Lindsay Petersen, MD
I walked into an examination room at our multidisciplinary breast clinic to see Jill, a 25-year-old single elementary school teacher who was recently diagnosed with breast cancer. Jill was a known BRCA gene mutation carrier, and her mother and a cousin were currently receiving treatment for breast cancer. Because her cousin was diagnosed at age 35, Jill opted to start screening at age 25. During Jill’s first screening, cancer was detected, and it had already spread to her axillary lymph nodes. Jill arrived at the appointment with her parents. When I asked her why she was seeking care at our clinic, because she and her mother reported that they were extremely happy with the treatment her mother was receiving at an outside institution, Jill replied that she was interested in fertility preservation and knew she would have options at a tertiary care center.
As I discussed fertility-preservation options with Jill and her parents, I felt sadness and also guilt, as I was obviously pregnant. It seemed especially cruel for Jill to hear about fertility options from a young pregnant fellow. Jill smiled and politely asked questions about how I was feeling with my pregnancy as a breast surgery fellow even though she was the one with a life-altering diagnosis. I felt fortunate to be healthy and expecting my first child.
One of the most difficult things as a breast surgery fellow is treating young women with cancer, some even younger than myself, in the early stages of their lives. Seeing these women and their families attempt to cope with their diagnosis and treatment is heartbreaking. Young women should be concerned about job challenges, family issues, and life goals—they should not have to worry about cancer and mortality.
Oncofertility, a term coined by Teresa Woodruff, PhD, of the Oncofertility Consortium, is the specialty dealing with the clinical care of patients who will lose their fertility due to cancer treatment. Oncofertility is very important in the care of patients with breast cancer for multiple reasons. Nationally, there is a trend toward more women delaying motherhood and having children at older ages. Also, more patients are surviving breast cancer and may become mothers after treatment—and more women certainly will have the life expectancies to be able to parent their children.
In 2006, the American Society of Clinical Oncology (ASCO) released recommendations regarding oncofertility; these recommendations were updated in 2013.1
Providers are encouraged to discuss the possible loss of fertility with reproductive-age patients with cancer, as well as refer patients to appropriate fertility preservation specialists. ASCO suggests this discussion should be documented in the medical record. There are multiple options for fertility preservation including embryo and oocyte cryopreservation.
Oncologists have often led the way in terms of discussing oncofertility with patients, as both chemotherapy and endocrine therapy impact ovarian function. However, surgical oncologists should discuss this important topic with their patients, as well. Surgeons are generally the first providers that patients interact with following a cancer diagnosis. There is an opportunity and obligation to discuss fertility concerns with any woman of childbearing age. Fertility preservation efforts can begin during workup prior to surgery, as patients wait for surgery, and as patients recover after surgery. These processes can take place concurrently, as fertility preservation procedures will not affect the cancer surgery or vice versa. Referring patients to a reproductive specialist at the time of the first appointment can save valuable time, as hormone stimulation can require weeks of treatments prior to the retrieval procedure.
Jill underwent oocyte cryopreservation after meeting with a reproductive specialist. While undergoing neoadjuvant chemotherapy, she is considering her surgical options. I am hopeful that she will be able to have a child after she is treated for her cancer.
Now that my son has arrived, it has hit home how important it is to discuss fertility preservation options with our patients. Women need to hear that breast cancer is treatable, their fertility can be preserved, and they can become mothers despite their diagnoses. Our sole focus should not be just treating the cancer. We must treat the whole patient, taking into consideration survivorship issues and oncofertility at the very first appointment.
Loren AW, Mangu PB, Beck LN, et al. Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013;31(19):2500- 2510. doi: 10.1200/JCO.2013.49.2678.