Promise Sefogah, MBChB, MPH, MD, FWACS
Nominated From: University of Michigan
Research Site: University of Ghana
Research Area: Cancer and reproductive health (Onco-fertility)
Primary Mentor: Dr. Cheryl Moyer
Barriers to fertility preservation among women undergoing breast cancer treatment in Ghana
Globally, breast cancer is the most diagnosed fatal cancer, and the leading cause of cancer death among women. This is particularly true in low-resource countries. (1) In higher-income countries, breast cancer is second to lung cancer as the most prevalent cause of cancer death amongst women. In Ghana, breast cancer is the most common cancer among women and accounts for the highest burden of mortality in women. (2) In a study by Ghartey FN, et al, they reported that in Ghana the average age for breast cancer diagnosis was 38years, with 30% of women diagnosed being below 35 years and only 26% of Ghanaian breast cancer patients being postmenopausal. (3) This was an instructive finding in a sub-Saharan African country reporting an increasing proportion of breast cancer cases in women below 35-years, and further suggesting a significantly increasing risk of the disease in younger Ghanaian women. (3) The peak age for breast cancer in Ghana has been reported to be ten years below that for the Caucasian population. Although the incidence of breast cancer increases with age, it has become the most commonly diagnosed malignancy in women of childbearing age, as many women now delay childbearing. These women present with advance disease, often requiring gonadotoxic chemotherapy that increases the risk of subsequent fertility impairment. While survival rates from breast cancer are increasing, there is an associated increase in the number of young women breast cancer survivors with fertility wishes and needs.(4) Cancer treatment in general may influence female reproduction through various mechanisms. Notably, at the level of the gonads, whole-body or pelvic only radiation may result in radiation-induced menopause as they can be toxic to the ovaries especially with high dose radiations. (5) These women may also develop premature ovarian insufficiency from depletion of their ovarian reserves. (6) One treatment alone, with gonadotoxic therapy, can affect gametes quality and DNA. The administration of chemotherapy in these younger women puts them at risk of premature ovarian insufficiency and in effect, reduced fertility potential. (7) There is on average a 20% risk of permanent chemotherapy-induced ovarian failure with the use of the current breast cancer treatment regimen in women below the age of 40. (8) Fertility impairment from cancer treatment also results from radiotherapy or surgical procedures that either remove the gonads or compromise their function.(9),(10) Infertility associated with chemotherapy has negative impact on the patient’s quality of life and more so patient outcomes as it has been found to have an effect on adherence to systemic chemotherapy in over a quarter of cases. (11) Facilities that have offered fertility preservation have been found to have seen a significant improvement in patient satisfaction. (11) Fertility Preservation (FP) refers to the medical treatment procedure to defer conception but safeguard one’s gametes from ageing. Owing to advancement in reproductive technology, breast cancer patients now have a variety of options for fertility preservation. Cryopreservation, a process by which gametes or gonadal tissues are frozen for future us, is one of the well-established options. (12) Also, the administration of gonadotropin releasing hormone agonist before and during chemotherapy has been suggested. (12) Cryopreservation in women includes egg-freezing, embryo-freezing or ovarian tissue freezing and appears most suitable, studied and universally accepted for cancer patients. (13) The American Society of Clinical Oncologists (ASCO) proposes embryo cryopreservation to be the safest and most likely to succeed of FP methods available. (14) Currently, available evidence indicates that at the time of diagnosis, nearly 50% of young women with breast cancer are concerned about their fertility function after treatment. However, only 10% used any form of fertility preservation strategies. (15) High rates of unmet information needs have been reported amongst breast cancer patients, despite their desire to have children (16) and this may be traced to the lack of information regarding FP options. (17) As a result, fertility preservation in young women with breast cancer has emerged as a very important issue bothering on the quality of life for these women during and after treatment. This needs to be thoroughly discussed with the patients in the reproductive age group early following their diagnosis followed by referral to the reproductive specialist. There has been limited data on the depth of discussion between healthcare workers and patients regarding FP options after cancer diagnosis. (6) It is however generally recommended that patients are made aware of the possibility of future infertility that comes with the diagnosis of malignancy in the reproductive age group. (15) In light of this, the option of Fertility Preservation (FP) should be discussed with the patient early in their management process. (18)
This study is important because increasingly, breast cancer is being diagnosed among women below 40years who either are yet to start or complete a family, and with increasing improvements in medical interventions, many of them are surviving cancer treatments and would wish to have biological children. Knowing about the possibility of preserving their fertility and getting to do so have been associated with improved quality of life for these breast cancer patients. This study there aims to explore how much these patients know about the concept and option of fertility preservation, their perspectives on it and what patient-related and provider-related barriers exist for fertility preservation in our setting. It is expected that findings from this study should set the tone for further engagements and discussions with policy-makers towards addressing these barriers in order to have fertility preservation become a systemic part of comprehensive care for breast cancer patients in Ghana and other low and middle income countries.