Written by: Dr. Mark Serverino, M.D., F.A.C.O.G.
and Dr. Courtney Vito, M.D.
According to the American Cancer Society, roughly 25% of all newly diagnosed breast cancers are diagnosed in pre-menopausal women, with an expected 11,500 diagnoses in women under the age of 40 this year alone. When you couple this information with the fact that the rate of first-time mothers over the age of 30 has increased by more than four-fold since the early 1990s, it’s plain to see that fertility issues bear greater importance in the breast cancer world than ever before. My daughter is a breast surgical oncologist in the greater Los Angeles area. I asked her for her point of view, and here are her thoughts:
“Thank you for the opportunity to chime in on this very important topic. As a breast surgeon, more and more, I have been finding myself in the difficult position of diagnosing and treating very young women with breast cancer. Although a cancer diagnosis is never easy, younger women face a unique set of challenges. They often present at later stages because they have not been undergoing annual mammography like the 40-and-over crowd. Their tumors are often more aggressive, and they may be related to the BRCA gene. Also, many younger women are still planning and having their families. It’s clear that things are changing. A recent study has shown an increase in breast cancer under the age of 40, and as we all know, many women are delaying their childbearing later than any generations before us which, in and of itself, raises the risk of developing breast cancer. There is an expanding segment of patients diagnosed with breast cancer for whom fertility preservation is important, and this is an incredibly understudied area that is becoming more and more common.
One of the greatest modern advances in breast cancer care is anti-hormonal treatment such as tamoxifen. Tamoxifen basically shuts down ovarian estrogen production, and by doing so, decreases the risk of recurrent breast cancer by 50%. That’s a huge benefit for my patients, but ultimately I am throwing them into premature menopause. How does that square with pregnancy? Pregnancy after breast cancer diagnosis is often a taboo subject. Doctors don’t often discuss it upfront with patients, because truthfully, we just don’t have a lot of answers. There never has been, and for ethical reasons, there never will be a randomized controlled clinical trial (the gold standard in medicine) looking at the risks of pregnancy after breast cancer. BUT…there are many other types of trials that seem to support the safety of pregnancy after breast cancer diagnosis.
There are a couple of key pieces of information for every breast cancer patient who may desire fertility after her diagnosis. First, before beginning any therapy that may limit your ability to become pregnant, such as chemotherapy or anti-hormonal therapy, you should have the chance to speak with a reproductive endocrinologist who is comfortable working with breast cancer patients. Check with your oncologist for referrals, and have a frank discussion with your oncologist about what your risks may be. Certain chemotherapies can shut down your ovaries prematurely, thusly limiting a woman’s fertility. Anti-hormonal therapy can block your ability to become pregnant while you are taking the medication or can damage a fetus if you do. For women with estrogen or progesterone receptor positive disease, we often recommend 5 or even 10 years of anti-hormonal treatment after diagnosis. If you are 30 at the time your breast cancer is diagnosed, you may not be off therapy until age 40, at which time, simply due to age, your fertility may be compromised. For women in these situations, I often recommend to my patients to consider harvesting their eggs either for freezing or to create embryos as soon as surgery is complete to remove the tumor but prior to embarking on chemotherapy or anti-hormonal therapy. Another important reason to consider fertility early after your diagnosis is finances. The cost of fertility preservation is often not covered by insurance and can be prohibitive for many of the women I see in practice. There are several charity organizations that will subsidize the cost of fertility preservation, such as Fertile Hope through the Lance Armstrong Foundation, but these charities often limit their grants to patients who have not yet had a single dose of fertility impairing medications. For many of my patients, these grants were the only reason they were able to afford fertility preservation, but had they not been proactive early after their diagnosis, these grants would not have been available. Finally, what I tell every patient is that the diagnosis of breast cancer, especially at such a young age, can shatter your world. It may be difficult to decide whether you want to become a mother or become a mother again when you feel like you are just fighting for your own life let alone that of any potential children. It is overwhelming. But…take charge now. Don’t burn bridges because of fear of exploring your fertility options. Hesitating now may close doors for you that you didn’t know existed. Also, I encourage women who have already undergone treatment and now find themselves in a situation where pregnancy seems difficult or impossible to explore their options too. Reproductive technologies are exploding, and what might not have been possible a few years ago might be routine now. A consultation with a fertility expert is only about gaining knowledge, not committing to treatment. Knowledge is power. Empower yourself.”
I was very excited to know that my daughter is appropriately referring and encouraging her patients to seek fertility counseling. Unfortunately, this is not always the case. In 2004, Dr. Anne Partridge et al conducted a study by surveying women in the Young Survivors Coalition, a group consisting of women 40 and under diagnosed with breast cancer. In the study, the respondents who said that fertility was of high concern in their breast cancer treatment, less than one-third were referred to a reproductive endocrinologist, and over half of women said their fertility concerns were not adequately addressed. Despite the inadequate counseling, just over half of the women in the study said that their own personal concerns impacted their decisions about accepting recommended medical care for their breast cancer. Clearly we need to do a better job. There are very safe ways to preserve fertility and allow a woman to have her medically necessary care for her breast cancer. Here at Red Rock Fertility, we are here to help you with these concerns. Should you or someone you know be facing a breast cancer diagnosis, please come in at least a consultation? We are here to help you and your family!
