Reproductive-age women with cancer need to have effective options
Executive Summary
It’s estimated that 859 out of 100,000 women of reproductive age receive a cancer diagnosis each year in the United States. Up to 80% of all women diagnosed with cancer prior to age 50 survive at least five years.
• Reproductive-aged women with cancer might be interested in deferring pregnancy temporarily or permanently at cancer diagnosis, during therapy, or after treatment.
• However, there are limited guidelines to aid clinicians in managing the contraceptive needs in this special population.
Consider intrauterine contraception for safe, effective use
Your next patient is 32 years old, married, and recently received a diagnosis of breast cancer. What is your counseling strategy regarding contraception?
A sizable number of reproductive-age women are diagnosed with cancer. It’s estimated that 859 out of 100,000 such women receive a cancer diagnosis each year in the United States.1 With advancements in cancer therapies, women have better chances for survival. Up to 80% of all women diagnosed with cancer prior to age 50 survive at least five years.2
Contraception is a crucial aspect of reproductive care for women with cancer, says Bat-Sheva Maslow, MD, fellow in the Division of Reproductive Endocrinology and Infertility in the Department of Obstetrics and Gynecology at the University of Connecticut Health Center in Farmington and lead author of a just-published study of contraceptive choices in women with cancer.2 More research is needed regarding contraceptive choices for these women, Maslow states.
To perform the current study, researchers conducted a cross-sectional survey of women ages 18-45 who had been diagnosed with cancer in the prior five years in the University of Pennsylvania healthcare system.2 Women contacted for the survey included survivors cared for by a breast cancer specialist, a general oncologist, and a fertility preservation specialist. All women were potentially at risk for pregnancy during or after cancer therapy.
Among the 163 eligible women who were contacted, 139 (85%) agreed to participate and 107 completed the survey. Most participants were older than age 25, Caucasian, nulliparous, and college-educated. Breast cancer was the most common diagnosis (52%), followed by lymphoma (22%). Almost half (48%) reported experiencing amenorrhea during their cancer treatment.
Almost half (43%) of women reported engaging in heterosexual sexual intercourse. In terms of contraception:
• 25% of women reported current abstinence;
• 14% said they used no contraception;
• 22% reported use of oral/vaginal ring contraceptives;
• 21% choose condoms;
• 4% relied on an intrauterine device (IUD);
• One woman reported a partner’s vasectomy.
No women reported use of injectable or implantable contraception, or prior tubal sterilization.
Seventy participants (65%) reported receiving contraceptive counseling from a healthcare professional prior to initiating cancer therapy. Women who received contraceptive counseling were over six times as likely to use such methods as surgical sterilization, long-acting reversible contraceptives, hormonal contraceptives, and diaphragm compared to women who did not report counseling (odds ratio 6.92, 95% confidence interval 1.14-42.11, p = .036). Among sexually active women, one-third of those who received counseling reported a Tier I/II contraceptive method compared to 10% of those who were not counseled (p = .05).
What are the options?
Reproductive-aged women with cancer might be interested in deferring pregnancy temporarily or permanently at cancer diagnosis, during therapy, or after treatment; however, there are limited guidelines to aid clinicians in managing the contraceptive needs in this special population.
Women of reproductive age who are undergoing cancer treatment generally are advised to avoid pregnancy due to concerns of the teratogenic effects of chemotherapy or radiation. Breast cancer survivors are counseled to avoid pregnancy for three years following cancer treatment due to concerns that pregnancy-related hormonal changes might increase the risk of recurrence.3 Clinicians need to remember that while chemotherapy and radiation reduce fertility and might cause ovarian failure, many cancer survivors remain fertile.4-6
After reviewing available evidence on the safety and efficacy of available contraceptive methods for women who have been diagnosed with cancer, the Philadelphia-based Society of Family Planning in 2012 issued clinical guidance that recommends women of childbearing age who are being treated for cancer avoid combined hormonal contraceptive methods whenever possible because they might further increase the risk of venous thromboembolism (VTE).7 (Readers can download a copy of the guideline at http://bit.ly/1w25vvc.)
First-line contraceptive option
The copper T380A intrauterine device, a highly effective, reversible, long-acting, hormone-free method, should be considered the first-line contraceptive option for women with a history of breast cancer, although for women being treated with tamoxifen, the levonorgestrel-containing intrauterine system, which decreases endometrial proliferation, might be preferable, the guidance states.7 Women with IUDs can undergo all forms of imaging, including computed tomography and magnetic resonance imaging.8
There are limited data on IUD use by women with immunosuppression due to cancer treatment. However, the World Health Organization and the Centers for Disease Control and Prevention state that IUDs can be used safely by women such as these.9
Women who develop anemia might benefit from use of a progestin-containing contraceptive; however, women who develop osteopenia or osteoporosis following chemotherapy should avoid the progestin-only contraceptive injection.7 For women who have been cancer-free for at least six months and have no history of hormonally mediated cancers, chest wall irradiation, anemia, osteoporosis or VTE, the use of any method of contraception can be recommended, the guidance states.7
Overestimating infertility
Contraceptive choices can be challenging for women with cancer, notes Andrew Kaunitz, MD, University of Florida Research Foundation professor and associate chairman of the Department of Obstetrics and Gynecology at the University of Florida College of Medicine — Jacksonville. However, contraception is important.
Keep in mind that female patients have been shown to overestimate their chance of becoming infertile from treatment, which might encourage risky sexual behavior.10 The usual signs of fertility might not be reliable in women who have undergone cancer treatments. Pregnancy has been reported in cancer survivors despite amenorrhea and follicle-stimulating hormone levels that are suggestive of menopause.11
By referring appropriate reproductive age female cancer survivors to clinicians who are up to date with and able to provide a broad range of contraceptives, oncologists can help optimize care and outcomes for this unique group of women, says Kaunitz.
Lines of communication are important among all members of a woman’s healthcare team when it comes to cancer, say researchers of the current paper.
"Increasing awareness among oncologists to the critical role of contraceptive counseling, as well as establishing better referral networks between oncologist and family planning specialists, would go a long way toward providing comprehensive care to women with cancer," they state.
References
- Patel AA, Mini S, Sutaria RP, et al. Reproductive health issues in women with cancer. J Oncol Pract 2008; 4(2):101-105.
- Maslow BS, Morse CB, Schanne A, et al. Contraceptive use and the role of contraceptive counseling in reproductive-aged women with cancer. Contraception 2014; 90(1):79-85.
- Helewa M, Levesque P, Provencher D, et al. Breast cancer, pregnancy, and breastfeeding. J Obstet Gynaecol Can 2002; 24:164-180.
- Mitwally MF. Fertility preservation and minimizing reproductive damage in cancer survivors. Expert Rev Anticancer Ther 2007; 7:989-1001.
- Hodgson DC, Pintilie M, Gitterman L, et al. Fertility among female Hodgkin’s lymphoma survivors attempting pregnancy following ABVD chemotherapy. Hematol Oncol 2007; 25:11-15.
- Partridge AH, Gelber S, Peppercorn J, et al. Fertility and menopausal outcomes in young breast cancer survivors. Clin Breast Cancer 2008; 8:65-69.
- Patel A, Schwarz EB; Society of Family Planning. Cancer and contraception. Release date May 2012. SFP Guideline #20121. Contraception 2012; 86(3):191-198.
- Schwarz EB, Hess R, Trussell J. Contraception for cancer survivors. J Gen Intern Med 2009; 24 Suppl 2:S401-406.
- Centers for Disease Control and Prevention. U.S. medical eligibility criteria for contraceptive use, 2010. MMWR Early Release 2010; 59:1-88.
- Partridge AH, Gelber S, Peppercorn J, et al. Web-based survey of fertility issues in young women with breast cancer. JCO 2004; 22:4174-4183.
- Sklar C. Maintenance of ovarian function and risk of premature menopause related to cancer treatment. J Natl Cancer Inst Monogr 2005: 25-27.
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