A breast cancer diagnosis doesn’t have to mean you can’t have a child later.
By Elaine K. Howley, Contributor
Nicole Page of Perth, Australia, comes from a family with an unfortunate history of breast cancer. Four of her father’s seven sisters had breast cancer, and one of them fought to get the whole family tested. Five of her aunts were found to be BRCA2 positive, meaning they had a genetic mutation on their BRCA2 gene that significantly increases their risk of developing breast and ovarian cancer. Page was just 23 years old in 2002 when she learned she also had the BRCA2 gene mutation. Her doctors recommended watchful waiting, and she underwent yearly screening, just in case. Page wasn’t expected to develop cancer until her mid-30s or later, so there didn’t seem to be much reason to panic.
However, in April 2007, a few weeks before her 28th birthday, Page went for a screening mammogram. As soon as the doctor returned to the room with her older films, she knew something had changed. The doctors immediately ordered a biopsy of the suspicious lump in her right breast. The next day she learned it was ductal carcinoma in-situ – abnormal cells inside a breast duct. A precancerous tumor, the lump needed to come out. Her doctors advised a lumpectomy, but Page, knowing all too well the struggle that could lie ahead from her aunts’ experiences, opted for a bilateral mastectomy, having both breasts removed, and reconstruction instead. She didn’t want to take chances with her future because at the same time, she was knee-deep in planning her wedding and getting ready for the next stage of her life – one that she hoped would include children.
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Page says her surgery went well, “with no complications,” and she was married in January 2008. “Then, in May 2009, we had our first child.” Page continues that “all was well and happy in our world until one day, when my son was 4-and-a-half months old, I found a lump in that same right breast while I was in the shower.”
At first, her doctors thought it was just a cyst – she’d had a mastectomy, so it was unlikely to be breast cancer, but after surgery to remove the lump, they learned it was stage 2 cancer. A few more tests determined that this was a recurrence, not a second cancer, and Page began a course of chemotherapy, radiation therapy and a year of tamoxifen treatment.
A full year after her last chemotherapy treatment, Page was given permission to stop taking tamoxifen and try to have another baby. Lily, who Page refers to as “my miracle baby,” was born in January 2012 without the need for in-vitro fertilization. She and her brother Tyler are healthy today.
Although Page’s experience is unusual, it serves to highlight what many people once thought would be inconceivable: It’s possible to have a baby after undergoing treatment for breast cancer.
Pregnancy After Breast Cancer
Dr. Nikita Shah, medical oncology team leader for the Breast Cancer Specialty Section and medical director of the Cancer Risk Evaluation Program at UF Health Cancer Center – Orlando Health, says that a breast cancer diagnosis “in women of child-bearing age can be a devastating diagnosis. There’s potential complications of infertility related to the treatment, and more often than not, it’s from the chemotherapy.” Endocrine therapy can also affect fertility, because in some women it pushes them into an early menopausal state.
“The other issue,” Shah says, “is that on average, 70 percent of all breast cancers involve positive estrogen receptors.” This means that as a woman’s hormone levels change as the baby is developing, that “can make the breast cancer cells take on a new life.”
But breast cancer doesn’t have to be a deal breaker for having children. Dr. Melissa Hulvat, medical director of the Bass Breast Center at the Kalispell Regional Medical Center in Kalispell, Montana, says preserving fertility is a question that should be addressed immediately upon diagnosis, as it will affect the course of treatment. “It’s an interesting conversation to have with people,” she says. “You tell them they have cancer, and their life flashes in front of them. But then the next question is, ‘Do you want to have babies in the future?’ But it’s so important to bring it up immediately.” Hulvat is an advocate for preserving fertility but says not all doctors are focused on what comes after treatment concludes. She urges women to be their own advocates on this issue, and even if you’re not certain about wanting to have children in the future, have the conversation with your doctor anyway to find out your options.
Hulvat says the primary means of preserving fertility is harvesting eggs and storing them to be implanted later once a woman has finished treatment and is declared cancer-free. Shah says “this way, the ovum [eggs] are not exposed to any medication” during chemotherapy or endocrine therapy. The problem with this approach is that it’s very expensive. “Fertility treatments can cost upwards of $10,000,” Shah says, and insurance may not cover it. There are also a few drugs that can be administered by injection that reportedly protect the eggs from the various medications a woman will be taking during treatment, but Hulvat says the evidence for their effectiveness isn’t conclusive.
In any event, the conversation around preserving fertility during breast cancer treatment is intensely personal and will have many variables depending on the woman’s wishes, her economic situation and the stage and type of cancer she’s facing.
Shah says that most women are advised to wait for about two years after their final treatment or declaration of being cancer-free before trying to have a baby. She says there’s no real magic to this timeline, and it can vary in individual circumstances, but generally speaking, breast cancer in younger women is a more aggressive disease and if it hasn’t recurred within two years, it’s less likely to do so. “Generally, if the pregnancy is far enough out, the risk is not worse than for anyone else their age.” She does note, however, that delaying having children can bring other risks unrelated to cancer. “A woman who’s planning to get pregnant at age 32 but has to wait until she’s in her late 30s is now in a higher risk category ” for complications with the pregnancy.
Pregnancy During Breast Cancer Treatment
For some women, a breast cancer diagnosis coincides with a pregnancy. According to a 2012 study published in Reviews in Obstetrics & Gynecology, “Breast cancer affects approximately 1 in 3,000 pregnant women and is the second most common malignancy affecting pregnancy.” As the trend in delaying child birth continues, however, the rate of breast cancer diagnosis during pregnancy may be on the rise.
For women who are pregnant when they receive a breast cancer diagnosis, some difficult choices lie ahead. Depending on the case, she may be advised to abort the fetus in an effort to save her life. “If she’s very early in her pregnancy when she’s diagnosed with breast cancer, more likely than not the patient would be recommended to have an abortion,” Shah says. “The remaining pregnancy term is so long and the chances of the breast cancer really becoming a problem in the next nine months is a big concern.” The stress of a breast cancer diagnosis has also caused miscarriages in some women.
In some cases, it’s possible to treat a woman for breast cancer while she’s carrying a child and still have the baby arrive healthy. During the first trimester, “the fetus is most sensitive to chemical sedation. At that point, we want to avoid anesthesia, so we try not to do any surgery in the first trimester.” However, if breast cancer is diagnosed during the second trimester, “we know that some chemo drugs are safe to give during the second trimester and beyond,” Shah says. In these cases, doctors may treat the woman for breast cancer and once the fetus is viable, at 32 or 34 weeks, induce delivery early to finish out the breast cancer treatment.
A study of 75 pregnant women who were treated for breast cancer during their pregnancies at the MD Anderson Cancer Center in Houston between 1989 and 2013 concluded that “for patients who received chemotherapy during pregnancy, survival was comparable to – if not better than – that of nonpregnant women.”
Nevertheless, undergoing breast cancer treatment while pregnant or right after having a baby is difficult. Not just physically, but emotionally, too. But for Page, having her young son to care for actually helped her get through her breast cancer treatment. “Sometimes I say I didn’t have time to get sick because Tyler needed me more,” she says. Page also points to significant support from her family during a difficult time and says that her experience with chemotherapy wasn’t as bad as it can be for some women.
For any woman who’s pregnant or thinking of becoming pregnant, if you’re concerned about your risk for developing breast cancer, speak with your doctor. Shah says it’s common for women to have engorged breasts during pregnancy – and that’s normal. This condition can present as a tender, red, swollen lump in the breast that goes away in a few days. These clogged milk ducts typically respond well to a warm compress and gentle massage. If that’s not the case, seek proper treatment as soon as you can.