Fertility and pregnancy-related issues are highly relevant for young (≤ 40 years) patients with breast cancer. Pregnancy related cancers and pregnancy after breast cancer both are extremely relevant topics in India where often we have women in their 30s and 40s developing breast cancer which is also the most common cancer in women of reproductive age group.
1) Pregnancy related breast cancer is diagnosed during pregnancy and within 1-year post-partum:
Breast cancer is the most common malignancy diagnosed during pregnancy. About 1 in 3000 to 10000 pregnancies are complicated. When we are evaluating cancer in pregnancy, both maternal and foetal well-being have to be kept in mind. Breast cancer is similar to like in non-pregnant women but more aggressive in behaviour and often there is delay in diagnosis due to concurrent breast changes. Normally, the intent is to give foetal-safe treatment till the patient safely delivers the baby and then continue further treatment. Surgery can be done and chemotherapy can be given in second and third trimesters of pregnancy. But we avoid radiation, hormones and scans which can harm foetus.
2) Pregnancy after breast cancer is possible and is a part of cancer survivorship in young women. Results provide reassuring evidence on the safety of conceiving in breast cancer survivors. Patients’ pregnancy desire should always be considered as a crucial component of their survivorship care plan.
Breast cancer survivors could have reduced likelihood of having a subsequent pregnancy compared with the general population due to various treatments and disease effect as well. However, there was no increase in congenital abnormalities and maternal safety is not affected. Some controversy about estrogen positive breast cancer and recurrence have not been proven.
Timing of subsequent pregnancy remains a challenging question to address in clinical practice. Some small studies show increased risk of recurrence in patients conceiving within six and 12 months after diagnosis in ER + BC. And so the general practice is that pregnancy post treatment can be delayed by around 2 years in stage I-II. For stage 3, deferring treatment for about 5 years is recommended and often avoided in stage 4.
However, its wiser to take an individualized approachtaking into account parameters including patient’s age, risk of recurrence, adjuvant therapy, and ovarian reserve.
3) Infertility can arise as a consequence of treatment or the oncological conditions. The parallel and continued improvement in both the management of oncology and fertility cases in recent times has brought to the fore-front the potential for fertility preservation in patients being treated for cancer.
Chemotherapy can affect fertility by- drug or dose related effect and age-dependent effect. Radiation to the pelvis ( dose dependent) can affect the ovaries and compromise fertility. Surgery in pelvis can comprise fertility as well .
The methods usually recommended for fertility preservation in women prior to start of definitive anti-cancer therapy include:
(a) Embryo Cryopreservation (well established treatment),
(b) Ovarian tissue preservation,
(c) Ovum preservation
(d) GNRH analogues to suppress ovarian cycle and thus inducing temporary menopause.
(e) Ovarian Transposition (oophorepexy)
With increasing diagnosis of cancer in modern times especially in younger population, fertility remains as important discussion in most patient and couple interactions. We as oncologist have to use available scientific evidence and make sure that survivorship of cancer is least traumatic and minimize psychosocial challenges.
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