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Patient-Related Awareness of Impact of Cancer-
Directed Therapy on Fertility in Young Women
Diagnosed of Breast Cancer
Nita S. Nair1Basila Ameer Ali1Shabina Siddique2Amita Maheshwari1Jyoti Bajpai3Vani Parmar1
Seema Gulia3Garvit Chitkara1Shalaka Joshi1Rohini Hawaldar2Rajendra A. Badwe1
1Department of Surgical Oncology, Tata Memorial Centre, Homi
Bhabha National Hospital, Mumbai, Maharashtra, India
2Clinical Research Secretariat, Tata Memorial Centre, Homi Bhabha
National Hospital, Mumbai, Maharashtra, India
3Department of Medical Oncology, Tata Memorial Centre, Homi
Bhabha National Hospital, Mumbai, Maharashtra, India
South Asian J Cancer
Address for correspondence NitaS.Nair,DNB(GenSurg),MRCS(Ed),
MCh (Surg Oncology), 1215, HBB 12th floor, Tata Memorial Hospital,
Dr E Borges Road, Parel, Mumbai 400012, Maharashtra, India
(e-mail: nitanair@hotmail.com).
Keywords
►breast cancer
►fertility preservation
►QOL
Abstract Chemotherapeutic agents used in the treatment of breast cancer (BC) adversely impact
growing ovarian follicles and can induce permanent premature ovarian failure or
reduce ovarian reserve in younger women. As treatments result in improved survival of
BC patients, young survivors face quality of life (QOL) issues, including treatment-
related infertility. We conducted a survey to evaluate awareness among patients
regarding the impact of cancer-directed therapy on fertility and available options of
fertility preservation (FP). We interviewed 350 women with BC under 40 years of ageat
the start of treatment, of which 321 (91.70%) were in varying stages of follow-up, 8
women (2.30%) were scheduled to start treatment, and 21 (6.00%)womenwereunder
treatment. All received chemotherapy or hormone therapy with or without ovarian
suppression. Of the 350 women who responded to the survey, 321 (91.70%) women
were on follow-up, 8 (2.30%) women were due to start treatment, and 21 (6%) women
were on treatment. The median age at diagnosis was 35 years, with 12.9% of women
aged less than 30 years, 15 (4.28%) were unmarried, 31 (8.85%) were nulliparous, and
98 (28%) had one child. Overall, 271 (77.42%) women were aware (at the start of
treatment) of impact of therapy on fertility, but only 48/271(17.71%) women were
aware of the options of FP. In this cohort, 94/350 (26.85%) women felt FP was a priority,
64/350 (18.28%) women perceived their family as incomplete, and 17/64 (26.56%)
women were willing to consider invasive reproductive assistance (IRA). Reasons for
refusal for IRA included cost, risk of relapse, and delay of treatment. There was an
association between being unmarried (p¼0.00), having an incomplete family (0.00),
Nita S. Nair
DOI https://doi.org/10.1055/s-0043-1771385 ISSN 2278-330X
How to cite this article: Nair NS, Ali BA, Siddique S, et al. Patient-
Related Awareness of Impact of Cancer-Directed Therapy on
Fertility in Young Women Diagnosed of Breast Cancer. South Asian
J Cancer 2023;00(00):00–00
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Original Article
Article published online: 2023-07-31
Introduction
Breast cancer is the most common cancer in women,1with a
median age of presentation in India being 47 years in India.2
On an average, woman under 35 years of age constitutes less
than 10% of patients presenting with breast cancer in India.3
Diagnosis of breast cancer at young age is associated with
greater frequency of adverse prognostic factor profiles, also
independently associated w ith poor prognosis4,5 and most of
these patients require chemotherapy. Additionally, selective
estrogen receptor modulator tamoxifen with or without
ovarian suppression is given to all hormone r eceptor-posit ive
breast cancer patients in the premenopausal age group for
the duration of at least 5 years as adjuvant endocrine thera-
py.6Chemotherapeutic agents used in the treatment of
breast cancer adversely impact the different stages of follicle
growth, induce permanent premature ovarian failure in the
older premenopausal women, and induce ovarian reserve
damage in the younger women.7Chemotherapy can affect
this reserve by directly inducing damage to the ovary the
magnitude of which is inversely related to age with younger
women at lower risk compared to older women.8Addition-
ally though tamoxifen is not known to cause infertility, it
may interfere with childbearing because of the duration of
the treatment 5 to 10 years during which time women are
advised not to get pregnant.9However, more recent results
from the positive trial may offer respite for women desirous
of a pregnancy while on adjuvant hormone therapy.10 As the
landscape of systemic therapy changes, we are seeing
improvements in survival and quality of life among survivors
has come to the forefront. Fertility-related concerns have a
significant impact on quality of life and often impact treat-
ment decisions among young women with breast cancer. As
the field of oncofertility continues to develop around the
globe, regular assessment of both international and regional
barriers to quality care must continue to guide process
improvements.11 Fertility preservation in a women with
cancer largely refers to safeguarding the ability of the indi-
vidual to conceive and carry a child to term, at a time they
wish to do so and the term oncofertility was thus coined by
Woodruff in 2006 for fertility preservation in cancer
patients.12 We conducted a survey to evaluate the awareness
among patients regarding the adverse effects of cancer-
directed therapy on fertility and available options of fertility
preservation.
Methodology
Objective: The aim of this study was to evaluate the level of
awareness regarding the adverse effect of cancer-directed
therapy on fertility and available options of fertility preser-
vation among young women diagnosed with breast cancer.
The study was approved by the institutional ethics board.
Method: We conducted a prospective observational study
wherein, after obtaining informed consent, we interviewed
350 women with curative breast cancer from August 2017 to
August 2018, who were under 40 years of age at the time of
their treatment, all of whom have or will receive chemo-
therapy and/or hormone therapy with or without ovarian
suppression using luteinizing hormone releasing hormone
agonist (LHRHa) or gonadotropin-releasing hormone ana-
logues, as part of their treatment. We excluded women over
40 years of age and those who had undergone a hysterecto-
my. All eligible women answered a predesigned question-
naire that was constructed by treating oncologists at our
center which is a tertiary cancer center. The survey included
questions curated by members of the breast cancer disease
management group and gynecologists at our tertiary cancer
center (Supplementary Material 1).
Statistical consideration: Assuming that 40%13 of the
target population will have knowledge about the effects of
cancer-directed therapy on fertility and methods of fertility
preservation, a sample size of 350 was required to achieve a
confidence interval of 95% with an alpha error of 0.05. The
study endpoints are descriptive and reported as percentages.
The association between patient factors and choices made
was compared using chi-squared test.
End-point: The awareness among patients regarding ef-
fect of cancer-directed treatment on fertility and the options
available for fertility preservation.
Results
Of the 350 women with nonmetastatic breast cancer who
responded to the survey, 321 women (91.70%) were in
varying stages of follow-up (and had not had a recurrence),
8 (2.30%) women were scheduled to start treatment, and 21
(6.00%) women were under treatment for breast cancer. The
median age at diagnosis of respondents was 35 years (range:
22–40), with 12.9% under 30 years of age. At presentation,
209 women (59.71%) had early breast cancer and 141
(40.28%) had locally advanced cancer, and 269 women
(76.85%) were homemakers (►Table 1).
Patients were interviewed for details of reproductive factors
and parity, wherein (►Table 2), 15 (4.28%) women were
unmarried and 335 (95.71%) were married. Majority of women
(221; 63.14%) had two or more children, 31 (8.85%) were
nulliparous, and 98 (28%) had one child. Among the 98 who
had one living child, 9/98 women (9.18%) gave history of having
considering more children (p¼0.00) and willingness to consider IRA. FP is a priority for
women treated for BC and an important QOL domain that needs to be addressed at the
start of treatment We found a high level of awareness of impact of cancer-directed
therapy to fertility in this cohort, but low awareness and acceptance for options for FP.
South Asian Journal of Cancer © 2023. MedIntel Services Pvt Ltd. All rights reserved.
Patient-Related Awareness of Impact of Cancer-Directed Therapy on Fertility in Young Women Diagnosed of
BC Nair et al.
required assisted reproductive methods in the past. When asked
if the women perceived their family was complete at the start of
treatment, 283 (80.85%) answered in the positive, while 64
(18.28%) wanted more children and 3 (0.85%) were not sure. Of
those with incomplete families, 31 were nulliparous, 21 had one
child, and 12 had two or more children.
At the start o f treatment, 271 (77.4 2%) women were aware
of adverse effect of cancer-directed therapy on fertility, 243
(89.66%) were informed by the treating physician, and the
remaining women were informed by the nurse (5.90%),
family and friends (3.32%), and media (2.22%). Overall,
48/271 (17.71%) women were aware of the options of
fertility preser vation, 13/271 (4.79%) were aware of LHRHa
use, 35 (9.22%) were aware of embryo preservation, 8 (2.95%)
were aware of oocyte preservation, 3 (1.10%) were aware of
ovarian tissue preservation, and only 40 (14.76%) were aware
of success rates of any fertility preservation technique.
Assuming additional information was given only to those
who had not completed their family, we evaluated the
frequency of information given to those 64 women who
reported their family is not complete, 52/64 (81.3%) were
aware of adverse effect of cancer-directed therapy on fertili-
ty, and of the 52 women , 13 (25%) women were aware of the
options of fertility preservation, 3 (5.8%) were aware of LHRH
use, 11 (21.2%) of embryo preservation, 02 (3.8%) of oocyte
preservation, 01 (1.9%) ovarian tissue preservation, and only
11(21.1%) were aware of success rates of any fertility preser-
vation technique.
One-hundred and thirty-two women (37.3%) reported that
the doctor took measures to preserve ovarian function and 46
(13.1%) women felt it was safe to have a child on treatment.
Misconceptions relatedto intercourse were also apparentwith
137/350 (39.14%) reporting they felt it was to not acceptable to
have intercourse while on treatment (►Table 3).
Of the 350, 65 (19%) women felt future pregnancies would
affect their cancer relapse.
Table 1 Patient characteristics
Patient characteristics No. of patients
Early breast cancer 209 (59.71%)
Locally advanced breast cancer 141 (40.28%)
On follow-up 321 (91.70%)
Under treatment
On NACT
Post-surgery
On adjuvant chemotherapy
On adjuvant radiotherapy
21 (6%)
06
06
06
03
Due to start treatment 8 (2.30%)
Homemakers 269 (76.85%)
Employed 66 (18.85%)
Self-employed 15 (4.28%)
Median age at diagnosis 35 years (mean 34.58
years, range 22-40)
25
25–29
30–35
36–40
14 (4%)
31 (8.90%)
138 (39.40%)
167 (47.70%)
Abbreviation: NACT, neoadjuvant chemotherapy.
Table 2 Marital status and parity
Factors that impact fertility needs
(marital status and parity)
No. of patients
Unmarried 15 (4.28%)
Married 335 (95.71%)
Nulliparous 31 (8.85%)
1 child 98 (28%)
2 or more children 221 (63.14%)
Table 3 Awareness of adverse effects of cancer-directed therapy on fertility and options of fertility preservations
No. of patients
Patients aware of adverse effects of cancer-directed therapy on fertility 271/350 (77.42%)
A) Source of information (could tick more than one option)
Patients informed by the treating Physician 243/271 (89.66%)
Patients informed by the nurse 16/271 (5.90%)
Patients informed by family and friends 9/271 (3.32%)
Patients informed by media 6/271 (2.22%)
B) Patients aware of options of fertility preservations 48/271 (17.71%)
C) Awareness on type of fertility preservation (could tick more than one option)
LHRHa use 13/271 (4.79%)
Embryo preservation 35/271 (9.22%)
Oocyte preservation 8/271 (2.95%)
Ovarian tissue preservation 3/271 (1.10%)
Success rates of fertility preservation 40/271 (14.76%)
luteinizing hormone releasing hormone agonist
South Asian Journal of Cancer © 2023. MedIntel Services Pvt Ltd. All rights reserved.
Patient-Related Awareness of Impact of Cancer-Directed Therapy on Fertility in Young Women Diagnosed of
BC Nair et al.
Of the 64 who felt they had not completed their family, 17
(26.56%) suggested they would consider an invasive proce-
dure (embryo or oocyte or ovarian tissue preservation) for
reproductive assistance. The reasons for refusal cited were
cost by 32 (50%) women, fear of invasive procedure 32 (50%)
women, risk of relapse or delay of treatment by 32 (50%)
women, and lack of awareness of safety of procedures by 35
(54.68%) women (►Table 4).
There was a significant association between being
unmarried/nulliparous versus having a child (p¼0.00), con-
sidering family incomplete versus not (0.00), wanting more
children versus not (p¼0.00) and th e wo men’s willingness to
consider invasive procedures for reproductive assistance. We
grouped the impor tance of fertility preser vation as perceived
by these as high, moderate, and low and found that 94/350
(26.85%) felt it was a high priority and 45/94 (47.87%) had not
completed their family at the time of treatment for breast
cancer (p¼0.00). Also 57 women suggested they considered
having a child if cancer free for a few years, while 42 (73.3%)
women considered fertility preservation a high priority
(p¼0.00).
Discussion
The cross-sectional study presented here evaluated the
knowledge and awareness of cancer-directed systemic ther-
apy on fertility among women treated for breast cancer.
Despite a median age at diagnosis of 35 years (range 22–40),
with 12.9% under 30 years of age in this cohort, over 80% had
completed their family; this is not unusual to the average
Indian family unit, which is in stark comparison to reports
from the west.14 Advances in treatment of breast cancer have
resulted in higher sur vival rates and with 20% young survi-
vors wanting to have children and many more facing symp-
toms associated with premature ovarian failure, fertility
preservation at the star tof treatment has been gaining focus.
The American Society of Clinical Oncology guidelines15
recommend that women in the reproductive age group
should be given the opportunity to preserve their fertility
with embryo cryopreservation, oocyte cryopreservation,
ovarian tissue cryopreservation or LHRHa, requiring health-
care providers to discuss the same with patients prior to
starting treatment.
Majority (77.4%) of women in this cohort were aware of
adverse effect of cancer-directed therapy on fertility, and
at the start of treatment, almost 90% were informed by the
treating physician. This may be a reflection of the survey
having been conducted at a tertiary referral center. Other
reports including a cross-sectional survey from a gynecol-
ogy department in north India reported that only 32% of
the patients were aware of the detrimental effect of cancer
treatment future fertility and was related to the socioeco-
nomic status of the woman and 32% received the informa-
tion from their treating physician.13 A systematic review16
reported on factors that influence a physicians discussion
on fertility preservation with young cancer patients and
suggested the physicians knowledge, sense of comfort,
patient factors, and availability of educational materials
were the main barriers. With fertility preservation being
incorporated in major guidelines, the attitude of oncolo-
gistshasalsoimprovedasisseeninoursurveywith90%
women being informed by their treating oncologist.
However, only 25% of those who felt their family was not
complete were aware of the options of fertility preservation
and 17/64 (26.56%) women suggested they would consider
an invasive procedure (embryo or oocyte or ovarian tissue
preservation) for reproductive assistance.
Despite awareness of the toxicity of systemic therapy and
desire to preserve fertility, there are many misconceptions
and fear in the mind of the women. The reasons for refusal to
consider future pregnancies with assisted reproduction
methods cited in our study included cost, fear of invasive
Table 4 Patients who wanted fertility preservation
N/D (%)
Patients who had completed their family 283/350 (80.85%)
Patients who weren’t sure about completeness of family 3/350 (0.85%)
Patients who wanted more children 64/350 (18.28%)
Nulliparous
One child
Two or more children
31/64 (48.43%)
21/64 (32.81%)
12/64 (18.75%)
Would consider invasive procedures for reproductive
assistance
Yes
No
17/64 (26.56%)
47/64 (73.43%)
Reasons for refusal
(Could tick more than one option)
Cost
Fear of invasive procedures
Risk of relapse or delay of treatment
Lack of awareness of safety of procedures
32/64 (50%)
32/64 (50%)
32/64 (50%)
35/64 (54.68%)
South Asian Journal of Cancer © 2023. MedIntel Services Pvt Ltd. All rights reserved.
Patient-Related Awareness of Impact of Cancer-Directed Therapy on Fertility in Young Women Diagnosed of
BC Nair et al.
procedure, risk of relapse or delay of treatment, and lack of
awareness of safety of procedures. Studi es have reported that
patients who found out about fertility preservation from
their healthcare providers were far more likely to use cryo-
preservation options than those who found out about it from
other means.17
With changes in guidelines and practices over the years,18
awareness among treating oncologists may have improved,
so we also reviewed our referral pattern for fertility preser-
vation in the more recent years. Options for fertility preser-
vation were offered to all eligible women and 22% chose the
option of gonadotropin realizing hormone but less than 2%
were willing for invasive procedures, and most refused the
same due to cost or fear of recurrence. This suggested that
despite more information for both oncologists and patients,
use of invasive methods of assisted reproduction and fertility
preservation is still not often discussed or chosen in our
oncology practice.
A strength of this cohort is that we included over 91%
women on follow-up without recurren ce, assuming now that
they can thus focus on quality-of-life concerns, we may get a
more accurate view of how these women prioritize fertility.
Limitations of this survey include a possible recall bias as
women were interviewed o n follow-up about discussion that
has taken place at the start of their treatment. Additionally,
we have not accessed the economic and educational level of
this cohort that may influence these choices and decisions.
Conclusions
Despite a high level of awareness of impact of cancer-direct-
ed therapy on fer tility in this coho rt, we found low awareness
and acceptance for options for fertility preser vation. Fertility
preservation must be discussed with women in the repro-
ductive age group prior to starting treatment to benefit
women for whom it is a high priority. Oncologists are the
most common source for this information for the patient and
can dismiss myths and fears related to cancer recurrence and
fertility preser vation.
Conflict of Interest
None declared.
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BC Nair et al.
