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Childbearing after breast cancer among young survivors


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XRAYS:  Making Sense of Cancer Headlines

Women who are diagnosed with breast cancer as an adolescent or young adult often have not yet begun or finished childbearing. Researchers studied the impact of breast cancer and related treatment on birth rates and birth outcomes in young survivors. Overall, adverse birth outcomes were not increased for young survivors compared to women without cancer.  However, women with ER-negative breast cancers had a modestly higher frequency of preterm and low weight births. The authors highlight the need for fertility counseling and potential fertility preserving methods prior to treatment. (5/10/18)


STUDY AT A GLANCE

This study is about:

birth rates and birth outcomes of women diagnosed with breast cancer as adolescents or young adults (15-39 years of age).

Why is this study important?

This is the first study to evaluate birth rates and birth outcomes among women who had breast cancer as adolescents or young adults. Researchers questioned whether birth outcomes differed among different types of breast cancer.

Study findings:

  1. Live birth rates are lower among adolescent or young adult breast cancer survivors
    • ​​Adolescent or young adult (AYA) breast cancer survivors have 57% fewer births after diagnosis than age-matched women in the general population who have no history of breast cancer.
    • The study found that as diagnosis age increases, women are less likely to have children. That is, women diagnosed between 15-29 years of age are more likely to have subsequent children than women diagnosed at 29-35 or women diagnosed at 35-39. This study does not determine whether this decrease in birth rate reflects difficulty in conception, pregnancy or personal choices about family planning.
    • Among AYA breast cancer survivors:
      • women with regional or distal cancer had fewer births than those with local or in situ cancer.
      • women treated with chemotherapy had fewer births than those with surgery only, regardless of whether they also had radiation or not.
      • women with ER-positive breast cancer had fewer births than those with ER-negative breast cancer. Researchers note that this may be due to longer cancer treatments or delays in childbearing after ER therapy.
  2. Adverse birth outcomes are similar among AYA survivors and women in the general population, except for women with ER-negative breast cancer.
    • The proportion of women who had preterm births, low weight births, small-for-gestational-age births and C-sections were similar between AYA survivors and women in the general population. Birth outcomes did not differ significantly by endocrine therapy, chemotherapy treatments or with ER-positive status.
      • AYA survivors with ER-negative breast cancer were more likely to have preterm births or low-weight births than women with no breast cancer history, even after adjusting for maternal age and race.
    • Given that birth outcomes are similar between AYA survivors and age-matched women in the general population, researchers suggest that psychological rather than biological barriers to childbearing may lead to a decrease in birth rate among AYA survivors. Alternatively there may also be other unexamined barriers such as those based on marital or socioeconomic status.

What does this mean for me?

  • If you had breast cancer as an adolescent or young adult, your chance of giving birth is lower than the general population. This lower birth rate may be due to delays in choosing to have children after breast cancer treatment or biological barriers to childbirth.
  • If you were diagnosed at 15 to 29, these rates are closer to those of the general population.
  • Your chance of having a C-section or having a child who is born prematurely (<37 weeks of gestation), has a low birth weight or is small for gestational age is similar to women who have not had breast cancer.
  • If you had an ER-negative breast cancer, your chance of having a baby who is born prematurely (<37 weeks of gestation) and/or has a low birth weight is slightly (1.3 times) higher than if you had an ER-positive breast cancer.

Questions to ask your health care provider:

  • What options for preserving my fertility are available prior to breast cancer treatment?
  • Is fertility or family planning counseling available?
  • What rates of childbirth and adverse birth outcomes are associated with my breast cancer treatment?

IN-DEPTH REVIEW OF RESEARCH

Study background:

Breast cancer is the most common cancer among adolescent and young adult (AYA) women ages 15-39. AYA women who have undergone cancer therapy may not have completed childbearing.

Researchers of this study wanted to know:

  1. whether the frequency of live births among AYA breast cancer survivors differs from the general population.
  2. how the frequency of adverse birth outcomes among children born to AYA breast cancer survivors compares to the general population.
  3. whether birth rate and adverse outcomes vary by tumor or cancer treatment.

Populations looked at in this study:

This study, conducted by researchers from the University of North Carolina, evaluated 4,978 women with a first primary breast cancer diagnosis between the ages of 15-39 from January 1, 2000 to December 31, 2013 as listed in the North Carolina Central Cancer Registry.

Researchers evaluated basic demographic information, diagnosis date, stage, cancer treatment and tumor information. Matched birth certificate information was used to determine race, number of births and total length of pregnancy. Births to women who were pregnant at the time of diagnosis (N=91) were excluded, but subsequent births to these women who also conceived after diagnosis were included (N=6).

For each AYA survivor, researchers randomly sampled 20 women from the general population who had a live birth but did not have a history of breast cancer. The women from the general population were matched by year of delivery and maternal age of each AYA breast cancer survivor (N=6,760 total women without prior breast cancer). The life history of AYA survivors was followed until the women reached age 46, had a live birth, died, or December 31, 2014, whichever occurred first.

Study findings:  

Live birth rates

  1. AYA breast cancer survivors have a lower birth rate than age-matched women in the general population.
    • 5% of AYA survivors gave birth within 5 years of diagnosis.
    • 8% of AYA survivors gave birth within 10 years of diagnosis
    • AYA survivors gave birth approximately 57% less frequently than women in the general population in North Carolina in 2013.
    • Birth rate did not differ significantly by race.
  2. Birth rate differed depending on age of diagnosis.
    • AYA survivors diagnosed at 17-29 years of age were more likely to give birth than those who were diagnosed between ages 29-35. AYA survivors diagnosed at 35-39 were the least likely to give birth.
  3. AYA survivors diagnosed with regional or distal cancer were less likely to give birth than those with local or in situ cancer.
  4. AYA survivors treated with chemotherapy were less likely to give birth than those with surgery only, whether or not they also had radiation.
  5. AYA survivors with ER-negative breast cancer were more likely to have a live birth than AYA survivors with ER-positive breast cancer. This may reflect longer cancer treatment or delay after ER therapy among AYA survivors with ER-positive cancer.
    • AYA survivors with ER-negative cancers were 1.3 times more likely to have a live birth within 8 years after diagnosis.
    • 10 years after diagnosis, similar birth rates (10%) were seen among AYA survivors who had ER-positive and ER-negative cancer.

Birth outcomes among live births

Among the 4,978 AYA survivors, 338 had one birth post diagnosis (48 had 2 births and 8 had 3 or more births). To assess birth outcomes, these 338 AYA survivors with newborns were compared to 6,760 age-matched women from the general population who were not previously diagnosed with cancer.

  1. Average maternal age at delivery was 35 years for the AYA survivors.
  2. Proportions for preterm births, low-weight births, small-for-gestational-age births and C-sections were similar between AYA survivors and women in the general population.
    • Prevalence of preterm births and low-weight births was slightly elevated for women with invasive breast cancer compared to those with no breast cancer history.
    • Small-for-gestational-weight births were similar among AYA survivors and women with no cancer history.
  3. AYA survivors with ER-positive breast cancer had birth outcomes similar to women with no breast cancer history.
  4. AYA survivors with ER-negative breast cancer were more likely to have preterm births or low-weight births than women with no breast cancer history, even after adjusting for maternal age and race.
  5. Birth outcomes did not differ significantly by endocrine therapy or chemotherapy treatments.

Limitations:

Researchers caution that the numbers of births evaluated are small, and some associations observed may have occurred by chance. They could not account for the impact of cancer recurrence on live birth frequency or birth outcomes, as their registry did not provide this information. Other features, such as socioeconomic status or health behaviors, may also confound interpretation. While researchers had information on whether AYA survivors had surgery, chemotherapy and/or radiation, they lacked information about the type of chemotherapy used or other treatment details. Researchers also noted that analysis of birth outcomes among women with particular treatments or tumor types was limited by sample size. Larger future studies are needed to confirm these findings.

Conclusions:

Among adolescent and young adult breast cancer survivors, the cumulative birth rate 10 years after diagnosis was 8%. Of the women evaluated (17-39 years of age at diagnosis), birth rates were lowest for women in their 30s, those with regional or distal cancers, and those treated with chemotherapy. Overall, adverse birth outcomes were not elevated for AYA survivors as compared to women without cancer. Women with ER-negative breast cancers did have an increased frequency of preterm and low-weight births. The importance of fertility counseling and potential fertility preserving methods prior to treatment were highlighted.

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Posted 5/10/18

Reference

Anderson C, Engel SM, Anders CK and Nichols HB. "Live birth outcomes after adolescent and young adult breast cancer." International Journal of Cancer. 2018;142(10):1994-2002. Epub Jan 4, 2018.

Related Information and Resources

FORCE Information: Fertility preservation and assisted reproductive technology

FORCE Information: Fertility in people diagnosed with cancer

FORCE Video: Pregnancy and fertility for previvors and survivors

FORCE XRAYS category: Pregnancy and Fertility

FORCE XRAYS category: Survivorship

The POSITIVE Study is an ongoing open clinical trial run by the International Breast Cancer Study Group that may be of interest to women with ER-positive breast cancer who are considering pregnancy. 

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