What is your approach to timing fertility preservation consultations in newly diagnosed breast cancer patients?

Highlights

• Newly diagnosed breast cancer patients should be referred for a fertility consultation immediately, ideally before treatment begins.
• Fertility preservation, such as egg or embryo freezing, is generally not possible after chemotherapy has been initiated.
• The egg or embryo freezing process requires at least two to three weeks, necessitating a prompt referral after diagnosis.
• Earlier consultations are crucial as more patients receive chemotherapy before surgery, shortening the window for fertility preservation.
• A fertility specialist can work with the patient's entire oncology team to develop an appropriate treatment and preservation timeline.

Expert Insights

The Imperative of Immediate Referral for Fertility Preservation

For newly diagnosed breast cancer patients of reproductive age, the timing of a fertility preservation consultation is not just a secondary consideration—it is a critical, time-sensitive component of initial management. Experts in both reproductive endocrinology and breast oncology unanimously advocate for referring patients to a fertility specialist immediately upon diagnosis. Dr. Anate Brauer, a reproductive endocrinologist, states this should be "one of the first conversations you have," recommending it occur "as soon as you possibly can." This urgency is echoed by breast oncologist Dr. Anastasia Martynova, who advises a consultation "as soon as possible after a breast cancer diagnosis." The experts acknowledge the overwhelming nature of this period for patients, who are often inundated with new appointments and information. However, they stress that the window of opportunity for fertility preservation is finite and closes rapidly once treatment begins.

"This should be one of the first conversations you have. It can be very overwhelming for patients because they face many appointments and imaging; they need to meet with the breast surgeon, the oncologist, and sometimes the radiation oncologist." Dr. Anate Brauer

The Chemotherapy Start Date as a Firm Deadline

The primary factor driving the need for a swift referral is the planned start of chemotherapy. As reproductive endocrinologist Dr. Joseph Letourneau explains, "Once chemotherapy has begun, we can generally no longer perform egg or embryo freezing." He clarifies that the cryopreservation process itself requires a minimum of two to three weeks, underscoring the necessity of initiating the process well in advance of the first chemotherapy infusion. Dr. Martynova reinforces this, noting that fertility preservation discussions are especially critical if the patient's treatment plan includes chemotherapy. This establishes a clear, non-negotiable deadline that the entire oncology care team must work against, making a prompt referral to a reproductive endocrinologist an essential first step.

"Once chemotherapy has begun, we can generally no longer perform egg or embryo freezing. The egg or embryo freezing process usually takes at least two to three weeks, so it's important to get a referral as soon as possible." Dr. Joseph Letourneau

Navigating Treatment Sequencing and Its Impact on Timing

The specific sequence of breast cancer therapy significantly influences the available timeframe for fertility preservation. Dr. Letourneau provides a key clinical insight, noting the increasing trend toward neoadjuvant chemotherapy, where chemotherapy is administered before surgery. This "chemotherapy-first" approach compresses the timeline available for ovarian stimulation and oocyte retrieval, making an immediate fertility consultation even more critical. Conversely, when surgery is performed first, a larger window may exist for fertility preservation procedures post-recovery. However, Dr. Letourneau cautions that even in this scenario, procedures must be carefully timed around the patient's surgical recovery to ensure safety and comfort. Therefore, understanding the proposed treatment sequence is vital for both the oncology and fertility teams to coordinate care effectively.

A Collaborative, Multidisciplinary Approach

Effective oncofertility care requires seamless collaboration between the patient's multidisciplinary team. Dr. Brauer emphasizes that an early referral allows the fertility specialist "to work with the entire care team to develop a protocol and timeline appropriate for treatment." This includes coordinating with the breast surgeon, medical oncologist, and sometimes the radiation oncologist. The initial conversation can be initiated by any member of the team, and patients should also be empowered to raise the topic themselves. Dr. Letourneau advises patients that "the first doctor they see after a cancer diagnosis is a good time to bring up fertility concerns." Acknowledging the anxiety patients face, as noted by Dr. Martynova, this proactive and collaborative approach ensures that fertility goals are integrated into the comprehensive cancer treatment plan from the outset, rather than being addressed as an afterthought.

"The first doctor they see after a cancer diagnosis is a good time to bring up fertility concerns and arrange to speak with a fertility specialist promptly." Dr. Joseph Letourneau