1. BREAST CANCER PATIENTS
Early: 81%
100% Breast cancer pts
Advanced: 19%
Premenopausal
26%
Postmenopausal
74%
ER–
46%
ER+
54%
ER–
27%
ER+
73%
˜25% of breast cancer patients are pre-menopausal (15% pts <45 yrs) at the time of diagnosis and survivors frequently are concerned regarding future childbearing
Decision Resources Epidemiology Data & Primary MR.

2. Is pregnancy safe for women survival after a dignosis of breast cancer?
Is chemotherapy detrimental for ovarian function?
Is LHRH-analogs treatment useful to preserve ovarian function?
What about other options about fertility preservations?

3. PREGNANCY AFTER BREAST CANCER … there are not prospective studies
AND PROGNOSIS
Healthy mother
effect
Available data show no adverse effect on survival of pregnancy after a diagnosis of breast cancer
BUT….
… there are not prospective studies

4. PREGNANCY after BREAST CANCER
Only 3% of women <45 yrs and 8% of women <35 yrs at diagnosis had full-term pregnancies (Mueller et al, 2003; Blakely et al, 2004)
It has been also reported an increased chance of spontaneous abortions (25% of cases of pregnancy) in women with a history of breast cancer (Velentgas et al, 1999)

5. Pregnancy prior to Breast Cancer
Largillier et al, ASCO 2006

6. Pregnancy after Breast Cancer
Largillier et al, ASCO 2006

7. Pregnancy prior to Breast Cancer
Largillier et al, ASCO 2006

8. However, concerns remain for some women and their physicians
Is it safe to get pregnant after breast cancer?
Available data suggests no adverse effect of subsequent pregnancy on prognosis of women with breast cancer
However, concerns remain for some women and their physicians
Ongoing perspectives studies should help to answer this question more definitively

9. THE IMPACT OF CHEMOTHERAPY
ON OVARIAN FUNCTION

10. Sklar et al, J Natl Cancer Inst 2005
Chemotherapy can compromise ovarian function resulting in premature ovarian failure (POF: defined as menopause before the age of 40 years or hypergonadotropic amenorrhea) and infertility (Byrne et al, 1999)
Dependending on the extent of damage to the ovaries, two forms of POF can be distinguished:
Acute Ovarian Failure (AOF) = loss of ovarian function during or shortly after the end of chemotherapy
Premature menopause = loss of ovarian function that occurs years after the end of chemotherapy (before age 40 yr)
Sklar et al, J Natl Cancer Inst 2005

11. Ovarian Structure
A constant number of resting primordial follicles enter the growth phase at any given time, independent of pituitary gonadotropins
Later stages of maturation require FSH and LH
Follicles either mature to ovulation or become atresic

12. Atresia
Is the degeneration of primordial follicles:
Ovaries have about 2 million primordial follicles at birth (Ovarian reserve!):
each containing a primary oocyte
By puberty:
number drops to about 250, ,000
400 oocytes ovulated during
the reproductive years
In the absence of LH/FSH, follicles undergo atresia
Once follicles are depleted, ovarian hormone production declines

13. Female Fertility
As a woman ages there is a rapid decline in the number of eggs as well as the quality of eggs.
Figure from:

14. Lobo, N Engl J Med 2005
In conclusion ….
… due to a continual process of atresia, the ovarian reserve of primordial follicles is progressively eroded over time (Gosden et al, 1994)

15. (Ratts et al, 1995; Tilly et al, 2003)
Gonadotoxic chemotherapy causes marked follicle loss through, presumably, apoptotic cell death
(Ratts et al, 1995; Tilly et al, 2003)

16. The likelihood of gonadal failure depend on the:
Age of the patient
Type of the cytotoxic agent(s)
Cumulative dose
Bines et al, 1996; Goodwin et al, 1999; Meirow et al, 1999

17. Treatment for Early Breast Cancer and the Effect on Fertility
Estimated number of women who become menopausal after treatment depending on their age at diagnosis
Graph adapted from Goodwin P, Ennis M, Pritchard K, Trudeau M, Hood N. Risk of menopause during the first year after breast cancer diagnosis. J Clin Oncol 1999;17(8):

18. Risk of Treatment induced Amenorrhea
Adjuvant endocrine therapy does not cause permanent infertility
but …. endocrine therapy usually entails years of treatment when pregnancy contraindicated and aging during that time may compromise fertility !

19. premature ovarian failure
Effect of age on risk of
premature ovarian failure
Mattle et al, 2005
The chemotherapeutic destruction of an already low follicular reserve, reduces the number of follicles below a certain ‘threshold’ number required to sustain ovarian function, resulting in menopause.
Meirow et al, 1999

20. Degree of gonadal failure associated with chemotherapeutic agents
Alkylating agents are extremely gonadotoxic because they are not cell cycle-specific and can damage resting primordial follicles, whereas cycle-specific agents such as MTX and 5-FU do not have any effect on ovarian reserve
Sonmezer, M. et al. Oncologist 2006;11:

21. Degree of gonadotoxicity related to the most commonly used
chemotherapy regimens in breast cancer
Copyright ©2006 AlphaMed Press
Sonmezer, M. et al. Oncologist 2006;11:

22. Dose of Cyclophosphamide (mg/kg)
Follicular damage from chemotherapy is not an
‘’all or nothing phenomenon’’
A dose-response effect exists
A dose of chemotherapy strong enough to destroy 50% of the ovarian primordial reserve does not affect reproductive performance
No. of
primordial
follicles
Dose of Cyclophosphamide (mg/kg)
Meirow et al, 1999

23. Studies assessing the impact of breast cancer chemotherapy on fertility issue, often use chemotherapy-induced amenorrhea as a surrogate marker for fertility
(Bines et al, 1996; Goodwin et al, 1999; Nabholtz et al, 2002)
BUT…
Premenopausal levels of estradiol have been detected in amenorrheic pts after chemotherapy thus indicating persisting ovarian function despite mestrual activity cessation (Braverman et al, 2002)
On the other hand, resumption of menstruation after chemotherapy does not imply that also the fertility has been preserved (Schmidt et al, 2005)

24. The incidence of immediate amenorrhea is lower in younger women, who have a larger primordial follicles pool. They will eventually experience premature ovarian failure (Rivkees et al, 1998; de Bruin et al, 2004; Larsen et al, 2003)
Two measurements of FSH>40 mIU/ml, regardless of mestrual bleeding OVARIAN FAILURE
The fertility is compromised if:
FSH >15 mIU/ml on d3 of the mestrual period
Estradiol >80 pg/ml on d3 of the mestrual period
(Licciardi et al, 1995; Scott et al, 1989)

25. INCIDENCE OF
OVARIAN FAILURE
FOLLOWING ADJUVANT
CHEMOTHERAPY FOR
BREAST CANCER

26. Bines, JCO 1996
Venturini, JNCI 2005
Bines, JCO 1996
Marty, NEJM 2005
Marty, NEJM 2005
Fornier, Cancer 2005
Adjuvant CMF caused ovarian failure in 40% of women <40 yrs and 76% of those >40 yrs (Bines et al, JCO 1996)
With doxorubicin-based regimens, none of the pts <30 yrs stopped menstruating, whereas 33% of the women yrs and 96% of those aged yrs experienced amenorrhea (Hortobagyi et al, 1986)

27. Percentage of women becoming amenorrheic within 6 months of initiation of chemotherapy by treatment regimen
FEC-T, fluorouracil, epirubicin, cyclophosphamide followed by docetaxel (n = 9); E-CMF, epirubicin followed by cyclophosphamide, methotrexate, and fluorouracil (CMF; n = 18); A-CMF, doxorubicin and CMF (n = 7).
Anderson RA, 2007

28. … contradictory results from animal and clinical studies …
IS THERE A PROTECTIVE
ROLE OF GnRH
ANALOGUES
AGAINST CHEMOTHERAPY-
INDUCED GONADAL
DAMAGE?
… contradictory results from animal and clinical studies …

29. HYPOTHALAMUS-HYPOPHYSIS-OVARY AXIS
LHRH analogs: downregulation of LHRH receptors
Oestrogens
Progesterone
Pituitary gland
LHRH
(hypothalamus)
Breast
Gonadotrophins
(FSH + LH)
Ovary

30. Since cytotoxic drugs most affect tissues with a rapid cellular turnover, it has been suggested that a state of induced gonadal inhibition during chemotherapy may protects the gonads (Rivkees et al, JAMA 1988)

31. There is no evidence for the presence of FSH or LHRH receptors on primordial follicles, thus there is currently no biological explanation for how LHRH-a can affect ovarian reserve (Clayton et al, Nature 1982)
… the lack of FSH and LHRH receptors on primordial follicles and oocytes does not make gonadal suppression an effective strategy of gonadal protection.

32. A clinical example of why gonadal suppression does not protect ovaries:
prepubertal children who undergo heavy chemotherapy still suffer from ovarian failure (Teinturier et al., 1998).
All of the younger patients who receive heavy gonadotoxic chemotherapy will suffer from premature ovarian failure (Grigg et al., 2000).

33. 18 women, 15-40 yrs, Hodgkin’s or non-Hodgkin’s lymphomas
Chemotherapy + LHRH-a
COMPARED TO:
historical matched control group of 18 women (17-40 yrs) treated with chemotherapy alone

34. Incidence of amenorrhoea vs regular cyclic ovarian activity
94%
39%
…but the mean follow-up was only years in the study group, compared with years in the control group.
Only 4 out of 16 pts in the study group received CTX (cumulative dose: mg/mq) vs 10 out of 18 in the control group (cumulative dose: mg/mq)

35. There is a limited number of prospective studies in humans…
Short-term follow-up
Lack of control group
None, with the exception of the study by Fox et al, used ability to conceive and live births as primary end-points.
In the abstract by Fox, spontaneus conception and pregnancy outcomes were suboptimal despite an 83% retention of menstruation.

36. Single center, prospective, single arm, phase II study
29 pts with breast cancer (stage I-III)
GOSERELIN + CHEMOTHERAPY
All but one pt received CEF q21 for 6 cycles
Goserelin 3.6 mg s.c., at least 1 week before the first cycle of cht
Pts with HR+, received tamoxifen at the end of chemotherapy and if a resumption of menstrual activity was observed during the 12-month follow-up, they restarted goserelin and continued it for at least 2 yrs

37. or Resumption of menses within 12 months after the end of chemotherapy
The success of the experimental treatment was defined by:
Resumption of menses within 12 months after the end of chemotherapy or
FSH < 40 IU/l between 3 and 12 months after the last cycle of chemotherapy

38. FSH <40 IU/l was not predictive of menses resumption
RESULTS
Pts with resumption of menses (72%)
Pts without menses but FSH <40 IU/l (25%)
28 (97%)
Expected rate of menses resumption with CEF regimens is nearly 40%
FSH <40 IU/l was not predictive of menses resumption

39. Cancer. 2006
100 premenopausal consecutive pts candidate to adjuvant chemotherapy after surgery for breast cancer (II-III stage) were enrolled
All pts received LHRH-a concurrently with chemotherapy, independently of HR status
After chemotherapy
64 pts: GnRH for 1 yr; HR+: TAM for 5 yrs
36 pts: GnRH for 2 yrs; HR+: AI for 2 yrs 
TAM for 5 yrs

40. CHEMOTHERAPY REGIMENS
26 pts, pT2-3, pN0, HR+
8 CMF - CTX: 7200 mg/tot -
11 pts, pT1-3, pN1 (<3),
6 FEC g 1,8 q21 - CTX: 3600 mg/tot -
54 pts, pT1-3, pN1 (3-4),
4 EPI 8 CMF q21 - CTX: 4800 mg/tot -
9 pts, pT1-3, pN>10,
4 EPI High-Dose ChtPBPCs 8 CMF q21
- CTX: 4800 mg/tot-

41. (100% for pts <40 yr and 56% for pts >40 yr)
RESULTS
After a median follow-up of 75 months, NORMAL MENSES were RESUMED by 67% of patients
(100% for pts <40 yr and 56% for pts >40 yr)
The addition of a GnRH analog to adjuvant chemotherapy and temporary estrogen suppression in pts with ER+ disease protected long-term ovarian function, and appeared to improve the expected clinical outcome

42. but …..
No planned sample size: this is an observational study rather than a phase II study
… treatment with LHRH-a has been continued for two yrs in ER- women …. ?
The lack of a study design and the small number of pts do not allow to draw valid conclusions on clinical outcome

43. Waxman et al., Cancer Chemother Pharmacol 1987
In the only prospective randomized study in humans, including 30 men and 18 women receveing chemotherapy for Hodgkin’s disease, LHRH-a has been demonstrated ineffective in preserving fertility as judged by sperm count and menstrual function.
30 men and 18 women
randomly assigned to
Buserelin + CHT
CHT
After 3 yrs of follow-up, all men and control groups became oligo/azospermic, while 4 of 8 women treated with LHRH-a and 6 of 9 female controls became amenorrheic

44. Fertility Options Wait and See IVF
Oocyte cryopreservation (egg freezing)
Ovarian tissue cryopreservation
Ovarian Suppression
Adoption
Oocyte and Embryo donation
Issues relating to each option include varying success rates, delays in cancer treatment, availability, cost and the impact on the cancer.

45. Fertility preservation options in females

46. ASCO Recommendations on Fertility Preservation in Cancer Patients
(Expert Panel, J Clin Oncol 2006)
Sperm and embryo cryopreservation are considered standard practice…; other available fertility preservation methods should be considered investigational…
but ……

47. Embryo Cryopreservation
It is the only established
method for fertility preservation
Survival rates per thawed embryos are in the range of 35%–90%, implantation rates are in the range of 8%–30%, and cumulative pregnancy rates exceed 60% (Sonmezer et al, 2004).

48. Embryo Cryopreservation
If the patient has a partner and sufficient time prior to cytotoxic treatment, embryos generated through IVF can be cryopreserved and stored for future use.
Because adjuvant chemotherapy is commonly initiated 4–6 weeks after surgery, there is usually adequate time to perform ovarian stimulation and IVF. Oocyte retrieval and embryo freezing can also be performed without ovarian stimulation; however, the embryo yield is low and typically no more than a single embryo can be generated (Oktay et al, 2003, Omland et al, 2001).
Because the effectiveness of IVF diminishes with every round of chemotherapy and because there is a potential for fertilizing a genetically damaged growing oocyte, it is not recommended to perform IVF after chemotherapy is initiated (Ginsburg et al, 2001, Dolmans et al, 2005).

49. Embryo cryopreservation
Requires ovarian stimulation
Requires in vitro fertilization
Requires partner or sperm donation
Delay in harvest may delay chemotherapy
May be theoretically harmful in hormone-sensitive tumors
Ovarian stimulation increases the number of follicles recruited to grow and increases estrogen production in proportion to the number of follicles recruited. As a result, estrogen can reach levels 10-fold or more higher than those in a natural cycle (Pittaway et al, 1983; Pena et al, 2002, Chen et al, 2003)

50. Oocyte cryopreservation
May be a more attractive option to patients without a partner
Drawbacks:
Requires stimulated ovulation similar to that in IVF cycles for embryo freezing
Success rates about 2% (Oktay et al, 2006)
To be suggested when embryo freezing cannot be performed, especially in single women who do not wish to use donor sperm for in vitro fertilization.

51. Cryopreservation Issues
Diagnosis of stage I–III breast cancer of invasive ductal type is not a contraindication for ovarian cryopreservation.
Nevertheless, prior to cryopreservation, a thorough evaluation of the patient and the tissue is required to rule out ovarian metastasis, in all cases.
Moreover, some of the young breast cancer patients may have BRCA gene mutations and, as a result, may harbour a co-existing primary ovarian cancer (Liede and Narod, 2002 ).
Even though ovarian cancer is rare prior to the age of 35 years (Massi et al., 1996), these patients should be counselled about that risk.

52. WARNING May Cause Birth Defects
Letrozole: Breast Cancer Drug Not for Fertility!
May Cause Birth Defects
- higher incidence of locomotor and cardiac malformations -
Letrozole has been used by Canadian fertility specialists to stimulate ovulation
in women who are infertile, or unable to become pregnant, as a treatment to increase their chances of becoming pregnant
Biljan et al, 2005

53. ASCO Recommendations on Fertility Preservation in Cancer Patients
(Expert Panel, J Clin Oncol 2006)
At this time, since there is insufficient evidence regarding the safety and effectiveness of GnRH analogs and other means of ovarian suppression on female fertility preservation, women interested in ovarian suppression for this purpose are encouraged to partecipate in clinical trials

54. SWOG 0230 study
It is an ongoing phase III study, in which ER- and PR-negative young breast cancer pts are randomized to receive chemotherapy alone or chemotherapy plus LHRH-a to evaluate the role of LHRH-a in the ovarian function preservation

55. Projected accrual: 280 pts
PROMISE-GIM6
Prospective, multicenter, randomized, phase III study
Premenopausal Women, yrs, stage I-III breast cancer, HR+/-, candidate for adjuvant chemotherapy
Chemotherapy
Chemotherapy +
Triptorelin
Primary endpoint
Incidence of chemotherapy-induced early menopause (at 1 year following the completion of cht, measured by FSH, E2, menses resumption)
Study start: Sept 2003
Projected accrual: 280 pts

56. The potential interaction between LHRH-a and chemotherapy
CONCERNS ABOUT THE USE OF LHRH-a BEFORE AND DURING CHEMOTHERAPY IN BREAST CANCER
The potential interaction between LHRH-a and chemotherapy
The potential detrimental effect on the outcome of the lack of chemotherapy-induced menopause

57. Eight-year DFS Rates With or Without Tamoxifen
CAF+TAM CAF  TAM
Patients (N)
DFS (%) p<
Albain et al, 2002
The National Surgical Adjuvant Breast and Bowel Project (NSABP), which has historically used concurrent chemotherapy and tamoxifen in its trials, has now modified trial designs to mandate sequential use of tamoxifen

58. Pagani et al., Eur J Cancer 1998
DFS according to amenorrhoea status by ER/PR status: 232 patients with ER/PR- status (a) and 964 patients with ER/PR+status (b).

59. Waiting for phase III studies
Is pregnancy safe for women survival from breast cancer?
YES
Is chemotherapy detrimental for ovarian function?
YES
Is LHRHa treatment useful to preserve ovarian function?
Waiting for phase III studies
What about safety of LHRHa concurrently used with cht?
Not yet estabilished

60. Thanks for
your attention!