What if I had the choice?
Fertility and motherhood have long been revered in most societies—but what if this choice becomes difficult upon receiving a breast cancer diagnosis? At a recent dinner gathering at a friend’s house, a lively conversation turned into a discussion about breast cancer and possible fertility complications in some women who may want to get pregnant. As a young black woman of child bearing age (15 – 44 years old, CDC), I quickly found myself paying a great deal of attention to this exchange. Given my background in science, I am aware that certain breast cancer treatments such as chemotherapy can lead to infertility. In spite of this knowledge; I have not given a lot of thought to this matter which also gave me pause to think about the many women who are dear to me and who fall into that age category.
A few days later, as I continue to ponder about this issue, I decided to write an article for this blog and more importantly, to shed some light on fertility preservation options that are available for women who might be considering the prospect of motherhood. Through some research, I came upon on the story of Dr. Jacqueline Walters and her struggles with breast cancer and infertility, along with some information from the Center of Disease Control (CDC). I also had the opportunity to have a conversation with Dr. Tawakalitu Salewa Oseni, a Surgical Oncologist at the Massachusetts General Hospital (MGH).
In her 2018 article from Women’s Health, Dr. Walters explains, “I was married at 38 and started trying to get pregnant at 39. And I did actually get pregnant! And then…I found out I had breast cancer,” she wrote. “Chemotherapy and radiation led to a miscarriage at six months. The doctors were clear with me that I was never going to get pregnant naturally after that. To this day, I’m still not sure if the miscarriage was caused by age or chemically induced because of the chemo and radiation. I tried everything I could within the limits of my situation, from medication to acupuncture, herbal tea and more to conceive, but it didn’t work out as planned”.
I find Dr. Walters‘ article remarkable for her willingness to share her painful and personal details regarding the importance of being informed about available options during the diagnosis of a cancer. Besides sharing her challenges, I also like the fact that she encouraged women to know that there are options available for fertility preservation.
Dr. Jacqueline Waters is a philanthropist, health expert, women’s advocate, TV personality and award-winning OBGYN. She has disclosed to be a two-time breast cancer survivor and the founder of the 50 Shades of Pink Foundation, an organization established in 2013 whose mission is to treat the inner and outer beauty of cancer survivors.
According to Center of Disease Control (CDC), 24,000 women under the age of 45 are diagnosed with breast cancer every year in the United States. However, significant advances in detection, and newly developed treatment strategies have remarkably improved the course of breast cancers . The National Cancer Institute estimated that the 5-year-survival rate for the women under age 45 was 88% in 2014 . With the increase in the survival rate of breast cancer, it has become important to consider cancer survivors' quality of life. Nowadays, more women tend to have children at later reproductive ages for various reasons, including education, employment, and financial stability. As a result, the number of women who experience breast cancer before completing childbearing is growing. In this context, young women face a unique challenge that are either not present or are less significant for older women (after menopause) which is the impact of breast cancer treatment on their fertility. This is even truer within black community as young African American women under the age of 35 have breast cancer rates that are two times higher than Caucasian women of the same age .
How can fertility be affected by the treatments?
Treatment for breast cancer usually involves chemotherapy, radiation therapy, or a combination of the two. These treatments can affect the reproductive system and, as a result, your fertility. Chemotherapy is the use of drugs that kill cancer cells. However, these drugs also kill some healthy cells, including those involved in the production of eggs. Many factors such as the type of medications used, the length of treatment, and the person's age at the time of treatment are all influencing factors that can affect the ovarian function. While it is unclear whether the use of chemotherapy drugs causes infertility, few studies have demonstrated the occurrence of amenorrhea. A study found that in some cases, the average rate of chemotherapy-related amenorrhea ranged from 30% to 40% in women aged less than 40 years and from 76% to 95% in women aged 40 or more years . Radiation therapy is the use of high-energy rays or radioactive substances for cancer treatment. Radiation kills cancer cells by interfering with their growth and division cycles. Radiation beams can pass through healthy tissues, which can lead to either temporary or permanent infertility. However, the potential adverse effect on fertility by radiation therapy would be lower than chemotherapy because the affected area is far away from the reproductive organs.
What fertility preservation options are available for breast cancer patients?
The current options for fertility preservation are the cryopreservation of embryo, oocytes, ovarian tissues, and inhibition of ovarian function during treatment.
Embryo or oocytes Cryopreservation
Cryopreservation is the process of freezing and storing eggs (oocytes) or embryos (fertilized eggs) for later use. Embryo cryopreservation is the most well-established method of fertility preservation. The procedure follows the same rule as in in vitro fertilization (IVF), which involves first stimulating the ovaries to make mature eggs (oocytes) that can be retrieved and fertilized. The embryos can then be implanted in the woman after she recovers from breast cancer treatment.
Oocyte cryopreservation is another option for fertility preservation for women who don’t have a committed male partner. The protocol is similar to embryo cryopreservation. Some concerns have been articulated regarding lower implantation and pregnancy rates than those obtained with fresh or frozen embryos . However, the techniques have recently been refined and oocyte cryopreservation has become more effective. The success rate may vary depending on age, number of oocytes frozen and the freezing protocol.
Ovarian Tissue cryopreservation
The ovarian tissue cryopreservation is an experimental method, which consists in resection of a tissue prior to the chemotherapy. The tissue is then cryopreserved and retransplanted upon treatment completion.
Ovarian function shutdown during treatment
Some recent studies have demonstrated the effectiveness of a new approach, which involves using hormones – known as gonadotropin-releasing hormone (GnRH) - to place the reproductive organs in an inactive state while undergoing cancer treatment [3, 4]. This process seems to protect the germ cells from damage by chemotherapy.
For BRCA mutations carrier (see our previous blog post), there is some evidence that the ovarian reserve may be lower and that patients are at high risk of ovarian cancer . They are more prone to chemotherapy-induced loss of ovarian reserve and ovarian insufficiency and should benefit from an appropriate counseling, which can include an oophorectomy when patients have finished their childbearing. For younger women with BRCA1 and BRCA2 mutation, a study shows that the use of oral contraceptives may reduce the risk of ovarian cancer .
The importance of medical counseling
Fertility preservation has become an essential part of the management of cancer patients. The need for timely and accurate information for women of reproductive age with breast cancer is crucial to preserve future fertility chances. In 2006, an article of the journal of Clinical Oncology, the American Society of Clinical Oncology (ASCO) recommends that oncologist should inform their patients about the potential negative effects of chemotherapy on fertility before initiating a treatment and promptly refer patients to reproductive specialist to discuss the risk of loss of fertility and currently available fertility preservation options .
In light of all this information, I wanted to know how these issues are addressed locally. So, I spoke to Dr. Tawakalitu Salewa Oseni who is a breast surgeon at the Massachusetts General Hospital.
Conversation with Dr. Tawakalitu Salewa Oseni, MD
Dr. Oseni specializes in breast surgery and is currently a member of the Division of Surgical Oncology at the Massachusetts General Hospital (MGH). She is also a surgical member of the multidisciplinary cancer team at both MGH and Southern New Hampshire Medical Center in Nashua, NH.
At the onset of my conversation with Dr. Oseni, she made it clear that referring women to receive counseling for fertility preservation is an important part of her medical practice. Another essential aspect she raised along this issue is the affordability of such options as that can influence who is able to access these services. She cited the 1998 Women Health Care Act, which provides insurance coverage to women diagnosed with cancer to get implants or prosthetics. Unfortunately, due to a lack of national mandate for infertility treatment, this is not the case when it comes to preserving fertility. In Massachusetts, insurance companies are mandated to provide coverage for certain infertility treatments, but the options for preserving fertility prior to breast cancer treatment or any type of cancer do not fall under the same regulations. Therefore, the policies, levels of coverage, and out pocket expenses remain at the discretion of the insurance companies and may vary from state to state. The lack of access to quality health care in certain states also increases the financial and public health burden in individuals facing these complex issues.
As I continued my conversation, Dr. Oseni also mentioned that for instance, New Hampshire is one of the states that doesn’t mandate coverage for fertility treatment or preservation. As a result, there is an up front out of pocket cost, which can limit the options available for women living there. With a pause, she noted that this health dilemma has become a quality of life issue and the costs for treatments should not be a determinant of whether or not a patient has a biological child.
In terms of recommendations, Dr. Oseni believes that both the health policy and mandated coverage need to be addressed at a federal level. In the meantime, her advice is for women of child bearing age to be informed and carefully choose their health insurance plans—while taking into consideration out of pocket costs. In addition, Dr. Oseni encourages young women to ask their health care providers about their options, especially if they would like to get pregnant after a treatment for cancer. She indicated that at MGH, cancer patients can have their fertility preserved up to 42 years old. Lastly, she added that when a woman is looking at fertility treatment costs, it is important to calculate applicable co-pays as well as prescription drug plan reimbursement.
To sum up this post, my words for my sisters are: If you are newly diagnosed with breast or any other cancer, act quickly and speak with your medical provider or team to get as much information as possible. Do focus on treating your cancer first, but it is also important that you consider life after cancer and the impact of any treatments you may choose. If you plan on having your biological child, ask to be referred immediately to a reproductive endocrinologist to discuss the options for fertility preservation.
Hardiesse Dicka studied chemistry and biology and graduated with a Master of Science in Analytical Chemistry at the University of Nantes in France. She holds an MSPH – Master of Science in Public Health and Environmental Health from the EHESP French School of Public Health at Rennes, France. Both Environmental justice and social justice have been in the forefront of her career. She had the opportunity during her previous experiences to engage in collaborative work with various partners, including the European Commission on climate change concerns and the Health Department of the French Army about exposure of firefighters to toxic chemicals. Hardiesse volunteers her time helping RSP in its mission to educate and empower women of African descent regarding the diseases of the reproductive system. Outside of work, Hardiesse is a food epicure and enjoys reading French literature.
The YAB Action Corner
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Make your voice heard. Call your Massachusetts State Senator and Representative to show your support for these three bills below. Each one can have a positive impact on women’s reproductive health and the lives of other people.
These bills are sponsored by one of the Resilient Sisterhood Project’s strong local collaborator --- Clean Water Action, funded in 1972 with a mission to protect our environment, health, economic well-being and community quality of life. Since their founding during the campaign to pass the landmark Clean Water Act in 1972, Clean Water Action has worked to win strong health and environmental protections by bringing issue expertise, solution-oriented thinking and people power to the table. They consistently organize strong grassroots groups and coalitions, and campaigns to elect environmental candidates and to solve environmental and community problems. https://www.cleanwateraction.org/
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An Act to protect children, families, and firefighters from harmful flame retardants (HD3012, SD1573)
Sponsors: Rep. Decker and Sen. Creem
Toxic flame retardants are added to highchairs, car seats, nursing pads, furniture, carpet pads, electronic equipment (including toys), and many more household products. Unfortunately, they are a risk to our health and aren't actually needed for fire safety. These bills will ban the use of 11 harmful flame retardant chemicals in children's products, residential furniture, mattresses, bedding, carpeting and window treatments.
An Act relative to the disclosure of toxic chemicals in children’s products (HD400, SD1518)
Rep. Hawkins and Sen. Friedman
Toxic chemicals in everyday products are increasingly linked to cancer, learning disabilities, asthma and many other diseases and disorders. This bill will create a list of "toxic chemicals in consumer products" and require that manufacturers of children’s products, personal care products, cleaning products, and certain other "formulated" products sold in Massachusetts that contain those chemicals report that information to the state.