Having Babies After Breast Cancer: The Odds and Options by Gina Shaw In April 2004, I was 36 years old, a newlywed, and planning with my husband to start trying to get pregnant with our first child. But a suspicious lump in my breast turned out to mean that we would be spending 2004 dealing with cancer, not new parenthood. When I was diagnosed with breast cancer, I became one of 25,000 women every year who develop the disease under the age of 45. (About one in four new cases of breast cancer occurs in women of childbearing age.) Because cancer survival rates are increasing, while at the same time women are becoming mothers later in life, more and more women are facing decisions about how and whether to have children after being treated for breast cancer. Itís a complicated issue, fraught with questions: Will you still be fertile after treatment? Will a pregnancy put you at greater risk of having the cancer come back? And if your cancer is genetically linked, will your children be at an added risk of developing cancer themselves? Unfortunately, because the population of women who become pregnant after having had breast cancer is still relatively small (scientifically speaking), the answers to those qu estions are all pretty much ìweíre not sure.î What Happens to Your Fertility? After I was diagnosed with cancer, as soon as the first stage of panic and thoughts such as, ìThis canít be happening to meî and ìAm I going to die?î passed, I started to wonder about the family weíd been planning. I was already past 35, which put me in a higher risk category and meant that I might have problems getting pregnant in the first placeóeven without the cancer treatment. I asked my oncologist: What were my options? Young women being treated for breast cancer are often given particularly strong chemotherapy for a number of reasons. First, the younger a woman is, the more likely it is that her body is strong enough to endure harsher side effects. Scientists have also noted that breast cancers in younger women tend to be more aggressive and faster growing, and to wipe out cancer for a 30-, 40- or 50-year-plus lifespan, doctors usually want to throw the toughest treatment they have at it. But the side effects of those drugs go beyond vomiting and hair lossófrequently, they include premature menopause. ìThe standard types of chemotherapy used in reproductive age tend to age the ovaries,î said Dr. Lynn Westphal, a reproductive endocrinologist who is an assistant professor in the Department of Obstetrics and Gynecology at the Stanford University School of Medicine. Westphal sits on the medical advisory board of Fertile Hope, a national nonprofit organization dedicated to providing reproductive information, support and hope to cancer patients whose medical treatments present the risk of infertility. ìIf youíre in your 20s or early 30s when you get chemotherapy, you may still have reasonable fertility afterward,î she said. In fact, some women, mostly younger, never enter whatís been dubbed ìchemopauseî and still have menstrual cycles throughout their treatment. ìAs women get closer to their 40s, there will be more significant damage, and youíre more likely to see a significant infertility rate in that group of patients.î Even if a womanís periods do return after cancer treatment, itís likely that sheíll go back into ìrealî menopause earlier than she would have otherwise. How long does it take for normal menstrual cycles to return, if theyíre going to? It varies, said Westphal, but usually if a woman hasnít had a period after about six months, the chances are that they are not going to return. At that point, if the woman wants, doctors can test hormone levelsóa fairly accurate way of determining whether or not sheís in permanent menopause. Because there is a chance of becoming infertile during breast cancer treatment, some younger women want to know if thereís anything they can do before starting chemotherapy to help make pregnancy afterward more likely. The answer is yesóbut those options can be complicated and costly, with varying success rates. ìThere isnít anything thatís a guarantee,î said Westphal. For most patientsódepending on their age and how important fertility is to themóshe recommends harvesting and freezing eggs before treatment and then taking a drug called Lupron while undergoing chemotherapy. Lupron temporarily suppresses ovarian function, and some doctors believe it may protect eggs from damage during treatment (although research is unclear on this point). ìEven though the data with Lupron isnít clear-cut, there doesnít appear to be much of a downside to going on it, although there are risks and benefits to everything,î Westphal said. ìIíve had patients who went on it and conceived easily when they attempted to get pregnant, although thatís anecdotal and of course they might have been able to conceive even without the drugs.î If a woman has eggs retrieved and then fertilized by in vitro fertilization and stored as frozen embryos, she can then try to get pregnant by implanting the embryos if her fertility doesnít return after treatment. This is the most proven option, and the one with the greatest overall success: About 40 percent of women under 35 who try this treatment are able to get pregnant, although success rates decline as you get older. But keep in mind, thatís with traditional embryo freezing and in vitro fertilization (IVF). Many breast tumors are sensitive to estrogen, and doctors are naturally concerned that higher hormone levels resulting from the standard methods of stimulating ovaries to produce more eggs for retrieval and IVF may inadvertently promote the growth of cancer cells. Some specialists are now experimenting with various other techniques to harvest eggs. These include retrieving only the eggs that mature naturally in a womanís menstrual cycle (which means that far fewer eggs are availableóusually only one or sometimes none per cycle), or stimulating the ovaries with the drug Tamoxifen, which is also used as a breast cancer therapy. Fertile Hope has an online tool that allows for easy comparison of the cost, risks and chances of success of these and other parenthood options, which can be found at www.fertilehope.org. They also offer a brochure on breast cancer and fertility, available through the Web site or by calling (888) 994-HOPE. ìThe most important thing is to ask your oncologist about fertility,î said Westphal. ìOncologists donít always bring these issues up, or just touch on them in passing. Theyíre better now about talking to patients about this than they used to be, but itís lower on the priority list, obviously, than getting rid of the cancer, so itís still discussed much less. If itís really important to you, make sure to ask your doctor about it and possibly seek a referral to a reproductive endocrinologist who can discuss your options in more detail.î Breastcancer.org, an excellent resource for women with breast cancer and their families and friends, suggests a few questions for women to ask their doctorsóand themselves: Do I feel well and strong enough to go through pregnancy and birth? How long after treatment is over should I wait before trying to get pregnant? Considering my age and the treatment I received, how likely am I to get pregnant? Are there any treatments Iíll have to stop if I want to get pregnant? Whatís the risk of stopping treatments to get pregnant? Will I be able to continue taking treatments after I have a baby? If I canít get pregnant ìthe usual way,î what kind of infertility treatments can I safely take? And can I put my eggs ìin the bankî before chemotherapy so I can use them lateróin case my treatment puts me into an early permanent menopause? Is It Safe? In addition to all of the questions about whether you can get pregnant after breast cancer, thereís another question: Should you? In other words, does pregnancy make it more likely that your breast cancer will come back? The answer again is, ìWe donít know.î In general, the research so far is encouraging. A study in the European Journal of Cancer published in April 2003 looked at all the research to date on pregnancy after breast cancer and found that it didnít seem to increase the risk of cancer recurrence or affect survival rates. ìI think the studies to date are fairly consistent in showing that in general there isnít an increase in recurrence in women who get pregnant after having had breast cancer,î said Westphal. ìThere isnít anything in most of these studies that would indicate that if a woman is doing well after breast cancer, she shouldnít get pregnant.î So whatís the problem? Itís difficult to study pregnancy after breast cancer because it happens in a comparatively small number of women, and those women are often so different from each otheróin age, stage of cancer at diagnosis, genetic profile of their cancer and so onóthat itís hard to make meaningful comparisons. As a result, most of the studies that have been done so far are fairly small, and many have design flaws and lack solid results. Whatís more, studies to date have been ìretrospectiveî studies, looking backward in time. ìBasically, everything thatís important in medicine is done with a prospective study,î explained Dr. Jeanne Petrek, director of the Evelyn H. Lauder Breast Center at Memorial Sloan-Kettering Cancer Center in New York. ìFor example, for all those years doctors were saying that hormone replacement therapy is good for women and it doesnít do any harm. Well, they finally did a prospective study and lo and behold, it is bad for you.î It may be, she said, that a prospective study will concur with the other studies, indicating that pregnancy after breast cancer is safeóor it may not. ìNo oneís done it until now, mainly because itís only recently that more and more women have been getting pregnant after breast cancer treatment,î she explained. ìAnd prospective studies take a long time. You have to accumulate a population of women and follow them closely. It takes at least five yearsóa year of treatment, a year or more to get pregnant, especially if theyíre not so fertile, almost a year of pregnancy, and then we want to know how theyíre going to do after that.î Despite those challenges, Petrek has undertaken the first prospective study of pregnancy in women who have had breast cancer. She first began accruing patients in 1998, and the study now has 800 participants. There have been 83 pregnancies so far among study patients. Its short-term results, focusing on premature menopause as a result of breast cancer treatment, will be presented at a major cancer conference in May, but the long-term resultsóon whether or not pregnancy increases the risk of cancer recurrence or mortalityówonít be known for another five years. Of course, most women who want to get pregnant canít wait that long. So what should they do in the meantime? ìItís important to realize that thereís a significant lack of evidence,î said Petrek. ìYou should ask yourself how you feel about doing something that no one really knows about. Of course, a lot of women do go ahead and become pregnant, and we canít say that itís unsafe. If we find it to be unsafe in some, itís still obviously been safe in a lot of others. And of course, pregnancy and having children is one of lifeís most important goals for many women. You just have to decide how much unknown you want to take.î If a woman does decide to try and become pregnant after breast cancer, most doctors will encourage her to wait between two and five years after treatment has ended, depending on what stage her cancer was diagnosed at and whether there were lymph nodes involved. Whether or not a post-breast cancer pregnancy increases the chance of the cancer returning, the pregnancy itself wonít necessarily be any more high risk than any other pregnancy, explained Westphal. ìI donít think a woman whoís post-breast cancer necessarily needs to be followed by a high-risk obstetrician, unless there are other factors involved,î she said. ìOf course, they need to have regular follow-ups with their oncologist as they always would, but I donít think they need to be treated in particular as high-risk pregnancies.î As for me, I chose not to pursue assisted reproductive options before being treated for breast cancer. My oncologist at Sloan-Kettering explained them all to me, but my husband and I decided to focus immediately on my treatment and worry about fertility later. Four months after the end of chemotherapy, my menstrual cycle still hasnít returned, but we remain hopeful that it might. And if it doesnít, weíre also pursuing one of the other avenues open to women whoíve had breast cancer: adoption. Whether through adoption, IVF, surrogacy, donor eggs or unassisted pregnancy, there are many options available, and thereís no reason why women whoíve had breast cancer should be denied the opportunity to have the family they dream of. Gina Shaw is the medical writer for The Washington Diplomat.