I FACED THE YOUNG WOMAN sitting in my office and discussed treatment options for her early-stage breast cancer, treatment necessary to give her the best chance of preventing recurrence. She faced the news of the recommendation for chemotherapy bravely. We then talked about the side effects of treatment, including the fact that her fertility could be adversely affected. She was incredulous that the treatment given to save her life could also change it so irrevocably, and was relieved to know that back-up plans were possible. We planned for her to meet with our fertility expert that same day, to learn about options for freezing eggs or embryos. Just having options and retaining some control over her future allowed this woman to move forward with treatment and all its challenges with a lifted spirit.
I am delighted to write the foreword to this groundbreaking book, Having Children After Cancer. As a breast cancer oncologist at the University of California San Francisco’s Comprehensive Cancer Center, I face this issue with my patients on a regular basis. Unfortunately, for young women and men facing a diagnosis of cancer, the issue of future fertility is often not addressed or even considered when discussing treatment options. The overwhelming anxiety of the cancer diagnosis eclipses other considerations for patients, and physicians have focused on the immediacy of cancer therapy rather than the ability to have children later in life. For some patients, the concern about losing fertility may adversely impact decisions about treatment, potentially leading young adults to choose less-than-ideal therapies. In this book, Gina Shaw presents a detailed and thoughtful guide to a variety of approaches for preserving future fertility for both women and men, as well as a detailed list of options for becoming parents when having a biological child is not possible.
Although current chemotherapy regimens for many cancers cause relatively less permanent damage to the function of the ovaries or testicles than treatments given in the past, the impact of chemotherapy, hormone therapies, and radiation on the subsequent ability to have children is largely unknown and is extremely complex. Some treatments are known to cause permanent loss of ovarian function or sperm production in all patients (such as whole body radiation), but most affect a subset of individuals. Risk factors include the type and duration of chemotherapy, patient age (particularly for women), and fertility before treatment, which is often unknown. Although there is information about risk factors that predict persistent loss of menses after chemotherapy and radiation, there is little data on the impact of these treatments as well as antihormone therapy on what is referred to in women as “ovarian reserve,” making it difficult or impossible to accurately predict the effect of many anticancer therapies on fertility for an individual patient. For women, many therapies lead to a temporary cessation of menses. Whether menses restart, and whether fertility will remain intact, remains a question for most patients. Very young women, or women and men receiving less intensive therapy, may retain fertility. Choices regarding treatment, and discussion of the potential impact of the chosen treatment on fertility, must take place as early as possible after diagnosis in order to maximize fertility preserving options.
Fertility is an established subspecialty within obstetrics and gynecology, but the interest in preserving options for childbearing in young patients with a diagnosis of potentially curable cancer has given rise to a specialty within fertility, termed “oncofertility” by many. This term encompasses both service in the form of rapidly attainable consultations, egg harvesting, in vitro fertilization, and other fertility treatments, as well as research into the effects of treatment on ovarian reserve and subsequent fertility. Newer tests can more accurately predict the “ovarian reserve” or the ovary’s potential to make fertilizable eggs, and help to predict the chances of achieving an unassisted pregnancy. At the University of California, San Francisco, we work very closely with our colleagues specializing in fertility, obtaining consultations before patients start systemic therapy including chemotherapy and hormone therapy, as well as radiation, in order to maximize fertility options as much as is feasible for each interested patient. Once a consultation is obtained, the patient and her partner or family can decide on the most appropriate plan for that woman’s individual situation. Harvesting eggs that are then fertilized with sperm and frozen as embryos (the process followed for in vitro fertilization, or IVF) is the most successful strategy but requires a partner or donor sperm. Many women who do not have a male partner are wary of using donor sperm but can now consider freezing unfertilized eggs, a process which is slowly becoming more common but is still associated with a lower success rate than IVF—although this is improving. As timing is critical in order to minimize the delay until the start of cancer therapy, and harvesting eggs is timed to the menstrual cycle, patients can usually be seen within one to two days of an initial call. As much as possible, we try to delay the start of chemotherapy and radiation therapy for these discussions and procedures to minimize effects on the ovaries. In most cases, a several week delay is both safe and feasible. Harvesting eggs is not for everyone, and options are discussed in this book for those who do not have this resource.
So, you have survived your cancer, and have recovered from the side effects of therapy. As a cancer survivor, is it safe or possible to have children? Safety issues are complex, and depend on the type of cancer, as well as whether or not hormones like estrogen can be potential growth factors for the cancer. However, misconceptions rather than factual information drive many of the recommendations given to prospective parents. Having Children After Cancer cannot provide individual risk information, but it does provide direction on the types of questions to ask your providers, and briefly reviews existing data as well as the opinions of a variety of experts in this area.
For a number of reasons, a diagnosis of breast cancer can make decisions regarding childbearing particularly difficult. First, many breast cancers respond to estrogen, and treatment to prevent recurrence includes estrogen-blocking agents given for at least five years following diagnosis. For women who are thirty-five or older at the start of therapy, this important treatment creates a dilemma in terms of maintenance of fertility, and attempting pregnancy. It is important to make a careful assessment of risk for cancer recurrence if treatment is curtailed, and weigh this against the risk of not being able to have children at an older age. For very low-risk cancers, the risk of recurrence may not be sufficient to delay an attempt at pregnancy, but the reverse is likely for higher risk disease. The author was not faced with this issue, due to the type of cancer she had, but details her decisions and concerns with her older age and exposure to chemotherapy. In addition, she discusses fertility issues for men, and those who received chemotherapy as children and are now adults.
Regardless of your situation, you should be able to discuss risks and benefits as well as ask appropriate questions of your oncologist. As Ms. Shaw outlines, existing data does not support a worse cancer outcome for women who have children after a cancer diagnosis, and for breast cancer patients, pregnancy may even be protective. However, for those who do not have this option, embryo or egg donation, surrogacy, and adoption are discussed with vignettes from real-life cancer survivors, some of whom are followed through several different experiences with both successes and failures. Ms. Shaw provides a number of resources, as well as an outline of different possibilities for adoption with a realistic assessment of each approach, and a detailed description of international adoptions by country.
Rarely, cancer is diagnosed during pregnancy, posing a special challenge to effective treatment. The good news is that certain chemotherapy agents appear to be safe after the first trimester. To document this, a recent series of patients with breast cancer diagnosed during pregnancy was presented at a national meeting and demonstrated healthy babies at the time of delivery. Longer term follow-up is more limited, but suggests no long-term impact to children exposed to a limited course of safe agents in utero. By giving chemotherapy before surgery, the cancer can be treated effectively without significant risk while the mother is still pregnant, allowing the baby to mature to term or near term. Treatment of cancer during pregnancy requires a specialist in the treatment of the specific cancer, as well as a high-risk obstetrician. For some patients with breast cancer, delaying surgery and proceeding with chemotherapy can allow for breast conservation following delivery.
In addition to discussing ways to preserve fertility, and options if pregnancy is not possible, Having Children After Cancer includes a chapter on how to stay healthy if you are a pregnant cancer survivor. The author discusses many challenges including poor or absent milk production from a breast which has received radiation to treat cancer, cancer screening, what to do and issues to consider if you get pregnant while taking antihormone therapy for cancer, as well as other topics. As in the other chapters, most situations are illustrated by real people’s experiences and decisions, as well as the opinions of experts. These “pearls” of information are an invaluable resource to a woman facing these issues, and most oncologists are not particularly knowledgeable about these topics.
Many of our patients are also parents, often of younger children. And if you do have children after a cancer diagnosis, you are still a cancer survivor—having faced your own mortality is a sobering reminder of the short and unpredictable nature of life. I love the chapter in this book titled, “What’s Cancer, Mom?” Seventeen years ago I was a daughter, with a mother who had cancer. Although I was an adult with small children myself, and a young doctor, I wish both of us had had the advice in this section. Ms. Shaw quotes a child psychologist: “Make memories and make them concrete,” and then goes on to provide her own suggestions about how to make this happen. I was pleased to see how these recommendations mirror those I give to my patients, and have taken to heart in my own family. The book ends with an important and heartfelt sentiment—building a family is “worth it all.”
Two messages are critical. First, if you have been diagnosed with early-stage cancer and are facing treatment that could impact your fertility, except in very rare cases you have time to consider your options, talk with a fertility expert, and determine the best approach for you and, if existing, your partner. Although the cost of many options can seem more than daunting, be empowered to explore funding sources. This book provides direction, resources, and even advice on how to approach insurance companies (who generally do not cover fertility treatment). Second, there are many routes to pursue in the road to becoming a parent, so if possible, keep your options and mind open.
A cancer diagnosis does not have to close the door to future fertility or the experience of parenting. This book provides an invaluable guide to a subject previously relegated to the backstage in the field of oncology. As more patients are cured of early-stage cancer, issues critical to quality of life for survivors, such as fertility, have moved closer to center stage. Read this book, learn more, use available resources, and ask questions!
—Hope S. Rugo, MD, medical oncologist specializing in breast cancer and professor of medicine, University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center