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Assisted reproduction feasible for women with breast cancer history
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Women with a history of breast cancer can utilize assisted reproductive technology to become pregnant without any detriment to their cancer outcome, according to study results.
Although previous studies have shown pregnancy to be safe following breast cancer, many women become infertile following systemic treatment.
According to study background, between 6% and 10% of women with breast cancer have the disease during their reproductive age. Those women who face infertility often inquire about assisted reproductive technology (ART) — such as ovulation induction associated with intercourse or intra-uterine insemination, controlled ovarian stimulation with gonadotropins for in vitro fertilization, or intra-cytoplasmic sperm injection and egg donation.
Hatem A. Azim, Jr., MD, associate scientific director of the BrEAST Data Centre at the Jules Bordet Institute in Brussels, Belgium, and colleagues sought to evaluate the effect of ART on recurrence and death rates in patients previously treated for breast cancer who subsequently became pregnant.
Hatem A. Azim
“Given the rising trend of delaying childbearing and the toxicity induced by anti-cancer medication on ovarian function, natural conception is challenging and sometimes not feasible and thus a lot of cancer survivors would need to consider assisted reproduction in order to become pregnant,” Azim told HemOnc Today. “However, the safety of this approach in already-treated breast cancer patients is unknown. In this study, we addressed — for the first time — the feasibility and safety of assisted reproduction in women who have already been diagnosed and treated for breast cancer.”
The investigators evaluated data from 198 women aged 18 to 45 years who were diagnosed with breast cancer between 2000 and 2009 and who later became pregnant. Researchers divided patients into two cohorts: those who used ART to achieve pregnancy following their systemic therapy for breast cancer (n = 25; 34 pregnancies) and those who became pregnant spontaneously (n = 173, 247 pregnancies).
Fewer women in the ART cohort had histological grade 3 tumors (36% vs. 59%; P = .033).
Approximately 90% of the entire population had received primary adjuvant chemotherapy and more than half of them had endocrine-sensitive disease. Patients in the ART cohort were older than the spontaneous group at diagnosis (mean: 33.7 years vs. 31.4 years; P = .009) as well as at time of conception (38 years vs. 35 years; P < .001).
ART patients experienced more miscarriages than the spontaneous group (23.5% vs. 12.6%). Seventy-seven percent of the spontaneous cohort and 76% of the ART cohort achieved full-term pregnancies.
After a mean follow-up between conception and last follow-up of 5.25 years in the spontaneous group and 4.16 years in the ART group, researchers observed no difference in breast cancer outcome between the two groups.
The researchers acknowledged they had a lack of information on the fertility drugs used and the protocols for in vitro fertilization or egg donation or the hormone levels achieved. Also, there was no assessment on the patients’ parity and fertility history, which may have influenced decisions for subsequent pregnancies and how to become pregnant after treatment.
Finally, the study design was limited statistically to estimate the impact of ART on the risk for recurrence, although the researchers wrote it is often difficult to conduct a prospective study powered to address such questions.
“We believe that this study would provide physicians with more reassurances when faced with women with history of breast cancer to consider assisted reproduction in order to conceive,” Azim said. “Based on our study, this approach does not appear to increase the risk for breast cancer recurrence and thus should not be discouraged, especially in women who have received adequate adjuvant therapy.” – by Anthony SanFilippo
For more information:
Hatem A. Azim, Jr., MD, can be reached at the Jules Bordet Institute, Boulevard de Waterloo 121, 1000 Brussels, Belgium; email: hatem.azim@bordet.be
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Nanette Santoro, MD
The prognosis for women with breast cancer has improved dramatically over the past decades, primarily due to the advent of effective hormonal therapies. Since breast cancer frequently strikes women in their reproductive years, preserving fertility and having pregnancies after the diagnosis is made and initial treatment is completed are very important life cycle issues for women with the disease.
The article by Goldrat and colleagues in European Journal of Cancer contains helpful information for women with breast cancer who wish to become pregnant after initial treatment.
Since many women are rendered infertile from the cancer treatment itself, a number of women will need assisted reproductive technology to conceive a child after breast cancer therapy. There is also a waiting period of at least 5 years for most women, because of the need to treat women with anti-estrogen drugs. These types of treatments have proven highly effective in reducing the heartbreaking late recurrences of breast cancer that used to happen.
The follow-up after pregnancy in this study was among the longest of any published work (4 to 5 years on average) and speaks to a lack of harm of pregnancy on affecting cancer recurrence risk.
However, there are several reasons that this information cannot be viewed as a green light for pregnancy after breast cancer.
First, the number of women studied was quite small — only 25 of them used assisted reproduction to conceive. Second, the optimal time of follow-up would be 10 years or more, and this study was only able to follow women for 4 to 5 years after pregnancy, which occurred 4 to 5 years after cancer diagnosis. Ideally, larger numbers of women followed for longer lengths of time would provide more reassurance.
However, in medicine, we sometimes have to take what we can get, and this is a helpful piece of incremental knowledge that reinforces the emerging use of reproductive technology to help breast cancer survivors achieve their desired family size.
It is unlikely that a randomized, controlled trial will ever be done, and there are few cancer centers that have the kinds of numbers of patients and lengths of follow up that will increase reassurance. In the meantime, we will wait for each piece of incremental knowledge, evaluate it, and hope that they all point in the same direction.
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