Editor's Note: Breast cancer is increasingly affecting younger women. More and more young patients are achieving long-term survival while continuing to have a strong desire to have children. Fertility preservation has therefore become an important component of comprehensive breast cancer care. At the recently held 19th National Breast Cancer Conference and 21st Shanghai International Breast Cancer Conference (SIBCS), Oncology Frontier invited Professor Peng Yuan from the Cancer Hospital, Chinese Academy of Medical Sciences, to share her experience regarding fertility preservation in young breast cancer patients, the timing of discussions between physicians and patients, treatment regimens that may affect fertility, and multidisciplinary support strategies for patients who have missed the optimal window for fertility preservation.Oncology Frontier: Based on your clinical experience, could you share a case that illustrates the “sighs behind treatment decisions”? In this case, what unspoken concerns lay behind the sigh? What were the greatest regrets for the physician and the patient?
Professor Peng Yuan: As clinicians, we frequently encounter situations in breast cancer diagnosis and treatment that leave us with a sense of regret. For example, more than ten years ago, I treated a patient who developed breast cancer shortly before the age of 30. She was clinically diagnosed with stage II disease, with an HR+/HER2− subtype. Her diagnosis came quite unexpectedly, and when we discussed the treatment plan with her, she readily accepted the proposed strategy.
The patient subsequently underwent chemotherapy, radiotherapy, and five years of endocrine therapy. During endocrine therapy, she also received ovarian function suppression. After more than ten years of drug treatment and follow-up, her disease remained under control, and her general health was very good. During an incidental conversation, she told me that she wanted to have a child. I explained that, given her current condition, pregnancy was actually possible: she had already completed ten years of treatment, and her risk of disease recurrence was not high.
From that point on, she began trying to conceive, but despite trying for a long time, she did not become pregnant. At a subsequent follow-up visit, she told me: “Although the disease has been cured, I still have a major regret: I was unable to fulfill my role as a wife and never experienced what it feels like to be a mother.”
Looking back, she said that immediately after her diagnosis, she and her family had focused on one thing: saving her life. Some people had suggested considering ovarian protection or egg freezing in advance, but neither she nor her family had given the matter much thought. Today, the patient has otherwise recovered well, but relevant gynecological examinations have shown a significant decline in ovarian function and very low ovarian reserve. Under these circumstances, her chances of becoming pregnant are very low. This experience had a profound impact on me.
Breast cancer incidence is currently high among young women. Our survey results indicate that breast cancer accounts for nearly 10% of cases among women under the age of 35, demonstrating that this is a substantial patient population. With early detection, the cure rate for these patients can reach 70%–80%. However, for patients who have never had children, the opportunity to conceive after five or even ten years of treatment may be very limited. This can affect their long-term quality of life and is an important consideration in comprehensive patient care.
Oncology Frontier: In treatment decision-making for young breast cancer patients, who should introduce fertility preservation into discussions between physicians and patients, when should this happen, and how should the topic be approached? Which treatment regimens directly affect patients’ fertility?
Professor Peng Yuan: Fertility preservation has become a particularly important topic of interest. We are encountering an increasing number of young patients who have concerns and needs in this area. Recently, I treated a 19-year-old university student with breast cancer, and during her treatment discussions, I raised the issue of fertility preservation with her parents.
For patients with HR+/HER2− breast cancer, the longer the subsequent course of drug treatment is expected to be, the earlier we should discuss issues such as future life planning with them. In my view, the best approach is for the physician conducting the initial consultation to raise this issue with the patient or her family at the first visit. Patients need to understand that early breast cancer still has a high cure rate, but treatment may affect their future fertility. Of course, this also depends on the patient’s age and ovarian reserve. Nevertheless, early intervention is essential: fertility preservation should be considered after diagnosis but before systemic drug treatment actually begins.
We know that neoadjuvant therapy plays an important role in the treatment of many breast cancer subtypes. This is particularly true for triple-negative and HER2-positive breast cancer, where more patients receive neoadjuvant treatment. Chemotherapy agents, immunotherapy drugs, and even other medications used during neoadjuvant treatment may have some impact on fertility. In particular, chemotherapeutic agents such as alkylating agents and platinum-based drugs have been proven to affect fertility.
Therefore, for patients who wish to have children, discussions should take place before systemic treatment begins. A specialist in obstetrics and gynecology should also assess ovarian function to determine whether assisted reproductive technologies should be used to preserve the patient’s fertility.
In addition, pharmacological ovarian protection is an important component of patient care. However, during treatment, patients need to discuss their options with a specialist in obstetrics and gynecology to identify an approach that will neither delay cancer treatment nor compromise fertility preservation, while helping ensure that patients can have a healthy baby when they are ready or wish to conceive.
Oncology Frontier: For patients who have already missed the optimal window for fertility preservation, how should the multidisciplinary team provide psychological, reproductive, and genetic support?
Professor Peng Yuan: If patients have missed the optimal window for fertility preservation—that is, if no additional measures were taken to protect fertility before initial systemic treatment—they can still consider this issue during the course of treatment. Their reproductive potential can be assessed at an appropriate stage or milestone during treatment, and assisted reproductive technologies may still be offered.
The earlier this is done, the better. However, even if the optimal timing has passed, this does not mean that all possibilities have been ruled out. A multidisciplinary team may need to work together, including not only oncologists but also reproductive medicine specialists and obstetricians and gynecologists, to provide patients with better recommendations.
Professor Peng Yuan
