxiety, living with a spouse or partner, and quality of life were independently associated with sleep disorder in Korean cancer survivors.

Systemic Therapy of Premenopausal Patients with Early Stage Hormone Receptor-Positive, HER2-Negative Breast Cancer - Controversies and Standards in Healthcare

In patients with existing ovarian function, there are some special aspects to adjuvant endocrine therapy in premenopausal patients with hormone receptor-positive, HER2-negative (HR pos./HER2 neg.) breast cancer. Treatment options include tamoxifen with or without a GnRH analog, and aromatase inhibitors with a GnRH analog. Furthermore, ovarian function is affected by previous chemotherapy. Both aromatase inhibitors (+GnRH analogs) and GnRH analogs in combination with tamoxifen are supposed to be indicated for patients at increased risk of recurrence. However, national and international guidelines and therapy recommendations do not provide a clear definition of intermediate or high risk; as a result, therapy decisions are often made for each patient on an individual basis. This is also reflected in the considerable variability at national and international levels, e.g., with regard to the use of aromatase inhibitors + GnRH analogs. This review summarizes the data on completed studies (e.g., SOFT, TEXT, EBCTCG meta-analyses) and the current multigene testing studies (TailorX, RxPonder, ADAPT), discusses the rationale for current studies (e.g., CLEAR-B), and looks ahead to future questions.

The Impact of Systemic Oncological Treatments on the Fertility of Adolescents and Young Adults-A Systematic Review

BACKGROUND

Over the past decades, advancements in oncological treatments have led to major improvements in survival. Particularly for adolescents and young adults (AYAs), fertility is an important concern in cancer survivorship. The purpose of the review is to provide physicians with a practical overview of the current knowledge about the impact of systemic oncological treatments on the fertility of female and male AYAs.

METHODS

A systematic review was performed based on relevant articles obtained from 4 databases up until 31 December 2022.

RESULTS

The mechanisms of gonadotoxicity and the concurrent risk is described for the following categories: chemotherapy, targeted therapy and immunotherapy. For the category "chemotherapy", the specific effects and risks are listed for the different classes and individual chemotherapeutics. In the category "targeted therapy", a distinction was made between tyrosine kinase inhibitors (TKIs) and monoclonal antibodies. Information concerning immunotherapy is scarce.

CONCLUSIONS

The effects of chemotherapy on fertility are well investigated, but even in this category, results can be conflicting. Insufficient data are available on the fertility effects of targeted therapy and immunotherapy to draw definitive conclusions. More research is needed for these therapies and their evolving role in treating cancers in AYAs. It would be useful to include fertility endpoints in clinical trials that evaluate new and existing oncological treatments.

Role of Ovarian Suppression in Early Premenopausal Breast Cancer

The benefit from removing ovaries to control premenopausal breast cancer growth was identified more than 100 years ago. Subsequent identification of estrogen receptor (ER) enabled targeting of this approach. Development of gonadotropin-releasing hormone agonists facilitated a reversible method of ovarian function suppression, suitable for young women with early breast cancer. Clinical trials have established the value of including ovarian suppression to reduce recurrence of ER-positive premenopausal early breast cancer. Ovarian suppression administered with chemotherapy can reduce the risk of premature menopause in ER-negative cancer, and increase the prospect of future pregnancy in premenopausal women, regardless of tumor hormone receptor status.

Breast cancer treatment and ovarian function

The aim of this study was to provide an update on ovarian function and the mechanisms of gonadal damage after exposure to chemotherapy in breast cancer survivors. The alkylating agents are toxic to both primordial and growing follicles. However, anti-metabolite drugs are more likely to destroy preantral and antral follicles. Younger patients are more likely to have a higher ovarian reserve, and therefore, more likely to retain some residual ovarian function after exposure to gonadotoxic regimens. However, there can be significant variability in ovarian reserve among patients of the same age. Furthermore, patients with critically diminished ovarian reserve may continue to menstruate regularly. Therefore age and menstrual status are not reliable indicators of good ovarian reserve and might give a false sense of security and result in an adverse outcome if the patient is consulted without considering more reliable quantitative markers of ovarian reserve (antral follicle count and anti-Müllerian hormone) and fertility preservation is not pursued. In contrast to well-documented ovarian toxicity of older chemotherapy regimens, data for newer taxane-containing protocols have only accumulated in the last decade and data are still very limited regarding the impact of targeted therapies on ovarian function.

The British menopause society consensus statement on the management of oestrogen deficiency symptoms, arthralgia and menopause diagnosis in women with treated for early breast cancer

This guidance document by the British Menopause Society provides an overview of the management of women experiencing oestrogen deficiency symptoms and arthralgia following a breast cancer diagnosis. It is now recommended breast cancer patients are referred to health care professionals with an expertise in menopause for management of such symptoms, which in turn often involves liaison with patients' breast cancer teams.¹ However, as many women initially present to primary health care professionals for advice, this statement is aimed to support the latter in such consultations by providing information about symptom aetiology, current management strategies and controversies and identifying useful practice points. This is an updated version of the 2018 consensus statement prepared by Miss Jo Marsden Consultant Breast Surgeon, King's College Hospital, London, (retired), Mr Mike Marsh, Consultant Gynae-endocrinologist, King's College Hospital, London, Dr Anne Rigg, Consultant Medical Oncologist, Guy's and St Thomas' Hospital, London.

Exploration of fertility and early menopause related information needs and development of online information for young breast cancer survivors

BACKGROUND

Approximately half of premenopausal women diagnosed with breast cancer desire to conceive after they finish treatment. Counseling about the risk of infertility prior to cancer treatment has been proven to improve quality of life after cancer treatment. As a result of this, guidelines focus on informing women on this topic prior to treatment. However, it is equally important to provide fertility related information after primary treatment has been completed, when the wish to conceive might become actual. Therefore, the aim of this study was to identify the fertility and early menopause related information needs of young breast cancer survivors and to design, develop and implement online information material with input of stakeholders.

METHODS

A phenomenological qualitative study consisting of four phases was performed: identification of information needs through semi-structured interviews from a professional perspective (1) and a patient perspective (2). Exploration of stakeholders perspective regarding development and implementation of online information material (3) and development and implementation of the information material (4).

RESULTS

Professionals indicated that there are no guidelines regarding the provision of fertility related information during cancer survivorship. Survivors reported unmet information needs. Women identified the following as most important information needs (a) fertility preservation options, (b) the risk of menopause or infertility, and (c) long term consequences of early menopause. A wide range of stakeholders involved in breast cancer care were interviewed. Based on their proposed design the information material was implemented on a nationwide website aiming at informing and supporting breast cancer patients.

CONCLUSIONS

Fertility and early menopause related information needs of young breast cancer survivors and their professionals were identified. Information material has been designed, developed and nationally implemented. This way, professionals in breast cancer care are provided with an information tool that helps them meet the information needs and preferences of their patients.

Younger women are more susceptible to inflammation: A longitudinal examination of the role of aging in inflammation and depressive symptoms

BACKGROUND

The degree to which effects of inflammation on mood and behavior vary across the lifespan remains relatively unexplored despite well-established, age-related alterations in both the immune and central nervous systems. Further, the implications of this developmental process within different symptom domains warrants careful consideration.

METHODS

Women diagnosed with breast cancer (n = 188; ages 27-89) provided blood samples and reported depressive symptoms prior to adjuvant treatment, at the end of adjuvant treatment, and 6-, 12-, and 18-months after completing adjuvant treatment via the CES-D. Blood was assayed for C-reactive Protein (CRP) and interleukin (IL)-6. We used mixed linear effect models to estimate within- and between-person effects of CRP or IL-6 on 4 domains of depressive symptoms: depressed affect, low positive affect, somatic complaints, and interpersonal problems.

RESULTS

High average inflammation was associated with elevated somatic complaints (CRP p = .009, IL-6: p = .05), interpersonal problems (CRP p = .002, IL-6 p < .001), and positive affect (IL-6 p = .03), but only among the youngest women in the sample (age 50 or younger). Younger women also reported more depressed affect at assessments when inflammation was higher (CRP p = .045, IL-6 p = .09).

CONCLUSIONS

The association between inflammation and specific depressive symptoms is dynamic and varies across the lifespan, which may help clarify apparent inconsistencies in the extant literature as well as inform more precise interventions targeting this pathway.

Brain Network Alterations in Rectal Cancer Survivors With Depression Tendency: Evaluation With Multimodal Magnetic Resonance Imaging

Surgery and chemotherapy may increase depression tendency in patients with rectal cancer (RC). Nevertheless, few comprehensive studies are conducted on alterations of brain network induced by depression tendency in patients with RC. Resting-state functional magnetic resonance imaging (rs-fMRI) and diffusion tensor imaging (DTI) data were collected from 42 patients with RC with surgery and chemotherapy and 38 healthy controls (HCs). Functional network (FN) was constructed from extracting average time courses in brain regions, and structural network (SN) was established by deterministic tractography. Graph theoretical analysis was used to calculate network properties. Networks resilient of two networks were assessed. Clinical correlation analysis was explored between altered network parameters and Hamilton depression scale (HAMD) score. This study revealed impaired FN and SN at both local and global levels and changed nodal efficiency and abnormal small-worldness property in patients with RC. On the whole, all FNs are more robust than SN. Moreover, compared with HC, patients with RC show less robustness in both networks. Regions with decreased nodal efficiency were associated with HAMD score. These cognitive dysfunctions are mainly attributable to depression-related brain functional and structural network alterations. Brain network reorganization is to prevent patients with RC from more serious depression after surgery and chemotherapy.

Management of Breast Cancer Survivors by Gynecologists

Breast cancer patients commonly present to their OBGYN during the process of diagnosis and treatment of breast cancer both for specific gynecologic needs and for primary care follow up. These patients require counseling on contraception, hormone use, and fertility at diagnosis. During treatment and survivorship, patients will face a variety of side effects from treatments leading to vasomotor symptoms, vulvovaginal discomfort, sexual dysfunction, osteoporosis, and vaginal bleeding. This chapters aims to enlighten providers on the unique range of issues a gynecologist may face when caring for breast cancer patients.

Cryopreservation of oocytes and embryos for fertility preservation

Background: In recent years, the demand for fertility preservation for both oncologic and nononcologic reasons, as well as for personal reasons, has increased dramatically.Current Concepts: Currently, embryo and oocyte cryopreservation after ovarian stimulation are the mainstays of fertility preservation treatment in women. Embryo cryopreservation is an established and the most successful method of fertility preservation when sufficient time (approximately 2 weeks) is available to perform ovarian stimulation. Recent advances in freezing techniques (vitrification) have significantly improved the outcomes from oocyte cryopreservation that are comparable with those from embryo cryopreservation.Discussion and Conclusion: This review focuses on the indications for the two techniques of fertility preservation and their results. For women to receive timely opportunities to preserve fertility, it is necessary to raise awareness among all medical departments and the public.

Chemotherapy-Induced Amenorrhea and Its Prognostic Significance in Premenopausal Women With Breast Cancer: An Updated Meta-Analysis

Objective

Chemotherapy-induced amenorrhea (CIA) is one of the most common side effects in premenopausal patients with breast cancer, and several factors may contribute to the incidence of CIA. In this meta-analysis, we aimed to summarize clinical risk factors associated with CIA incidence and to evaluate their prognostic effects in patients with breast cancer.

Methods

Three electronic databases (Cochrane Library, EMBASE, and MEDLINE) were systematically searched for articles published up to October 2021. The articles included clinical trials that evaluated risk factors associated with CIA and their prognostic value in treatment. For the meta-analysis, pooled odds ratio estimates (ORs) and 95% confidence intervals (CIs) were calculated using the inverse variance-weighted approach, in addition to publication bias and the chi-square test.

Results

A total of 68 studies involving 26,585 patients with breast cancer were included in this meta-analysis, and 16,927 patients developed CIA. From the 68 studies, 7 risk factors were included such as age group, hormone receptor (HR) status, estrogen receptor (ER) status, progesterone receptor (PR) status, tamoxifen administration, chemotherapeutic regimen, and tumor stage. Based on our results, patients with age of ≤40, HR-negative status, ER-negative status, PR-negative status, no use of tamoxifen, and use of anthracycline-based regimen (A) compared with anthracycline-taxane-based regimen (A+T) were associated with less incidence of CIA in patients with breast cancer. Moreover, CIA was associated with favorable disease-free survival (OR = 0.595, 95% CI = 0.537 to 0.658, p < 0.001) and overall survival (OR = 0.547, 95% CI = 0.454–0.660, p < 0.001) in premenopausal patients with breast cancer.

Conclusion

Age, HR status, ER status, PR status, tamoxifen administration, and chemotherapeutic regimen can be considered independent factors to predict the occurrence of CIA. CIA is a favorable prognostic factor in premenopausal patients with breast cancer. CIA should be a trade-off in the clinical management of premenopausal patients with breast cancer, and further large cohort studies are necessary to confirm these results.

Management of genitourinary syndrome of menopause in breast cancer survivors: An update

There is increasing attention about managing the adverse effects of adjuvant therapy (Chemotherapy and anti-estrogen treatment) for breast cancer survivors (BCSs). Vulvovaginal atrophy (VVA), caused by decreased levels of circulating estrogen to urogenital receptors, is commonly experienced by this patients. Women receiving antiestrogen therapy, specifically aromatase inhibitors, often suffer from vaginal dryness, itching, irritation, dyspareunia, and dysuria, collectively known as genitourinary syndrome of menopause (GSM), that it can in turn lead to pain, discomfort, impairment of sexual function and negatively impact on multiple domains of quality of life (QoL). The worsening of QoL in these patients due to GSM symptoms can lead to discontinuation of hormone adjuvant therapies and therefore must be addressed properly. The diagnosis of VVA is confirmed through patient-reported symptoms and gynecological examination of external structures, introitus, and vaginal mucosa. Systemic estrogen treatment is contraindicated in BCSs. In these patients, GSM may be prevented, reduced and managed in most cases but this requires early recognition and appropriate treatment, but it is normally undertreated by oncologists because of fear of cancer recurrence, specifically when considering treatment with vaginal estrogen therapy (VET) because of unknown levels of systemic absorption of estradiol. Lifestyle modifications and nonhormonal treatments (vaginal moisturizers, lubricants, and gels) are the first-line treatment for GSM both in healthy women as BCSs, but when these are not effective for symptom relief, other options can be considered, such as VET, ospemifene, local androgens, intravaginal dehydroepiandrosterone (prasterone), or laser therapy (erbium or CO2 Laser). The present data suggest that these therapies are effective for VVA in BCSs; however, safety remains controversial and a there is a major concern with all of these treatments. We review current evidence for various nonpharmacologic and pharmacologic therapeutic modalities for GSM in BCSs and highlight the substantial gaps in the evidence for safe and effective therapies and the need for future research. We include recommendations for an approach to the management of GSM in women at high risk for breast cancer, women with estrogen-receptor positive breast cancers, women with triple-negative breast cancers, and women with metastatic disease.

Preserving Oocytes in Oncofertility†

The prodigious rise of cancer survival rates enables many cancer survivors to live long lives. Therefore, the side effects of cancer treatments as well as the long-term quality of life after cancer have become more relevant. Ovarian toxicity is a major off-target effect of anticancer agents for childhood and young adult female cancer patients. Both chemotherapy and irradiation have been demonstrated to damage the ovary and increase the risks of premature ovarian failure (POF), early menopause, ovarian endocrine disorders, and sub- or infertility. Oncofertility is an emerging and multidisciplinary research and medical field that focuses on providing cancer patients with fertility preservation options. Oocyte quality and quantity are one of the most important factors to determine women's fertility success; therefore, preserving oocytes is paramount for maintaining the ability of young female cancer patients' reproduction after their recovery. This review summarizes peer-reviewed literature on current oocyte preservation options in oncofertility. We describe in-depth oocyte and embryo cryopreservation, ovarian suppression, ovarian tissue cryopreservation, in vitro maturation, ovarian transposition, and adjuvant therapy. Further, we discuss current guidelines and practices of female fertility preservation that cover preserving oocytes.

Factors Associated with Unplanned Pregnancy Among Cancer Survivors

Background: Approximately half of all pregnancies in the United States are unintended. However, women who are diagnosed with cancer in their reproductive years may be a unique population. This study examines the prevalence of and identifies factors associated with unplanned pregnancy among cancer survivors. Methods: Female cancer survivors aged 22-45 years, diagnosed between ages 20-35 years and at least 2 years postdiagnosis, and women with no history of cancer were interviewed about their reproductive histories, including pregnancy intention. Using a random matching process, comparison women were assigned an artificial age at cancer diagnosis equal to that of her cancer survivor match. An adjusted Cox model was fit examining time to unintended pregnancy after cancer for each of 1,000 matches. Cox proportional hazards models were also fit to assess associations between participant characteristics and unplanned pregnancy after cancer among survivors. Results: Cancer survivors (n = 1,282) and comparison women (n = 1,073) reported a similar likelihood of having an unplanned pregnancy in models adjusted for race, income, history of sexually-transmitted infection, and history of unplanned pregnancy before diagnosis (adjusted hazard ratio [aHR] 1.06, 95% simulation interval 0.85-1.36). After adjusting for confounders, unplanned pregnancy among survivors was associated with age <30 years at diagnosis (hazard ratio [HR]: 1.79, 95% confidence interval [CI]: 1.32-2.44), black race (HR: 1.55, 95% CI: 1.13-2.12; referent: white), receiving fertility counseling (aHR: 1.41, 95% CI: 1.04-1.92), and having at least one child before diagnosis (aHR: 1.44, 95% CI: 1.05-1.97). Conclusion: Cancer survivors and comparison women had similar likelihood of unplanned pregnancy. Rates of unplanned pregnancy after cancer were not higher for cancer survivors compared with comparison women, but 46.4% of survivors with a postcancer pregnancy reported an unplanned pregnancy. Cancer patients may benefit from patient-centered guidelines and counseling before cancer treatment that covers both risks of infertility and risks of unplanned pregnancy.

Multidisciplinary consensus on the criteria for fertility preservation in cancer patients

Infertility is one of the main sequelae of cancer and its treatment in both children and adults of reproductive age. It is, therefore, essential that oncologists and haematologists provide adequate information about the risk of infertility and the possibilities for its preservation before starting treatment. Although many international clinical guidelines address this issue, this document is the first Spanish multidisciplinary guideline in paediatric and adult oncological patients. Experts from the Spanish Society of Medical Oncology, the Spanish Fertility Society, the Spanish Society of Haematology and Haemotherapy, the Spanish Society of Paediatric Haematology and Oncology and the Spanish Society of Radiation Oncology have collaborated to develop a multidisciplinary consensus.

A Survey Study Reveals the Positive Impact of Oncofertility Knowledge and Attitude on Oncofertility Practice Among Oncologists in China

Purpose: The advances of early cancer diagnoses and treatment methods allow many adolescent and young adult-aged cancer patients to live long lives after having cancer. There is a rising concern regarding cancer treatment-induced reproductive toxicities and infertility. Oncologists are the first line of medical professionals interacting with cancer patients and playing essential roles in oncofertility practice. This study aimed to assess the oncofertility knowledge, attitude, and practice of oncologists in China. Methods: We created an online questionnaire survey to examine 927 Chinese oncologists' demographics, knowledge, attitude, experience, and practice regarding young female cancer patients' infertility risk and fertility preservation. Results: Results showed that there is an inadequate oncofertility knowledge among surveyed oncologists, which was affected by oncologists' demographic background of education level, clinical title, and working experience. The majority of surveyed oncologists (84.8%-88.7%) held a positive attitude on young female cancer patients' infertility risk and their fertility preservation demand, but their attitude was impacted by marriage status and patients risk of cancer recurrence. Only 11.8% of surveyed oncologists often referred their patients for fertility preservation, while 66.3% and 21.9% of them have referred once or never, respectively. The oncologists' oncofertility practice was not correlated with their demographic background but was significantly influenced by their oncofertility knowledge and attitude. Conclusion: Our study demonstrates that there is an urgent unmet need to improve oncologists' oncofertility knowledge, attitude, and practice in China as well as remove the communication barrier between oncologists and fertility specialists.

Genitourinary symptoms in women with breast cancer: what do oncology health professionals think and do about them?

OBJECTIVES

We aimed to improve understanding of health professional knowledge and management of genitourinary symptoms (GUS) in women with early breast cancer (EBC).

METHODS

A survey was sent to 872 health professionals caring for women with EBC. Questions addressed most common GUS seen, experience treating GUS, and attitudes to treatment options.

RESULTS

144 surveys were completed. Respondent characteristics: median age 50 years; 76% female; 42% medical oncologists; 24% nurses; 20% breast surgeons; 8% radiation oncologists. Most (68%) reported prescribing endocrine therapies for EBC, 99% were aware endocrine therapies can cause GUS, and 55% reported "often" or "always" asking patients on endocrine therapy if they have GUS. Respondents thought vaginal dryness was the most bothersome symptom for their patients (66%), followed by dyspareunia (11%). 81% of respondents reported seeing women stop endocrine therapy prematurely due to GUS. Respondents reported receiving "none" (19%) or "a little" (46%) training or education in managing GUS and only 16% reported feeling "very confident" managing GUS. The proportions of respondents reporting "often" and "very often" recommending the following vaginal treatments were: lubricants (81%); moisturisers (68%); oestrogens (21%); and laser (3%). Vaginal oestrogens were considered "safe" or "probably safe" by 77% and 90% of respondents for women with hormone receptor positive and negative EBC, respectively.

CONCLUSIONS

Despite health professionals frequently encountering GUS in women with EBC and seeing patients stop endocrine therapies prematurely, only 16% felt confident managing these symptoms. Education and training for health professionals are needed to better address this common problem.

Identifying women at risk of weight gain after a breast cancer diagnosis: Results from a cohort of Australian women

ISSUES ADDRESSED

This study aimed to identify risk factors associated with weight gain post a diagnosis of breast cancer in a cohort of Australian women.

METHODS

In this retrospective clinical audit, objectively measured weight, age and menopause status, treatment type/s, grade, stage, oestrogen receptor and progesterone receptor (PR) status were extracted for 73 breast cancer patients from an ongoing breast cancer treatment quality assurance project. Weight gain or loss was classified as a body mass increase or decrease of ≥5% of weight at diagnosis.

RESULTS

When compared to weight at diagnosis, 57% of patients maintained, 22% gained, and 21% lost weight at 24 months post-diagnosis. Factors associated with weight gain were a diagnosis of grade II (P < .001) or grade III (P < .001) compared to grade I breast cancer, and refusal of radiotherapy (P < .001). Factors associated with weight loss were being postmenopausal compared to premenopausal (P = .033), PR positive compared to PR negative (P < .001), refusal of chemotherapy (P < .001) and radiotherapy recommended (P < .001).

CONCLUSIONS

The maintenance of weight in a majority of women in this cohort is a novel finding. Early identification of women at risk of weight gain post a breast cancer diagnosis can assist health professionals identify, and therefore assisting patients in the prevention and management of weight gain and associated sequela. Investigating the weight-related communications between a patient and specialist, their access to allied health professionals and social support may assist in understanding the overall positive changes in this cohort.

Long-term effects of adjuvant treatment for breast cancer on carotid plaques and brain perfusion

Purpose

Breast cancer treatment has been associated with vascular pathology. It is unclear if such treatment is also associated with long-term cerebrovascular changes. We studied the association between radiotherapy and chemotherapy with carotid pathology and brain perfusion in breast cancer survivors.

Methods

We included 173 breast cancer survivors exposed to radiotherapy and chemotherapy, assessed ± 21.2 years after cancer diagnosis, and 346 age-matched cancer-free women (1:2) selected from the population-based Rotterdam Study. Outcome measures were carotid plaque score, intima-media thickness (IMT), total cerebral blood flow (tCBF), and brain perfusion. Additionally, we investigated the association between inclusion of the carotid artery in the radiation field (no/small/large part), tumor location, and these outcome measures within cancer survivors.

Results

Cancer survivors had lower tCBF (− 19.6 ml/min, 95%CI − 37.3;− 1.9) and brain perfusion (− 2.5 ml/min per 100 ml, 95%CI − 4.3;− 0.7) than cancer-free women. No statistically significant group differences were observed regarding plaque score or IMT. Among cancer survivors, a large versus a small part of the carotid artery in the radiation field was associated with a higher IMT (0.05, 95%CI0.01;0.09). Also, survivors with a right-sided tumor had lower left carotid plaque score (− 0.31, 95%CI − 0.60;− 0.02) and higher brain perfusion (3.5 ml/min per 100 ml, 95%CI 0.7;6.2) than those with a left-sided tumor.

Conclusions

On average two decades post-diagnosis, breast cancer survivors had lower tCBF and brain perfusion than cancer-free women. Also, survivors with a larger area of the carotid artery within the radiation field had a larger IMT. Future studies should confirm if these cerebrovascular changes underlie the frequently observed cognitive problems in cancer survivors.

Cognitive-Behavioral Therapy to Alleviate Treatment-Induced Menopausal Symptoms in Women With Breast Cancer: A Systematic Review

BACKGROUND

Numerous women with breast cancer (BC) exhibit early menopausal symptoms after undergoing cancer treatments. Medications that control menopausal symptoms can cause severe side effects and are contraindicated for patients with BC. Therefore, complementary and alternative medicines should be used. This study investigates the use of cognitive-behavioral therapy (CBT) for patients with menopausal symptoms after BC treatment.

OBJECTIVE

A systematic review was conducted to determine the efficacy and availability of CBT interventions in reducing treatment-induced menopausal symptoms in female patients with BC.

METHODS

Keywords were searched in Medical Subject Headings and 5 databases. The search criteria included randomized controlled trials (RCTs), non-RCTs, and single-group pre- and post-studies. Because of the risk of bias in non-RCTs using Joanna Briggs Institute's critical appraisal tools and single-group studies, the Critical Appraisal Skills Programme checklist for qualitative studies and RCTs was appraised using the Jadad scale.

RESULTS

After the review, 9 suitable studies were identified. Standard CBT programs lasted for 6 consecutive weeks, with 1 session of 1.5 hours weekly. The follow-up time was approximately 9 to 26 weeks. Women receiving CBT exhibited improvement in physical function and psychological state. This review supported the use of CBT to effectively improve the mental health of and reduce treatment-induced menopausal symptoms in BC survivors.

CONCLUSIONS

Cognitive-behavioral therapy interventions yielded positive outcomes in patients with BC, particularly in those experiencing menopausal symptoms.

IMPLICATIONS FOR PRACTICE

Cancer treatment generated severe menopausal symptoms in patients with BC. However, health professionals may use CBT to alleviate patients' menopausal symptoms.

Management of hormone receptor-positive, HER2-negative early breast cancer

The majority of breast cancers are diagnosed at an early stage and are hormone receptor (HR)-positive and human epidermal growth factor receptor 2 (HER2)-negative. Significant advances have been made in the management of early stage HR-positive, HER2-negative breast cancer, resulting in improved survival outcomes. In this review, we discuss important factors to consider in the management of this disease. In particular, we discuss the role of adjuvant endocrine therapy, specific endocrine therapy agents, the duration of adjuvant endocrine therapy, treatment-related side effects, and the role of genomic assays and other biomarkers when considering treatment recommendations for individuals with HR-positive, HER2-negative early breast cancer. Finally, we address emerging data to individualize therapeutic decision-making and provide future considerations.

Drug metabolising enzyme polymorphisms and chemotherapy-related ovarian failure in young breast cancer survivors

Cyclophosphamide is associated with chemotherapy-related ovarian failure (CROF) in breast cancer survivors, however little is known about predicting individual risks. We sought to identify genetic alleles as biomarkers for risk of CROF after cyclophosphamide treatment. One hundred fifteen premenopausal women with newly diagnosed breast cancer were genotyped for single nucleotide polymorphisms (SNPs) in genes involved in cyclophosphamide activation (CYP3A4 and CYP2C19) and detoxification (GSTP1 and GSTA1). Patients prospectively completed menstrual diaries. With median follow up of 808 days, 28% experienced CROF. Survivors homozygous for the GSTA1 minor allele had lower hazards for developing CROF (HR 0.22 [95% CI 0.05-0.94], p=.04), while survivors homozygous for the CYP2C19 minor allele had higher hazards for developing CROF (HR 4.5 [95% CI 1.5-13.4], p=.007) compared to patients with at least one major allele. In separate multivariable models adjusting for age and tamoxifen use, the associations were no longer statistically significant (GSTA1 HR 0.24 [95% CI 0.06-1.0], p=.05; CYP2C19 HR 2.5 [0.8-7.6], p=.11). CYP3A4 and GSTP1 SNPs were not significantly related to CROF. In younger breast cancer survivors undergoing cyclophosphamide-based chemotherapy, genetic variation in CYP2C19 and GSTA1 merits further study to determine its relationship with CROF.IMPACT STATEMENTWhat is already known on this subject? Young breast cancer survivors face important potential implications of chemotherapy-related ovarian failure (CROF). Little is known about individual risk for CROF. Cyclophosphamide, a particularly gonadotoxic drug commonly used in breast cancer treatment, is metabolised by various cytochrome p450 enzymes. Studies have shown genetic variation in p450 enzymes is associated with differential clinical outcomes after cyclophosphamide treatment: breast cancer patients homozygous for GSTA1 minor allele had improved overall survival; lupus patients homozygous for CYP2C19 minor allele had increased risk for CROF; and CYP3A4*1B I was associated with decreased risk for CROF.What do the results of this study add? We show a surprising opposite trend for the risk of CROF in breast cancer patients with GSTA1 and CYP2C19 variants, while we did not show a significant risk for genetic variation in CYP3A4 (which had previously been shown to have a protective effect) or GSTP1.What are the implications of these findings for clinical practice and/or further research? This study shows the complexity of genetic variation in predicting outcomes to treatment. We advocate for future replicative studies to potentially validate GSTA1 and CYP2C19 and definitively negate CYP3A4 and GSTP1 as biomarkers for risk of CROF after cyclophosphamide treatment. Understanding genetic variation in chemotherapy metabolism has the potential to individualise treatment regimens to maximise efficacy and minimise toxicity.

NSAS-BC02 substudy of chemotherapy-induced amenorrhea (CIA) in premenopausal patients who received either taxane alone or doxorubicin(A) cyclophosphamide(C) followed by taxane as postoperative chemotherapy

BACKGROUND

Chemotherapy-induced amenorrhea (CIA) is one of the critical side effects from the chemotherapy in premenopausal patients with breast cancer. The goals of our study are the following: (1) to investigate the factors affecting the incidence of CIA; and (2) to evaluate the prognostic role of CIA in premenopausal patients with breast cancer.

METHODS

We conducted a post hoc retrospective substudy to examine the incidence of the CIA and the relationship between CIA and prognosis in NSAS-BC02 that compared taxane alone to Doxorubicin(A) Cyclophosphamide(C) followed by taxane in postoperative patients with node-positive breast cancer RESULTS: Of 395 premenopausal women, 287 (72.7%) had CIA due to protocol treatment. Regarding type of protocol regimen, proportion of CIA was 76.9% in AC Paclitaxel(P), 75.2% in AC Docetaxel(D), 62.8% in PTX, and 75.2% in DTX. Predictive factors of CIA were age increase by 5 years (OR 1.50), ER positivity (OR 2.08), and HER2 3 + ( OR 0.40) according to logistic regression analysis. According to the log rank test and the Cox proportional hazards model, CIA group had significantly better disease-free survival than non-CIA group (P < .0001). However, according to time-dependent Cox model that was used to reduce guarantee-time bias, CIA was not a statistically significant prognostic factor in both ER-positive and ER-negative patients.

CONCLUSION

Treatment with taxane alone caused high frequency of CIA in premenopausal women with breast cancer. CIA did not turn out to be an independent prognostic factor, taking guarantee-time bias into consideration. Further clinical studies are needed to validate these findings.

Amenorrhea after lung cancer treatment

OBJECTIVE

More than 5,000 premenopausal women are diagnosed with lung cancer annually in the United States. Limited data exist regarding the risk of treatment-related amenorrhea, a surrogate for infertility and early menopause, after systemic therapies for lung cancer.

METHODS

Premenopausal women diagnosed with lung cancer under age 50 were surveyed at diagnosis and annually thereafter about their menstrual status as a part of the Mayo Clinic Epidemiology and Genetics of Lung Cancer Research Program. Types of lung cancer-directed treatments were recorded, and frequencies of self-reported menopause at each survey were calculated.

RESULTS

A cohort of 182 premenopausal women were included in this study, with average age at lung cancer diagnosis 43 years (SD 6). Among the 85 patients who received chemotherapy, 64% self-reported that they had become menopausal within a year of diagnosis. Platinum salts were universally included in these chemotherapy regimens, and the majority of these women also received taxanes within 1 year of diagnosis. Only 15% of the 94 patients who did not receive systemic therapy within 1 year of diagnosis experienced self-reported menopause. Three patients received targeted therapy alone, two of whom remained premenopausal at the final qualifying survey, completed a median of 3 years after diagnosis.

CONCLUSIONS

Chemotherapy for lung cancer patients appears to increase risk of early loss of menses in survivors.

Amenorrhea, fertility preservation, and counseling among young women treated with anthracyclines and taxanes for early-stage breast cancer, a retrospective study

Chemotherapy may cause ovarian toxicity and infertility. Cancer patients are usually overwhelmed, and focus exclusively on cancer diagnosis and may not pay attention to fertility-related issues. In this paper we look at the rate of amenorrhea and fertility counseling among such young patients.Premenopausal women with early-stage breast cancer treated with adjuvant or neoadjuvant chemotherapy were recruited. Amenorrhea was defined as absence of menstruation for ≥12 months after the completion of chemotherapy.A total of 94 patients met the eligibility criteria and were included in this analysis. Median age at diagnosis was 35.7 (range, 22-44) years. Seventy-nine (85.9%) respondents were counseled about amenorrhea and 37 (40.2%) were considering having children. Long-term amenorrhea was reported by 51 (54.3%) patients. The addition of taxanes to anthracyclines, in 2 different regimens, increased the risk of amenorrhea to 69.2% and 66.7% compared to 38.9% with anthracycline-alone, P < .0001. Longer duration of chemotherapy (≥24 weeks) might also be associated with higher rate of amenorrhea (67.7%) compared to 43.4% in those who had shorter duration (<24 weeks), P = .031.The addition of taxanes to anthracycline-based chemotherapy increased the risk of amenorrhea. However, shorter duration of chemotherapy, even with taxanes, may lower such risk. Our study highlights the importance of fertility counseling to improve fertility preservation rates. Given the importance of taxanes, shorter regimens are associated with lower amenorrhea rates and should be preferred over longer ones.

Controversies Regarding Ovarian Suppression and Infertility in Early Stage Breast Cancer

A common side effect of chemotherapy in breast cancer is early menopause in premenopausal patients, which is mainly a result of an indirect form of ovarian ablation, and is associated with substantial impairment of quality of life. Suppressing the production of ovarian estrogen has been shown to reduce the recurrence of hormone receptor-positive early breast cancer in premenopausal women, but whether it has an added advantage over tamoxifen is being discussed. Types of permanent ablation of the ovarian function include surgical oophorectomy and radiation-induced ovarian failure. Both are associated with similar response rates in hormone receptor-positive metastatic breast cancer. Medical castration with luteinizing hormone-releasing hormone analogs (LHRHa) has the benefit of being a reversible approach. Another advantage that premenopausal patients who wish to reduce the risk of developing premature ovarian insufficiency induced by chemotherapy may be offered LHRHa irrespective of whether they desire pregnancy and their age at diagnosis. This also helps reduce the risk of menopausal signs and symptoms as well as the loss of bone density in the long-term, which are primary concerns for women. This is of utmost importance to premenopausal women who do not want to conceive after treatment or are not candidates for fertility preservation strategies because of age. It should be emphasized that for women who are interested in fertility preservation, gamete cryopreservation remains the first option, and LHRHa is not an alternative. During chemotherapy, however, temporary ovarian suppression with LHRHa may be given to women who either have no access to a fertility clinic or who have declined chemotherapy or have contraindications.

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.

Impact of Breast Cancer Treatment on Fertility

Malignancy may unfortunately present quite early in a woman's life. In the case of breast cancer, rescue of the breast cancer patient's life is the top priority, but after completion of the effective treatment , the question about the ability to accomplish a pregnancy arises. The treatment strategies in breast cancer patients include surgical interventions, chemotherapy , radiotherapy, hormonal therapy and other special types of mainly targeted biologic therapies. Under normal circumstances, surgery for breast cancer does not involve any intervention in the ovaries or the uterus. Thus, even after an extended operation, the anatomic integrity of the gynecological system is guaranteed, and fertility is unaffected.The chemotherapeutic factors that influence fertility are the drug category used, the total dose given, the patient's age at treatment , the drug combination and finally whether targeted therapy is used or not. Alkylating agents are considered to be the most toxic ones. In young breast cancer patients there is a trend to modify regimens to achieve less gonadotoxicity.Evidence regarding tamoxifen, the main used endocrine drug, is scarce and controversial on its direct effect on ovarian reserve. There are not enough studies on the impact of aromatase inhibitors on fertility. Also, HER2-directed agents have not yet demonstrated significant ovarian toxicity and there are scarce data on their effect on fertility.

Impact of BRCA1 and BRCA2 mutations on ovarian reserve and fertility preservation outcomes in young women with breast cancer

Purpose

To determine the impact of BRCA1 and BRCA2 mutations on ovarian reserve and fertility preservation outcome. The main purpose and research question of the study is to determine the impact of BRCA1 and BRCA2 mutations on ovarian reserve and fertility preservation outcomes.

Methods

Prospective study: 67 breast cancer patients between 18 and 40 years old, undergoing a fertility preservation by means of oocyte storage were considered. Inclusions criteria for the study were age between 18 and 40 years old, BMI between 18 and 28, breast cancer neoplasm stage I and II according to American Joint Committee on Cancer classification (2017) and no metastasis. Exclusion criteria: age over 40 years old, BMI < 18 and > 28, breast cancer neoplasm stage III and IV and do not performed the BRCA test. A total of 21 patients had not performed the test and were excluded. Patients were divided into four groups: Group A was composed by 11 breast cancer patients with BRCA 1 mutations, Group B was composed by 11 breast cancer patients with BRCA 2 mutations, Group C was composed by 24 women with breast cancer without BRCA mutations, and Group D (control) was composed by 181 normal women.

Results

Group A showed significant lower AMH levels compared to Group C and D (1.2 ± 1.1 vs 4.5 ± 4.1 p < 0.05 and 1.2 ± 1.1 vs 3.8 ± 2.5 p < 0.05). BRCA1 mutated patients showed a significant lower rate of mature oocytes (MII) compared to Group C (3.1 ± 2.3 vs 7.2 ± 4.4 p < 0,05) and Group D (3.1 ± 2.3 vs 7.3 ± 3.4; p < 0,05). Breast cancer patients needed a higher dose of gonadotropins compared to controls (Group A 2206 ± 1392 Group B2047.5 ± 829.9 Group C 2106 ± 1336 Group D 1597 ± 709 p < 0,05). No significant differences were found among the groups considering basal FSH levels, duration of stimulation, number of developed follicles, and number of total retrieved oocytes. Regarding BRCA2 mutation, no effect on fertility was shown in this study.

Conclusions

The study showed that BRCA1 patients had a higher risk of premature ovarian insufficiency (POI) confirmed by a diminished ovarian reserve and a lower number of mature oocytes suitable for cryopreservation.

Fertility preservation before neoadjuvant chemotherapy in a premenopausal breast cancer patient: a case report

Neoadjuvant chemotherapy is now a widely accepted treatment modality for operable breast cancer and therefore fertility preservation is an important component of care for young patients with breast cancer. It is critical that oocyte retrieval is completed without delays in the initiation of neoadjuvant chemotherapy. Here we report the case of a 34-year-old woman who was diagnosed with Stage IIA triple-negative breast cancer and underwent ovarian stimulation for fertility preservation prior to the initiation of neoadjuvant chemotherapy. Oocytes were retrieved and in vitro fertilization was conducted before neoadjuvant chemotherapy was started. Upon completion of neoadjuvant chemotherapy, the patient underwent breast surgery. Subsequently, a pathological complete response was achieved. She received a frozen embryo transfer 10 months after breast surgery. The patient became pregnant and delivered a healthy baby.

The maintenance effect of acupuncture on breast cancer-related menopause symptoms: a systematic review

Background: Acupuncture has been used for many breast cancer treatment-related problems, but how long the effect lasts is unknown. This meta-analysis aims to evaluate how long the effect of acupuncture on breast cancer-related hot flushes and menopause symptoms lasts.Methods: The research design followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement, without language restrictions. Seven databases from inception through February 2019 were accessed; only randomized clinical trials (RCTs) that examined the maintenance effect of acupuncture on hot flushes or menopause symptoms after treatment were included. Cochrane criteria were followed and RevMan 5.2 software was used to analyze trials.Results: In total, 943 patients from 13 RCTs were analyzed. The meta-analysis showed that acupuncture had no significant long-term maintenance effect on the frequency or severity of hot flushes (p = 0.29; p = 0.34), but had a significant 3-month maintenance effect of ameliorating menopause symptoms at 3 months after treatment ended (p = 0.001). No adverse events were reported.Conclusions: Acupuncture significantly alleviated menopause symptoms for at least 3 months, but not hot flushes. Breast cancer patients concerned about the adverse effects of hormone therapy could consider acupuncture as an alternative. Additional acupuncture at 3 months after the initial treatment course could be considered. A large-scale study may help to define the optimal guideline for this issue.

Structural tuning of acridones for developing anticancer agents targeting dihydrofolate reductase

Targeting dihydrofolate reductase, here, we report the tumor growth inhibitory activity of substituted acridones. The screening of the molecules over 60 cell line panel of human cancer cells identified (S)-oxiran-2-ylmethyl 9-oxo-9,10-dihydroacridine-4-carboxylate (19) with average GI₅₀ 0.3 μM. The specificity of the compound to CCRF-CEM, MOLT-4 and SR cell lines of leukemia and SW-620, SF268, LOXIMVI, ACHN and MCF7 cancerous cells exhibiting GI₅₀ in the nM range was observed. C6 Glioma cells treated with compound 19 showed differentiated cell morphology and cell cycle arrest in G2/M phase. The interactions of the compound with dihydrofolate reductase were ascertained with the help of enzyme immunoassays, molecular docking and molecular dynamic studies.

Vaginal CO2 laser for the treatment of vulvovaginal atrophy in women with breast cancer: LAAVA pilot study

PURPOSE

Vulvovaginal atrophy (VVA) is a commonly reported issue among breast cancer patients, and its aetiology is multifactorial. Treatment is difficult in these women, particularly because the use of oestrogens has traditionally been discouraged. Vaginal laser treatment has been reported to improve symptoms. We aimed to assess the impact on symptoms and sexual function of vaginal laser in women with early breast cancer (EBC).

METHODS

We performed a single-arm investigator initiated pilot study of female EBC patients with symptomatic VVA. A total of 3 vaginal laser treatments were administered 4 weeks apart. Questionnaires were completed at baseline, 4, 8 and 12 weeks. Our primary endpoint was symptomatic improvement of VVA at 12 weeks on 10 cm visual analogue scales. Our secondary endpoints were improvement in sexual function using the Female Sexual Function Index (FSFI) and patient-reported improvements in symptoms, sexual function and quality of life. Statistical analysis was performed with a Wilcoxon Signed Rank test.

RESULTS

26 patients were enrolled between February 2016 and August 2017. All patients were post-menopausal, 25 of whom had received anti-oestrogen therapy for their breast cancer. Questionnaire compliance was high (98%) and all patients received the three pre-planned treatments. There was significant improvement in each of the VVA symptoms: dryness (p < 0.001), itch (p < 0.001), burning (p = 0.003), dysuria (p < 0.001) and dyspareunia (p < 0.001). Patients also reported improvement in sexual function on the FSFI (p ≤ 0.001).

CONCLUSIONS

Patients receiving vaginal laser had improvement in VVA symptoms and sexual function. Further randomised sham-controlled trials are needed to further assess this treatment.

Gonadotropin-releasing hormone agonists during chemotherapy for ovarian function and fertility preservation for patients with early-stage breast cancer

Breast cancer remains the most common cancer among women worldwide. Many patients, especially in our region, are affected while young and during their child-bearing years. Chemotherapy, more commonly used in this age group, may result in premature ovarian failure and thus negatively impact their fertility. Several fertility-preservation methods are currently in use in this age group. Unfertilized ova cryopreservation and in vitro fertilization plus embryo cryopreservation are widely used in clinical practice. More recently, ovarian tissue cryopreservation is gaining in popularity. Several clinical trials and meta-analyses have shown that premenopausal women who received ovarian function suppression with gonadotropin-releasing hormone agonists while on chemotherapy were less likely to experience ovarian failure and had higher rates of menses resumption compared to those who did not. Some studies have also shown higher rates of successful pregnancies among treated patients. Given the conflicting results of the reported clinical trials and even the many published meta-analyses, this approach continues to be controversial and should only be used when other established fertility preservation methods cannot be utilized. The current review seeks to provide an updated summary on this controversial topic by reviewing all recently published clinical trials and meta-analyses.

Cancer Treatment-Related Infertility: A Critical Review of the Evidence

Cancer treatments may compromise the fertility of children, adolescents, and young adults, and treatment-related infertility represents an important survivorship issue that should be addressed at diagnosis and in follow-up to ensure optimal decision-making, including consideration of pursuing fertility preservation. Risk of infertility varies substantially with patient and treatment factors. The ability to accurately assess fertility risk for many patients is hampered by limitations of the current literature, including heterogeneity in patient populations, treatments, and outcome measures. In this article, we review and synthesize the available data to estimate fertility risks from modern cancer treatments for both children and adult cancer survivors to enable clinicians to counsel patients about future fertility.

British Menopause Society consensus statement on the management of estrogen deficiency symptoms, arthralgia and menopause diagnosis in women treated for early breast cancer

This guidance document by the British Menopause Society provides an overview of the management of women experiencing estrogen deficiency symptoms and arthralgia following a breast cancer diagnosis. It is now recommended that breast cancer patients are referred to health care professionals with an expertise in menopause for the management of such symptoms, which in turn often involves liaison with patients' breast cancer teams. However, as many women initially present to primary health care professionals for advice, this statement is aimed to support the latter in such consultations by providing information about symptom aetiology, current management strategies and controversies and identifying useful practice points.

Efficacy of Internet-Based Cognitive Behavioral Therapy for Treatment-Induced Menopausal Symptoms in Breast Cancer Survivors: Results of a Randomized Controlled Trial

PURPOSE

We evaluated the effect of Internet-based cognitive behavioral therapy (iCBT), with or without therapist support, on the perceived impact of hot flushes and night sweats (HF/NS) and overall levels of menopausal symptoms (primary outcomes), sleep quality, HF/NS frequency, sexual functioning, psychological distress, and health-related quality of life in breast cancer survivors with treatment-induced menopausal symptoms.

PATIENTS AND METHODS

We randomly assigned 254 breast cancer survivors to a therapist-guided or a self-managed iCBT group or to a waiting list control group. The 6-week iCBT program included psycho-education, behavior monitoring, and cognitive restructuring. Questionnaires were administered at baseline and at 10 weeks and 24 weeks postrandomization. We used mixed-effects models to compare the intervention groups with the control group over time. Significance was set at P < .01. An effect size (ES) of .20 was considered small, .50 moderate and clinically significant, and .80 large.

RESULTS

Compared with the control group, the guided and self-managed iCBT groups reported a significant decrease in the perceived impact of HF/NS (ES, .63 and .56, respectively; both P < .001) and improvement in sleep quality (ES, .57 and .41; both P < .001). The guided group also reported significant improvement in overall levels of menopausal symptoms (ES, .33; P = .003), and NS frequency (ES, .64; P < .001). At longer-term follow-up (24 weeks), the effects remained significant, with a smaller ES for the guided group on perceived impact of HF/NS and sleep quality and for the self-managed group on overall levels of menopausal symptoms. Additional longer-term effects for both intervention groups were found for hot flush frequency.

CONCLUSION

iCBT, with or without therapist support, has clinically significant, salutary effects on the perceived impact and frequency of HF/NS, overall levels of menopausal symptoms, and sleep quality.

Tamoxifen and pregnancy: an absolute contraindication?

PURPOSE

Breast cancer is the most common malignancy among young women of reproductive age. Adjuvant treatment with tamoxifen reduces the risk of recurrence in hormone-sensitive breast cancer. However, the use of tamoxifen is considered contraindicated during pregnancy, because of a limited number of case reports demonstrating potential adverse effects on the fetus. The objective of this report is to give a more broad overview of the available data on the effect of tamoxifen exposure during pregnancy.

METHODS

A literature review was performed using PubMed and the databases of the Netherlands Pharmacovigilance Centre Lareb and of the International Network on Cancer, Infertility, and Pregnancy.

RESULTS

A total of 238 cases of tamoxifen use during pregnancy were found. Of the 167 pregnancies with known outcome, 21 were complicated by an abnormal fetal development. The malformations described were non-specific and the majority of cases concerned healthy infants despite exposure to tamoxifen.

CONCLUSION

There seems to be an increased risk of fetal abnormalities when taking tamoxifen during pregnancy (12.6% in contrast to 3.9% in the general population), but the evidence is limited and no causal relationship could be established. The possible disadvantage of postponing or discontinuing tamoxifen for the maternal prognosis is unclear. Patients should be counseled about the use of tamoxifen during pregnancy instead of presenting it as being absolutely contraindicated.

Full-term pregnancy in breast cancer survivor with fertility preservation: A case report and review of literature

A 43-year-old woman with an associated history of gynecological pathology and breast cancer with only one cryopreserved embryo wished to be a mother. Several factors that influenced the success of the pregnancy in this case were analyzed. Favorable factors included: triple positive breast cancer [positive hormone receptors and positive human epidermal growth factor receptor 2], which is more hormosensitive and chemosensitive; absence of metastasis; correct endometrium preparation; and the patient’s optimistic attitude and strict health habits. In contrast, the factors against success were: breast cancer; adjuvant breast cancer therapy gonadotoxicity; the age of the patient (> 40-year-old); endometriosis; ovarian cyst; hydrosalpinx; submucosal fibroids and the respective associated surgery done for the above-mentioned pathology (all resolved prior to the embryo transfer); and a low quantity of ovules (low ovarian reserve) after ovarian stimulation. This is a very special clinical case of a patient with theoretically low pregnancy success probability due to the consecutive accumulation of gynecological and oncological pathologies, who nonetheless became pregnant and delivered a full-term infant and was able to provide adequate breastfeeding.

Sleepless from the Get Go: Sleep Problems Prior to Initiating Cancer Treatment

PURPOSE

Cancer patients are likely to experience sleep problems. Understanding their perception of sleep problems is important as subjective symptom experience is associated with treatment-seeking behavior. We explored the prevalence of sleep problems and its correlates in a large sample of cancer patients at an important but understudied stage of their cancer journey: prior to initiating treatment.

METHODS

Cancer patients (5702) (67.5% female; 76.9% White; 23.0% Hispanic), following diagnosis and prior to initiating cancer treatment, completed an electronic screening instrument. Patients across eight different cancer diagnoses (breast, gastrointestinal, gynecological, head and neck, hematological, lung, prostate, urinary) rated their sleep problems on a five-point scale, with those reporting "severe" or "very severe" sleep problems classified as having high sleep problems.

RESULTS

Overall, 12.5% of patients reported high sleep problems. Across diagnoses, the proportion of patients reporting high sleep problems ranged from 4.3 to 13.8%, with prostate cancer patients least likely and gastrointestinal cancer patients most likely to report high sleep problems. Older age, having a partner, higher education, and higher household income were associated with a lower likelihood of experiencing sleep problems. Being female, Black, Hispanic, and reporting anxiety or depression was associated with an increased likelihood of sleep problems.

CONCLUSIONS

A sizeable proportion of cancer patients experience significant problems with their sleep before any treatment has occurred. This clinical issue cannot be ignored as treatment is likely to worsen existing sleep problems. Oncology providers should routinely screen for sleep-related problems. Identifying and treating patients for sleep problems during a vulnerable period early in their cancer trajectory should be an essential component of clinical care.

Attitudes toward fertility and fertility preservation in women with glioma

Background

No studies have examined the fertility priorities of women undergoing treatment for their glioma. Glioma patients frequently undergo chemotherapy as part of their treatment; however, it is unknown whether patients truly are aware of its possible effects on their fertility. Our objective was to assess the fertility priorities of glioma patients and ascertain whether female glioma patients are being effectively counseled on the effects of chemotherapy on their fertility prior to beginning treatment.

Methods

The sample was composed of female patients from the Neuro-oncology clinic of the University of California, San Francisco. Participants completed a cross-sectional survey between October 2010 and December 2013 exploring their attitudes toward fertility and their experience with fertility counseling prior to chemotherapy initiation.

Results

Seventy-two women completed the survey. Analysis of the survey results showed that 30% of women receiving chemotherapy reported having a discussion regarding fertility preservation prior to beginning treatment. Of those who reported having this discussion, 80% were aware that chemotherapy could negatively affect their fertility. Many women reported that while fertility preservation was not important to them at the time of diagnosis, it was a priority for them at the time of survey completion. Although interest in having children tended to decrease after cancer treatment, the majority of respondents reported wanting a child after treatment.

Conclusions

The data obtained in this study suggest a lack of understanding of reproductive priorities, which may be addressed with a more comprehensive fertility discussion prior to beginning treatment.

Ovarian survival after pelvic radiation: transposition until the age of 35 years

Purpose

To evaluate the effectiveness of ovarian transposition (OT) prior to radiation therapy (RT) and to evaluate the effect of age on ovarian survival (OS) after OT.

Methods

We performed a retrospective control study, with women (aged < 45 years) who underwent OT prior to pelvic radiation, versus women diagnosed with cervical cancer and treated with hysterectomy/trachelectomy and radiation therapy. All women were treated between 1989 and 2010. The 5 years OS rate was calculated, with a sub-analysis for age (25–30; 31–35 and 36–40 years). Ovarian failure was defined as climacteric complaints (with or without starting hormone replacement therapy) and/or laboratory measurements (FSH > 40 IU/L and/or estradiol < 100 pmol/L), or bilateral salpingo oophorectomy. Women were censored at recurrence.

Results

Twenty-seven women after OT and 29 controls were included. The radiation dose was 44.8 Gy (25.0–63.0 Gy) and 46.3 Gy (45.0–50.0 Gy), respectively. The 5-year ovarian survival rate was 60.3% versus controls 0% (p < 0.001 95% CI 3.48–11.50). Despite the decrease in ovarian survival after OT with increasing age, in all age groups (25–30, 30–35 and 35–40) ovarian survival after OT was significantly better compared to women without OT (p = 0.001; p = 0.004 and p = 0.000, respectively). Neither intra-vaginal radiation therapy of concomitant chemotherapy in addition to pelvic radiation significantly altered ovarian survival.

Conclusions

Our data shows that ovarian transposition prior to pelvic radiation is effective in women until the age of 35 years and needs to be discussed in patients aged 36–40 years.