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2–3 Web-Based Survey of Fertility Issues in Young Women With Breast Cancer
or that infertility and the treatment of it had different effects on breast cancer susceptibility. Only a prospective cohort study with complete ascertainment of both the causes of infertility and the treatments used can clarify this causal uncertainty. For now, we can reassure
our patients of the lack of demonstrated or certain associations between the treatment of infertility (adjusted for late age at first birth and nulliparity) and the risk of breast cancer.
2–3
agnosis was 32.9 years, and the mean age at response to the survey was 35.8 years. At diagnosis, 62% of women were married, 8% were living as married, 7% were divorced or separated, and 23% had never married. Most (62%) of the respondents had been diagnosed with breast cancer 2 years earlier; 10% had been diagnosed with stage 0 disease, 27% with stage I disease, 47% with stage II disease, 13% with stage III disease, and 3% were unsure. Breast-conserving surgery was performed in 40% of cases, and only 7% of women had comorbid conditions at the time of diagnosis. Ninety-two percent of the women had regular monthly periods at diagnosis, 59% had been pregnant at least once, and 48% had at least 1 live birth before diagnosis. Half of the women had attempted to become pregnant before their diagnosis. Fifty-six percent indicated a desire to have a child or more children in the future. Reflecting on their feelings at diagnosis, 56% recalled having had substantial fear of breast cancer recurrence, and 73% had had some degree of concern regarding future fertility (16% a little concerned, 18% somewhat concerned, and 39% very concerned). Factors associated with greater concern over fertility included a wish to have more children (odds ratio [OR], 120; P < 0.0001) previous number of pregnancies (OR, 0.78; P = 0.01), and a history of previous difficulty conceiving (OR, 1.86; P = 0.08). Age and disease stage at diagnosis were not found to be significant factors in multivariate analysis. Concern about fertility influenced treatment deci-
Web-Based Survey of Fertility Issues in Young Women With Breast Cancer Partridge AH, Gelber S, Peppercorn J, et al (Dana-Farber Cancer Inst. Boston; Brigham and Women’s Hosp, Boston; Harvard Med School, Boston; et al) J Clin Oncol 22:4174-4183, 2004
Background.—The impact of a diagnosis of breast cancer on young women often includes concern about the effects of the treatment on their fertility. The focus of this evaluation was to determine the proportion of premenopausal women with early-stage breast cancer who were concerned about becoming infertile after treatment, to determine the percentage of women who considered fertility in choosing their breast-cancer treatment, and to compare women desiring to preserve fertility with those who did not with regard to fear of recurrence and various sociodemographic, clinical, and psychological factors. Methods.—A survey developed for this investigation dealt with fertility issues for young women (those aged 40 years or younger) with a history of earlystage breast cancer. The instrument was sent by e-mail to all 1,702 registered Young Survival Coalition survivor members, and e-mail reminders were used as needed. Findings.—Among the 657 women who were eligible and responded to the survey, the mean age at breast cancer di-
134 134
®
V. G. Vogel, MD, MHS
Breast Diseases: A Year Book Quarterly Vol 16 No 2 2005
Reference 1. Klip H, Burger CW, Kenemans P, et al: Cancer risk associated with subfertility and ovulation induction: A review. Cancer Causes Control 11:319344, 2000.
sions for 29% of the women; fertility concerns were discussed with a doctor by 72% of the respondents or with a fertility specialist by 17%. Half felt that their concerns had been addressed appropriately, but 26% felt their concerns were not adequately handled at the time of diagnosis. Eighty-six percent reported being aware that adjuvant chemotherapy could affect fertility. The risk of becoming menopausal as a result of treatment was overestimated by most women, with younger women estimating a lower risk for this complication (P = 0.0031). Conclusions.—Young breast cancer survivors expressed a high degree of concern over fertility issues. Health care practitioners should take care to identify and address fertility concerns at diagnosis and during the treatment-planning phase. Young breast cancer survivors should be offered interventions to minimize the impact of infertility that address both psychosocial and medical concerns. In this Web-based retrospective cross-sectional survey by Partridge and colleagues, the authors examined attitudes about fertility among premenopausal women 40 years of age or younger who had had a previous diagnosis of breast cancer (noninvasive or invasive). Of the 1,702 members of the Young Survival Coalition, 860 women gave electronic consent to participate and 657 were included in the final analysis. In multivariate analyses, the authors found that those who were more
concerned about fertility wanted to have more children, had had fewer prior pregnancies, and had had a history of difficulty conceiving. Most women had discussed their fertility concerns with a physician, although 26% felt that their concerns had not been adequately addressed. Also, most women indicated that concerns about fertility did not influence their treatment decisions. However, for those whose fertility concerns did influence the choice of treatment, the desire for children (or more
children), prior difficulty conceiving, and recalling severe depressive symptoms before diagnosis played a role. Although the generalizability of these results could be questioned on the basis of the demographic and socioeconomic status of those included in the survey, the results seem to make sense for those who treat breast cancer in young women. The President’s Cancer Panel has recognized the unique needs of young cancer survivors, including the issue of future fertility. Those who treat
cancer in young women must be sensitive to the effects that the treatments have on their lives as cancer survivors. Oncologists must have programs or mechanisms in place to answer questions about fertility or, at a minimum, should be able to refer them to support groups such as the Young Survival Coalition and Fertile Hope.
decade with 26 without cancer. All subjects provided blood samples on several occasions to allow characterization of CTCs; only cells meeting strict cytomorphologic, immunophenotypic, and fluorescence in situ hybridization (FISH) criteria were defined as CTCs. Blood samples from another 5 women preparing to undergo breast cancer surgery were obtained for measuring the CTC half-life in the presence of active tumor. Findings.—Thirteen of the 36 patients (36%) had CTCs, and CTCs were usually present on several testing occasions. Those 13 women had no clinical evidence of disease and were tested 7-22 years after mastectomy. In contrast, 1 of the 26 control subjects had a single cell that matched cytomorphologic and immunophenotypic but not aneusomic criteria for CTCs; this was considered a falsepositive finding. The half-life of the CTCs in the 5 women with active breast cancer ranged from 1 to 2.4 hours. Conclusions.—In this study, about one third of patients in breast cancer remission had CTCs but no clinical evidence of disease. Because the CTC halflife is so short, these cells must be replenished many times a day, yet a bal-
ance seems to have been established between tumor replication and cell death. In fact, in some patients this balance was evident as long as 22 years after treatment. These findings suggest that a “dormancy state” may be possible in breast cancer, and they support the hypothesis that cancer is a chronic, rather than an acute, condition.
K. M. Gwyn, MD, MSc, MPH
2–4
Circulating Tumor Cells in Patients With Breast Cancer Dormancy Meng S, Tripathy D, Frenkel EP, et al (Univ of Texas Southwest Med Ctr, Dallas; Dallas Breast Ctr; Vysis, Inc., Downers Grove, Il; et al) Clin Cancer Res 10:8152-8162, 2004
Background.—In some cases, breast cancer can recur many years after their initial tumor was treated. This pattern suggests that breast cancer remission may be associated with dormancy of the tumor cell population. In a previous study, these authors induced remission in mice with cancer and found that that remission reflected a balance between tumor cell replication and tumor cell death. The purpose of this study was to test the hypothesis that tumor cell population dynamics are similar in humans with breast cancer by using an assay to detect and analyze circulating tumor cells (CTCs). Methods.—Subjects were 36 women with breast cancer who had undergone mastectomy and had had no clinical evidence of disease for at least 7 years; these women were matched according to age
This interesting article from Meng and colleagues described the detection of CTCs in patients with a history of primary breast cancer and no clinical evidence of metastatic disease, a phenomenon called tumor dormancy. The authors collected 30-mL blood samples in EDTA vacutainer tubes from 36 patients who had had no evidence of recurrent disease for more than 7 years (the reason for choosing this interval was not stated). Their study also included age-matched controls. Cells were isolated with an immunomagnetic enrichment technique targeting EpCAM, an antibody directed to epithelial cells. Cells were also characterized by cytologic examination and by fluorescence in situ hybridization. Evidence of CTCs was found in 13 pa-
®
Breast Diseases: A Year Book Quarterly Vol 16 No 2 2005
135 135
our patients of the lack of demonstrated or certain associations between the treatment of infertility (adjusted for late age at first birth and nulliparity) and the risk of breast cancer.
2–3
agnosis was 32.9 years, and the mean age at response to the survey was 35.8 years. At diagnosis, 62% of women were married, 8% were living as married, 7% were divorced or separated, and 23% had never married. Most (62%) of the respondents had been diagnosed with breast cancer 2 years earlier; 10% had been diagnosed with stage 0 disease, 27% with stage I disease, 47% with stage II disease, 13% with stage III disease, and 3% were unsure. Breast-conserving surgery was performed in 40% of cases, and only 7% of women had comorbid conditions at the time of diagnosis. Ninety-two percent of the women had regular monthly periods at diagnosis, 59% had been pregnant at least once, and 48% had at least 1 live birth before diagnosis. Half of the women had attempted to become pregnant before their diagnosis. Fifty-six percent indicated a desire to have a child or more children in the future. Reflecting on their feelings at diagnosis, 56% recalled having had substantial fear of breast cancer recurrence, and 73% had had some degree of concern regarding future fertility (16% a little concerned, 18% somewhat concerned, and 39% very concerned). Factors associated with greater concern over fertility included a wish to have more children (odds ratio [OR], 120; P < 0.0001) previous number of pregnancies (OR, 0.78; P = 0.01), and a history of previous difficulty conceiving (OR, 1.86; P = 0.08). Age and disease stage at diagnosis were not found to be significant factors in multivariate analysis. Concern about fertility influenced treatment deci-
Web-Based Survey of Fertility Issues in Young Women With Breast Cancer Partridge AH, Gelber S, Peppercorn J, et al (Dana-Farber Cancer Inst. Boston; Brigham and Women’s Hosp, Boston; Harvard Med School, Boston; et al) J Clin Oncol 22:4174-4183, 2004
Background.—The impact of a diagnosis of breast cancer on young women often includes concern about the effects of the treatment on their fertility. The focus of this evaluation was to determine the proportion of premenopausal women with early-stage breast cancer who were concerned about becoming infertile after treatment, to determine the percentage of women who considered fertility in choosing their breast-cancer treatment, and to compare women desiring to preserve fertility with those who did not with regard to fear of recurrence and various sociodemographic, clinical, and psychological factors. Methods.—A survey developed for this investigation dealt with fertility issues for young women (those aged 40 years or younger) with a history of earlystage breast cancer. The instrument was sent by e-mail to all 1,702 registered Young Survival Coalition survivor members, and e-mail reminders were used as needed. Findings.—Among the 657 women who were eligible and responded to the survey, the mean age at breast cancer di-
134 134
®
V. G. Vogel, MD, MHS
Breast Diseases: A Year Book Quarterly Vol 16 No 2 2005
Reference 1. Klip H, Burger CW, Kenemans P, et al: Cancer risk associated with subfertility and ovulation induction: A review. Cancer Causes Control 11:319344, 2000.
sions for 29% of the women; fertility concerns were discussed with a doctor by 72% of the respondents or with a fertility specialist by 17%. Half felt that their concerns had been addressed appropriately, but 26% felt their concerns were not adequately handled at the time of diagnosis. Eighty-six percent reported being aware that adjuvant chemotherapy could affect fertility. The risk of becoming menopausal as a result of treatment was overestimated by most women, with younger women estimating a lower risk for this complication (P = 0.0031). Conclusions.—Young breast cancer survivors expressed a high degree of concern over fertility issues. Health care practitioners should take care to identify and address fertility concerns at diagnosis and during the treatment-planning phase. Young breast cancer survivors should be offered interventions to minimize the impact of infertility that address both psychosocial and medical concerns. In this Web-based retrospective cross-sectional survey by Partridge and colleagues, the authors examined attitudes about fertility among premenopausal women 40 years of age or younger who had had a previous diagnosis of breast cancer (noninvasive or invasive). Of the 1,702 members of the Young Survival Coalition, 860 women gave electronic consent to participate and 657 were included in the final analysis. In multivariate analyses, the authors found that those who were more
concerned about fertility wanted to have more children, had had fewer prior pregnancies, and had had a history of difficulty conceiving. Most women had discussed their fertility concerns with a physician, although 26% felt that their concerns had not been adequately addressed. Also, most women indicated that concerns about fertility did not influence their treatment decisions. However, for those whose fertility concerns did influence the choice of treatment, the desire for children (or more
children), prior difficulty conceiving, and recalling severe depressive symptoms before diagnosis played a role. Although the generalizability of these results could be questioned on the basis of the demographic and socioeconomic status of those included in the survey, the results seem to make sense for those who treat breast cancer in young women. The President’s Cancer Panel has recognized the unique needs of young cancer survivors, including the issue of future fertility. Those who treat
cancer in young women must be sensitive to the effects that the treatments have on their lives as cancer survivors. Oncologists must have programs or mechanisms in place to answer questions about fertility or, at a minimum, should be able to refer them to support groups such as the Young Survival Coalition and Fertile Hope.
decade with 26 without cancer. All subjects provided blood samples on several occasions to allow characterization of CTCs; only cells meeting strict cytomorphologic, immunophenotypic, and fluorescence in situ hybridization (FISH) criteria were defined as CTCs. Blood samples from another 5 women preparing to undergo breast cancer surgery were obtained for measuring the CTC half-life in the presence of active tumor. Findings.—Thirteen of the 36 patients (36%) had CTCs, and CTCs were usually present on several testing occasions. Those 13 women had no clinical evidence of disease and were tested 7-22 years after mastectomy. In contrast, 1 of the 26 control subjects had a single cell that matched cytomorphologic and immunophenotypic but not aneusomic criteria for CTCs; this was considered a falsepositive finding. The half-life of the CTCs in the 5 women with active breast cancer ranged from 1 to 2.4 hours. Conclusions.—In this study, about one third of patients in breast cancer remission had CTCs but no clinical evidence of disease. Because the CTC halflife is so short, these cells must be replenished many times a day, yet a bal-
ance seems to have been established between tumor replication and cell death. In fact, in some patients this balance was evident as long as 22 years after treatment. These findings suggest that a “dormancy state” may be possible in breast cancer, and they support the hypothesis that cancer is a chronic, rather than an acute, condition.
K. M. Gwyn, MD, MSc, MPH
2–4
Circulating Tumor Cells in Patients With Breast Cancer Dormancy Meng S, Tripathy D, Frenkel EP, et al (Univ of Texas Southwest Med Ctr, Dallas; Dallas Breast Ctr; Vysis, Inc., Downers Grove, Il; et al) Clin Cancer Res 10:8152-8162, 2004
Background.—In some cases, breast cancer can recur many years after their initial tumor was treated. This pattern suggests that breast cancer remission may be associated with dormancy of the tumor cell population. In a previous study, these authors induced remission in mice with cancer and found that that remission reflected a balance between tumor cell replication and tumor cell death. The purpose of this study was to test the hypothesis that tumor cell population dynamics are similar in humans with breast cancer by using an assay to detect and analyze circulating tumor cells (CTCs). Methods.—Subjects were 36 women with breast cancer who had undergone mastectomy and had had no clinical evidence of disease for at least 7 years; these women were matched according to age
This interesting article from Meng and colleagues described the detection of CTCs in patients with a history of primary breast cancer and no clinical evidence of metastatic disease, a phenomenon called tumor dormancy. The authors collected 30-mL blood samples in EDTA vacutainer tubes from 36 patients who had had no evidence of recurrent disease for more than 7 years (the reason for choosing this interval was not stated). Their study also included age-matched controls. Cells were isolated with an immunomagnetic enrichment technique targeting EpCAM, an antibody directed to epithelial cells. Cells were also characterized by cytologic examination and by fluorescence in situ hybridization. Evidence of CTCs was found in 13 pa-
®
Breast Diseases: A Year Book Quarterly Vol 16 No 2 2005
135 135