ESMO Commentary: Preserving fertility in breast cancer patients: new promises

VIENNA, Austria – Loss of fertility is a primary concern for some breast cancer patients as 10% of breast cancers occur in women younger than 40 years of age. Chemotherapy destroys rapidly dividing cells and the ovaries can be sensitive to this. The type and amount of chemotherapy affect fertility and pregnancy differently, and the risk of permanent menopause increases with age.

New approaches have been investigated to offer the best management of breast cancer and preserve ovarian activity. Professor Frédéric Amant, Head of the Gynaecological Oncology Unit at KULeuven, Belgium, and specialist at Antoni van Leeuwenhoek in Amsterdam, the Netherlands, led the discussion on the management of pregnancy during cancer and the importance of contraception for women undergoing treatment when he presented his research at ESMO 2014.1 Today he comments on a new and less invasive option for breast cancer patients who want to have a child after the end of treatment. 

Is there any less invasive strategy on the horizon? 

Amant: A less invasive approach is ovarian suppression with luteinizing hormone-releasing hormone agonists (LHRHa), which has been investigated by M. Lambertini in a meta-analysis of randomised studies presented at the European Cancer Congress 2015 (ECC 2015) in Vienna, Austria.2 The study examined whether the use of LHRHa during chemotherapy in premenopausal breast cancer patients would reduce the treatment-related premature ovarian failure rate and increase the pregnancy rate. The researchers showed that women who used the drug were more likely to have menstrual periods, which is a sign of fertility, and they were more likely to conceive afterwards. It means that for women with breast cancer who really want children and who are still young enough, LHRHa could be offered them to increase the likelihood, although it’s no guarantee.

How is the preserving of fertility issue currently managed by oncologists?

Amant: Still today many women do not realise at the start of getting chemotherapy that it may affect their fertility. Historically, fertility was not always addressed but a good oncologist takes the time to discuss this with young women or to refer them to a fertility specialist.

Now we can also offer solutions. This reassures patients who want to have a child in the future, and may help them to accept the influence of cancer treatment on their fertility. It gives them more positive outlook and may help with recovery from cancer. A close collaboration with a team of gynaecologists specialised in fertility problems and a written protocol are the best guarantee to help these young women. 

What are the current options for young women to preserve fertility?

Amant: The best option is embryo cryopreservation. But time is needed to stimulate the ovaries to retrieve oocytes, fertilise them in the lab and store the embryo until after breast cancer treatment. This is in vitro fertilisation (IVF) which has a one in three chance of success. Other options, which are more experimental and complicated, are the cryopreservation of ovarian tissue or cryopreservation of oocytes. Women need to have an operation and the success rates are less good when compared to embryo cryopreservation. 

What are the potential advantages of the LHRHa strategy over other methods?

Amant: Firstly, there is no surgery needed, so LHRHa is less invasive than other methods. In addition, there are few downsides to this approach and it has a longer time window. This means that women who are unsure about fertility preservation can still try LHRHa when it is too late for cryopreservation. 

Results suggest that LHRHa may be suitable for young women with breast cancer who are really motivated to conceive and have a good expected outcome. But the benefits are still uncertain. The results are promising but they should be interpreted with caution because it was not a randomised study even though the investigators did include most of the randomised studies in their meta-analysis.

Is LHRHa treatment accessible to patients?

Amant: I can tell you how the situation is in the country where I work: the health service in Belgium pays for LHRHa in fertility clinics but does not reimburse it for breast cancer patients, because it is not an official indication. I can imagine that this is the scenario in many countries. It leaves cancer patients paying for this very expensive treatment themselves, or in some cases the treating institution pays or the drug company contributes half of the cost. The fairest situation would be full reimbursement by the health service for all patients who want to use this option. 

Notes

1F. Amant’s research from ESMO 2014:

http://www.esmo.org/Conferences/Past-Conferences/ESMO-2014-Congress/Press-Media/Cancer-During-Pregnancy-Chemotherapy-and-Radiotherapy-are-Safe-for-Babies-Studies-Show

2 Abstract at ECC 2015, held 25–29 September in Vienna, Austria:

1957: Ovarian suppression with luteinizing hormone-releasing hormone agonists during chemotherapy as a strategy to preserve ovarian function and fertility in breast cancer patients: A systematic review and meta-analysis of randomized studies. M. Lambertini, Italy. P146 - Monday 28th September 2015 – 09:15-11:15 Poster Session HALL C

Information contained in this commentary was provided by the interviewee.