There can be a child even after a tumor

In Italy, every year, over 3,000 women get breast cancer when they are still of childbearing age. But the diagnosis does not necessarily mean that they will no longer be able to have children. In many cases, it is possible to cryopreserve oocytes or ovarian tissue and now there is a way to protect the ovaries from chemotherapy. It is also possible to interrupt hormone treatments for a short period of time to try to get pregnant. And we know that breastfeeding does not seem to increase the risk of recurrence. All these possibilities exist today thanks to Italian academic research. Which was a pioneer in this field already 25 years ago, when oncology was more focused on the treatment of the tumor than on the treatment of the person.

Young people's expectations

Lucia Del Mastro , full professor of Medical Oncology at the University of Genoa and director of the Medical Oncology Clinic at the Policlinico San Martino, was among the first in the world to ask what could be done to ensure that therapies did not compromise the expectations of young women with breast cancer. A line of research that began in 2000 and that has led to changes in clinical practice for fertility preservation, not only for those with breast cancer. Above all, to change the mentality of the world of oncology.

A pioneering work

Recovering from cancer does not only mean no longer having the disease, but having the same prospects as people who have never been ill. “This was the principle that moved us. Since it is not a line of research sponsored by the pharmaceutical industry,” says Del Mastro, “the only possibility to carry it forward was to find funding elsewhere. It is true, our work was pioneering, but so was the vision of the Airc Foundation, which supported us, accepting the challenge in an era in which fertility was certainly not considered a priority in oncology.”

Del Mastro's intuition was to use a drug that puts the ovaries to "rest" (an Lhrh analogue) to protect them from the toxicity of the treatments. Chemotherapy, in fact, mainly affects tissues in active replication, with the side effect of inducing early menopause in about a quarter of patients. "In 2001," explains the professor, "the first phase 2 study began on 30 patients and, to our surprise, we observed that over 90% of the women returned to having their menstrual cycle. Thanks to these results, and again with the support of the Airc Foundation, we were able to conduct the phase 3 study, which involved 16 Italian centers and which confirmed a clear reduction in the incidence of chemotherapy-induced menopause. That's not all: after the tumor, the women in that study treated with Lhrh analogues had double the number of pregnancies compared to the others."

Impressive results

Two results so striking that they were published, in 2011 and 2015, in the Journal of the American Medical Association (Jama) : demonstrating how important that research was for all of medicine, and not just oncology. Also in 2015, the American Society of Clinical Oncology (Asco) included it among the most significant advances.

“Beyond the results,” Del Mastro continues, “I believe that the most important impact of this research is its contribution to a cultural change. I remember the skepticism during the first conferences in which I presented the results. Among the objections, it was said that women could not also be burdened with the problem of fertility when such a serious diagnosis was communicated. That this would have a negative emotional impact. In reality, young women are much more afraid of the future than of chemotherapy. If we tell them that after the treatments they will still be able to have children, what do you think the emotional impact will be? It is anything but negative.”

Thus, Italy, with the Italian Association of Medical Oncology (Aiom), was among the first countries in the world to draft guidelines on fertility preservation – of which Del Mastro is coordinator – and the new protocol is also included in international guidelines, including those of Asco recently updated.

But research on fertility and pregnancy after cancer has not stopped and has contributed to breaking down other taboos, even for women with Brca mutations (the so-called “Jolie mutations”). With her is Matteo Lambertini (of the Policlinico San Martino and the University of Genoa) who, thanks to an Airc grant for young oncologists, will study the effect of new therapies on fertility.