- Question from Vicki: I have metastatic breast cancer with mets in my spine and shoulder. I have been responding well to Femara and Aredia. I have not given up on the idea of having my own children. How should I be evaluating the risks of going off of medication for a time period?
Marisa Weiss, M.D.
If you have metastatic breast cancer, generally ongoing treatment is necessary to control the growth of the breast cancer, so there are a number of issues that your question raises. First, if you were to go off of your treatment for an extended period of time—long enough to get pregnant and carry a pregnancy—that would be about a year or so at least without anti-cancer treatment. Most doctors would consider that choice a dangerous one.
In addition, when there are known cancer cells in your body that may grow more rapidly in response to all the hormones that go along with pregnancy, that too poses a significant potential threat to your health.
Women in this situation that you're in may find another way to go that will allow them the experience of motherhood without stopping treatment and attempting pregnancy themselves. Adoption is an option, or an attempt to grow relationships with family members that are already in your life, where you can have a critical nurturing role that is deeply satisfying, and that goes along with continuing treatment to extend your own life.
- Kutluk Oktay, M.D. One thing that comes up in patients like this is if they receive chemotherapy but have not suffered from ovarian failure, can we stop these medicines for a brief period and then resort to one of the preservation procedures, and then put the patient back on the treatment so she can use the embryos for the gestational carrier? What if she stops for three months or so? That comes up all the time, and we don't have a good answer.
- Leslie R. Schover, Ph.D. There have been protocols where aromatase inhibitors are used along with fertility drugs that stimulate the ovaries. The aromatase inhibitors help stimulate the ovaries to produce more mature eggs and they may also offer protection against the high levels of fertility hormones.
- Marisa Weiss, M.D. Dr. Schover and Dr. Oktay, can you describe the steps a woman might go through to have her ovaries stimulated to produce ovulation?
Kutluk Oktay, M.D.
There may be a possibility to take you off the breast cancer medicines for several months, and for you to undergo ovarian stimulation with aromatase inhibitors. Aromatase inhibitors help stimulate the ovaries to result in extra egg production during a cycle. We can use these along with standard low-dose fertility drugs to make extra eggs that can be fertilized and saved, and then you may go back on your cancer treatment. And those embryos in the meantime can be used with a gestational carrier (surrogate).
Again, for breast cancer patients who have been diagnosed but have not undergone chemotherapy, another option is to use tamoxifen as a fertility drug. It was originally used as a contraceptive, but didn't work well because it increased ovulation.
There is a third and more experimental option, which is removing ovarian tissue before chemo and freezing it, and then transplanting it back into the body. There have been fewer than a dozen of these procedures done so far. We were able to get embryos from the patients who underwent the transplant, and we are working on a first pregnancy.
But if the patient does not have enough time to undergo ovarian stimulation, ovarian tissue freezing may be the only option. In summary, we can do ovarian stimulation with tamoxifen or an aromatase inhibitor, we can freeze your eggs by themselves or as fertilized embryos, or we can do ovarian tissue transplants.
- Marisa Weiss, M.D. There are so many emotional issues that go along with all these medical considerations. Dr. Schover, after a woman finishes her intensive breast cancer treatment, she has to deal with a whole other set of difficult issues that surround potential infertility. How do you counsel a woman with her partner or a woman without a partner to handle these tough issues?
Leslie R. Schover, Ph.D.
One thing that is very important is to acknowledge the grieving women go through. And for a young woman, the loss of her belief that she has a long future and that nothing that bad could happen to her is a trauma and a grief in itself. Then to have infertility on top of that is a real double whammy. Many people in a woman's own life try to minimize the importance of the infertility, saying things like, "You could adopt" or "You're lucky to be alive," and that can make a woman angry and make her feel misunderstood.
Doing realistic problem solving about the options—the risks and benefits of each—is necessary, and there's nothing easy here. There are potential barriers and things you have to confront. If you can have a natural pregnancy, you are very lucky, but we still can't say for sure that pregnancy won't increase chance of recurrence. The fear that you may have a daughter who could also have breast cancer is also a concern. And what if you don't live long enough to see your children grow up? These are all real concerns that need to be addressed.
For women who can't get pregnant, or decide not to, there are also concerns about barriers to adoption. How much should I tell the home care? Should I consider international adoption, since some countries are more favorable to cancer patients? Do I need a letter from my oncologist saying my prognosis is excellent? What about an egg donor? Who would be the donor, and would the child love the biological mother as well? If there is counseling available, that's a good place to talk out all the ambivalent feelings a woman may have.
- Marisa Weiss, M.D. Motherhood can take on so many forms. So much of being a mother is how you create the relationship with the person you bring into this world, either through your own body with your partner, or through adoption as an alternative. There is so much about motherhood that you create yourself, beyond how the baby came to you. That is where so much of the opportunity is for you to experience motherhood.
- Leslie R. Schover, Ph.D. Although I agree with you, I think that can sometimes be the kind of statement women aren't ready to hear. There is such a sense of loss at not being able to do what it seems that every other woman around you can do, which is to get pregnant and carry your own child. It's true that social parenting is very important and there are joyful ways to be around children. But often when women are infertile, they don't have the ability to enjoy some of those other ways, because they're so busy with the negative thoughts about not being able to have a child themselves. So it may take time to be able to be a wonderful aunt or teacher or foster parent.
- Marisa Weiss, M.D. As a parent, if you have a child yourself, or if you adopt a child, or if you take on stepchildren, so much of motherhood in each of those contexts is a day-to-day, week-to-week, year-to-year relationship that you create and build. I wasn't so much referring to other types of relationships where nurturing is important. But I do agree that giving up the hope of having a baby yourself represents a huge disappointment to most women who desire that. As you grieve and move on through the process, and as you come to terms with your situation, new possibilities can present themselves.
The Ask-the-Expert Online Conference called Pregnancy and Fertility Issues featured Kutluk Oktay, M.D., Leslie Schover, Ph.D., and moderator Marisa Weiss, M.D. answering your questions about pregnancy and fertility before, during, and after breast cancer treatment, as well as the options of adoption and gestational carriers (surrogate mothers).
Editor's Note: This conference took place in August 2004.
The materials presented in these conferences do not necessarily reflect the views of Breastcancer.org. A qualified healthcare professional should be consulted before using any therapeutic product or regimen discussed. All readers should verify all information and data before employing any therapies described here.
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