Improving outcomes for young women with breast cancer: fertility and childbearing issues

Expert Guidelines

The National Comprehensive Cancer Network (NCCN) provides guidelines for fertility in people diagnosed with cancer. 

The NCCN recommends doctors discuss the following with adolescents and adults with cancer before treatment begins:

• fertility plans and preferences
• fertility preservation options, including:
  • whether therapy can be delayed long enough for a cycle of egg stimulation
  • cryopreservation
  • medications like GnRH agonist therapy during adjuvant chemotherapy to preserve ovarian function in premenopausal women with breast cancer
• importance of follow-up with a gynecologist or fertility specialist to monitor ovarian function over time
• risks for infertility due to cancer and related treatment
• affects of treatment on breastfeeding
• the importance of avoiding pregnancy and options for safe and effective birth control while in treatment
• safe timing for considering pregnancy after treatment 
• emotional impact of discussions about fertility preservation
• financial resources for fertility preservation
• effects of treatment on sexual function during and after treatment

Doctors should refer patients as indicated for the following services:

• All patients who are interested in preserving their fertility should be referred to a fertility preservation clinic before starting treatment.
• Patients who need assistance with complex medical decision-making should be referred to a mental health professional.
• Patients who are experiencing sexual disfunction should be referred to a sexual health specialist. 

The National Comprehensive Cancer Network (NCCN) recommends screening and treatment of distress as part of the recommended standard of care. 

These recommendations include:

• Healthcare providers should inform patients, families and treatment teams that distress management is a key part of their medical care, and they should provide information about psychosocial services.
• Ideally, healthcare providers should screen patients for distress at every medical visit— minimally at a patient’s initial visit and then as clinically indicated, especially with changes in disease status (i.e., remission, recurrence, progression or treatment-related complications).
• Healthcare providers should assess and manage distress according to clinical practice guidelines.
• Experts in psychosocial aspects of cancer should be readily available, either as staff members or by referral.
• Assessments should include psychosocial issues (e.g., quality of life and patient and family satisfaction).

Patients should expect to receive distress screening and help at your doctor visits. If your distress isn’t addressed, ask for help. NCCN provides a "Distress During Cancer Care" pamphlet that provides more information.

The American Society for Clinical Oncology (ASCO) points out several therapies for anxiety and stress for patients to consider during or after cancer treatment:

• acupuncture
• massage
• meditation, particularly mindfulness stress-reduction programs
• music therapy
• stress management therapy.
• yoga 

Questions To Ask Your Health Care Provider

• Is it safe for me to become pregnant after treatment for breast cancer?
• I have had breast cancer and I am interested in having children. What factors should I consider?
• How might my cancer treatment affect my future ability to have children?
• Are there ways to preserve my fertility? How might they impact my risk of cancer recurrence?
• Before I start treatment, is there anything that I should know about preserving my fertility?
• I am experiencing anxiety or distress, can you refer me to a mental health expert? 

Open Clinical Trials

The following research studies related to fertility preservation are enrolling patients.

Fertility preservation studies for women

• NCT01503190: The Immune System's Response to Young Women's Breast Cancer. This an observational trial looking at tissue samples from patients with Pregnancy-Associated Breast Cancer (PABC) versus non-PABC to understand how the immune system responds.
• NCT05443737: Evaluation of a Telehealth Oncofertility Care Intervention in Adolescent and Young Adult Cancer Patients. The purpose of this study is to evaluate the effectiveness of an intervention to improve young cancer survivors' oncofertility care.
• NCT0301168: Fertility Preservation Using Tamoxifen and Letrozole in Estrogen Sensitive Tumors Trial (TALES). Infertility as a result of cancer treatment effects long-term quality of life in survivors of reproductive-age cancers. This trial will study different options for fertility preservation in patients with estrogen-receptor-positive breast cancer.
• NCT00823654: Serum Biomarkers to Characterize the Effects of Therapy on Ovarian Reserve in Premenopausal Women With Early-stage Breast Cancer or BRCA Mutations. This study will look at how cancer treatment affects the ovaries. Researchers will review blood samples before, during and after cancer treatment to look at levels of hormones that are produced by the ovaries and ask patients to fill out questionnaires about their menstrual cycles (periods), overall health and pregnancies.
• NCT01788839: Longitudinal Sexual and Reproductive Health Study of Women With Breast Cancer and Lymphoma. This study looks at how cancer treatment affects sexual and reproductive function. The patient will be asked to give a blood sample to see if and how cancer treatment affects the ovaries and the ability to have children (fertility). These blood draws are optional; patients can participate in the study questionnaire even if they choose not to have their blood drawn.
• NCT01558544: Cryopreservation of Ovarian Tissue. The study hopes to contribute to the development of technologies of ovarian tissue freezing-thawing the preserve fertility. The study is open to women who will undergo treatment or surgery for cancer or women with an inherited mutation who are considering undergoing risk-reducing surgery.
• NCT01788839: This study's goal is to see how cancer treatment affects sexual and reproductive function. Participants will also be asked to participate in optional blood tests to see if and how cancer treatment affects the ovaries and the ability to have children. 

Fertility preservation for men

• NCT02972801: Testicular Tissue Cryopreservation for Fertility Preservation. Testicular tissue cryopreservation is an experimental procedure where testicular tissue is retrieved and frozen. This technique is reserved for young male patients, with the ultimate goal that their tissue may be used in the future to restore fertility when experimental techniques emerge from the research pipeline.