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Audra Outlaw was only 31, a bride of just eight months, when she was diagnosed with breast cancer.
"We wanted kids really badly, and then all this happened," says the Austin resident, now 34. Her top priority became beating her cancer, and she began chemotherapy at once.
Her doctor told her the drugs would probably leave her infertile. Two months into chemo, her menstrual periods stopped. Months passed, chemo ended, and still, no periods.
Only about a quarter of breast cancers are diagnosed in women under 50, far fewer in women under 40. But the disease tends to be more aggressive in premenopausal women, who also must deal with the chance of becoming infertile from their treatment.
Now that women are waiting longer than ever to begin or complete their families, cancer and infertility specialists are encountering more breast cancer survivors like Outlaw.
Fertility is an issue with most young cancer patients, but in some ways it's more complicated in breast cancer patients. Most have tumors that feed on hormones, so fertility drugs or even pregnancy itself could raise their risk of a recurrence, at least theoretically.
"It's an issue, and we worry about it," says breast cancer specialist Ann Partridge at Harvard's Dana Farber Cancer Institute. The little available data suggest that pregnancy does not raise recurrence risk, she says.
But, Partridge says, "we have good reason to believe that people are not as fertile after breast cancer chemotherapy as they were before." Even if women resume ovulating after chemo, she says, data show that they're likely to go through menopause sooner than if they hadn't had treatment.
Most doctors tell women to wait at least two years -- during which the recurrence risk is highest -- before trying to conceive, says Elyce Cardonick of Cooper University Hospital in Camden, N.J., a specialist in high-risk pregnancies. That advice is based on the fear that a woman could die of a recurrence shortly after delivering, not that pregnancy itself will bring the cancer back, Cardonick says.
Young mothers who have survived breast cancer say they think about the possibility of not seeing their kids grow up, but it doesn't rule their lives.
"You can't live your whole life based on 'What if?'" says Robin Shoulla, 31, an exceptionally young 17 at diagnosis. "You can't live life standing on death's doorstep." Shoulla, of Snellville, Ga., has boys ages 12 years and 20 months, and a newborn girl.
Roberta Schwartz, 35, who met her husband while undergoing chemo for breast cancer diagnosed in 1997, describes herself as "probably the most practical person you'll ever meet."
So before having kids, she considered that she might not get to raise them. "My husband is probably the best man in the universe," says Schwartz, a hospital executive whose third child is due next month. "His family is incredibly tight and solid. I knew the kids would be OK."
Because Schwartz wasn't in a serious relationship when diagnosed, "I don't know that having kids was the foremost thing on my mind."
But young, newly diagnosed breast cancer patients should look into fertility preservation, advises Kutluk Oktay, director of the fertility preservation program at New York-Cornell Medical Center and an associate professor at Cornell's Weill Medical College.
If they have time and a partner, the best option is in vitro fertilization before beginning treatment, Oktay says. Frozen embryos can be used later.
Hormones affect treatment
Doctors usually avoid giving breast cancer patients standard fertility drugs, which increase estrogen levels, thus, possibly, fueling nascent tumors, Oktay says. But he has developed protocols using low-dose fertility drugs with tamoxifen or letrizole, both taken by breast cancer survivors to prevent a recurrence.
Women without a partner could take ovary-stimulating drugs and then have their eggs frozen. Worldwide, only 120 babies have been born from frozen eggs, Oktay says.
Patients who must begin cancer treatment at once don't have time for fertility drugs. They can have ovarian tissue removed and frozen for reimplantation later. But only one or two babies have ever been born to women who went this route, Oktay says.
Outlaw, who works in real estate marketing, says her oncologist gave her no options. After chemo and surgery, she says, she considered fertility treatments but was turned down because of her cancer history.
A gynecologist suspected that tamoxifen might be blocking ovulation. At the doctor's suggestion, she went off the drug in January 2004 to see whether she'd start ovulating.
Tamoxifen is supposed to be taken for five years, but not during pregnancy. Some women have surrogates carry their fetuses while they continue on tamoxifen. Some have a baby before going on it, while others stop taking it, have a baby and then go back on it. It's not yet known how timing might affect the drug's effectiveness.
Outlaw was pregnant by June 2004. Used to bad news, Outlaw says, she and her husband didn't know how to react. After an uneventful pregnancy, son Gage was born in April.
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