Ann Partridge

Ann Partridge, MD, MPH, is a medical oncologist at Dana-Farber Cancer Institute and Assistant Professor of Medicine at Harvard Medical School specializing in Breast Oncology. She received her M.D. from Cornell University Medical College and subsequently completed a residency in Internal Medicine at the Hospital of the University of Pennsylvania. Dr. Partridge then went on to complete fellowships in Medical Oncology and Hematology at the Dana-Farber Cancer Institute. She also received a Masters in Public Health at the Harvard School of Public Health. Dr. Partridge's research focuses on psychosocial, behavioral and communication issues in breast cancer care and treatment. She has several ongoing projects including evaluating adherence with hormonal therapies in women with early stage breast cancer, fertility issues in very young women undergoing breast cancer treatment, and communication with patients following participation in a clinical trial.

In 2003, Dr. Partridge received an American Society of Clinical Oncology Career Development Award for her work on cancer communication issues. Also in 2003, she was the primary investigator on a web-based survey of fertility issues in young women with breast cancer in collaboration with the Young Survival Coalition. Dr. Partridge is currently running a large cohort study of young women with breast cancer to evaluate short and long-term medical and psychosocial outcomes, as well as to more fully understand the biology of breast cancer in young women.

Questions & Responses:

Question Seven:

I know that chemo can put pre-menopausal women into permanent menopause. I know that the closer you are to menopause the more likely you are to be pushed over by chemo, but what I don't know is hard numbers. What studies show what drugs cause what percentage of women to
go into permanent menopause at what ages?

Dr. Partridge:

Unfortunately, only a few studies in recent years have followed the effects of treatment on menopausal status. The table below summarizes published data regarding the effects common breast cancer treatments on chemotherapy related amenorrhea by age when available.

Table 1: Percentage Risk of Amenorrhea with Common Treatment Regimens (Goodwin, JCO 1999;Burstein, NEJM 2000; Martin, JCO 2005; Parulekar, JCO, 2005; Petrek, JCO, 2006; Fornier, Cancer, 2005)

• AC = doxorubicin and cyclophosphamide
• CMF = cyclophosphamide, methotrexate, 5-fluorouracil
• CAF = cyclophosphamide, doxorubicin, 5-fluorouracil
• CEF = cyclophosphamide, epirubicin, 5-fluorouracil
• TAC = docetaxel, doxorubicin, cyclophosphamide
• T = paclitaxel

Question Six:

For reasons having nothing to do with my breast cancer (we believe) I'm currently seeing a reproductive specialist for infertility. I had radiation only, no chemotherapy. Multiple rounds of Clomid with inseminations have not worked, and our next step is to do in-vitro fertilization. How safe is this for someone who had DCIS? I had high grade extensive DCIS with no node involvement and no invasion, but it required a mastectomy and radiation - almost 6 years ago.

Dr. Partridge:

There are no formal data on the safety of fertility treatments including IVF after breast cancer. There may be some risk to receiving exogenous hormones given the fact that we know hormonal blockade with tamoxifen prevents cancer recurrence and new breast cancers. Given the fact that you are so far out from your disease, it was only DCIS, and you had a mastectomy which results in a very low risk of recurrence (1% in modern series), the major risk you face is a new primary breast cancer in the other breast. Your baseline risk of a new primary in the opposite breast depends on many factors that you should discuss with your doctor. Whether IVF affects that is not at all clear at this point.

Question Five:

When I did IVF one of the things my endocrinologist pointed out to me was that just because you get your period back does not mean that you aren't in menopause or that your fertility is not otherwise compromised. She did not think there were any studies that went further then just asking the only somewhat helpful question of whether patients' periods returned to test fertility in women under 40 after chemotherapy. Is this true? If so, are there any in the works?

Dr. Partridge:

This is unfortunately true, though there are a number in the works.

Question Four:

Many women undergoing breast cancer treatment (myself included) are given Lupron shots or another ovarian suppression drug with the idea that if we put our ovaries to sleep during chemo they will be less likely to be damaged. My oncologist said that there were no conclusive studies about this, but it was a theory that many oncologists found persuasive. What studies are there on this topic?

Dr. Partridge:

Your oncologist is correct. There are currently two ongoing randomized clinical trials evaluating the use of ovarian suppression with medications during breast cancer chemotherapy for the preservation of menstrual functioning and the results these are not yet available. There have been several small, preliminary studies some of which are promising. However, some do not reveal likely benefit and many reproductive endocrinologists (fertility specialists) do not feel that it is likely to work. Therefore, at this point in time, we do not know that it works. (Please refer to a recently published guideline put out the American Society of Clinical Oncology entitled: "American Society of Clinical Oncology recommendations on fertility preservation in cancer patients" for details on the actual studies reported to date)

Question Three:

Is it true that Arimidex should only be used on post-menopausal women? I am 42 and still getting my period even though it comes every three months, or so. Thanks so much for your answer.

Dr. Partridge:

Yes, although studies are ongoing, the efficacy of aromatase inhibitors in premenopausal women with early breast cancer is not at all clear at this point.

Question Two:

I have been trying to find out if I could still be fertile. I had chemotherapy induced menopause. My period came back over a year ago. This over 2 years after treatment stopped. My menstrual cycle is not regular. I have been trying to get pregnant over a year. I want to know if it is still possible or am I infertile. I am 34. I was diagnosed at 30.

Dr. Partridge:

Fertility and pregnancy are important concerns for many young women with breast cancer. One possible side effect of breast cancer treatment is amenorrhea (not having periods), which may result in loss of fertility. The risk of amenorrhea from chemotherapy depends on a woman's age and the specific drug regimen used.

It is important to understand that amenorrhea may be temporary, lasting for a number of months, or permanent, resulting in menopause. For most women, if periods have not resumed within the first year after treatment, amenorrhea is permanent. Also, women whose periods continue after chemotherapy may go through menopause earlier than they would have if they had not received the treatment.

However, the presence or absence of periods during the first several months after chemotherapy is not the best indicator of fertility. The return of menstrual cycles does not necessarily mean that the ovaries are producing normal eggs that will result in a healthy pregnancy, and the absence of menstrual cycles after chemotherapy does not necessarily mean that fertility has been permanently lost.

You should speak to your physician if you are concerned about whether you can become pregnant after chemotherapy and seek a referral to a doctor who specializes in fertility early if you are having difficulty becoming pregnant. There are some tests that a fertility specialist can do to help to evaluate potential fertility including hormonal levels (FSH, Estradiol).

Question One:

Thank you for taking time to answer our questions. My question is about becoming pregnant after treatment. I was 30 when diagnosed with stage IIa, grade 3 breast cancer. I am estrogen receptor positive (ER+). There was no node involvement, and my tumor was 2 cm. I am currently taking tamoxifen and have been on it for 2 years.

Is it safe for ER+ women to have a child? Is it safe to stop tamoxifen to have a baby and then go back on? We would love to have a child, but do not want to if it's not safe.

Dr. Partridge:

Women of childbearing age diagnosed with breast cancer may be concerned about their future fertility and family planning. Today, there are more options available and talking with your oncologist about these issues can be very helpful with this important decision. Although research in this area is limited, available studies have revealed no increased risk of breast cancer recurrence in women who become pregnant after breast cancer treatment, regardless of the ER status of a woman's tumor. Furthermore, children born after treatment for breast cancer seem to have no increased risk of birth defects.

Many oncologists encourage patients to delay child bearing after diagnosis. This is because the majority of young women who develop recurrent breast cancer do so within the first five years of diagnosis with the most aggressive cancers recurring within the first 2-3 years.

Tamoxifen is a hormonal therapy that is often used in women with estrogen receptor–positive breast cancer. Treatment with tamoxifen is usually given over a period of 5 years to block the action of estrogen and potentially stop or slow the growth of cancer cells. Five years of tamoxifen offers women the greatest benefit in prevention of breast cancer recurrence. Tamoxifen treatment generally does not cause early menopause; however, periods can become irregular. Furthermore, fertility may be naturally declining with age during this time. Some women with low-moderate risk tumors may decide with their doctors to take less than the full 5 years of tamoxifen and forego some of the benefits of tamoxifen in terms of disease recurrence. Pregnancy can occur during treatment with tamoxifen but is not safe because of an increased risk of birth defects and miscarriage (the first trimester). Therefore, effective non-hormonal contraception is strongly recommended during treatment with tamoxifen.