Breast cancer & Fertility. Do we provide good information?

Transcription

1 Breast cancer & Fertility. Do we provide good information? M Fastrez, C Houba CHU S t Pierre Réseau IRIS University of Brussels

2 We have no conflict of interest to disclose.

3 Summary Introduction: epidemiology Effects of breast cancer treatment on fertility Surgery Radiotherapy Systemic therapy: chemotherapy hormonal treatment Fertility sparing options Breast cancer & pregnancy Importance of information Family Hope

4 Increasing number of women surviving breast cancer Berry DA et al. New Engl J Med 2005

5 women/year in Belgium are diagnosed with BC (1) 1/20 is less than 40 (1) Data from the US (2) : young BC survivors have minor (73%) and major (39%) concerns about treatment-induced infertility ½ felt that their fertility concerns were sufficiently addressed (1) National cancer registry, Belgium, 2008 (2) Partridge AH et al. J Clin Oncol Oct 15;22(20):

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7 Effect of breast-conserving surgery on QOL Waljee et al. JCO 2008.

8 Effect of breast-conserving surgery on QOL Effect on fertility? Waljee et al. JCO 2008.

9 Surgery for prevention of BC BSO recommended to BRCA-mutation carriers by the age of 40 Encourage early maternity Bilateral salpingectomy may reduce ovarian cancer risk, no effect on BC risk Other prevention strategies: Early screening (clinical examination, mammography, MRI) from the age of 25 Chemoprevention: tamoxifen reduces risk of BC by 62% in BRCA-2 mutation carriers ACOG Practice Bulletin No Gynecol Obstet 2009

10 Radiotherapy effects After adjuvant chemotherapy No gonadotoxicity Precaution principle: abdominal head apron Fertility strategies: Possibility to stimulated ovaries during the radiotherapy Use of aromatase inhibitors Chemotherapy after radiotherapy Buchholtz et al.lancet 2011

11 Effect of chemotherapy

12 Chemotherapy-induced premature Is directly correlated to: Agents used Total dose delivered Patient s age menopause High cumulative doses of alkylant agents > 35 years high probability of premature menopause = Major concern for young women with BC and influence therapeutic decision & treatment adherence F Cardoso et al. Eur J Cancer 2012

13 Chemotherapy-induced infertility Is directly correlated with premature menopause Toxic effect of CT: On primordial ovarian oocyte pool infertility Granulosa cells irregular cycles Infertility is not always associated with amenorrhea Fertility sparing options must be discussed with the patient before treatment!

14 Hormonal treatment effects 2/3 of women less than 40 5 years Tamoxifen GNRH agonists not recommended untill new data Oncological consequence: Reduced mortality by 40 % Fertility consequence: 5 years delay before conception Stop tamoxifen ealier For good prognosis tumors Wash out 3 months Start again Tamoxifen after pregnancy

15 How to preserve Gold standard: Embryo vitrification New promising technique: Oocyte vitrification (1) Experimental protocoles: Ovarian tissue autotransplantation (2) Future: Complete IV follicule growth (3) New oocytes from oogonial stem cells (4) Oncological view: ensure the best recovery rate Fertility view: ensure the best pregnancy rate They need to work closely ASRM Guidelines 2013 (1) Cobo et al. Fertil Steril Mar 28 (2) Demeestere et al. Obstet Gynecol Int. 2012;2012: (3) Telfer et al. IVI Seviila 2013 (4) Dori et al. Reprod Sci 20(1):7-15 (2013)

16 Other parenthood options Eggs donation Adoption

17 Pregnancy after breast cancer Should not be discouraged Individual risk should be discussed No consensus about the delay Azim HA Jr et al. Eur J Cancer. 2011

18 Pregnancy after breast cancer Delay 2 years for patients with high risk of relapse Early interruption of adjuvant therapy risk of recurrence Ovarian stimulation remains debatable Azim HA Jr et al. Eur J Cancer. 2011

19 Management of BC during pregnancy Pregnancy shouldn t be aborted because of BC Standard management according to stage of pregnancy Management in a multidisciplinary team Neonatal morbidity < prematurity no induced delivery before 37 weeks Amant F et al. Eur J Cancer 2010 Being pregnant doesn t seem to affect overall survival if treatment is completed (*) (*) Amant F et al. JCO 2013

20 Why is information important? For patients <10% young (before 40 y.o.) patients with breast cancer will have a child (1) 50% of them want to have a child (1) 50% have the feeling that their concern about fertility was addressed adequately (2) No increase of death if pregnancy after breast cancer (3, 4) Also patients between 40 and 45 (1) Mueller BA et al. Cancer 2003 Sep 15;98(6): (2) Partridge AH et al. J Clin Oncol Oct 15;22(20): (3) Ives A et al. BMJ Jan 27;334(7586):194. (4) Largillier et al. Cancer 2009 Nov 15;115(22): doi: /cncr.24608

21 Why is it difficult? For the oncologist They forgot 8% of patients are less than 40 Not a frequent case, no well established timetable care Not enough time During consultation Before the adjuvant therapy Not the good moment No great familiarity with prognosis and fertility preservation options No rapid links with a fertility consultation Poor compliance For the patient increased psychological distress Ethical choice sometimes difficult, they need support from partner, close friends, parents, gynecologist, and family doctor Tool to provide good information at the good moment for patients and health care providers

22 Fertility sparing options amoung women with breast cancer Importance of information

23 How to inform? In 2012, the Fondation Roi Baudouin and the Fonds Pink Ribbon support creation of a national web site with the purpose to inform women diagnosed with breast cancer about fertility sparing treatment options (online 1/10/2013) 7 belgian universities involved: ULB, VUB, UCL, KUL, ULG, UGent, UAntwerp

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25 Aims of the Family Hope project To provide information in all 3 national languages to all belgian patients and/or her families To bring all belgian university centers together into the same oncofertility consortium To develop a network of reference (online 1/10/2013)