infertility

1. !
!
!
!
!
Breast!Health!&!Infer/lity!

2. • Whatdowemeanbybreasthealth?
• Whatdoesriskmean–andwhatare
riskfactors?
• Whatchoicescanwemakeaboutour
lifestylethatwillreduceourriskof
gettingbreastcancer?
• FertilityPreservationoptions
• FertilityTreatment
!

3. Whatis
breasthealth?

4. Breast!health!is…!
knowingyourownbreasts–
howtheylookandfeel
visitingahealthcare
professionaltodetermineif
abreastproblemneeds
treatmentandfurther
OptionsincaseofCancer
detection

5. Breast!health!includes…!
ClinicalBreastExam(CBE)
onceayear
Screeningmammogramevery
yearforwomenaged40-49
Screeningmammogramevery
onetotwoyearsforwomen50
andover

6. Changing!our!health!habits!!
Risk!Reduc/on…!

7. Making!
!small!and!las7ng!changes!
toward!Breast!health!!

8. Canada’sGuidelines!for!
Healthy!Ea7ng!
Enjoyavarietyoffoods
Emphasizecereals,breads,othergrains,fruitsand
vegetables
Chooselowerfatdairyproducts,leanermeats,andfoods
preparedwithlittleornofat
Achieveandmaintainahealthybodyweightbyenjoying
regularphysicalactivityandhealthyeating
Limitsalt,alcoholandcaffeine

9. Breast!Health!&!Fer/lity!
• When!Health!faces!Ill!
health..Breast!Cancer!…!!
Op/ons!
• 1.!Fer/lity!Preserva/on!
!(Egg!Freezing,Embryo!freezing)!
• 2.!Fer/lity!Treatment!aLer!
washout!period!of!
!chemotherapy!

10. !
Breast!Cancer,!Fer/lity!and!Family!
Building!
• Approximately!6%!of!women!diagnosed!with!
!breast!cancer!are!of!reproduc/ve!age!(<40!years)!
!
• Many!will!not!have!started/completed!their!
childbearing!plans!
!
• Importance!of!addressing!fer/lity!and!family!
building!issues!!

14. !
Impact!of!Breast!Cancer!Treatment!on!
Fer/lity!
• Age!
• Depends!on!type!of!therapy!
• Chemotherapy!
– Age!
• The!risk!of!amenorrhea!aLer!receiving!typical!adjuvant!
chemotherapy!regimens!
!in!women!under!40!is!21Y71%!versus!49Y100%!!for!
those!over!40.!
– Baseline!fer/lity!status!
– Type!
– Dose!

15. Timing!of!Concep/on!
• It!depends…!requires!though^ul!discussion!with!!
!!pa/ent!and!her!health!care!providers!
!
Usually!recommended!once!you!are!out!of!!
!!!!window!of!early!relapse/recurrence!
!
Must!have!period!of!adequate!treatment!washout!

16. Building!Your!Family!
• Some/mes!requires!you!to!reshape!the!way!you!!
!!!!thought!about!building!your!family!
• Range!of!op/ons!
– Natural!intercourse!
– Ovula/on!induc/on!+/Y!intrauterine!insemina/on!
– Assisted!Reproduc/ve!Technology!(ART)!
• Oocyte!cryopreserva/on!(“egg!freezing”)!
• In!vitro!fer/liza/on!(IVF)!
– ThirdYparty!Reproduc/on!
• Donor!Egg!
• Donor!Embryo!
– Surrogacy!
– Adop/on!

17. AmericanSocietyofClinicalOncology
RecommendationsonFertilityPreservationin
PeopleTreatedforCancer
Eligibleforprovenfertilitypreservationmethod!
Male:!Female:!
sperm!cryopreservation!embryo!cryopreservation!
conservativegynecologicsurgery!
oophoropexy!
•!
•!
•!Patientatriskfortreatment!-!inducedinfertility!
•!Patientinterestedinfertilitypreservationoptions!
Refertospecialistwithexpertiseinfertilitypreservationmethods!
Investigationalfertility!
preservationtechnique*!
•!Cryopreservation!of!
testicularorovariantissue!
•!Cryopreservation!of!oocytes!
•!Ovariansuppression!
*Clinicaltrialparticipation!
encouraged!
Eligibleforprovenfertilitypreservationmethod!
Male:!Female:!
sperm!cryopreservation!embryo!cryopreservation!
conservativegynecologicsurgery!
oophoropexy!
•!Assessmentofriskforinfertility!
•!Communicationwithpatient!
•!Patientatriskfortreatment!-!inducedinfertility!
•!Patientinterestedinfertilitypreservationoptions!
Investigationalfertility!
preservationtechnique*!
•!Cryopreservation!of!
testicularorovariantissue!
•!Cryopreservation!of!oocytes!
•!Ovariansuppression!
*Clinicaltrialparticipation!
encouraged!
www.asco.org(Leeetal.,JClinOnc;2006)

18. OvarianReserveinSurvivorsCompared
toControls
Survivors(n=20)Controls(n=20)P-value
AntralFollicle
Count(AFC)
5.211.30.0042
Anti-Mullerian
Hormone
(AMH)
0.571.770.0004
Follicle
Stimulating
Hormone
11.568.040.02
InhibinB(InB)24.346.60.02
Estradiol(E2)126.038.80.14
Prospec7ve!studies!are!needed!to!determine!the!predic7ve!value!of!these!
tests!for!pregnancy!aAer!chemotherapy!!
(Ruddyetal.,FertilityandSterility,InPress)

28. FertilityTreatment
• Azim,etal20081
– RiskofletrozoleandFSHonrecurrence
– 215breastcancerpatients
– Prospective,non-randomizedtrial,
2002-2007
• 79patients:letrozole+FSH
• 136patients:controls,nofertilitytreatments
• Meanfollowupafterchemotherapy:23.4
monthsvs33months(control)
– Recurrence
• PFS:Nodifference(HR0.56,CI95%.17-1.9)
– Conclusion
• Useofletrozole+FSHforovarianstimulation
doesnotappeartoincreasetheriskof
recurrenceintheshortterm
• Longerfollowupisneeded
1AzimAAetal.,JClinOncol2008;26:2630–5
RelapseYfree!survival!in!women!with!breast!cancer!s/mulated!with!
letrozole!versus!control!group.!KaplanYMeier!plot!(hazard!ra/o!
0.56,!95%!CI!0.17–1.9).!

30. SafetyandTimingof
PregnancyafterCancer
• Conventionalwisdomistowaituntilpatientgets
through
theperiodofhighestriskrecurrence
– Receiveoptimaltherapy(endocrinetherapymaybe
prolonged)
• Nodatatosuggestharminpregnancysooner
• Noevidenceforincreasedriskofdiseaserecurrence
associatedwithmostfertilitypreservationmethods
andpregnancy-littledata!
• Asidefromhereditarygeneticsyndromesandin-utero
exposuretochemotherapy,noevidenceforincreased
riskofcancerorabnormalityinprogeny

31. Conclusions:FertilityConcerns
inCancerSurvivors
• Verycomplexanddifficultissues
• Limitedavailabledata
• Patientpreferencescriticalinsome
settings
• Managingexpectationsoftennecessary

32. Conclusions:FertilityConcerns
inCancerSurvivors(cont.)
• Addressfertilityissuesupfront;
includefertilityconcernsintherisk-
benefitanalysis
– Refertofertilityspecialistsearly
• Intheeventofpregnancy,consider
highriskobstetricsmanagement

33. Candidatesforfertilitypreservation
BreastCancer
• BreastCancer
– 232,340womenwillbediagnosedin20141
• 30%priortoage44
• Treatment
– Multi-agent,mainlycyclophosphamide
based,cytotoxicchemotherapyregimens
• Timing
– 6weekintervalfromsurgeryto
chemotherapy
• Concerns
– Hormoneresponsive(ER,PR)
• Options
– Ovulationinduction
• Aromataseinhibitors
• SERMs-Tamoxifen
– Tissuecryopreservation
• Raremetastasistoovaries
1http://seer.cancer.gov/csr/1975_2011/results_single/sect_01_table.01.pdf