Are Breast Cancer Patients Sufficiently Informed about Fertility Preservation?

Although advances in assisted reproductive technology have improved the ability of breast cancer patients to preserve their fertility prior to treatment, a Cleveland Clinic study has found that only a small percentage of patients received documented fertility counseling to explain and explore their options.

In a retrospective chart review of women diagnosed with breast cancer who were treated and followed at Cleveland Clinic between 2006 and 2014, less than one-third had a documented fertility discussion (FD) with their physician to review fertility preservation alternatives. Of those who did receive documented counseling, nearly 90 percent sought some form of fertility preservation, demonstrating the impact that formalized education sessions can have on cancer patients’ childbearing choices.

While it is possible that some fertility preservation counseling took place without being documented in patients’ electronic medical records, the research results nonetheless highlight the need to improve.

“This study brings awareness to healthcare professionals that we can do a better job of educating and discussing fertility options with patients and documenting it,” says senior author Stephanie Valente, DO, a breast surgeon and Director of Cleveland Clinic Cancer Center’s Breast Cancer Surgery Fellowship program. “In this world of documentation and electronic medical records, if it’s not recorded, it did not happen.”

The study results were presented at the 2016 American Society of Breast Surgeons Annual Meeting.

Discussing and documenting fertility options

Breast cancer is the most frequently diagnosed form of cancer among women of reproductive age, according to the National Cancer Institute. Depending on dose and duration, chemotherapy, anti-hormonal therapy and radiotherapy can be ovotoxic, causing premature ovarian failure.

A range of new and increasingly effective strategies is available to preserve fertility in anticipation of breast cancer treatment, including:

• Oocyte and embryo cryopreservation
• Ovarian shielding and transposition
• Ovarian tissue cryopreservation and transplantation

Suppressing ovarian activity during chemotherapy, although controversial, may lessen the treatment’s negative impact on fertility. Following treatment, in vitro fertilization (IVF) using banked autologous or donor oocytes or embryos may be used to assist conception.

Discussion and consideration of those choices prior to treatment initiation, as well as recording the decision and outcome, is important. “Fertility preservation typically involves decisions made in advance of this therapy, with options being more limited once treatment is underway,” Dr. Valente says.

“We need to document these discussions and make appropriate referrals to fertility specialists when necessary,” she says. “The internet has helped make patients more informed consumers and they should be aware of the fertility preservation options as part of their breast cancer treatment plan.”

Considering the retrospective, observational nature of the study, Dr. Valente says it is possible that more fertility discussions are taking place than the statistics indicate. In some cases, physicians may have inquired about their patients’ interest in fertility preservation, but that patients’ negative responses were not documented.

A closer look at study results

Retrospective chart review was undertaken to identify all women age 40 and younger who were treated for breast cancer with chemotherapy and/or anti-hormonal therapy at Cleveland Clinic from 2006 to 2014. Researchers identified 303 such patients. The average age at diagnosis was 35.1 years. Thirty-two percent were single; 68 percent were married. Eighty-two (27 percent) had no children at the time of diagnosis.

Fertility preservation:

• After diagnosis, 80 of the full study cohort of 303 women (26 percent) had a documented FD.
• 9 of 80 (11 percent) of those having discussions chose no fertility options.
• 21 of 80 (26 percent) were prescribed gonadotropin-releasing hormone (GnRH) agonist for ovarian protection during chemotherapy.
• 55 of 80 (69 percent) had an IVF consultation, and 17 of 55 (31 percent) pursued oocyte retrieval. (Five patients had both GnRH agonist and an IVF consultation.)

Pregnancy after treatment:

• With a median follow-up duration of 3.7 years (range 4 months to 9.5 years), 22 of 303 patients (7 percent) became pregnant.
• Among those prescribed GnRH agonist alone, 5 of 16 (31 percent) became pregnant.
• Of those who pursued oocyte retrieval, 4 of 17 (24 percent) became pregnant via embryo transfer. Another 3 of 17 (18 percent) became pregnant without embryo transfer (2 of those 3 also were prescribed GnRH agonist).
• Three of nine patients (33 percent) who had a FD but did not pursue fertility preservation options became pregnant.
• Seven of the 223 women who had no documented FD became pregnant.

Overall, successful pregnancy was associated with younger age at the time of diagnosis and estrogen-receptor negative and progesterone-receptor negative tumors.

Dr. Valente notes that the median follow-up period of 3.7 years might be too short to include all fertility-related outcomes since most women undergo cancer treatment for approximately one to two years. “With our follow-up, we may not have captured all of the women who eventually did become pregnant,” she says. “A 7 percent overall pregnancy rate after breast cancer treatment suggests that we, as healthcare professionals, either are not discussing fertility options enough or maybe some of these women just wanted to wait a few more years to see how their prognosis turned out before they tried to have children.”

Coordinating care for young women with breast cancer

Fertility preservation counseling is one of many services provided by Cleveland Clinic’s recently established Young Women’s Breast Cancer Clinic. The clinic’s multidisciplinary team assists young women throughout their diagnosis and treatment. Patients meet with a surgeon, medical oncologist, radiation oncologist, radiologist, plastic surgeon, psychosocial specialist, rehabilitation specialist, a geneticist and a fertility specialist.

“This all happens in one day, so it can be overwhelming for the patient,” says Dr. Valente. “But the advantage is that her cancer treatment can begin immediately. When she leaves the clinic later that day, she has a treatment plan and there is no delay.

“Typically, it could take several weeks to see all of these different healthcare professionals to help develop a plan,” she says. “Without such coordination of care, something could be missed — such as discussing your fertility options. We make sure that discussion takes place and that patients are aware of and understand all of their alternatives.”

Dr. Stephanie Valente is a breast surgeon at Cleveland Clinic’s Comprehensive Breast Cancer Program. Her special interests include young women with breast cancer, oncoplastic breast surgery, nipple sparing mastectomy and intraoperative radiation therapy (IORT).