Faster fertility preservation technique did not delay time to breast cancer treatment

Fertility preservation with the 2-week random start ovarian stimulation technique did not delay time to initiation of neoadjuvant chemotherapy for women with breast cancer, according to preliminary study results.

“Women with breast cancer should feel confident about undergoing fertility preservation before starting chemotherapy,” Mitchell Rosen, MD, associate professor of obstetrics, gynecology and reproductive sciences at University of California, San Francisco, said in a press release. “The data clearly show that it will not delay their treatment, even in the neoadjuvant setting.”

Neoadjuvant chemotherapy is a widely accepted treatment modality for operable breast cancer.

Random start ovarian stimulation — which takes 2 weeks instead of the standard 4 weeks for fertility preservation — has become increasingly utilized. However, the effect of random start ovarian stimulation on time to initiation of neoadjuvant chemotherapy is not well understood.

Rosen and colleagues assessed the length of time to neoadjuvant chemotherapy initiation among 89 patients with breast cancer aged 18 to 45 years who received treatment at UCSF Center for Reproductive Health.

Investigators pooled data from medical records of patients referred to the clinic prior to initiating neoadjuvant chemotherapy between 2011 and 2017.

Two-thirds of the overall study population harvested their eggs with the newer, faster technique before starting neoadjuvant chemotherapy.

On average, women who underwent the fertility preservation technique started treatment within 38 days, whereas those who did not undergo fertility preservation started treatment within 39 days.

HemOnc Today spoke with Rosen about the study, the potential impact of the findings, and why it is important for women with cancer to consider or discuss fertility preservation options with their physicians.

Question: Can you provide insights into this ovarian stimulation technique?

Answer: Random start stimulation is a treatment strategy that enables patients to start stimulation for egg harvesting immediately, with an average completion time of 2 weeks. This treatment strategy is available for all cancer types, and it is considered safe and effective. Early referrals are paramount to minimizing delays in cancer treatment.

Q: What prompted this research?

A: The reluctance from oncologists to refer patients for fertility preservation out of fear that it would delay the more aggressive timeline of neoadjuvant chemotherapy. Breast surgeries are treated differently these days. Aggressive cancers are being treated with chemotherapy first, followed by surgery. The way we are doing things now is a definite shift from the way we have done things in the past, when it was very common to have surgery first, followed by chemotherapy. If someone has surgery first and then chemotherapy, the time from diagnosis to chemotherapy initiation is at least 6 weeks to 8 weeks. In those cases, if a woman desires to preserve her fertility, we are able to use those weeks in between to attempt cryopreservation. However, we saw that women were still being referred later in their workup, or after surgery. Therefore, we were still motivated to shorten the duration of our treatment. We, along with others, have developed a treatment protocol that minimizes the time it takes to cryopreserve eggs or embryos. As a result, the time between consultation to cancer treatment can be 2 weeks, without a compromise in success. The shortened window of providing treatment has reduced anxiety about perceived delays in cancer treatment and has enabled more women to undergo fertility preservation. In the setting of neoadjuvant chemotherapy, questions remained from patients and oncology teams about whether the process to preserve fertility would create delays. However, we found that early referrals to clinics with the ability to offer patients urgent consultations and having expertise in treating patients with cancer minimizes any delays.

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Q: How did you conduct the research?

A: We performed an observational study in which we compared women who underwent fertility preservation in our center with those who presented to our clinic but did not pursue fertility treatment. We assessed whether there were differences in time to initiation of chemotherapy.

Q: What did you find?

A: We found no differences in the time to chemotherapy between the two groups. Thus, the perception of delays can be removed in settings that are equipped to provide fertility preservation services. We also analyzed the safety of performing the fertility preservation treatment in the neoadjuvant setting and found no difference in pathologic complete response. Although these are preliminary data, it is reassuring that fertility preservation treatment can be performed with minimal delays and without evidence of increased risk.

Q: What are the clinical implications of the findings?

A: Women should have the right to undergo fertility preservation. They should not feel the anxiety and pressure that there may be delays because, in general, there will not be delays. Our findings are important because it is fundamental to be able to procreate, and we should be protecting this right.

Q: Why is it important for women with cancer to consider or discuss fertility preservation with their physicians?

A: There is definitely potential for reproductive compromise — especially delayed reproductive compromise. Some of these women may be able to get pregnant right after treatment. A considerable volume of research shows that learning about fertility preservation options is highly valued by reproductive-aged patients. Not all patients will be appropriate for intervention, but most of them can safely spare the time for a consultation with a reproductive endocrinologist. Even patients who receive neoadjuvant chemotherapy should be offered the opportunity to consider their desires for family-building in the future. – by Jennifer Southall

Reference:

Letourneau JM, et al. Hum Reprod. 2017;doi:10.1093/humrep/dex276.

For more information:

Mitchell Rosen, MD, can be reached at UCSF Medical Center, 499 Illinois St., Sixth floor, San Francisco, CA 94158; email: mitchell.rosen@ucsf.edu.

Disclosure: Rosen reports no relevant financial disclosures.