Female Health Issues After Breast Cancer
Then, most importantly, number one issue, is never to forget one’s heart. Heart disease in women, whether with breast cancer or not, is the number one killer. So we try to remind all our women in the menopause and actually perimenopausal too, don’t forget your heart. You have to try and know your lipids and maximize that your cholesterol is low and that your HDL is high and that your LDL are low and you do that by healthy diet and healthy living, which is exercise, again, not smoking. If one has diabetes, managing the diabetes well.
So I would say those are the major issues for the older postmenopausal women that I would want people to think about as they’re trying to improve their every day health.
With respect to the premenopausal women, I want to share some very interesting information and data that we’re starting to look at with respect to conception. Traditionally pregnancy was actually discouraged following a diagnosis of breast cancer due to fears that the concept of high levels of gestational hormones would negatively impact on the recurrence risk and the overt survival of a woman. It was always thought that there was a link between the female sex steroid hormones and reproductive factors with the potential of re-igniting breast or mammary cancer.
What’s been very interesting is: We know some of the factors that we always tell people decrease the risk of breast cancer like late menses, early menopause, having multiple children, having children before age 30, but actually what we find is that when we look at the concept of the link between female hormones and breast cancer in patients that decide to actually conceive, if you review the literature, there really isn’t a correlate that bears out. So this fear that you would re-ignite a dormant micro metastasis with gestational hormones is actually not considered true. The data that we have is very old data and in looking at the past 20 years and looking at different series from not only the United States but also in Europe, we have found that that is not the case. Actually in a few reviews they’ve looked at women who did get pregnant after having had breast cancer treatment and those women actually did better. They had better outcomes, better survival. That’s actually very fascinating information and it’s information that we want to share with our patients because it puts a different light on the options for women who are premenopausal who would like to have a family.
What we do know from a point of view of the impact on fertility, the surgery itself of the breast does not impact a woman’s fertility. It does affect the potential to breastfeed, but it doesn’t affect one’s ovarian function. We also know that radiation to the chest has not been shown to affect a pregnancy nor the potential of having a viable healthy baby does not affect it and it does not affect ovulation or reproduction. We do know that radiation can affect lactation of the breast and has been shown sometimes to not allow a woman to be able to breast feed from that side that received the radiation.What we do know from a point of view of getting, receiving systemic chemotherapy to women who are premenopausal that that can affect their ovarian function and in many women it can cause premature ovarian failure.
What has been interesting to see is in women who are younger than 35 who have received chemotherapy, they have had the greatest ability to regain normal ovarian function. But, unfortunately, these chemotherapy drugs are relatively toxic to the ovary and often can cause premature failure in these individuals. So what medicine has offered us in the past several years is the opportunity for these women who do have to have chemo to have the option of cycles of invitro fertilization before their chemotherapy and we are now getting very close to being able to really offer women the option of ovarian cryopreservation, which means freezing a piece of ovary or freezing oocytes, which are eggs, for the future for when someone is well and able to maintain a pregnancy.
It’s been very interesting to now be able to have more substantial data where we see that the old concepts really don’t bear themselves out. There was often fear amongst physicians and patients that doing an invitro fertilization cycle before chemotherapy would trigger more hormones and trigger more risk to the breast cancer patient, but then actually in multiple studies has born out to be not true. So this offers the woman who’s premenopausal some options with respect to her fertility and does not close doors.
With respect to taking care of oneself from a point of view of health issues in the premenopausal women, would the same issues come back in that a woman who has had chemotherapy and may have lack of ovarian function loses the cardio protection, the heart protection that the ovaries give and losses the bone protectorate that the ovaries provide. I would want that individual, again, as I said for the postmenopausal woman, to watch her heart carefully, to exercise, good diet, and watch her lipids, to take in good calcium intake and have her bone density assessed.
Many of the premenopausal women who maybe estrogen receptor positive are taking Tamoxifen and so they have the issue to address that they often may have some bleeding; they may have cysts that are associated with the Tamoxifen, and what we found has been very interesting in the European data is that often people who are taking Tamoxifen are given the Progesterone IUD from a point of view of control of the lining of the uterus and protection against cancer of the uterus and at the same time it acts like a contraceptive.
One of the topics that I was asked to address is: What are contraceptive options for the premenopausal woman who’s had breast cancer? The progesterone-only IUD, Mirena, is a very good option, as is the ParaGard, which is a copper-only IUD. We really still do stray away from the use of estrogen containing birth control in women who’ve had beast cancer. However, many of the progesterone only options are very good. In addition to the IUD that has progesterone, there is a mini-pill, Micronor, that we often use. Some people even use Depo, which is a depository of Provera, which is a progesterone agent. So we have some non-hormonal medication, non-estrogen containing medications that help with contraception.
From a perspective of risk factors for daughters of women who have had breast cancer, what should they be thinking and what should they be looking at? So it’s very important to know that the age with which the mom had breast cancer. So we’re advising women who either have a mom or an aunt or family member who has had breast cancer to at least ten years before that individual had their disease to begin their testing. Many times we advise the daughters that they need to sit down with their family members and consider the option of genetic screening within the family so that they can be involved in some screening programs for high risk individuals.
As many of you may have seen in the recent news, we have found that in women who they themselves are at high risk or their families members who are at high risk for breast cancer MRI, magnetic resonance imaging, is very useful in helping detect early disease. So it’s certainly important to make a plan with daughters of women who’ve had breast cancer a risk analysis for them and how they are going to be vigilant for themselves as a prevention.
With these factors in mind, I hope the women who are interested in premenopausal conservation of fertility have learned some really breathtaking information that we now I think are really very fortunate in that we can tell women a totally different suggestion than we did in the past, that we have found in really substantial data that in women who have completed over ten months of treatment and are post-treatment by over ten months, they have had the opportunity of having successful pregnancy, pregnancies without malformations and without increased recurrence of disease. I think we have some very encouraging information for patients and for the menopausal women we have some very encouraging self-preservation opportunities with respect to daily health and with respect to vaginal health.
So on that note, I would be glad to open up to the audience the opportunity for questions and see if I can help you answer things that have been burning on your minds.
Janet from New York is online. Please go ahead.
Janet: Yes, I like to ask this question: If I had my ovaries removed, does that mean that I can’t get ovarian cancer?
Dr. Elena Kamel: In the majority of women the answer would be yes. There is a very rare disease which is called primary peritoneal cancer. It’s almost like a cousin to ovarian cancer that comes from that lining that the abdomen has, the peritoneum. Despite having one’s ovaries removed, one can develop this cancer. It is very rare.
Dr. Elena Kamel: It’s called primary peritoneal cancer.
