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Fertility Options in Young Breast Cancer Survivors:
A Review of the Literature
Karen Hassey Dow, PhD, RN, FAAN, and Deanna Kuhn, RN, MSN, ARNP
Key Points . . .
Purpose/Objectives: To describe the impact of treatment on fertil-
ity, discuss fertility-sparing options available for women with breast
cancer, and explore pregnancy subsequent to breast cancer.
Cyclophosphamide and advanced maternal age are the great-
Data Sources: Published research, clinical articles, book chapters,
est risk factors for amenorrhea; paclitaxel with less total cy-
and abstracts.
clophosphamide may reduce amenorrhea.
Data Synthesis: The risk of amenorrhea associated with alkylating
New assistive reproductive technology options may help to
agents in breast cancer survivors is well known. Fertility-sparing options
preserve ovarian function.
before, during, and after treatment are possible with the use of assistive
Case-control and population-based studies about survival after
reproductive technology. Young breast cancer survivors are concerned
subsequent pregnancy indicate a better survival outcome. Sur-
about stimulating recurrence with subsequent pregnancy, health during
vival may be related to a "healthy mother effect" or the antitu-
pregnancy, and family matters.
mor effects of pregnancy.
Conclusions: Current data about the effects of treatment on amen-
orrhea, subsequent pregnancy after treatment, preservation of ovarian
Counseling young women requires a thoughtful and multidis-
function during adjuvant therapy, and management of ovarian failure in
ciplinary approach.
young women with breast cancer are important to include in discus-
sions and counseling.
Implications for Nursing: Young women deserve a thoughtful dis-
cussion about their concerns among their multidisciplinary team, in-
Goal for CE Enrollees:
cluding oncology nurses, oncologists, and social workers. Effects of
To enhance nurses' knowledge about fertility and preg-
treatment on fertility are well known. Women with fertility concerns
nancy issues for young women with breast cancer.
should be referred to a reproductive endocrinology team at the time of
diagnosis rather than after treatment has ended.
Objectives for CE Enrollees:
On completion of this CE, the participant will be able to
1. Identify factors that increase the risk of amenorrhea and
ess than 20% of women with breast cancer are pre-
ovarian failure in women undergoing treatment for breast
menopausal, yet the impact of cancer treatment on fer-
tility is a major cause of distress among young breast
2. Outline options for preserving ovarian function in young
cancer survivors (Dow, 1994; Dow, Harris, & Roy, 1994).
women receiving treatment for breast cancer.
Advanced maternal age (i.e., older than age 35) and the alky-
3. Describe the impact that pregnancy can have on young
lating agent cyclophosphamide are well-known risk factors
breast cancer survivors.
influencing fertility (Bines, Oleske, & Cobleigh, 1996; Lower,
Blau, Gazder, & Tummala, 1999; Moore, 2000). Women who
receive cyclophosphamide are four times more likely to ex-
Karen Hassey Dow, PhD, RN, FAAN, is a professor in the School of
perience ovarian failure than women who do not receive this
Nursing in the College of Health and Public Affairs at the University
agent (Meirow & Nugent, 2001). Each course of chemo-
of Central Florida, and Deanna Kuhn, RN, MSN, ARNP, is adjunct
therapy results in a significant loss of ovarian reserve. Even
faculty in the Department of Nursing at the Florida Hospital College
of Health Sciences, both in Orlando. This article was supported, in
if women do not become menopausal during treatment, they
part, by a grant from the Susan G. Komen Breast Cancer Founda-
may experience premature menopause and infertility after
tion. (Submitted October 2002. Accepted for publication September
treatment ends (Oktay et al., 2003). Women who maintain
30, 2003.)
fertility after chemotherapy and start a course of tamoxifen
therapy also must delay pregnancy until after hormonal
Digital Object Identifier: 10.1188/04.ONF.E46-E53
therapy is complete. Women who remain fertile after chemo-
28% of patients younger than 35 developed persistently ab-
therapy often are advised by clinicians to delay subsequent
normal menses.
pregnancy for at least two years until the greatest risk of re-
Women of advanced maternal age who receive cyclophos-
currence has passed. Unfortunately, women may have di-
phamide are at greatest risk of amenorrhea. As early as 1977,
minished ovarian reserve at the end of the two-year wait
Koyama, Wada, Nishizawa, Iwanaga, and Aoki found that an
average cumulative dose of 5.2 g cyclophosphamide resulted
Compared to men, women infrequently are referred for re-
in amenorrhea in women in their 40s compared to a total dose
productive and endocrine counseling before treatment
of 9.3 g cyclophosphamide for women in their 30s. Bines et
(Schover, Brey, Lichtin, Lipshultz, & Jeha, 2002). Fertility-
al. (1996) found the incidence of amenorrhea in women re-
sparing procedures with assistive reproductive technology
ceiving CMF was 76% for women older than 40 compared to
(ART) are available for women but are considered more time-
40% of women 40 and younger. Goodwin, Ennis, Pritchard,
consuming compared to procedures for men because they
Trudeau, and Hood (1999) further supported the knowledge
may interfere with the start of cancer treatment. In addition,
that advanced maternal age strongly predicted chemotherapy-
some female fertility-sparing procedures are based on hor-
induced amenorrhea. They determined that the risk increased
monal treatments that are considered contraindicated in these
at age 35 for the majority of women older than age 45 expe-
patients. Today, newer treatments using ART enable selected
riencing amenorrhea after receiving six months of CMF or
breast cancer survivors to maintain fertility and have children
cytoxan, epirubicin, and 5-fluorouracil with or without
after treatment. A discussion of ART options with their asso-
ciated risks and benefits is important for young women who
Taxanes may decrease the risk of amenorrhea. Stone et al.
are concerned about fertility.
(2000) reported a retrospective comparison of the rates of
The purpose of this article is to describe the effects of can-
amenorrhea in 98 premenopausal women treated for early-
cer therapy on fertility, discuss fertility-sparing options avail-
stage breast cancer. Patients receiving AC were compared to
able for women with breast cancer, and identify additional fer-
those receiving AC and paclitaxel. The investigators found
tility concerns facing young women with breast cancer.
that the incidence of chemotherapy-induced amenorrhea in-
creased with age but not with the addition of paclitaxel. More
Effects of Cancer Therapy on Fertility
recently, Ibrahim et al. (2003) surveyed 320 patients at the
start of chemotherapy who were randomized to adjuvant or
neoadjuvant chemotherapy and younger than 50. Patients re-
ceived either four cycles of paclitaxel-based chemotherapy
The effects of chemotherapy on fertility, specifically the
followed by four cycles of 5-fluorouracil, doxorubicin, and
alkylating agent cyclophosphamide, are well known and
cyclophosphamide (FAC) or eight cycles of FAC. Of the 146
documented. Cyclophosphamide increases the risk of amen-
returned surveys, 88 patients had complete data. They re-
orrhea by damaging the small fraction of cycling ovarian fol-
ported that menses resumed or was maintained in 53% of
licles (Moore, 2000). Chemotherapy may act on primordial
patients on paclitaxel-based chemotherapy compared with 31%
follicles through induction of apoptotic changes in preg-
of patients who received eight cycles of FAC. Using logistic
anulosa cells leading to follicle loss (Meirow, 2000). Cyclo-
regression analyses, the researchers determined taht patients re-
phosphamide results in an increase in ovarian estrogen pro-
ceiving paclitaxel-based chemotherapy were 3.56 times more
duction followed by a decrease in circulating estrogen levels
likely to resume menses compared with those receiving FAC.
and a corresponding increase in luteinizing hormone and fol-
Although women may continue to have normal menses af-
licle-stimulating hormone levels in premenopausal women.
ter chemotherapy, regular menstrual cycles do not necessar-
The initial cytotoxic damage to the ovary may result in a com-
ily mean that the ovaries did not sustain cytotoxic damage.
pensatory increase in follicular recruitment, thus placing more
Rather, partial loss of primordial follicle reserve during treat-
ovarian tissue at risk for damage. The degree of amenorrhea
ment can result in premature menopause after therapy is com-
varies but is related to the total dose of cyclophosphamide;
plete (Meirow, 2000).
therefore, as the cyclophosphamide dose increases, so does
For patients receiving higher doses of chemotherapy as a
the risk of amenorrhea.
result of bone marrow transplantation, this treatment causes
The combination of cyclophosphamide and doxorubicin
permanent ovarian failure; however, Hershlag and Schuster
(AC) may result in a decreased risk of amenorrhea compared
(2002) reported four cases of pregnancy after the procedure:
with cyclophosphamide, methotrexate, and 5-fluorouracil
two patients with advanced breast cancer and two patients
(CMF). Premenopausal women younger than 50 who receive
with Hodgkin disease. The patients with advanced breast can-
combination AC are less likely to experience amenorrhea com-
cer were 30 and 41 years old and became pregnant while on
pared to women receiving CMF (Bines et al., 1996). Lower et
tamoxifen therapy.
al. (1999) evaluated the prevalence and timing of menstrual
abnormalities in 142 women with early-stage breast cancer
Hormonal Therapy
receiving adjuvant methotrexate- or anthracycline-based che-
Tamoxifen originally was synthesized as a contraceptive
motherapy; information was available for 109 women. Sixty-
and was used as an ovarian induction agent in Europe,
nine patients received methotrexate chemotherapy, 33 patients
whereas a related compound, clomiphene, was used as a fer-
received anthracycline chemotherapy, and 7 patients received
tility agent in the United States (Oktay et al., 2003). In oncol-
both treatments. Amenorrhea occurred in about a third of the
ogy, tamoxifen is better known as an antihormonal agent that
patients during chemotherapy using the methotrexate or an-
decreases the risk of recurrence in women with estrogen re-
thracycline regimen. Forty-five percent of the patients were
ceptor-positive breast cancer regardless of menopausal status,
amenorrheic one year after completing chemotherapy. Amen-
nodal status, or tumor size. Women with estrogen receptor-
orrhea occurred primarily in women older than 35, although
positive tumors are advised to take tamoxifen 20 mg daily for
four weeks (one menstrual cycle) and may require delaying
at least five years after completion of chemotherapy. Even
the start of cancer treatment. In addition, the patient must have
when premenopausal women do not experience premature
an available partner or donor sperm.
menopause with combination therapy, they may have reduced
Embryo cryopreservation after ovarian stimulation with
potential for pregnancy because pregnancy is contraindicated
tamoxifen and IVF has resulted in successful fertility pres-
while on tamoxifen. Thus, they must use birth control for at
ervation (Oktay et al., 2003). The investigators used tam-
least five years. As a result, they may be perimenopausal or
oxifen to stimulate follicle growth and induce ovulation be-
even postmenopausal at the end of tamoxifen therapy.
fore the start of breast cancer treatment. Tamoxifen's dual
The aromatase inhibitors (e.g., anastrozole, letrozole) ini-
action as an ovarian-stimulating agent and antihormonal
tially were used as second-line endocrine therapy for postmeno-
agent was used to increase the number of oocytes. Twelve
pausal women with advanced breast cancer. Recent evidence
women with breast cancer received tamoxifen 4060 mg for
shows that they are at least as effective as, if not superior to,
a week beginning on days 23 of their menstrual cycle and
tamoxifen as first-line endocrine therapy in postmenopausal
had IVF with either fresh embryo transfer or cryopreservation.
women for at least two to three years (Baum et al., 2003). Be-
The women were compared with a retrospective control group
cause of their mechanism of action, aromatase inhibitors are not
of five women with breast cancer having natural-cycle IVF to
used with premenopausal women except in clinical trials.
freeze embryos for fertility preservation. None of the women
in the natural cycle IVF group received a gonadotropin-re-
Radiation Therapy
leasing hormone (GnRH) antagonist or ovarian stimulation.
Primary breast radiation therapy has a negligible effect on
The investigators found that tamoxifen with IVF resulted in
the ovaries. Radiation therapy has an indirect effect on the
a higher number of mature oocytes and subsequent embryos
ovaries through internal radiation scatter. The overall effect of
per cycle. Two of six patients on tamoxifen with IVF became
radiation on ovarian function is relatively small compared
pregnant compared with two of five patients on natural-cycle
with chemotherapy. However, women who have had radiation
IVF. One patient in the tamoxifen with IVF group delivered
therapy and later become pregnant and carry their pregnancies
a set of twins. This limited but promising data suggest that
to term will have very limited or absent lactation in the radi-
tamoxifen with IVF offers a safe method of fertility sparing
ated breast (Dow et al., 1994).
in women with breast cancer.
In summary, advanced age and cyclophosphamide present
GnRH antagonists have been used to induce ovulation and
the greatest risk of amenorrhea in women. Limited evidence
IVF prior to chemotherapy or surgery. Conventional regimens
shows that fewer cycles of cyclophosphamide combined with
using GnRH agonists are time consuming, with treatment ex-
paclitaxel compared to eight cycles of cyclophosphamide may
tending from 2030 days because these agents require pitu-
decrease the risk of amenorrhea. Women who maintain their
itary downregulation before administration of gonadotropin.
fertility must wait at least two years to attempt subsequent
Treatment with a GnRH antagonist requires less time (X = 12
pregnancy. The wait time of at least two years when women
days). GnRH antagonists are not associated with an initial
are on hormone ablation therapy may reduce the chance for
gonadotropin secretion and are given during the later stages
successful pregnancy.
of follicular maturation to prevent luteinization and ovulation.
Anderson et al. (1999) reported six case histories of women
Fertility-Sparing Options for Women
with newly diagnosed cancer having ovulation induction or
IVF prior to chemotherapy or surgery using a GnRH antago-
With Breast Cancer
nist. Three of the six women had node-negative breast cancer.
Because the effects of chemotherapy on fertility are well
The investigators started GnRH administration in the early
known, women may seek ART to preserve fertility, ideally
follicular phase and added cetrorelix (i.e., a GnRH antagonist)
before treatment begins. Fertility-sparing options for women
from day 6 of treatment. After human chorionic gonadotropin
with breast cancer are divided into three areas: before, during,
administration, Anderson et al. successfully recovered oocytes
and after treatment.
that were fertilized and cryopreserved the embryos.
For women who are single and do not have a partner or
Before Treatment
sperm donor, oocyte cryopreservation has been used but is
ART that has been used in women with breast cancer in-
considered experimental. In this procedure, mature eggs are
cludes embryo cryopreservation combined with in vitro fer-
removed, frozen without fertilization, and stored. Oocyte
tilization (IVF). Other ART procedures such as oocyte
cryopreservation takes about 1214 days per cycle. This pro-
cryopreservation and ovarian cryopreservation and transplan-
cedure has been used on a limited basis because it results in
tation are considered experimental and neither procedure has
very few oocytes, and oocytes do not respond well to cryo-
been reported in women with breast cancer.
preservation. No case reports of women with breast cancer
Embryo cryopreservation has been used for many years
using oocyte cryopreservation have been documented.
with comparable implantation rates similar to those using
During Treatment
fresh embryos (Anderson, Kinniburgh, & Baird, 1999). This
procedure provides a potential for women to conceive using
GnRH agonists have been used to induce gonadal quiescence
their own oocytes if patients are expected to develop ovarian
and thereby protect ovarian function in premenopausal women
failure as a result of treatment. In this procedure, oocytes are
during chemotherapy. GnRH agonists theoretically induce a
removed, fertilized using standard IVF, cryopreserved, and
prepubertal state that may reduce cytotoxic damage to the ova-
stored. The procedure is recommended before chemotherapy
ries, but these treatments are considered experimental.
begins to help ensure an adequate number of available oo-
Fox, Scialla, and Moore (2001) examined the use of the
cytes. A disadvantage of this procedure is that it takes at least
GnRH agonist leuprolide during chemotherapy in 24 women
with breast cancer. The median age of the patients was 35
pregnancy (Kroman, Jensen, Melbye, Wohlfahrt, & Mourid-
years (range = 2342 years). All patients became amenorrheic
sen, 1997). Women having full-term pregnancy after treat-
by the third cycle of chemotherapy, and menses resumed in 23
ment for breast cancer had a nonsignificant, reduced risk of
of 24 patients within 12 months of completing chemotherapy.
death compared to women who had no full-term pregnancy.
Six pregnancies were reported in five patients: Three pregnan-
Miscarriage or induced abortions did not influence prognosis.
cies resulted in miscarriage, one was terminated because of
Sankila et al. (1994) conducted a population-based matched
Down syndrome, one resulted in live birth, and another
survival study with more than 2,500 Finnish women younger
woman was pregnant at the time of the study's publication.
than age 40, in which 91 had subsequent pregnancy. They
Three patients required fertility treatment but were unsuccess-
found that the subjects in the control group had a 4.8-fold
ful in achieving pregnancy. The investigators concluded that
higher risk of death compared to breast cancer survivors with
although leuprolide is not associated with amenorrhea, its fer-
subsequent pregnancy. The researchers postulated a potential
tility-sparing effect is inconsistent.
"healthy mother effect" of subsequent pregnancy, meaning
that women who became pregnant were more likely to be free
After Treatment
of disease than women who did not have subsequent preg-
Fertility-sparing options after treatment has ended are lim-
Von Schoultz, Johansson, Wilking, and Rutqvist (1995)
ited because cytotoxic damage may have occurred. Some
evaluated 2,119 women with breast cancer who were younger
women continue to have regular menstrual cycles, which may
than 50 years at diagnosis and found 50 subsequent pregnan-
not result in successful pregnancy (Hensley & Reichman,
cies. They concluded that hormonal changes associated with
1998). However, data show that women can have successful
pregnancy after breast cancer had little influence on progno-
pregnancies after breast cancer treatment (Dow, 1994; Gelber
sis. Velentgas et al. (1999) also observed no overall associa-
et al., 2001; Sankila, Heinavaara, & Hakulinen, 1994; Sutton,
tion between pregnancy after breast cancer and risk of death
Buzdar, & Hortobagyi, 1990; Velentgas et al., 1999).
in 53 women who had subsequent pregnancies after treatment
Parenting options for women who become infertile after
compared to 265 case-matched healthy controls. However, the
cancer treatment include donor embryos, surrogacy, and
rate of miscarriage among women who previously had breast
adoption. According to Fertile Hope (2001), donor embryos
cancer was 24% compared to 18% in the control group who
allow the experience of pregnancy and birth, but the breast
never had breast cancer. The observed pregnancies ending in
cancer survivor does not have any genetic relationship to the
miscarriage were 70% higher than expected. Velentgas et al.
child. The major disadvantage of donor embryos is that recipi-
attributed the difference to the result of an altered hormone
ents must have uterine preparation with estrogen and proges-
profile after breast cancer treatment.
terone, making this a less viable option and contraindication
Gelber et al. (2001) evaluated the impact of subsequent
for breast cancer survivors. Surrogacy and adoption alterna-
pregnancy on prognosis. The investigators identified 108 pa-
tives are parenting options that may be considered.
tients with early-stage breast cancer through the Interna-
Pregnancy After Breast Cancer
tional Breast Cancer Study Group; data were available for 94
subjects. Gelber et al. determined that subsequent pregnancy
Breast cancer survivors who want to become pregnant of-
did not adversely affect the prognosis of early-stage breast
ten question whether pregnancy would stimulate recurrence
cancer. The survival may reflect what is considered a "healthy
of their disease and worry that their children may have a
patient" selection bias, but survival also was consistent with
higher risk of birth defects or be at higher risk of develop-
an antitumor effect of pregnancy. In a recent analysis by
ing cancer.
Blakely et al. (2004), the investigators found a 23% recur-
rence for women having subsequent pregnancy compared
Effects of Subsequent Pregnancy on Recurrence
with 54% recurrence for women not having subsequent preg-
Women with breast cancer often express initial worry that
subsequent pregnancy may increase their risk of disease re-
In summary, the accumulated clinical evidence shows that
currence. However, data do not show an increased risk of re-
women with breast cancer do not have adverse clinical out-
currence based on subsequent pregnancy alone. In one of the
comes with subsequent pregnancy. Some investigators postu-
first retrospective institutional studies, White (1955) re-
late that healthy women with early-stage breast cancer are
ported that 67% of patients with subsequent pregnancy sur-
more likely to become pregnant and carry to full term. Infants
vived at least five years and 58% survived 10 years com-
born to mothers who have had breast cancer do not demon-
pared with women with breast cancer not having subsequent
strate an increased risk of low birth weight or birth defects
pregnancy. Case-matching studies were conducted as early
compared with the general population.
as 1965 to control for the influence of pregnancy occurring
only in patients with good prognoses and found similar sur-
Having Children After Breast Cancer
vival results. Case-control studies using newer treatment
regimens were reported from 19901997 and showed simi-
Very few reports have been documented about the experi-
lar survival rates (Dow et al., 1994; Gelber et al., 2001; Sutton
ence of young breast cancer survivors having children after
et al., 1990).
treatment. Dow (1994) reported the results of a qualitative
Four large population-based studies examined the effect of
study of 20 women who had children after treatment. A
pregnancy on survival in breast cancer survivors and deter-
semistructured interview guide was used to identify reasons
mined that previous disease had no adverse effect on preg-
that the young women decided to become pregnant, describe
nancy. In a population-based cohort study of 5,725 women
their concerns about pregnancy, and determine helpful behav-
aged 45 or younger in Denmark, 173 women had subsequent
iors in making decisions to become pregnant. Participants
indicated that they were eager to resume their life goals that
cause ART is associated with expenses that may or may not
were stalled by breast cancer. For these women, having chil-
be covered by health insurance, the reproductive endocrinol-
dren was a high priority at the time of their diagnosis. Having
ogy team may provide additional guidance and develop real-
children had many meanings for them: They believed that
istic expectations of fertility-preserving outcomes with
they were "cured," they were well enough to look forward to
women. Some ART procedures are highly promising, but they
a future, and having children meant reconnecting with their
have been used in small numbers of patients. Although lim-
peers, friends, and family. Having children was a strong
ited information about ART is available, the Fertile Hope
stimulus to "get well" again. Young women with subsequent
Web site (www.fertilehope.org) offers current and thorough
pregnancies believed that having children after treatment had
patient information.
the greatest impact on improving their quality of life. Children
The type of chemotherapy may result in differences in
gave them a reason to start their day and provided a normal
amenorrhea based on a small number of studies. Nevertheless,
structure in their lives. Participants expressed concerns about
a discussion about different chemotherapy options that may
the potential for disease recurrence, the need to be vigilant
help to preserve menstrual function during treatment may be
about cancer follow-up with breast examinations, and not
having mammography during pregnancy. The participants
Any woman over the age of 35 is considered of advanced
identified helpful behaviors, including having a realistic per-
maternal age with significant decline in overall fertility. When
spective about a normal pregnancy, learning to live with and
women are receiving treatment for several months and must
manage uncertainty about the future, having love and support
wait at least two years after treatment before attempting preg-
from a partner, and distinguishing the difference between per-
nancy, their options for achieving pregnancy may become
sonal and medical decision making. Participants also cau-
even more limited. Helping women to develop realistic expec-
tioned that some family members expressed grave concern
tations of pregnancy outcomes at an older age is an important
about the survivors' decision to become pregnant. Family
supportive function.
members may not often agree with this decision; therefore,
Data about survival outcomes with subsequent pregnancy
women contemplating subsequent pregnancy must be pre-
after treatment are very promising, as well as reports that hav-
pared for a somewhat less than enthusiastic family response.
ing children after breast cancer helps to improve quality of
life. Oncology nurses can offer hope when discussing fertil-
Nursing Implications
ity and pregnancy options with their young patients. In addi-
tion, developing a stronger partnership between the oncology
Fertility and subsequent pregnancy are major quality-of-life
team and the reproductive endocrinologist can improve infor-
concerns for young women with breast cancer. Because ART
mation in the future with respect to fertility-sparing options
options are available, healthcare professionals should discuss
and subsequent pregnancy after breast cancer.
these options, ideally before cytotoxic treatment begins. Tim-
The authors would like to thank Lauren Hassey for her assistance in the
ing of ART before chemotherapy provides the best chance of
manuscript's review and Sharon Austin and Thalia Montes for their assistance
successful embryo cryopreservation, but women often are not
with the manuscript's preparation.
aware of these options and have not received information to
help them pursue ART. Referral to a reproductive endocri-
Author Contact: Karen Hassey Dow, PhD, RN, FAAN, can be
nologist who can work with the oncology team in helping
reached at kdow@mail.ucf.edu, with copy to editor at rose_mary@
women maintain fertility can be invaluable. In addition, be-
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White, T. (1955). Carcinoma of the breast in the pregnant and nursing patient.
American Journal of Obstetrics and Gynecology, 68, 12771286.
Moore, H. (2000). Fertility and the impact of systemic therapy on hormonal
status following treatment for breast cancer. Current Oncology Reports, 2,
For more information . . .
Oktay, K., Buyuk, E., Davis, O., Yermakova, I., Veeck, L., & Rosenwaks, Z.
(2003). Fertility preservation in breast cancer patients: IVF and embryo
cryopreservation after ovarian stimulation with tamoxifen. Human Repro-
duction, 18(1), 9095.
Sankila, R., Heinavaara, S., & Hakulinen, T. (1994). Survival of breast can-
Breast Cancer Fund
cer patients after subsequent term pregnancy: "Healthy mother effect."
American Journal of Obstetrics and Gynecology, 170, 818823.
Schover, L.R., Brey, K., Lichtin, A., Lipshultz, L.I., & Jeha, S. (2002). Knowl-
Breast Cancer Action
edge and experience regarding cancer, infertility, and sperm banking in
younger male survivors. Journal of Clinical Oncology, 20, 18801889.
Stone, E., Slack, R., Novielli, A., Ellis, M., Baidas, S., Gelmann, E., et al.
Links can be found using www.ons.org.
(2000). Rate of chemotherapy-related amenorrhea (CRA) associated with
adjuvant Adriamycin and cytoxan (AC) and Adriamycin and cytoxan fol-
The continuing education examination
and test form for the preceding article
appear on the following pages.
ONF Continuing Education Examination
Fertility Options in Young Breast Cancer Survivors: A Review of the Literature
Credit Hours: 1.3
17. Women with breast cancer often express initial worry that
Passing Score: 80%
a subsequent pregnancy may
Test ID#: 04-31/3-06
a. Decrease their survival rate.
Test Processing Fee: $15
b. Increase their risk of disease recurrence.
The Oncology Nursing Society is accredited as a provider
c. Result in a child at higher risk for birth defects.
of continuing education (CE) in nursing by the
d. Result in a child at higher risk for developing cancer.
American Nurses Credentialing Center's Commission on
18. Which of the following is used to induce quiescence and
protect ovarian function in premenopausal women during
California Board of Nursing, Provider #2850.
a. Alkylating agent
CE Test Questions
b. Ovarian induction agent
11. Which drug combination is least likely to cause amenor-
c. Gonadotropin-releasing hormone agonist
d. Gonadotropin-releasing hormone antagonist
a. Cyclophosphamide and doxorubicin
19. Parenting options for women who become infertile after
b. Cyclophosphamide and methotrexate
cancer treatment include
c. Cyclophosphamide, methotrexate, and 5-fluorouracil
a. Donor embryos, surrogacy, and adoption.
d. Cyclophosphamide, epirubicin, and 5-fluorouracil
b. Embryo cryopreservation and surrogacy.
12. Which of the following results in ovarian failure?
c. Oocyte cryopreservation and surrogacy.
a. Aromatase inhibitors
d. Ovarian transplantation and in vitro fertilization.
b. Hormonal therapy
10. Sankila, Heinavaara, and Hakulinen (1994) postulated a
potential "healthy mother effect" of subsequent preg-
c. Bone marrow transplantation
nancy, meaning that women who became pregnant are
d. Second-line endocrine therapy
13. Which of the following combinations presents the great-
a. At a higher risk of death compared to women in the
control group.
est risk of amenorrhea?
b. Less likely to be free of disease than women who do
a. Advanced age and taxanes
not have subsequent pregnancy.
b. Advanced age and cyclophosphamide
c. More likely to be free of disease than women who do
c. Doxorubicin and cyclophosphamide
not have subsequent pregnancy.
d. Doxorubicin, cyclophosphamide, and paclitaxel
d. More likely to have a nonsignificant reduced risk of
14. Which procedure provides the potential for women to
death compared with women who have no full-term
conceive using their own oocytes when they are expected
to develop ovarian failure after treatment?
11. Gelber et al. (2001), the most recent study evaluating the
a. Transplantation
impact of subsequent pregnancy on prognosis, concluded
b. Oocyte cryopreservation
c. Ovarian cryopreservation
a. Survival was inconsistent with an antitumor effect of
d. Embryo cryopreservation
the pregnancy.
15. Ideally, when should women receiving treatment for
b. Survival did not reflect what is considered a "healthy
patient" selection bias.
breast cancer seek assistive reproductive technologies to
preserve fertility?
c. Subsequent pregnancy adversely affects the prognosis
a. After completing hormonal therapy treatment
of early-stage breast cancer.
d. Subsequent pregnancy did not adversely affect the
b. Before beginning chemotherapy treatment
prognosis of early-stage breast cancer.
c. During chemotherapy treatment
d. Two years after completing chemotherapy treatment
12. When compared with the general population, infants born
to mothers with breast cancer
16. The limited data reported by Oktay et al. (2003) suggest
a. Demonstrate an increased risk of prematurity.
that tamoxifen with in vitro fertilization
b. Demonstrate an increased risk of low birth weight.
a. Has been used but is considered experimental.
c. Do not demonstrate an increased risk of birth defects.
b. Is time consuming, with treatment requiring 2030
d. Do not demonstrate an increased risk of developmen-
tal delays.
c. Results in a higher number of immature oocytes and
13. A helpful behavior when deciding whether to get pregnant
embryos per cycle.
identified by the participants in the Dow (1994) study was
d. Offers a safe method of fertility-sparing in women
a. Believing that they were "cured."
with breast cancer.
b. Reconnecting with peers, friends, and family mem-
c. Impart added hope in fertility and pregnancy discus-
c. Having a realistic perspective about a normal preg-
d. Provide data that having children after breast cancer
helps to improve quality of life.
d. Having family members agree with their decision to
15. Based on a small number of studies, the type of chemo-
become pregnant.
14. For women older than 35 who are attempting pregnancy,
a. May result in differences in amenorrhea.
nurses should
b. Results in persistently abnormal menses for all women.
a. Discuss assistive reproductive technology options
c. Results in increased amenorrhea with the addition of
during cytotoxic treatment.
b. Assist in the development of realistic expectations for
d. Does not result in differences in amenorrhea in pre-
pregnancy outcome.
menopausal women.
Oncology Nursing Forum Answer/Enrollment Form
Fertility Options in Young Breast Cancer Survivors: A Review of the Literature
(Test ID #04-31/3-06)
To receive continuing education (CE) credit for this issue, simply
form along with a check or money order for $15 per test pay-
1. Read the article.
able to the Oncology Nursing Society. Payment must be in-
2. Oncology Nursing Society members may take the test and
cluded for your examination to be processed.
get results immediately on the ONS Web site. Simply log on
4. The deadline for submitting the answer/enrollment form is
to www.ons.org and click on ONF (Oncology Nursing Forum)
two years from the date of this issue.
under the Publications heading. Use your ONS membership
5. Contact hours will be awarded to RNs who successfully com-
number to access the site, select the issue you wish to use,
plete the program. Successful completion is defined as an
scroll down to find the CE test, and follow the instructions.
80% correct score on the examination and a completed evalu-
After successfully completing the test, pay with a credit card.
ation program. Verification of your CE credit will be sent to
3. To enroll via the mail, record your answers on the form be-
you. Certificates will be mailed within six weeks following
low and complete the program evaluation (you may make
receipt of your answer/enrollment form. For more informa-
copies of the form). Mail the completed answer/enrollment
tion, call 866-257-4667, ext. 6296.
a  10.
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placing an "x" in the
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answer. This is a stan-
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2. How well did you meet the CE activity's objectives (see page E46)?
Objective #1
Objective #2
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3. To what degree were the teaching/learning resources helpful?
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4. Based on your previous knowledge and experience, do you think
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After completing this form, mail it to: Oncology Nursing Society, P.O. Box 3510, Pittsburgh, PA 15230-3510.
For more information or information on the status of CE certificates, call 866-257-4667, ext. 6296.