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Pregnancy among young women with breast cancer requires tailored support, multidisciplinary approach
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MIAMI — Pregnancy among young women with breast cancer requires a multidisciplinary team approach and modification of standard algorithms to create the most effective treatment plan, according to a presenter at Miami Breast Cancer Conference.
“Fertility and pregnancy are major concerns for young [women with breast cancer] and survivors,” Ann H. Partridge, MD, MPH, founder and director of the program for young women with breast cancer and director of the adult survivorship program at Dana-Farber Cancer Institute, said during a presentation. “Not only do these women face the ‘slings and arrows’ that all of our patients with breast cancer face, but they are diagnosed at a nonnormative time in their lives when things like fertility, pregnancy and role-functioning are also taking off. Because of all of this, we need to do more to tend to these patients.”
According to the most recent data from the SEER database, while most patients have improved in terms of cancer-specific survival for several decades, the same cannot be said for younger patients with breast cancer.
“This, of course, is a real problem,” Partridge said. “One of the explanations for this is that breast cancer subtypes differ by age. Young women are more likely to have HER2-positive breast cancer and triple-negative disease. Also, when these women have HER2-positive breast cancer, it is more likely to be luminal A.”
Younger women are also more likely to be nonadherent to hormonal therapy. Several studies have shown reasons for low adherence include the side effects associated with treatment and the desire to become pregnant.
Partridge and colleagues conducted a web-based survey on fertility issues among young 657 women (median age at diagnosis, 33 years) with breast cancer and found that women felt that fertility concerns influenced their treatment decisions, including the choice to not adhere to hormonal therapy.
More than half (57%) recalled having substantial concerns at diagnosis about fertility after treatment. Moreover, 29% reported that fertility concerns influenced treatment decisions.
“This is a real problem needing to be addressed. A lot of work has gone into trying to figure out how we can ensure that these women can have a child if they wish to become pregnant, and also give them the best breast cancer care,” Partridge said.
Data presented at last year’s San Antonio Breast Cancer Symposium showed ovarian suppression during chemotherapy was associated with improvements in premature ovarian insufficiency rates and post-treatment pregnancy rates. DFS and OS also appeared comparable, including among those with HER-positive disease, according to Partridge.
“If we are preserving fertility, are we comfortable allowing these women to get pregnant? Data from large meta-analyses suggest that women who do become pregnant after breast cancer have good outcomes — if not better — than women who do not become pregnant after breast cancer,” Partridge said.
In general, women with breast cancer who wish to become pregnant are advised to do so after treatment. However, pregnancy may be difficult to achieve as these women age, and due to the cytotoxic chemotherapy they received. Consequently, they may require assisted reproduction.
Research suggests there is no harm associated with assisted reproduction for women with breast cancer trying to become pregnant when compared with women with breast cancer who are able to conceive on their own, according to Partridge.
In the ongoing POSITIVE trial, Partridge and colleagues aim to evaluate safety and pregnancy outcomes of interrupted hormonal therapy among a cohort of young women with breast cancer. The prospective, nonrandomized trial has accrued approximately 370 premenopausal women aged younger than 42 years with a desire to become pregnant.
“Women will stop hormonal therapy early — somewhere between 18 and 30 months into treatment,” Partridge said. “There will be a washout period before [in vitro fertilization] or any other assisted modality is introduced, and then we plan to get them back on hormonal therapy after pregnancy. This will be a difficult study to run, but we will be looking at disease, reproductive and psychosocial outcomes for this very important issue facing our young patients. Hopefully, within the next 5 to 10 years I will be presenting these data — stay tuned.”
For young women diagnosed with breast cancer during pregnancy, the absence of randomized data to support safety and efficacy of standard treatment algorithms makes it difficult to know the best course.
Partridge recommended therapy goals for these women, including surgery, which can be successfully performed with sentinel node biopsy and radiation; and standard chemotherapy, which can be provided with doxorubicin, cyclophosphamide and paclitaxel. However, tamoxifen, trastuzumab (Herceptin, Genentech) or radiation therapy should be avoided in women who are pregnant.
“The only time this comes up a lot is in HER2 breast cancer, which is where we have to have real heart-to-heart discussions about keeping pregnancy and if the patient wants to keep the baby, then we have to come up with a different treatment approach,” she said.
Partridge emphasized the importance of having a multidisciplinary team involved in treatment plans for young women with breast cancer who are pregnant.
“Ensure that you have a team. It is difficult on all clinicians involved and we need to make sure we are communicating with each other,” Partridge said. “Also, be very clear on what the right treatment is for the individual patient at their specific disease stage and for their specific disease type. These women need to receive optimal care despite the many challenges involved.” – by Jennifer Southall
Reference:
Partridge A. Breast cancer in pregnancy and in younger women. Presented at: Miami Breast Cancer Conference; March 7-10, 2019; Miami.
Disclosure: Partridge reports serving as co-author of the Breast Cancer Survivorship section for UpToDate.