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Session Fertility and Pregnancy 13-10-2006 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 FL-BBM 2006 2 Fertility concerns among young women with breast cancer Fabienne Liebens MD Breast Unit- CHU Saint Pierre Brussels Fertility concerns among women with breast cancer • 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? FL-BBM 2006 4 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 5 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 6 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% • 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 7 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 8 Fertility concerns among women with breast cancer • 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? FL-BBM 2006 9 Web-Based Survey of Fertility Issues in Young Women With Breast Cancer •Premenopausal •Age < = 40 years at the time of breast cancer diagnosis. FL-BBM 2006 Partridge, A. H. et al. J Clin Oncol; 22:4174-4183 2004 10 Web-Based Survey of Fertility Issues in Young Women With Breast Cancer • Concerned about becoming infertile: 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% FL-BBM 2006 Partridge, A. H. et al. J Clin Oncol; 22:4174-4183 2004 11 Web-Based Survey of Fertility Issues in 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 Partridge, A. H. et al. J Clin Oncol; 22:4174-4183 2004 12 Perceived percentage likelihood of menopause with therapy among young women with breast cancer Web-Based Survey of Fertility Issues in Young Women With Breast Cancer FL-BBM 2006 Partridge, A. H. et al. J Clin Oncol; 22:4174-4183 2004 13 Fertility- Related Information Needs of Younger Women With Early BC. May change over time p <.001 FL-BBM 20062005 Thewes, B. et al. J Clin Oncol; 23:5155-5165 14 Top 10 questions about fertility Fertility- and Menopause-Related Information Needs of Younger Women With Early BC. 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%) 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%) Thewes, B. et al. J Clin Oncol; 23:5155-5165 2005 FL-BBM 2006 15 Fertility- Related Information Needs of Younger Women With Early BC. Which women were significantly more likely to rate fertility-related information as extremely important? – Younger women, – Women with plans for childbearing at diagnosis, – Women with no children at diagnosis, – Women who were single. FL-BBM 20062005 Thewes, B. et al. J Clin Oncol; 23:5155-5165 16 FL-BBM 2006 17 Fertility concerns among women with breast cancer • 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? FL-BBM 2006 18 Discussions Regarding Reproductive Health for Young Women With Breast Cancer Undergoing Chemotherapy • Communication between health professionals and patients •Questionnaire interview •N: 166 •Age < = 45 •Stage I-III •Before chemotherapy Duffy CM, Journal of Clinical Oncology, Vol 23, No 4, 2005: pp. 766-773 FL-BBM 2006 19 Discussions Regarding Reproductive Health for Young Women With Breast Cancer Undergoing Chemotherapy • The median number of physicians: 4 • All women: oncologist and surgeon • More than half: radiation oncologist, obstetrician/gynecologist, or primary care physician. Duffy CM, Journal of Clinical Oncology, Vol 23, No 4, 2005: pp. 766-773 FL-BBM 2006 20 Issue discussed Discussions Regarding Reproductive Health for Young Women With Breast Cancer Undergoing Chemotherapy • The possibility of early menopause: 68%. • Fertility: 34%. • Side effects of treatment: 98%. Duffy CM, Journal of Clinical Oncology, Vol 23, No 4, 2005: pp. 766-773 FL-BBM 2006 21 Physician discussing side effects by specialty Discussions Regarding Reproductive Health for Young Women With Breast Cancer Undergoing Chemotherapy Type of Medical Provider (%) Medical Impact Discussed Menopause Fertility Side effects Impact on normal activities Percent of All Physicians Discussing Side Effects, by Specialty n = number of women reporting seeing that physician regarding breast cancer. Surgeon (n = 144) Medical Oncologist (n = 144) 68.2 34.1 98.5 90.0 61.1 28.5 96.5 84.0 All Physicians Family Practice (n = 80) OB/GYN (n = 144) Radiation Oncologist (n = 83) 24.3 9.0 37.5 41.7 7.2 6.0 44.6 28.9 6.3 2.5 15.0 6.3 13.1 4.8 7.1 2.3 (n = 84) Duffy CM, Journal of Clinical Oncology, Vol 23, No 4, 2005: pp. 766-773 FL-BBM 2006 22 Are guidelines available? FL-BBM 2006 23 ASCO GUIDELINES 2006 Lee, S. J. et al. J Clin Oncol; 24:2917-2931 2006 FL-BBM 2006 24 EUROPA DONNA Working Group for Young Women with Breast Cancer 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 becoming a mother in the future • Knowing the prospects for adoption and being eligible as a breast cancer survivor FL-BBM 2006 25 Conclusion Fertility 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 26 Conclusion Fertility 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 27 …Fighting Breast Cancer is giving Hope. Europa Donna Belgium FL-BBM 2006 28 Top 10 questions about fertility Fertility- and Menopause-Related Information Needs of Younger Women With Early BC. 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%) FL-BBM 20062005 Thewes, B. et al. J Clin Oncol; 23:5155-5165 29