By Dr. Krystal Redman, DrPH, MHA (they/she)
Many patients of “reproductive age” who have been diagnosed with breast cancer, and who desire to preserve their fertility, have questions about the implications of their diagnosis and treatment on fertility and reproduction. These questions include what options are available and what outcomes to expect, with and without the use of assisted reproductive technologies (ART). Even oncologists worry about the use of ARTs in young people affected by breast cancer.
Assisted reproductive technologies can include, but are not limited to, controlled ovarian stimulation (COS), hormone replacement therapy (HRT), in-vitro fertilization (IVF), embryo transfers under HRT, and oocyte (a cell in an ovary) donation. Besides worrying about their diagnosis and fertility implications, patients also worry about the risk of unfavorable cancer outcomes, or even pregnancy, birthing, and fetal outcomes. These challenges are more prominent in Black women, who, evidence shows, are less likely to receive infertility treatment and have worse reproductive outcomes than white women.
Recently published results from a research study showed that pregnancy after breast cancer in patients with germline BRCA mutations is safe and was associated with favorable cancer and fetal outcomes (Lambertini et al., JCO, 2021). In the abstract presented by Dr. Maryam Lustberg during this year’s San Antonio Breast Cancer Symposium (SABCS), the research group studied patients who had been exposed to ART while trying to achieve pregnancy, as compared to people who were able to achieve the pregnancy without ART. In this study, the median age of the ART group was 33 years, versus groups under 30 years old in the non-ART group. Other demographic characteristics were similar between both groups. The researchers found that pregnancy outcomes were similar between patients who underwent ART and non-ART patients. Importantly, pregnancy did not appear to worsen the prognosis of young people affected by breast cancer, including those with hormone receptor-positive disease. Undergoing COS at cancer diagnosis delays anticancer treatment by about 6 days; however, this was not associated with worse cancer outcomes in that group. The researchers concluded that ART is safe for people with a history of breast cancer and BRCA1 alterations.
While the Lambertini study provides useful information, it focuses on patients with early stage breast cancer. Additional resources need to be directed at the needs of patients living with advanced and metastatic breast cancer. Black women are more likely to be diagnosed with an advanced stage of breast cancer; therefore, benefits accruing from research on early stage disease may be less likely to reach this population. Increasing equitable access to care will require a reassessment of research priorities and efforts to increase participation of Black women in clinical trials and research studies on breast cancer must be deliberate and targeted to be successful. Making sure they are represented on patient committees will not be sufficient.
Besides inequities in clinical research access and representation, Black women also face financial and other barriers to accessing fertility preservation techniques. We know that Black communities, specifically Black women, are disproportionately at a higher risk of getting breast cancer, and prone to having worse outcomes, compared to white women. These communities are also subject to inequitable pay and inequities in comprehensive healthcare that include the full range of sexual and reproductive care and coverage. Unfortunately, Black women are also not provided full disclosure of all resources and care options that are available to them. The conversation around equitable access to all fertility options and technologies needs to be offered to all breast cancer patients who desire to preserve their fertility.
A deeper question is about how many providers even ask Black women (and other folx in the gender spectrum who have a uterus and ovaries) if they would like to preserve their fertility in the first place. But that topic regarding forced sterilization, medical cohesion, and medical eugenics is for another time. For now, it suffices to know that all patients should be informed that they have the right to make their own choices, to know their options, and have equitable access to all of those possible options, including carrying a pregnancy, not carrying one, ART, adoption, surrogacy, conception without ART, and any other fertility preservation treatment that exists. Patients should have all the information and resources needed to make informed decisions about their bodies, lives, and futures.