Treating the Younger Patient with Breast Cancer: Pay Attention to Fertility Issues
Both elderly patient and younger patients present special challenges for doctors. In the case of a younger patient there is a great deal of emotional intensity to the first meetings, and I find that an initial visit (usually 2 hours) is not enough time, and arrange for a follow up visit. Most younger patients benefit significantly from adjuvant chemotherapy, particularly patients in their 30s with node positive breast cancer.
The first emotionally challenging issue is to trying to deal with the sadness of having breast cancer at such a young age - with so much of life ahead of the patient. Younger persons are generally used to a life of good health and to have breast cancer is truly a curve ball that they rarely thought would happen to them.
An issue that apparently is often overlooked in young patients is the issue of fertility preservation. There has been more news press about this in some of the journals and popular articles I have seen. It is a particularly difficult issue to deal with on top of the burden of dealing with a life threatening a life illness.
The younger a patient is, the more likely her menstruation is to resume following adjuvant chemotherapy. If a woman is close to menopause in age (and the age of a patient's mother often can be a surrogate for when that woman might go through menopause) then adjuvant chemotherapy might render them postmenopausal. Often younger women will become amenorrheic, but the younger a woman during adjuvant chemotherapy the more likely menses are to resume.
Yet there is still much to learn about chemotherapy affecting future fertility. We used to feel that giving Goserelin (a medicine that basically "shuts down" the ovaries during chemotherapy) might help prevent infertility - but a recent abstract I came across showed this not to be the case, much to the frustration of the doctors and the patients.
While at ASCO I had some poster presentations, and one of the neighboring posters showed that oncologists frequently do not bring up fertility issues with their younger patients with breast cancer (I think that there was no discussion of these issues an alarmingly high percent of the time).
In San Francisco, we have several top notch gynecologists who specialize in infertility that are well prepared to see our patients with breast cancer. Because of the timing issues they have a "fast track" and can typically get our patients in within 3 or 4 days to talk about issues such as fertility, family planning, and even egg harvesting - a procedure where eggs can be removed from the ovary and stored for the future in case fertility is lost from postoperative ("adjuvant") chemotherapy.
However, this cannot always be the case depending on where you live. In a big city there are often infertility physicians around - but in less populated areas the distance to travel to see an infertility specialist starts to be greater. Many women may not have the same options. But for certain we oncologists can be sure to discuss these issues at length prior to recommending adjuvant chemotherapy - 100% of the time.