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Posted 03.24.04
[MAMM Magazine] Fertile Hopes
Post-treatment infertility may not be as common as many young survivors think

By Jasmin Chua

In the largest study of young breast cancer survivors to date, researchers found that more than half underestimated their chances of having children after treatment. A quarter of the women also felt that their fertility issues were not sufficiently addressed. Results of the web-based survey of 657 women were presented last December at the San Antonio Breast Center Symposium by Ann H. Partridge, MD, MPH of the Dana-Farber Cancer Institute. All of the respondents were members of the Young Survival Coalition, an international advocacy group that brings together young women with breast cancer.

The women tended to believe they were at higher risk of treament-related infertility than they actually were, Dr Partridge says. The reason for this perceived increase in risk were not entirely clear. "Developing breast cancer is not a happy time for any woman. For younger women it's affecting them at a time in their life where they are still trying to do things that many of us consider the right of every person, such as to go on and have a family."

These women also tend to have a different set of stresses and concerns from those of older breast cancer patients such as building a career or tending to very young children. "We know that in general younger patients have a more stressful experience with cancer than older patients," says Patricia Ganz, MD, director of cancer prevention and control research at the Jonsson Cancer Center at the University of California, Los Angeles. "If you're 55 or 60 you might have seen a few other friends have breast cancer. You're also at a time when your children are grown and you have relative independence in terms of your job and work schedules. It's always distressing to tell somebody that they have cancer, but I think that the life experience of older patients may buffer them."

Young women with breast cancer are regarded as a minority and the American Cancer Society estimates that over 11,000 age 40 or younger are diagnosed with breast cancer each year. The average age of the women who responded to the survey was 35.8 years and their age at diagnosis was about 33 years.

According to the survey, more than half, or 57 percent of the respondents were concerned about becoming infertile as a result of treatment. The majority of the women-72 percent-said that they had discussed fertility issues with their doctor and 17 percent had spoken with a fertility specialist.

The average age of menopause is 51 and premature amenorrhea--the early suppression or absence of menstruation--is generally an indicator of infertility. A 1999 article published in the Journal of Clinical Oncology suggested that the strongest predictors of early menopause with breast cancer treatment were age and the choice of chemotherapy. The closer you are to natural menopause in age, the higher your risk of amenorrhea. If your period comes back, however, you'll still be able to conceive.

"In previous NSABP (National Surgical Adjuvant Breast and Bowel Project) data we have patients who menstruate again after 18 or 24 months," Dr. Ganz says. "However, part of the reason why doctors don't say 'Oh you have x, y or z chances' [of becoming and/or staying infertile] is because we don't [know enough]."

Partridge's study also found that concerns about fertility were independent of the woman's age, the number of children they already had or the extent of their disease. Instead, the desire for a child was the foremost factor. "A lot of us have conventionally thought that a very young person who walks into your office or someone with a low risk disease is a person who should be concerned about fertility," Partridge says. "We didn't find that stage or age really mattered. It really mattered more about their fertility desires as well as their prior history of conceiving. That leaves me with a very simple question for people: do you wish to have children in the future?" For the women who answer in the affirmative, doctors need to spend some time discussing their options with them. She also notes that in the survey, 29 percent of the women said that fertility concerns colored their decisions about their choice of treatment.

Partridge admits to some limitations in her study including selection bias and a bias against non-responders of the survey. Because it is a retrospective study that questioned women about their concerns at the time of their diagnosis, the respondents may have also recalled things a little differently. When asked to comment on the study, Ganz thought it would have been interesting to know if these women had continued to menstruate or not. While a woman who has a serious disease might be thinking more about survival than about fertility, Partridge and Ganz both agree that more research is needed and that doctors should leave the subject open to discussion. "Our priority needs to be treating the whole patient," Partridge says. "This includes their goals for future fertility and family."

Published in MAMM Magazine, Jan/Feb 2004