Session Session Fertility andFertility andPregnancyPregnancy

13-10-2006

FL-BBM 2006 2

Specific questions

• Risk of premature ovarian failure• Ability to become pregnant• Safety of pregnancy• Influence of BC treatment on

offspring • Contraception options

Thewes, B. et al. J Clin Oncol; 23:5155-5165 2005

Fertility concerns among Fertility concerns among young women young women

with breast cancerwith breast cancer

Fabienne Liebens MDBreast Unit- CHU Saint Pierre

Brussels

FL-BBM 2006 4

• Why do we need to address this issue?

• To what extent are women with BC concerned by their fertility?

• How do health professionals communicate about this matter?

• Guidelines?

Fertility concerns among women Fertility concerns among women with breast cancerwith breast cancer

FL-BBM 2006 5

Why do we need to address this issue?Why do we need to address this issue? Fertility concerns among women with breast cancer

• The incidence of breast cancer has increased by 0.5% per year over the past decade, whereas the death rate decreased by 1.4% per year during the same period. (Ghafoor A, CA Cancer J Clin 2003).

• 25% of breast cancer cases occur before the age of menopause, – 15% occur under the age of 45.

FL-BBM 2006 6

Why do we need to address this issue?Why do we need to address this issue? Fertility concerns among women with breast cancer

In Belgium per year• 30-34 yrs: 125 cases• 35-39 yrs: 250 cases• 40-44 yrs: 500 cases

FL-BBM 2006 7

Why do we need to address this issue?Why do we need to address this issue? Fertility concerns among women with breast cancer

• Polyagent chemotherapy– Risk of menopause range

from 13% to 98%13% to 98%• Variability related to

– Definitions of menopause – Patient (age) and treatment

characteristics– Follow up duration

Sonmezer, M. et al. Oncologist 2006;11:422-434

FL-BBM 2006 8

Why do we need to address this issue?Why do we need to address this issue? Fertility concerns among women with breast cancer

• There have been recent advances in the field of fertility preservation.

Donnez J et al, 2004

FL-BBM 2006 9

• Why do we need to address this issue?

• To what extent are women with BC To what extent are women with BC concerned by their fertility?concerned by their fertility?

• How do health professionals communicate about this matter?

• Guidelines?

Fertility concerns among women Fertility concerns among women with breast cancerwith breast cancer

FL-BBM 2006 10Partridge, A. H. et al. J Clin Oncol; 22:4174-4183 2004

Web-Based Survey of Fertility Issues in Web-Based Survey of Fertility Issues in Young Women With Breast Cancer Young Women With Breast Cancer

•Premenopausal•Age < = 40 years at the time of breast cancer diagnosis.

FL-BBM 2006 11Partridge, A. H. et al. J Clin Oncol; 22:4174-4183 2004

Web-Based Survey of Fertility Issues in Web-Based Survey of Fertility Issues in Young Women With Breast Cancer Young Women With Breast Cancer

• Concerned about becoming infertile: 57%57%– most common among women

who had a desire for future children regardless of their age or stage of disease,

• Infertility influenced their decisions about treatment: 29%29%

FL-BBM 2006 12Partridge, A. H. et al. J Clin Oncol; 22:4174-4183 2004

Web-Based Survey of Fertility Issues in Web-Based Survey of Fertility Issues in Young Women With Breast Cancer Young Women With Breast Cancer

• Discussion fertility issues: 72%– 17% discussed these issues with fertility

specialists.

• Satisfaction after discussing the issue: 51%

• Fertility concerns had not been adequately addressed: 26%

FL-BBM 2006 13Partridge, A. H. et al. J Clin Oncol; 22:4174-4183 2004

Perceived percentage likelihood of menopause with Perceived percentage likelihood of menopause with therapy among young women with breast cancertherapy among young women with breast cancerWeb-Based Survey of Fertility Issues in Young Women With Breast CancerWeb-Based Survey of Fertility Issues in Young Women With Breast Cancer

FL-BBM 2006 14

Fertility- Related Information Needs of Fertility- Related Information Needs of Younger Women With Early BC.Younger Women With Early BC.

Thewes, B. et al. J Clin Oncol; 23:5155-5165 2005

p <.001

May change over time

FL-BBM 2006 15

Top 10 questions about fertilityTop 10 questions about fertilityFertility- and Menopause-Related Information Needs of Younger Women With Fertility- and Menopause-Related Information Needs of Younger Women With Early BC.Early BC.

Thewes, B. et al. J Clin Oncol; 23:5155-5165 2005

What should I be doing about contraception?What should I be doing about contraception?106 106 (47.1%)(47.1%)

Am I currently fertile?Am I currently fertile?94 94

(41.8%)(41.8%)

Am I going to be able to become pregnant after treatment?Am I going to be able to become pregnant after treatment?94 94

(41.8%)(41.8%)

If I become infertile, does it happen immediately?If I become infertile, does it happen immediately?52 52

(23.3%)(23.3%)

What are the statistics about my chances of becoming What are the statistics about my chances of becoming pregnant?pregnant?

63 63

(28.4%)(28.4%)

Would a future pregnancy influence my prognosis (my Would a future pregnancy influence my prognosis (my chances of a recurrence)?chances of a recurrence)?

58 58

(26%)(26%)

FL-BBM 2006 16

Fertility- Related Information Needs of Fertility- Related Information Needs of Younger Women With Early BC.Younger Women With Early BC.

Thewes, B. et al. J Clin Oncol; 23:5155-5165 2005

– Younger women,– Women with plans for childbearing at

diagnosis,– Women with no children at diagnosis, – Women who were single.

Which women were significantly more likely to rate fertility-related information as extremely important?

FL-BBM 2006 17

FL-BBM 2006 18

• Why do we need to address this issue?

• To what extent are women with BC concerned by their fertility?

• How do health professionals How do health professionals communicate about this matter?communicate about this matter?

• Guidelines?

Fertility concerns among women Fertility concerns among women with breast cancerwith breast cancer

FL-BBM 2006 19

Discussions Regarding Reproductive Discussions Regarding Reproductive Health for Young Women With Breast Health for Young Women With Breast Cancer Undergoing Chemotherapy Cancer Undergoing Chemotherapy

Duffy CM, Journal of Clinical Oncology, Vol 23, No 4, 2005: pp. 766-773

• Communication between health professionals and patients

•Questionnaire interview•N: 166•Age < = 45 •Stage I-III•Before chemotherapy

FL-BBM 2006 20

Discussions Regarding Reproductive Discussions Regarding Reproductive Health for Young Women With Breast Health for Young Women With Breast Cancer Undergoing ChemotherapyCancer Undergoing Chemotherapy

Duffy CM, Journal of Clinical Oncology, Vol 23, No 4, 2005: pp. 766-773

• The median number of physicians: 4

• All women: oncologist and surgeon

• More than half: radiation oncologist, obstetrician/gynecologist, or primary care physician.

FL-BBM 2006 21

Issue discussedIssue discussedDiscussions Regarding Reproductive Health for Young Women With Discussions Regarding Reproductive Health for Young Women With Breast Cancer Undergoing ChemotherapyBreast Cancer Undergoing Chemotherapy

Duffy CM, Journal of Clinical Oncology, Vol 23, No 4, 2005: pp. 766-773

• The possibility of early menopause: 68%.

• Fertility: 34%. • Side effects of treatment:

98%.

FL-BBM 2006 22

Physician discussing side effects by Physician discussing side effects by specialtyspecialtyDiscussions Regarding Reproductive Health for Young Women With Discussions Regarding Reproductive Health for Young Women With Breast Cancer Undergoing ChemotherapyBreast Cancer Undergoing Chemotherapy

Duffy CM, Journal of Clinical Oncology, Vol 23, No 4, 2005: pp. 766-773

Medical Impact

Discussed

Type of Medical Provider (%)

All Physicians (n = 144)

Medical Oncologist (n = 144)

Surgeon (n = 144)

Radiation Oncologist (n

= 83)

Family Practice (n

= 80)

OB/GYN (n = 84)

Menopause 68.2 61.1 24.3 7.2 6.3 13.1Fertility 34.1 28.5 9.0 6.0 2.5 4.8Side effects 98.5 96.5 37.5 44.6 15.0 7.1Impact on normal activities

90.0 84.0 41.7 28.9 6.3 2.3

Percent of All Physicians Discussing Side Effects, by Specialty

n = number of women reporting seeing that physician regarding breast cancer.

FL-BBM 2006 23

Are guidelines available?Are guidelines available?

FL-BBM 2006 24

Lee, S. J. et al. J Clin Oncol; 24:2917-2931 2006

ASCO GUIDELINES 2006ASCO GUIDELINES 2006

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EUROPA DONNA Working Group for EUROPA DONNA Working Group for Young Women with Breast CancerYoung Women with Breast CancerConcerns and Priorities Concerns and Priorities

• Raising awareness of breast cancer in young women amongst gynaecologists and other doctors, through training

• Being informed about side effects of treatment, such as hormonal therapy and symptoms of early menopause

• Having access to information about clinical trials, their results and how to participate in them

• Understanding the fertility issues, the possibilities of Understanding the fertility issues, the possibilities of becoming a mother in the futurebecoming a mother in the future

• Knowing the prospects for adoption and being Knowing the prospects for adoption and being eligible as a breast cancer survivoreligible as a breast cancer survivor

FL-BBM 2006 26

ConclusionConclusionFertility concerns among women with breast cancer

• The available evidence suggests that fertility preservation is of great importance to many young women diagnosed with breast cancer

• Infertility resulting from cancer treatment may be associated with psychosocial distress

• Clinicians should not assume that women who are younger or have better prognoses are more interested in exploring fertility issues.

FL-BBM 2006 27

ConclusionConclusionFertility concerns among women with breast cancer

• It may be impossible for physicians to know how important fertility preservation is to their patients unless they ask– about plans for childbearing – about preferred amount of information when discussing fertility

• Clinicians should provide information about the impact of adjuvant treatment on fertility status in a timely fashion before treatment begins, so that women can explore fertility-preserving options.

• Participation in clinical trials in centers with the necessary expertise should be encouraged.

FL-BBM 2006 28

…Fighting Breast Cancer is Fighting Breast Cancer is giving Hope.giving Hope.Europa Donna Belgium

FL-BBM 2006 29

Top 10 questions about fertilityTop 10 questions about fertilityFertility- and Menopause-Related Information Needs of Younger Women With Fertility- and Menopause-Related Information Needs of Younger Women With Early BC.Early BC.

Thewes, B. et al. J Clin Oncol; 23:5155-5165 2005

What should I be doing about contraception? 106 (47.1%)

Am I currently fertile? 94 (41.8%)

Am I going to be able to become pregnant after treatment? 94 (41.8%)

What are the risks or benefits of having a child after breast cancer? 41 (18.3%)

How long after treatment can I check whether I'm still fertile? 38 (17%)

What has happened to other breast cancer survivors who have decided to have children?

42 (18.7%)

Are there any health concerns for children I might have in the future as a result of my treatment?

30 (13.3%)

If I become infertile, does it happen immediately? 52 (23.3%)

What are the statistics about my chances of becoming pregnant?

63 (28.4%)

Would a future pregnancy influence my prognosis (my chances of a recurrence)?

58 (26%)