Board Review

A 32-year-old woman undergoes postoperative follow-up evaluation. The patient was diagnosed with a 1.9-cm, stage II, estrogen receptor–positive, progesterone receptor–positive, HER2-positive grade 3 invasive ductal carcinoma of the left breast, with 2/6 positive lymph nodes. She underwent breast excision 2 weeks ago. Medical history is otherwise noncontributory. She and her husband have one child and wish to have additional children.

On physical examination, vital signs are normal. There is a healing left breast incision. There is no lymphadenopathy. The remainder of the examination is unremarkable.

Laboratory studies are normal.

Which of the following is the most appropriate next step in the management of this patient?

A) Begin adjuvant chemotherapy without trastuzumab

B) Delay chemotherapy until after further childbearing

C) Recommend embryo cryopreservation before chemotherapy

D) Advise against further pregnancies

Answer: C - Recommend embryo cryopreservation before chemotherapy

Objective: Manage preservation of fertility in a patient about to start chemotherapy for stage II breast cancer.

Key Point

Women being treated for breast cancer who wish to preserve fertility should be referred to a fertility specialist to discuss embryo cryopreservation or other fertility preservation methods before adjuvant chemotherapy is initiated.

Embryo cryopreservation or other fertility preservation methods before chemotherapy should be recommended to this patient who wishes to have additional children. She has stage II breast cancer that is hormone receptor positive and HER2 positive. Adjuvant chemotherapy with trastuzumab should be started within 4 to 6 weeks of surgery. Although infertility effects of chemotherapy are age-, dose-, and drug-dependent, with younger women being affected less often than older women, patients of any age can become infertile, particularly after taking cyclophosphamide. Starting adjuvant chemotherapy and trastuzumab now will result in infertility in a significant percentage of women and is not the best option for this patient who desires continued fertility.

Fertility preservation is almost always done with the assistance of a fertility specialist with expertise in fertility preservation procedures and can usually be completed within a few weeks. An established fertility preservation option for a woman with a partner is in vitro fertilization with embryo freezing. Newer options, often done as part of clinical trials, include freezing of unfertilized eggs and ovarian cryopreservation with future reimplantation.

Trastuzumab does not cause infertility. It is the chemotherapy itself that can result in premature menopause and infertility. Adding trastuzumab to chemotherapy as adjuvant treatment for HER2-positive breast cancer decreases the risk of recurrence by 50% and should be included in this patient's adjuvant regimen.

Delaying chemotherapy until after the patient completes further childbearing will result in a higher risk of distant recurrence and is not a safe option. Studies evaluating the ideal sequence of adjuvant chemotherapy and primary breast radiation showed that giving chemotherapy after radiation was associated with a higher risk of systemic recurrence. Based on these studies, a delay of more than 12 weeks in starting adjuvant chemotherapy may be detrimental and should be avoided.

There is no reason to recommend against future pregnancies in this patient. Several large retrospective studies have shown that breast cancer recurrence is not increased and survival is not decreased in breast cancer survivors who become pregnant, including patients with hormone receptor–positive cancers.

Loren AW, Mangu PB, Beck LN, et al; American Society of Clinical Oncology. Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013 Jul 1;31(19):2500-10. Link Out