We have to talk about it: Bringing fertility into the conversation for young women with breast cancer

Abstract

Breast cancer is the most common type of cancer diagnosed in young women, and women under the age of 45 years compose approximately 10% of new breast cancer cases. However, a breast cancer diagnosis presents a unique set of challenges for younger women in comparison with their older counterparts. First and foremost, a young age at the time of diagnosis is associated with adverse outcomes because aggressive clinicopathologic features are more often seen in younger patients. In addition to these diseasespecific concerns, young patients with breast cancer are also faced with challenges surrounding family planning and fertility. Advances in breast cancer care and subsequently improved prognoses, as well as societal trends toward delaying parenthood, have led to an environment in which fertility concerns are often an integral part of treatment decisions for premenopausal patients with breast cancer. Fertilityrelated concerns are of particular importance in hormone receptor– positive (HR+) breast cancer because of the prolonged treatment timeline. For the treatment of HR+ disease in premenopausal women, current guidelines recommend a minimum of 5 years of endocrine therapy, with additional benefit from extending treatment to 10 years, along with the option of ovarian suppression in conjunction with the use of an aromatase inhibitor. Many young women also benefit from adjuvant chemotherapy followed by endocrine therapy, which further extends the total treatment period. This lengthy treatment course, as well as possible chemotherapyrelated impairment of fertility, poses significant challenges for reproductiveage patients who have not yet completed their families. In this issue of Cancer, Sella et al explore the relationship between fertility concerns and treatment decisions. In this large cohort of women aged 40 years or younger and recently diagnosed with HR+ breast cancer, onethird (213 of 643) indicated that concerns regarding fertility affected endocrine therapy decisions. Other studies have noted similarly high numbers of women for whom fertility is a concern. Partridge et al found that 57% of young breast cancer survivors reported concerns regarding treatmentassociated infertility at the time of diagnosis, whereas 29% reported that fertility concerns affected treatment decisions. Another survivorship study demonstrated that 56% of young women fell into a “high concerns group” on the basis of a reproductive concerns scale score, and it additionally noted that women in this group were more likely to make treatment decisions based on fertility preservation. Concerns about premature menopause, menopausal symptoms, and infertility are most common in patients younger than 50 years and have been linked to lower reported quality of life and more significant emotional distress after treatment. It is increasingly apparent that fertility concerns in this population of breast cancer patients and survivors are a pervasive issue that should not go unaddressed. Because the current standard of care for HR+ breast cancer includes 5 o 10 years of adjuvant endocrine therapy, medication nonadherence or discontinuation is an everpresent challenge. Even without underlying fertility concerns, longterm medication adherence is suboptimal, particularly among younger patients. One review noted that across age groups, adherence was widely varied, ranging from 41% to 72%, with younger age negatively associated with adherence. Wassermann et al demonstrated a nonadherence rate as high as 51% among breast cancer patients younger than 40 years who were prescribed endocrine therapy. In another study, women younger than 40 years were 50% more likely to discontinue endocrine therapy and 40% more likely to be nonadherent (P < .001). Rates of endocrine therapy nonadherence and noninitiation in Sella et al’s study are consistent with results noted herein: overall, 6% of women did not initiate endocrine therapy within 2 years of their diagnosis, and 20% were nonpersistent.