Impact of breast cancer chemotherapy on ovarian reserve: a prospective observational analysis by menstrual history and ovarian reserve markers Andrea Reh, M.D., Ozgur Oktem, M.D., and Kutluk Oktay, M.D. Department of Obstetrics and Gynecology, Weill Medical College of Cornell University, New York Presbyterian Weill Cornell Medical Center, New York, New York Objective: To determine whether addition of taxanes to anthracycline and cyclophosphamide regimens impact ovarian function as assessed by menstrual history and ovarian reserve markers. Design: Prospective observational analysis. Setting: Large university fertility center. Patient(s): Forty-five women with a history of breast cancer of stages I IIIA who either received anthracycline, cyclophosphamide, and paclitaxel (ACT) or received anthracycline with cyclophosphamide (AC). Intervention(s): Menstrual histories were obtained at 6 months and at a mean of 28 months after chemotherapy. Early follicular phase FSH and E 2 samples were obtained at the second follow-up. Main Outcome Measure(s): Incidence of amenorrhea and abnormal laboratory values. Result(s): There was no statistically significant difference in the rates of amenorrhea at 6 months after chemotherapy (AC group, 41.7%; ACT group, 29%). At the second follow-up, a mean of 28 months after chemotherapy, there was a trend toward higher amenorrhea in the ACT patients (35.7%, vs. 9.1% in the AC group). When the ovarian markers were included, an additional eight menstruating patients were identified with abnormally elevated FSH or E 2 levels. Conclusion(s): We found no significant long- or short-term impact of taxanes on rates of amenorrhea. Future studies on the reproductive effects of chemotherapeutic agents should incorporate ovarian reserve markers, because menstrual history alone may underestimate the impact of these cytotoxic agents. (Fertil Steril Ò 2008;90:1635 9. Ó2008 by American Society for Reproductive Medicine.) Key Words: Chemotherapy-related amenorrhea, taxanes, ovarian reserve, fertility preservation Breast cancer is the most common malignancy encountered in reproductive age women, and it is estimated that 25% of patients with breast cancer are premenopausal at time of diagnosis (1), with 15% of all cases estimated to occur at <40 years of age (2). Although the nonreproductive side effects of different chemotherapy regimens are well studied, the precise effects on ovarian function, including premature menopause and infertility, are less well known. Chemotherapeutic agents have been shown to be detrimental to one s fertility via a dose- and drug-dependent depletion of the primordial follicle pool (3, 4). Cyclophosphamide is an alkylating agent that has significant, well-documented gonadotoxicity, with high rates of subsequent premature ovarian failure in survivors (5). Recent adjuvant chemotherapy regimens such as anthracycline with cyclophosphamide (AC) have incorporated the taxanes (ACT) into the treatment of early stage breast cancer, because these have been shown in phase III trials to prolong disease-free and overall survival Received August 27, 2007; revised and accepted September 26, 2007. Presented at the 62nd Annual Meeting of the American Society of Reproductive Medicine, New Orleans, Louisiana, October 21 25, 2006. Reprint requests: Kutluk Oktay, M.D., Department of Obstetrics and Gynecology, New York Presbyterian Weill Cornell Medical Center, 515 East 71st Street, Suite S-305, New York, New York 10021 (FAX: 212-746-5929; E-mail: koktay@fertilitypreservation.org). (6, 7). However, data on the effects of the taxanes on reproductive function are limited. Although earlier clinical studies showed no additive effect on menstruation (8, 9), a larger, more recent prospective trial showed an increase in the rates of amenorrhea with the taxanes (10). Although those studies were limited by their reliance on menstruation as the only surrogate for ovarian function, newer research has suggested that ovarian reserve markers such as anti-m ullerian hormone and FSH may be useful in the assessment of the toxicity of chemotherapeutic agents (11, 12). Attempts to characterize the effects of chemotherapy regimens are difficult, likely as a result of differing definitions of post-chemotherapy menstrual status, differences in follow-up duration, and treatment-related characteristics (13). In general, most studies show that the likelihood of premature menopause increases with age and varies with regimen, duration, total cumulative dose of chemotherapy (8, 14), and timing of treatment within the menstrual cycle (15). Even though irregular menstrual pattern or amenorrhea is highly likely to occur in a significant number of patients during the chemotherapy and sometimes lasts for a considerable period after its completion, many patients return to a pre-chemotherapy menstrual pattern (16 18). However, especially as women approach menopause, cycles typically become shorter and less variable, making the significance of resumption of 0015-0282/08/$34.00 Fertility and Sterility â Vol. 90, No. 5, November 2008 1635 doi:10.1016/j.fertnstert.2007.09.048 Copyright ª2008 American Society for Reproductive Medicine, Published by Elsevier Inc.
menses after chemotherapy questionable (11). Furthermore, retention of menstruation after chemotherapy is not a sign of reproductive normalcy, because all patients who receive chemotherapy remain at a higher risk for premature ovarian failure and infertility (19). The pathogenesis of chemotherapy-induced ovarian failure has been compared with primary ovarian failure (20, 21), with the assumption that they both are associated with loss of ovarian reserve. Although it has been studied extensively in populations undergoing assisted reproductive technologies (22), less is known about the ovarian reserve of cancer survivors. In assisted reproductive technology populations, FSH levels consistently >12 DPC Immunolite (Diagnostic Products Corporation, Los Angeles, CA) on the 3rd day of the menstrual period indicate severely impaired fertility (23, 24). Likewise, an elevated day 3 E 2 (>80 miu/ml) also is associated with low or nonexistent fertility, because it reflects the acceleration of the menstrual cycle as a result of high FSH levels (25). Although the precise prognostic value of existing ovarian reserve tests is debated (26), such hormonal markers can illustrate the infertile period that precedes the onset of menopause. Because most studies on ovarian function in cancer patients focus on menstrual bleeding, it is possible that the effects of chemotherapy are underestimated when other methods for assessing ovarian reserve are not also used. A more precise ability to predict the timing and likelihood of ovarian failure would facilitate a more informed choice of therapy for physicians and would enable a more individualized approach to fertility preservation. Our goal, therefore, was twofold: [1] to determine whether addition of taxanes impacted ovarian function as compared with standard AC regimens and [2] to compare and assess these two treatment groups by both menstrual history and ovarian reserve markers. MATERIALS AND METHODS We conducted a prospective observational study with ovarian reserve assessment on a population of women who had a history of breast cancer of stages 1 3A and who had received either [1] AC or [2] AC plus paclitaxel (ACT). Our study was conducted over two follow-up periods. During the first period, from April 2001 through May 2005, women were asked to keep a record of their menstruation, during and %6 months after chemotherapy treatment. Information regarding their tumor stage and grade, treatment modalities, cancer recurrence, menstrual history, and demographic data were collected by using a written questionnaire after informed written consent was obtained. All patients had R1 year of follow-up after the initiation of chemotherapy. A second follow-up study was conducted from December 2005 through February 2006, an average of 28.2 months (range, 15 86 mo) after chemotherapy. Patients were surveyed over the phone regarding their menstrual history and whether they would be willing to undergo a day 2 or 3 serum hormonal measurement for FSH, E 2, and LH. Consent for the follow-up phone call was obtained through the initial written questionnaire. Menstrual cycles were classified as regular, amenorrheic, or oligomenorrheic. Amenorrhea was defined as the absence of menstrual cycles for 6 months. Oligomenorrhea was defined as cycles lasting >35 days. An abnormal FSH level was considered to be R12 DPC, and an abnormal E 2, to be >80 miu/ml. Amenorrhea, oligomenorrhea, and/or abnormal hormonal markers were regarded as suggestive of ovarian compromise. Differences in age as well as time intervals were analyzed by using the t-test, assuming equal variances, whereas rates of amenorrhea and menstrual dysfunction were studied by using the c 2 test. We hypothesized that taxanes regimens showed higher rates of amenorrhea and that the incorporation of serum markers would identify more patients with ovarian compromise than would menstrual history alone. When the rates of amenorrhea were compared between the AC vs. ACT groups, a one-tailed test was used because it was hypothesized that taxanes could only have an additive cytotoxic effect. For all other comparisons, a two-tailed test was used. For all comparisons, P<.05 was considered significant. This study was approved by the institutional review board. RESULTS First Follow-Up Between the years 2000 and 2005, 273 patients who were being counseled for fertility preservation before chemotherapy at our center were asked to participate in the study (Fig. 1). From these patients, we identified 45 women with breast cancer stages 1 3A, of whom 28 received ACT and 17 received AC. The mean (SD) length of follow-up at the first study period was 30 13.6 mo (range, 12 70 mo). Patients who received ACT were younger than those receiving AC (34.0 1.0 vs. 37.2 1.0, P¼.03). During chemotherapy administration, 96% (27/28) of ACT patients and 82% (14/17) of AC patients ceased menstruation. When patients on GnRH agonists were excluded (ACT, n ¼ 4; AC, n ¼ 0), among these amenorrheic patients, 57% (13/23) of ACT patients and 64% (9/ 14) of AC patients regained menstruation after 7 4.3 months of (temporary) amenorrhea. At 6 months after chemotherapy completion, there was no difference in the rates of persistent amenorrhea between ACT patients not on GnRH agonist suppression (10/24, 41.7%) and AC patients (5/17, 29%; P¼.21). Among these patients with persistent amenorrhea, the percentage of patients receiving tamoxifen was similar (AC vs. ACT, 80% vs. 85%, P>.05). Second Follow-Up Of the 45 patients reached at the first follow-up, 20 were excluded at the second follow-up because of receiving additional chemo (n ¼ 3), undergoing oophorectomy (n ¼ 1), developing a new primary cancer (n ¼ 1), or refusal (n ¼ 4) or inability (n ¼ 11) to contact. Twenty-five patients were included in the 2nd follow-up after a mean of 28 months 1636 Reh et al. Ovarian reserve after chemotherapy Vol. 90, No. 5, November 2008
FIGURE 1 Participation and follow-up of study participants. (range, 15 86 mo), of whom 14 received ACT and 11 received AC. The results are summarized in Table 1. The mean age and time from chemotherapy and last follow-up was similar in both groups, and no patients currently were receiving GnRH agonists. Although results did not reach significance, we saw a trend toward a higher incidence of amenorrhea in ACT patients vs. AC patients (ACT, 35.7% vs. AC, 9.1%; P¼.06). There was also a higher incidence of oligomenorrhea in the AC group (4/11, 36.4%), as compared with in the ACT group (0/14, 0; P¼.03). Of the 25 patients with whom a second follow-up was performed, 14 agreed to undergo day 2 or 3 serum FSH and E 2 measurements (Fig. 1). Of 11 patients with an average age of 39.6 4 years who were having some type of regular menstruation (regular menses or oligomenorrhea), an abnormally elevated FSH or E 2 level was found in three of six ACT patients and in five of five AC patients (Table 2). Therefore, as compared with the case of using amenorrhea alone as a surrogate for ovarian function, using the hormonal markers identified an additional eight patients who had compromised ovarian reserve. When combining the amenorrheic patients with those with abnormal serum markers, the rate of overall ovarian dysfunction was increased in the case of both ACT (8/14 ¼ 57.1%) and AC (6/11 ¼ 54.5%; P¼.9). DISCUSSION In this study, we saw no difference in the incidence of amenorrhea with regimens using taxanes, both at the first followup, at 6 months (42% vs. 29%), and at the second follow-up, an average of 28 months later (36% vs. 9%). With the consideration of abnormal serum markers, the rates of ovarian compromise increased to 57% and 55%, respectively. Our findings are consistent with those of earlier studies based on menstruation (8, 9) that showed no impact of taxanes on amenorrhea after 12 months. This contrasts with the findings of Petrek et al. (10), which showed a slightly higher rate of amenorrhea in the taxanes group after 36 months. Because most previous studies on the effects of taxanes remained limited to menstrual bleeding as a surrogate for ovarian function (8 10), it is important to note that a regular menstrual cycle is not synonymous with fertility, just as irregular menses or amenorrhea does not always imply infertility (26). In addition, the timing of menopause is highly variable (27). By the time menopause occurs, women may have been infertile for 5 10 years as a result of an age-related decline in fertility and ovarian reserve (11), of which amenorrhea is merely the last clinical manifestation. Because certain chemotherapy agents can accelerate the reproductive aging process, studies elsewhere that have used only menstrual history as a surrogate for ovarian reserve appear to have underestimated the impact of these cytotoxic agents. Studies assessing the ovarian reserve in cancer patients are limited but have supported our current findings. As compared with controls, studies of childhood cancer survivors have shown a decrease in antral follicle counts and inhibin B levels (19), as well as a difference in anti-m ullerian hormone and Fertility and Sterility â 1637
TABLE 1 Outcomes at second follow-up. Parameter ACT (n [ 14) AC (n [ 11) P value Age (y) 38.4 5.6 41.4 3.3 NS Mean time from chemotherapy (mo) 38.3 24 37.2 10 NS Mean time from follow-up (mo) 17.3 12 18.0 5 NS Patients with abnormal menstrual status Amenorrhea 5/14 (35.7) 1/11 (9.1).12 Oligomenorrhea 0/14 (0) 4/11 (36.4).014 Patients with normal menstruation No. undergoing blood tests 6 5 With abnormal FSH or E 2 levels a 3/6 (50.0) 5/5 (100).06 Total patients with ovarian compromise (amenorrhea þ abnormal serum markers) 8/14 (57.1) 6/11 (54.5).9 Note: Data are mean SD or are n (%). a Abnormal FSH defined as R12 DPC; abnormal E 2 defined as >80 miu/ml. FSH levels (28). More recent prospective studies have shown that anti-m ullerian hormone levels decline after chemotherapy in breast cancer patients despite continued menstrual activity (11, 12). Our study has several limitations, including a small sample size with a low follow-up rate between our initial and second study periods. We attribute this in part to the nature of a phone survey; many patients screened their calls or stated that they were too busy to participate. Furthermore, relying on menstrual history introduces a recall bias and therefore can be less reliable than written diaries. A larger prospective trial is needed in this area to further assess ovarian reserve at baseline before chemotherapy, as well as at discrete time points from their treatment. Moreover, future studies could incorporate additional markers of ovarian reserve, such as anti- M ullerian hormone, inhibin B, and antral follicle counts in determining the effects of chemotherapy regimens on ovarian function. Ultimately, a functional assessment of the ovarian reserve will facilitate a better understanding of the impact of newer chemotherapeutic agents, thereby providing patients with useful information regarding their fertility and allowing physicians to individualize treatment efforts in fertility preservation. In summary, we found no significant long- or short-term impact of taxanes on ovarian function, particularly when FSH and E 2 measurements were included. However, future studies on the reproductive effects of chemotherapeutic agents should incorporate ovarian reserve markers, because menstrual history alone may underestimate the impact of these cytotoxic agents. TABLE 2 Results of ovarian reserve testing in patients with regular menstruation after chemotherapy. Patient, by regimen Age (y) FSH (DPC) E 2 (miu/ml) Time from chemotherapy (mo) Menstrual status ACT 1 40 6.0 391 28 Oligomenorrhea 2 41 14.7 32 44 Regular 3 34 23.6 21.5 56 Regular 4 43 23.3 32 26 Oligomenorrhea 5 40 12.0 <32 51 Regular AC 1 41 15.6 21.6 10 Regular 2 44 14.5 32 17 Regular 3 37 6.53 81.9 28 Regular 1638 Reh et al. Ovarian reserve after chemotherapy Vol. 90, No. 5, November 2008
Acknowledgment: The authors thank Kathy Lostritto, R.N., for her assistance in this study. REFERENCES 1. Hankey BF, Miller B, Curtis R, Kosary C. Trends in breast cancer in younger women in contrast to older women. J Natl Cancer Inst Monogr 1994;16:7 14. 2. Jemal A, Murray T, Samuels A, Ghafoor A, Ward E, Thun MJ. Cancer statistics, 2003. CA Cancer J Clin 2003;53:5 26. 3. Chapman RM, Sutcliffe SB, Malpas JS. Cytotoxic-induced ovarian failure in women with Hodgkin s disease. I. Hormone function. JAMA 1979;242:1877 81. 4. Sonmezer M, Oktay K. Fertility preservation in female patients. Hum Reprod Update 2004;10:251 66. 5. Byrne J, Fears TR, Gail MH, Pee D. Early menopause in long-term survivors of cancer during adolescence. Am J Obstet Gynecol 1992;166: 788 93. 6. Sparano JA. Taxanes for breast cancer: an evidence-based review of randomized phase II and phase III trials. Clin Breast Cancer 2000;1:32 40. 7. Estevez LG, Gradishar WJ. Evidence-based use of neoadjuvant taxane in operable and inoperable breast cancer. Clin Cancer Res 2004;10:3249 61. 8. Fornier MN, Modi S, Panageas KS, Norton L, Hudis C. Incidence of chemotherapy-induced, long-term amenorrhea in patients with breast carcinoma age 40 years and younger after adjuvant anthracycline and taxane. Cancer 2005;104:1575 9. 9. Davis AL, Klitus M, Mintzer DM. Chemotherapy-induced amenorrhea from adjuvant breast cancer treatment: the effect of the addition of taxanes. Clin Breast Cancer 2005;6:421 4. 10. Petrek JA, Naughton MJ, Case LD, Paskett ED, Naftalis EZ, Singletary SE, et al. Incidence, time course, and determinants of menstrual bleeding after breast cancer treatment: a prospective study. J Clin Oncol 2006;24:1045 51. 11. Oktay K, Oktem O, Reh A, Vadhat L. Measuring the impact of chemotherapy on fertility in women with breast cancer. J Clin Oncol 2006;24:4044 6. 12. Anderson RA, Themmen AP, Al-Qahtani A, Groome NP, Cameron DA. The effects of chemotherapy and long-term gonadotrophin suppression on the ovarian reserve in premenopausal women with breast cancer. Hum Reprod 2006;21:2583 92. 13. Bines J, Oleske DM, Cobleigh MA. Ovarian function in premenopausal women treated with adjuvant chemotherapy for breast cancer. J Clin Oncol 1996;14:1718 29. 14. Goodwin PJ, Ennis M, Pritchard KI, Trudeau M, Hood N. Risk of menopause during the first year after breast cancer diagnosis. J Clin Oncol 1999;17:2365 70. 15. Di Cosimo S, Alimonti A, Ferretti G, Sperduti I, Carlini P, Papaldo P, et al. Incidence of chemotherapy-induced amenorrhea depending on the timing of treatment by menstrual cycle phase in women with early breast cancer. Ann Oncol 2004;15:1065 71. 16. Wallace WH, Shalet SM, Crowne EC, Morris-Jones PH, Gattamaneni HR, Price DA. Gonadal dysfunction due to cis-platinum. Med Pediatr Oncol 1989;17:409 13. 17. Low JJ, Perrin LC, Crandon AJ, Hacker NF. Conservative surgery to preserve ovarian function in patients with malignant ovarian germ cell tumors. A review of 74 cases. Cancer 2000;89:391 8. 18. Tangir J, Zelterman D, Ma W, Schwartz PE. Reproductive function after conservative surgery and chemotherapy for malignant germ cell tumors of the ovary. Obstet Gyncol 2003;101:251 7. 19. Larsen EC, Muller J, Schmeigelow K, Rechnitzer C, Andersen AN. Reduced ovarian function in long-term survivors of radiation- and chemotherapy-treated childhood cancer. J Clin Endocrinol Metab 2003;88: 5307 14. 20. Dnistrian AM, Schwartz MK, Fracchia AA, Kaufman FJ, Hakes TB, Currie VE. Endocrine consequences of CMF adjuvant therapy in premenopausal and postmenopausal breast cancer patients. Cancer 1983;51:803 7. 21. Dowsett M, Richner J. Effects of cytotoxic chemotherapy on ovarian and adrenal steroidogenesis in pre-menopausal breast cancer patients. Oncology 1991;48:215 20. 22. Scott RT Jr, Hofmann GE. Prognostic assessment of ovarian reserve. Fertil Steril 1995;63:1 11. 23. Licciardi FL, Liu HC, Rosenwaks Z. Day 3 estradiol serum concentrations as prognosticators of ovarian stimulation response and pregnancy outcome in patients undergoing in vitro fertilization. Fertil Steril 1995;64:991 4. 24. Lutchman SK, Davies M, Chatterjee R. Fertility in female cancer survivors: pathophysiology, preservation, and the role of ovarian reserve testing. Hum Reprod Update 2005;11:69 89. 25. Klein NA, Battaglia DE, Fujimoto VY, Davis GS, Bremner WJ, Soules MR. Reproductive aging: accelerated ovarian follicular development associated with a monotropic follicle-stimulating hormone rise in normal older women. J Clin Endocrinol Metab 1996;81:1038 45. 26. Singh KL, Davies M, Chatterjee R. Fertility in female cancer survivors: pathophysiology, preservation, and the role of ovarian reserve testing. Hum Reprod Update 2005;11:69 89. 27. Treloar AE. Menstrual cyclicity and the pre-menopause. Maturitas 1981;3:249 64. 28. Bath LE, Wallace WH, Shaw MP, Fitzpatrick C, Anderson RA. Depletion of ovarian reserve in young women after treatment for cancer in childhood: detection by anti-mullerian hormone, inhibin B, and ovarian ultrasound. Hum Reprod 2003;18:2368 74. Fertility and Sterility â 1639