Breast Cancer Update for Surgeons, Issue 1, 2017 (Video Program)Fertility issues in early BC
4:50 minutes.
TRANSCRIPTION:
DR LOVE: I see that you’ve been involved, and I saw a paper in JAMA Oncology, in the issue of fertility in breast cancer. Can you comment on some of the things that you think are important for physicians to know about in that regard? DR GRADISHAR: It’s particularly important, obviously, when we’re evaluating younger patients. And there’s many ways to come at this topic. From the standpoint of somebody who has a diagnosis of breast cancer and are, say, in their thirties, just got married, interested in having kids, we have time to have them be evaluated by a fertility expert. So in other words, if decisions are being made about chemotherapy or egg retrieval, whatever the issue is, there is some time for the vast majority of patients to have that discussion and to have a strategy. And we do know that in those that are going to get chemotherapy, that their fertility can be impacted, some evidence that you can use drugs like GnRH agonists that can help maintain ovarian function after the chemotherapy is done, increasing the chances of fertility. So those are all things that have to be considered before you start systemic therapy. We also know that now that we’re talking about longer durations of therapy with endocrine therapy that you may close the window on a woman if you say, “You have to complete all your therapy before you can consider getting pregnant,” particularly if we’re talking about 5 and 10 years in a 30-year-old woman. So as a practice, it’s not uncommon for us to accept that a break is acceptable, if they want to try and get pregnant. There is a registration trial that’s now looking at that to see if taking breaks in your endocrine therapy to get pregnant impacts on outcome. And one of my fellows and I submitted a paper just looking at our own experience with 30-some patients who took breaks from tamoxifen in the era where everybody got antihormone therapy, compared to controls. And we found that there was no adverse effect from doing that. So, obviously, you need a much bigger trial. DR LOVE: But when you say “no adverse effect,” in terms of — DR GRADISHAR: Recurrence risk. DR LOVE: Recurrence risk. And then what was the experience in terms of pregnancies and offspring? DR GRADISHAR: This was a population of patients who did get pregnant. DR LOVE: Oh, I see. That's interesting. DR GRADISHAR: They all got pregnant and just followed out to see if there was any difference in terms of risk of recurrence and survival. And we did not see — DR LOVE: Any data out there in terms of whether or not — fertility. In other words, after being on tamoxifen, do we know whether it affects future fertility? DR GRADISHAR: We know they could enhance it, in a sense — it was being developed as a morning-after pill at the outset, way back in history. DR LOVE: Really? I didn’t know that. DR GRADISHAR: Yes. DR LOVE: Huh. DR GRADISHAR: And in reality, it had just the opposite effect. But in any case, obviously we don’t continue tamoxifen during efforts to get pregnant. There’s still an age dependency on your success in getting pregnant. We don’t know with certainty that that adversely affects your ability to get pregnant, but it’s probably the chemotherapy more than anything, as well as the diminishing likelihood of success as a woman gets older and the number of eggs available diminishes. So I don’t think that we could say that by simply being on tamoxifen you have reduced your chances of fertility compared to a population of similar age who didn’t get tamoxifen. I’m not aware of that data, anyway. DR LOVE: What about the use of chemotherapeutic agents during pregnancy? Which are the ones that you feel comfortable about and which are the ones you’re not? DR GRADISHAR: We use, most commonly, in pregnancy — and we see a few of these patients every year — we typically use AC. There’s some very limited data with taxane use there. We’re still hesitant to do that, although there are some reports of it being used without adverse effect. We’ve typically stuck with an anthracycline-based regimen preoperatively. And there’s also anecdotal reports of a few patients getting trastuzumab, which I’d also be hesitant to do, because there is some potential risk with that as well. So the tried and true anthracycline, AC-like regimen, is our typical go-to recipe in a pregnant woman. |