Cancer and Fertility

Cancer and Fertility

I have been working with women with cancer in various roles throughout my nursing career - too many years to mention! Many of the women I have spoken to have voiced concerns about their fertility and how their cancer treatment may affect this. Words: Sarah Hunter

Many cancers, including breast cancer, are now diagnosed earlier in the course of the disease, which means that treatments are likely to be more effective. But future quality of life becomes a pressing and valid concern. Add to this the increasing average age at which New Zealand women have their children and we have a relatively new and rapidly growing issue in cancer care.

Female fertility is complicated. Basically, a lifetime supply of eggs is manufactured before birth and this supply is not renewable. A woman’s peak number of eggs is reached while she is still in her mother’s womb (not much use then!) and declines over her lifetime until menopause. Each month, a number of these eggs are developed for potential fertilisation. From the age of about 30 onwards, fertility is already reducing and this speeds up from the age of around 35, with a rapid decline from 40 onwards.

Although the breast cancer treatment ‘journey’ is different for each woman, the majority of younger women (aged 20-50) will undergo surgery to remove the tumour and assess the lymph nodes in the armpit area. Following this, any combination of chemotherapy, hormonal therapy and/or radiation therapy may be recommended. Breast surgery and/or radiation therapy to the breast/armpit area does not affect fertility in women as these are both treatments that only affect the area to which they are given. Hormonal therapy comes in many guises, but the most common Tamoxifen, or an aromatase inhibitor such as Arimidex, do not directly and permanently affect fertility on their own accord. The effect comes from the length of time on the treatment (usually [at least] five years) during which a woman’s natural fertility will decline due to her increasing age. More permanent hormonal therapy involving the removal of the ovaries will result in permanent fertility damage.

The main culprit of fertility damage from breast cancer treatment is chemotherapy. Chemotherapy medications are given either by mouth or through a vein and they travel throughout the body. They work by damaging cells that are fast and active, which cancer cells generally are. Unfortunately, some of our own cells are also fast and active, such as hair follicle cells, cells lining the mouth and gut, and the cells in the ovary that assist with developing the eggs each month for fertilisation. This means that the store of eggs and the cells that produce the female hormones are both reduced with each cycle of chemotherapy. There are many different chemotherapy ‘drugs’ and these are often given in combination to increase their effect. The ones that are most effective in treating breast cancer can severely affect fertility, particularly in women over the age of 35. (Some of the newer breast cancer treatments such as Herceptin do not yet have enough research data to tell us whether, or how, they affect fertility in the long-term.)

There are two broad ways in which fertility damage can show itself after cancer treatment. The most dramatic is a permanent lack of periods, although the ‘permanence’ of this takes a number of months to determine, as periods can stop and start again; if this is indeed the end of periods, symptoms of menopause such as hot flushes and mood changes may happen too. A less dramatic demonstration of fertility damage is either the inability to conceive despite regular periods, or menopause happening far earlier than it naturally would have.

So, what can we do about this? The main thing that young women with breast cancer have on their side, compared to young women with other cancers, is time; there is a window of opportunity in which fertility discussions and actions can take place between surgery and chemotherapy without decreasing the effectiveness of treatment - at least six weeks of healing time is needed after surgery before chemotherapy can be given safely. Some women may find that in the rush of diagnosis and treatment discussions about fertility issues are not raised by the healthcare team. It is important for women to raise this concern themselves if this is so - ask your surgeon or oncologist, ask to speak with a specialist nurse or be referred to another doctor or nurse who specialises in this area. It is vital that any actions to preserve fertility are undertaken as soon as possible so that all available and appropriate options can be explored.

There are a huge number of research studies happening internationally that are looking at better ways to preserve fertility during cancer treatment. Many of these options are still considered experimental and are therefore not readily available or government funded; not all of the options available in New Zealand are appropriate for every woman - this should be determined by a doctor specialising in fertility. Potential options include: freezing eggs for future use or freezing embryos (fertilized egg) for future use (both of these options require hormone injections to make the eggs develop in large numbers which may not be safe for women with hormone sensitive cancers); removing a portion of ovary and freezing this for future use; giving medication to return the hormones to pre-puberty levels to protect the ovary during chemotherapy. As mentioned above, all of these procedures are new and may still be considered ‘experimental’; their availability is dependent on each woman’s situation, the expertise of the fertility service and the funding available.

Sarah Hunter is a Registered Nurse and Doctoral candidate with a clinical and research interest in cancer in younger people. Sarah has worked in a number of cancer-related roles throughout her 20 year career, including community palliative care, community cancer nursing for the Cancer Society and inpatient and outpatient work at the Cancer Centre in Auckland.

Research on fertility damage from cancer treatment
For women whose fertility is damaged by cancer treatment the emotional effects can be huge. It has been described as ‘rubbing salt into the wound’ and like ‘adding insult to injury’. Added to this, fertility damage may affect a woman’s self-esteem, confidence, spirituality, sexuality and psychological recovery from the horror of a cancer diagnosis and treatment; this may also have an effect on partners or potential partners. To help health professionals understand the impact of this, and then improve how they work with women around this issue, Sarah is currently studying the emotional and relationship effects of fertility damage from cancer treatment in younger women. The study involves Sarah spending one to two hours talking one-on-one with women who have finished their initial cancer treatment and believe that their fertility may have been damaged. The interview focuses on the emotional impact, relationship impact and support strategies experienced by the women who participate. For more information about the study please contact Sarah on 027 264 3502 email shun044@ec.auckland.ac.nz