Fertility preservation in women with breast cancer

Fertility preservation can sometimes be challenging if the patients have a life-threatening disease or a problematic clinical predicament. One such example is the patients with cancer, who may experience a definite surgical excision, radiotherapy, chemotherapy, targeted therapy and a combination of many, and all as the standard treatment, which may directly/indirectly destroy the reproductive organ and/or impair the reproduction function, resulting in transient or permanent infertility. 

Dramatical improvement in cancer therapy has led to the development of a relatively new discipline, called onco-fertility. 

However, there are still some challenges that need to be transparent and well balanced between the risk and benefits of onco-fertility. Thus, the experience sharing and/or an established consensus to guide the onco-fertility patients is urgently needed. 

Two studies published in September in the Taiwanese Journal of Obstetrics and Gynecology talked about fertility preservation among young breast cancer patients and directed to reconsider the importance of the need for oncofertility while treating young cancer patients, with a desire for fertility preservation.

Oncofertility is always associated with challenges, since treating cancer, keeping of progression-free survival (PFS) or invasive disease-free survival (IDFS) and prolonged overall survival (OS) are always aimed during cancer therapy.

For fertility preservation, such as cryopreservation of oocytes and embryos, the following independent factors may delay the initiation of cytotoxic agent treatment in breast cancer patients-

• Time to schedule and perform a new consultation with a reproductive expert, 
• Time consumed during patient decision-making, 
• Time to conclude the fertility preservation process

This prolonged interval (between diagnosis of breast cancer and initiation of adjuvant chemotherapy) is associated with worsening morbidity and mortality in breast cancer patients. 

A recent retrospective cohort study assessing this time-lapse suggested that using controlled ovarian stimulation (COH) for fertility preservation is a safe option for breast cancer patients who are facing gonadotoxic treatment regimens and desire future fertility. a COS cycle does really delay the initiation of systemic treatment by approximately 2 weeks from the start of stimulation medication, and fortunately, the time does not exceed the maximally tolerable interval, suggested by evidence (<12 weeks, with a mean of 4–6 weeks), since breast cancer patients will be maximally benefitted from systemic therapy administered within 12 weeks after surgery. This theory and the real-world data are enough to support the onco-safety of this delay since it does not affect either recurrence or overall survival (OS).

Concerning onco-safety, the long GnRHa protocol is not considered standard for fertility preservation in breast cancer patients, and it is also associated with an increased risk of OHSS.

SOURCE- Chen SF, Lee FK, Wang PH. Fertility preservation in women with breast cancer, Taiwanese Journal of Obstetrics and Gynecology. 2022;61(1):3-4. https://doi.org/10.1016/j.tjog.2021.11.002.