The second day of the two day conference began at 9:00 am. Unfortunately the morning traffic in Dublin was worse than anticipated and we arrived half an hour late. However, we weren’t the only ones caught up in gridlock, so the conference delayed the day’s start a bit and we didn’t miss too much.
The day began by discussing tumour biology. Dr. Karen Gelmon, one of Rethink’s medical advisors, discussed whether the biology of breast cancer is different in young women and if the same kind of breast cancer behaves differently in a younger women’s body than an older woman’s body. Women under 40 had higher rates of HER2 positive breast cancer and triple negative breast cancer, which are known to be more aggressive types of breast cancer. More than half of breast cancer in women under 40 is one of these types whereas less than thirty percent of women over 50 have one of these types of cancer. However, the treatment outcomes for these types of breast cancer are the same for younger women as for older women – that is a 35 year-old woman with early stage Her2+ breast cancer can expect the same length of disease free survival and rate of recurrence as a 55 year old woman with the same diagnosis.
In contrast, younger women diagnosed with ER+ (luminal) breast cancer had worse outcomes than older women. More research is needed to understand both how these tumors may differ biologically and react different to hormones in younger women and how the changing current treatments, such as offering ovarian suppression to more young women with ER+ breast cancer, could improve outcomes.
As part of her talk, Dr. Gelmon presented some of the results from an important study she lead that shows that breast cancer recurrence rates are much lower now than they were in the 1980s. You can read more about this great news here.
One other interesting piece of information that Dr. Gelmon presented is that one quarter of women under 40 diagnosed with triple negative breast cancer test positive for the BRCA 1 or 2 gene mutation. For women under 40 of Ashkenazi Jewish decent more than 50% of those diagnosed with triple negative are BRCA1 or 2 positive. You can read more about BRCA mutations and rapid testing in the Day 1 Highlights.
Next up were various presentations about treatments for breast cancer in young women. There was discussion of neo-adjuvant chemotherapy, which is chemotherapy given before surgery. For women with triple negative breast cancer, having a pathological complete response (pCR) to neo-adjuvant chemotherapy (total tumor shrinkage) means a much better outcome than women who don’t have complete response. Age is not a factor. For women with HER2+ breast cancer, pCR is more important in younger women than older women.
For women with ER+ breast cancer, tamoxifen is still a very important treatment to help reduce the rate of recurrence. While the current standard is 5 years of tamoxifen, some studies are saying that 10 years may be even more effective. There was also some discussion of the TEXT and SOFT trials that looks at the effectiveness of ovarian function suppression combined with tamoxifen or an aromatase inhibitor. You can find out more about these trials here.
While tamoxifen, aromatase inhibitors and ovarian suppression help lower breast cancer recurrence, they have side effects that can be difficult for many women. These side effects include bone loss, impacts of cognitive functions, impacts on fertility and sexual functioning. Quality of life issues should be taken into consideration when discussing hormone therapy options.
Because there is a need for more data about the biology of breast cancer in young women and responses to treatments and the long-term effects of treatments, there have been calls for more clinical trials for young women with breast cancer. Once of the issues has been that a couple of trials for young patients only did not have enough enrollment for the trials to go forward. The solution to this would be to open all clinic trials to include young women as well (many only include women over 50). This is especially important for younger women with metastatic breast cancer. The oncology community (as well as patient advocates) can do more in the future to encourage young women to enroll in clinical trials and to lobby the pharmaceutical industry to include younger women in more trials.
The next topic area explored was pregnancy and fertility. Rethink Breast Cancer’s research has shown that the majority of young women who are concerned about the impact of treatment on their fertility are not being referred to a fertility specialist – an alarming statistic which we want to change.
Before a discussion of fertility preservation there was a presentation about pregnancy after breast cancer. With the increasing age at which women in developed countries have their first pregnancy, more young women diagnosed with breast cancer would like to become pregnant after treatment. Some of the issues that can impact becoming pregnant after therapy include the impact of some chemotherapy (especially platinum based) on fertility, taking tamoxifen (one should not take tamoxifen during pregnancy and nursing) and the fear of a recurrence due to hormonal changes during pregnancy.
Good news – there is no evidence that being pregnant after treatment increases the rate of breast cancer recurrence! In general, it is recommended that one waits two years after finishing treatment before attempting to become pregnant. But if you are prescribed tamoxifen, it is for 5 years or longer and waiting until you finish taking tamoxifen may not be an option. More good news – a new trial will soon be underway to see if taking a break from tamoxifen to become pregnant and nurse and then continuing it again has any long-term impacts of recurrence and survival.
Regarding the impact of chemotherapy on fertility, women who were ER– & PR– and who were given goserelin to supress ovarian function while receiving chemotherapy had more success become pregnant after treatment. However, goserelin has additional side effects on top of the side effects from the chemo.
There was a lot of discussion about women with metastatic breast cancer who would like to become pregnant. With advances in treatment, more women with metastatic breast cancer are living longer. Should a woman with metastatic breast cancer who wants to become pregnant be encouraged to do so? Some people expressed their opinion that these women should not be encouraged to become pregnant while others noted that it should be up to the woman herself to make that decision. As my colleague Shawna eloquently stated, “We need to shift the paradigm of how we see women with metastatic breast cancer to stop seeing them as dying and to start truly seeing them as living.”
Next up was a look at updates in fertility preservation. One option for women diagnosed with breast cancer is IVF to freeze eggs or embryos before treatment and then implant them after. Studies have shown that frozen eggs are just as healthy as fresh eggs so there are no issues in freezing the eggs and then fertilizing them at a later date. It is important to begin fertility preservation as soon as possible after diagnosis so that treatment can start as soon as possible. This is why it is important for oncologists to discuss fertility issues with newly diagnosed women so that they have time to make decisions about their fertility!
One fertility preservation technique that is increasingly being used is ovarian tissue freezing. A few ovarian strips are extracted, frozen and then replanted when one wants to try getting pregnant. The advantage of this technique is that it doesn’t take much time so there aren’t any delays to beginning treatment. So far there has been good success with achieving pregnancy after re-implantation, but this technique only works in women younger than 35.
There was also discussion that for women who have ER+ breast cancer (about 50% of young women) that taking tamoxifen is an option during IVF to reduce estrogen and counter the hormonal surge of ovarian stimulation and there is no evidence that it damages the eggs. However, tamoxifen should not be taken during pregnancy.
Finally, there is good news for women who carry the BRCA 1 or BRCA 2 mutation. While there has been suspicion that they might have a reduced ovarian reserve which would make them less responsive to IVF, studies have shown that this is not the case and that they have healthy ovarian reserve!
As you can see the morning was jam-packed. Stay tuned for Part 2 of Day 2 of the Breast Cancer in Young Women Conference.