Breast Cancer and Fertility: Making Hard Choices Easier

1
Breast Cancer and Fertility Making Hard Choices
Easier

• The Development and Evaluation of a
  Fertility-Related Decision Aid for Young Women
  with Early Breast Cancer

• McLachlan, SA1, Peate M,2,3, Meiser B2,3, Hickey
  M4, Thewes B2, Zorbas H5, Butow P6, Saunders C7
  Friedlander M2,3.
• Deapt of Med Oncolosy, St Vinvents Hospital, VIC
• Dept of Med Onc, Prince of Wales Hospital, NSW
• Prince of Wales Clinical School, University of
  NSW
• Dept of Obs and Gyn University of WA

• National Breast Cancer Centre
• MPRU, University of Sydney
• Dept of Surgery, University of WA

This study has been funded by the Cancer Council
of NSW.
2
Breast Cancer in Australia

• Approximately 10,000 women are diagnosed with
  breast cancer each year
• Approximately 6-7 of these women are under the
  age of 40

3
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 http//www.sydneyivf.com/pages/ferti
lity/infertility/age.cfm
4
Treatment for Early Breast Cancer and the Effect
on Fertility
Treatment for breast cancer varies. Generally, it
involves one or more of the following

• Lumpectomy or mastectomy
• Radiation therapy
• Chemotherapy
• Early menopause
• Temporary amenorrhoea (stopped periods)
• Endocrine (hormonal) therapy
• Time taken to complete treatment may mean that
  when treatment is over a woman may have past her
  reproductive age.

Does not impact fertility
May impact fertility
5
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 199917(8)2365-2370.
6
Fertility Options

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

7
Information Needs

• High-quality, fertility-related information for
  young women with breast cancer identified as a
  priority
• Fertility-related information rated important at
  time of treatment decision-making.

8
The Current Experience

• I found it hard to do a crash course in
  chemo and fertility treatments in one week I am
  bitterly disappointed I have to progress with
  chemo at the expense of my ability to have
  children.
• It is stressful enough without having to
  co-ordinate decisions to have treatments on
  contradicting advice I find that there is not
  enough information as to how the treatment will
  effect my fertility and therefore solutions
  around this

9
Decision Aids

• Present structured information in a user friendly
  manner and provides exercises to weigh up the
  positive and negative consequences of different
  choices
• Not to persuade, but can provide decision
  support by helping the patient to
• Comprehend relevant clinical information
• Clarify and communicate own
• attitudes towards decision
• Arrive at a decision consistent with
• their personal values

10
Do Decision Aids Work?

• Decision aids improve
• Knowledge
• Quality of decision making
• Choices more likely
• to be based on
• More realistic
• expectations
• Clearer values

11
Is this a Difficult Decision?

• Suit situations where the best solution to a
  clinical decision is influenced by uncertainty
  and personal values
• Why is this a difficult decision
• Not enough information and time.
• Uncertainty surrounding
• Impact of cancer treatment on fertility
• Success of fertility treatment
• Eligibility and availability of fertility
  treatment
• Delays in cancer treatment
• Impact on the family
• Making a decision that may impact on quality of
  life after cancer
• Currently no decision aids specific to
  fertility-related issues

12
Need for a Decision Aid.

• Difficult decisions where information is complex
  with uncertain outcomes

Need for better fertility-related educational
materials

DECISION AID
13
Aims of the study

• The development of a fertility-related decision
  aid
• Evaluation of the decision aid compared to usual
  care

14
Hypotheses
The decision aid will lead to

• Better understanding of fertility related issues
• Educated involvement in decision-making
• Increased consumer satisfaction

15
Development of the Decision Aid

• Decision aid includes
• Background information about breast cancer and
  female fertility
• Assisted reproductive technology options
• Values clarification exercises

16
?

• Decision aid is being pilot tested with 20 women

17
Prospective Multicentre Study

• 20 clinics around Australia
• Recruitment of 150 women by Breast Care Nurses
  over 2 years
• Eligibility
• Aged between 18 and 40
• Pre-menopausal at time of diagnosis
• Have not completed their families
• No history of Metastatic disease
• Able to read and understand English
• Able to give informed consent
• Not yet commenced adjuvant therapy

18
Recruitment- block assignment
Baseline (0 weeks)BCNs establish eligibility and
invite patients to Participate
Patients receive baseline questionnaire package
with either control booklet or decision aid.
Patients are asked to complete the questionnaire
then read the booklet before their oncologist
appointment
1st follow-up (1 month) Women are sent
questionnaire 2
INFORMATION BOOKLET
Final follow-up (12 months) Women are sent
questionnaire 3
19
Measures

• The questionnaires include
• Informed choice (MMIC)
• Hospital Anxiety and Depression Scale
• Knowledge about fertility options
• Decisional Conflict Scale
• Decisional Regret Scale
• Medical decision-making and information
  preference style
• Validation of care sub-study
• Survey of clinic staff in relation to
  acceptability

20
Current Progress
Development of Decision Aid
Pilot
Ethics at 19/20 sites (1 still pending)
Recruitment to trial
1st Follow-up data collection
Jan 06 Mar 06 May 06 Jun 06 Aug 06 Oct 06
Dec 06 Feb 07
21
Current Sample
0 Pending
3 Pending
1 Withdrawn
0 Pending
Withdrawn
22

• Advising patients about the availability of
  fertility preservation options will result in the
  patient having a better quality of life after the
  cancer treatment is complete By talking to
  patients about their options to preserve
  fertility at the earliest phase of the treatment
  plan, we are providing a positive prognosis for
  outcome... It reinforces the positive message of
  hope
• Pasquale Patrizo
• ASCO Health Services Committee.
• (Quote from http//www.medicalnewstoday.com )

23
Acknowledgements

• Thanks also to the following clinics and their
  staff for their involvement and assistance
• NSW Prince of Wales Hospital, Royal Womens
  Hospital, Mater Medical Centre, Royal North Shore
  Hospital, Strathfield Breast Centre, Liverpool
  Hospital, Campbelltown Hospital, Wollongong
  Hospital, St George Hospital, Westmead Hospital,
  Royal Prince Alfred Hospital, Shoalhaven Hospital
• VIC St Vincents Hospital, Peter MacCallum
  Cancer Institute, Goulburn Valley Base Hospital
• SA Royal Adelaide Hospital
• WA Sir Charles Gardner Hospital, Mount Medical
  Centre, Royal Perth Hospital, Perth.
• QLD Royal Brisbane Women's Hospital
• ACT Calvary Hospital

24
Acknowledgements

• This study has been funded by the Cancer Council
  of NSW.
• Thanks to the following people for their
  assistance R Martinello, J Fallon-Ferguson, K
  Parkinson, C Wakefield, K Luxford, E Villanueva,
  C Lewis, S Rovelli, F Boyle, L Peterson, K
  Andrews, SA McLachlan, S Stewart, M Arvin, A
  Sullivan, J Maskell, G Delaney, AM Griffin, I
  Olver, J Iasiello, E O'Brien, C O'Driscoll, P
  Clingan, M Brien, R Mikleus, V Millwood, G Swift,
  J Hollis, L Horning, J Lynch, A Szwajcer, N
  Wilcken, R Winter, A Hamilton, R Wicks, A Chan, C
  Griffiths, KA Phillips, T Griffiths, A Redfern, L
  Kydd, S Reid, R Allison, P Creed, R
  Stuart-Harris, B Crowe, Kerry Pattford.
• Special thanks to the women participating in this
  study.