Correspondence
Survivors of Breast Cancer
N Engl J Med 2001; 344:309-310January 25, 2001
- Article
To the Editor:
In their review article (Oct. 12 issue),1 Drs. Burstein and Winer touch on the psychosocial issues related to the diagnosis and treatment of breast cancer. Universally, breasts evoke diverse associations, ranging from a woman's sense of attractiveness, femininity, and sexuality to her capacity for nurturing and reproduction. At least 80 percent of survivors of breast cancer report some psychological distress, including problems with body image and self-image, sexual problems, and effects on relationships, priorities, and goals for the future. Women who express their concern about these issues have greater satisfaction with their lives, improved sexual fulfillment, diminished anxiety and depression, and reduced pain.2 Some reports suggest that psychological support may slow the progression of cancer and increase survival.3
As survivors live longer, doctors must consider the consequences of treatment with regard to women's sexual health. Libido, physical comfort, and women's sense of desirability are changed or threatened by cancer therapy. Although ovarian failure is the most common consequence of chemotherapy, fertility sometimes returns, especially in younger women. Contraception should therefore be continued for one year after the onset of amenorrhea. Combination oral contraceptive pills should be avoided because of the potential for hormonal stimulation of residual disease. In the general population, current use of oral contraceptives is associated with a small increase in the risk of breast cancer (relative risk, 1.2)4; recent data suggest that the risk may be even higher in women with a family history of breast cancer.5 The safety of contraceptives containing only progestin in survivors of breast cancer is unknown; among women in the general population who use depot medroxyprogesterone, the risk of breast cancer is not increased.6
6 ReferencesJennifer Potter, M.D.
Amy N. Ship, M.D.
Harvard Medical School, Boston, MA 021151
Burstein HJ ,Winer EP . Primary care for survivors of breast cancer. N Engl J Med 2000;343:1086-1094
Full Text | Web of Science | Medline2
Spiegel D . A 43-year-old woman coping with cancer. JAMA 1999;282:371-378
CrossRef | Web of Science | Medline3
Maunsell E ,Brisson J ,Deschenes L . Social support and survival among women with breast cancer. Cancer 1995;76:631-637
CrossRef | Web of Science | Medline4
Collaborative Group on Hormonal Factors in Breast Cancer
CrossRef | Web of Science | Medline5
Grabrick DM ,Hartmann LC ,Cerhan JR , et al. Risk of breast cancer with oral contraceptive use in women with a family history of breast cancer. JAMA 2000;284:1791-1798
CrossRef | Web of Science | Medline6
Shapiro S ,Rosenberg L ,Hoffman M , et al. Risk of breast cancer in relation to the use of injectable progestogen contraceptives and combined estrogen/progestogen contraceptives. Am J Epidemiol 2000;151:396-403
Web of Science | Medline
To the Editor:
Burstein and Winer present a balanced review on pregnancy after breast cancer, reaching a conclusion that the available data “offer reassurance for women who wish to become pregnant.” Other available data, however, suggest the opposite. In uniparous women, as compared with nulliparous women, the risk of breast cancer appears to be higher in the 5 years immediately after delivery and lower after 10 to 15 years.1 Lambe et al. attribute this transient increase in risk to “a growth-enhancing effect of high estrogen levels during pregnancy on tumor cells whose malignant transformation has already begun.”1 In the National Surgical Adjuvant Breast and Bowel Project study on tamoxifen for the prevention of breast cancer, this selective estrogen-receptor modulator prevented the clinical development of hormone-receptor–positive breast cancer.2 Together, these data regarding the effect of the hormonal milieu on preclinical disease suggest that, generally, pregnancy is likely to increase the risk of a recurrence of breast cancer, at least in patients whose tumors are hormone-receptor–positive — a category that includes the majority of tumors that occur before menopause.
2 ReferencesRichard R. Love, M.D.
University of Wisconsin Comprehensive Cancer Center, Madison, WI 537921
Lambe M ,Hsieh C ,Trichopoulos D ,Ekbom A ,Pavia M ,Adami H-O . Transient increase in the risk of breast cancer after giving birth. N Engl J Med 1994;331:5-9
Full Text | Web of Science | Medline2
Fisher B ,Costantino JP ,Wickerham DL , et al. Tamoxifen for prevention of breast cancer: report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. J Natl Cancer Inst 1998;90:1371-1388
CrossRef | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: The correspondents raise important questions about the potential risks of exposure to endogenous and exogenous hormones after a diagnosis of breast cancer. In our review, we acknowledged the theoretical risk that such exposure might pose in women with hormonally sensitive tumors. As Drs. Potter and Ship note, fertility may return in younger women after chemotherapy-related amenorrhea. Women who do not wish to become pregnant should continue to use effective forms of contraception. Because there are no data on the safety of oral or depot hormonal-contraceptive use among survivors of breast cancer, these methods are probably less preferable than other forms of birth control that do not require exposure to hormones.
Dr. Love believes that pregnancy will increase the risk of a recurrence of cancer, on the basis of data suggesting that first-time pregnancy may transiently increase the risk of a new diagnosis of breast cancer. However, the limited experience among survivors of breast cancer does not suggest that subsequent pregnancy increases the risk of a recurrence of cancer.1-5 Survivors of breast cancer who are contemplating pregnancy face difficult choices and have only imperfect data to guide them. Counseling patients on both the theoretical issues of concern and what clinical data we have is appropriate.
5 ReferencesHarold J. Burstein, M.D., Ph.D.
Eric P. Winer, M.D.
Dana–Farber Cancer Institute, Boston, MA 021151
Burstein HJ ,Winer EP . Primary care for survivors of breast cancer. N Engl J Med 2000;343:1086-1094
Full Text | Web of Science | Medline2
Sankila R ,Heinavaara S ,Hakulinen T . Survival of breast cancer patients after subsequent term pregnancy: “healthy mother effect.“ Am J Obstet Gynecol 1994;170:818-823
Web of Science | Medline3
von Schoultz E ,Johansson H ,Wilking N ,Rutqvist LE . Influence of prior and subsequent pregnancy on breast cancer prognosis. J Clin Oncol 1995;13:430-434
Web of Science | Medline4
Malamos NA ,Stathopoulos GP ,Keramopoulos A ,Papadiamantis J ,Vassilaros S . Pregnancy and offspring after the appearance of breast cancer. Oncology 1996;53:471-475
CrossRef | Web of Science | Medline5
Gelber S, Coates AS, Goldhirsch A, et al. Effect of pregnancy on overall survival following the diagnosis of early stage breast cancer. J Clin Oncol (in press).
- Citing Articles (3)
Citing Articles
1
Tayebeh Fasihi Harandy, Fazlollah Ghofranipour, Ali Montazeri, Monireh Anoosheh, Eesa Mohammadi, Fazlollah Ahmadi, Farkhondeh Amin Shokravi, Shamsaddin Niknami. (2010) Health-Related Quality of Life in Iranian Breast Cancer Survivors: A Qualitative Study. Applied Research in Quality of Life 5:2, 121-132
CrossRef2
François Eisinger, Wylie Burke. (2003) Breast cancer and breastfeeding. The Lancet 361:9352, 176-177
CrossRef3
B. Alex Matthews, Frank Baker, Danette M. Hann, Maxine Denniston, Tenbroeck G. Smith. (2002) Health status and life satisfaction among breast cancer survivor peer support volunteers. Psycho-Oncology 11:3, 199-211
CrossRef
