My presentation was on fertility issues in breast cancer patients undergoing adjuvant treatment. Of course this is an important topic because a lot of patients are diagnosed below the age of 40 and for this reason they are facing the problem of gonadotoxicity of anti-cancer treatment which has the possibility of permanently damaging their ovarian function. We know and we have now a lot of data indicating that pregnancy after breast cancer is safe. So we have a lot of case controlled studies with long-term follow-up indicating that pregnancy after breast cancer can be considered safe, both in the hormone receptor positive and hormone receptor negative patient population. So there is now a clear consensus on recommending fertility preservation counselling to all premenopausal patients undergoing anti-cancer treatment.

Unfortunately, breast cancer patients have the lowest chance to become pregnant after a diagnosis as compared to the other population of cancer survivors. This might be a combination of age at diagnosis and the risk of toxicity from anti-cancer treatments. We know that ovarian function and ovarian reserve decrease over time and the risk of permanent failure of ovarian function is dependent by the age at the start of chemotherapy and, of course, by the type of chemotherapy. Nowadays we have a lot of strategies to preserve fertility in breast cancer patients, including oocyte or embryo cryopreservation, ovarian tissue cryopreservation and also the possibility of inducing temporary ovarian suppression with GnRH agonists. The embryo or oocyte cryopreservation are the preferred choice for these patients; ovarian tissue cryopreservation is still experimental because there is a risk of malignant cell contamination of ovarian tissue so nowadays it should be reserved only for prepuberal girls.

The possibility of temporary ovarian suppression with GnRH agonists should be considered for the majority of our patients because we have a lot of data indicating that this strategy is associated with a lower risk of permanent ovarian failure as compared to control and also an increase in the rate of pregnancy after treatment as compared to control. This cannot be considered as a substitute for embryo or oocyte cryopreservation but is something that should be discussed with all the patients who are interested in maintaining their ovarian function.

So we can conclude that it is important to stress the fact that pregnancy is safe after breast cancer so there are no reasons to deny the possibility of a pregnancy in breast cancer survivors. For this reason it’s important to discuss the possibilities, all the strategies for preserving fertility in young breast cancer patients and, of course, it is critical early referral to the oncofertility team to avoid delays in starting anti-cancer treatment.

Is cryopreservation accessible?

It depends, nowadays it’s also depending from the national health system, for instance in Italy it comes for free for breast cancer patients. We have, however, only the possibility for oocyte cryopreservation and not for embryo cryopreservation. But it’s important to discuss all the options with the patients independently from the parity.

This is not available in all the institutions because centres have the possibility to offer all these strategies so that’s why it’s important to early discuss and early refer the patient to the proper institution. In this perspective the GnRH agonists are very cheap and they can be offered to all the patients so that’s why it’s something that is important to discuss with all the patients.