This section includes information about things women may need to consider when making decisions about treatment.
Travelling
Women who live outside a major city may need to travel to see a specialist surgeon, radiation oncologist or medical oncologist.
Once the treatment plan has been decided, it’s usually possible to have chemotherapy at a hospital in the nearest regional town. However, some women have to travel for surgery and radiotherapy.
It may be possible for women who need to travel to get financial assistance, accommodation or other practical help during treatment.
Pregnancy
Some breast cancer treatments are not recommended for women who are pregnant when diagnosed with breast cancer. Some treatments can also affect a woman’s ability to have children in future.
Treatment for breast cancer during pregnancy
If a woman is pregnant when she is diagnosed with breast cancer:
- it’s possible to have breast surgery with only a slight risk of miscarriage; the risk of miscarriage is lower after the first trimester
- radiotherapy is not recommended because it may harm the unborn baby; radiotherapy can be given after the baby is born
- chemotherapy is not recommended during the first trimester because it may harm the unborn baby; chemotherapy is often given during the second and third trimesters, when the risk of harm is lower
- hormonal therapy and trastuzumab (Herceptin®) are not recommended.
Pregnancy during treatment for breast cancer
It’s recommended that women do not become pregnant during treatment for breast cancer. Treatments such as chemotherapy and radiotherapy can harm the unborn baby.
Women should use contraception if it’s possible that they could become pregnant during treatment, even if periods become irregular or stop during treatment.
Effects of breast cancer treatment on fertility
Some treatments for breast cancer can affect a woman’s fertility. Once treatment has finished there’s no reliable test to find out if a woman will be able to fall pregnant in future.
Women who were planning to have children before their breast cancer diagnosis should speak to their oncologist before starting treatment for breast cancer. It may be possible to see a fertility specialist to discuss the available options.
Some treatments for breast cancer can affect your fertility (your ability to have children).
Once your cancer treatment has finished there is no reliable test to find out if you can still become pregnant. If your periods stop for a year or more, it’s more likely that your menopause will be permanent. If your menopause is permanent, you will be unable to get pregnant naturally.
If being able to have children is important for you, speak to your treatment team about fertility and family planning before starting treatment for breast cancer. Your oncologist may suggest that you see a fertility specialist to discuss your options.
Surgery or radiotherapy to the ovaries and fertility
Surgery and/or radiotherapy to the ovaries causes permanent infertility.
If a woman has her ovaries removed by surgery, or if she has radiotherapy to the ovaries, she will no longer be able to have children naturally.
Chemotherapy and fertility
Some chemotherapy drugs can cause a woman to become infertile.
Some women (usually women under 35 years) find that their periods return once chemotherapy finishes. However, this doesn’t mean that they are able to have children.
The effect of chemotherapy on fertility depends on a number of things, including the woman’s age and the type of drugs she receives. These effects can also vary between different women of the same age.
Hormonal therapies and fertility
Treatment with hormonal therapies (endocrine therapies) doesn’t cause infertility. However, a woman’s fertility may fall naturally while taking hormonal therapies. Most hormonal therapies for breast cancer are given for 5 years. After 5 years, a woman’s fertility will have fallen naturally because she’s older.
Although hormonal therapies for breast cancer can cause menstrual periods to stop, this doesn’t necessarily mean that a woman can’t become pregnant while taking hormonal therapies. Women who are sexually active while taking tamoxifen should use effective contraception if they don’t wish to become pregnant during this time.
Treatments for breast cancer may reduce fertility temporarily or permanently. However, this doesn’t mean it’s impossible to become pregnant during or after treatment.
Contraception after breast cancer treatment
Treatments for breast cancer may reduce fertility temporarily or permanently. However, this does not mean it is impossible to become pregnant during or after treatment.
Contraception containing hormones, such as the oral contraceptive pill (‘the pill’), implants or injections, should generally not be used after breast cancer. Therefore it’s recommended that you use non-hormonal forms of contraception, such as condoms, diaphragms, intrauterine contraceptive devices (IUDs) or male or female sterilisation if you don’t want to become pregnant. It’s still possible to catch sexually transmitted infections (STIs) after menopause. Condoms are the most effective way of protecting against STIs.
If you were pre-menopausal before breast cancer and you are sexually active, talk to a member of your health care team about suitable methods of contraception for you.
Although some breast cancer treatments can cause menstrual periods to stop, this doesn’t necessarily mean a woman can’t become pregnant during treatment. It’s important for women who are sexually active to continue to use contraception during and after breast cancer treatment.
There’s no evidence about whether or not it’s safe to take the oral contraceptive pill (‘the pill’) or use implants (etonogestrel implants) during or after treatment for breast cancer. Therefore it’s recommended that women use non-hormonal forms of contraception, such as condoms, diaphragms, intrauterine contraceptive devices (IUDs) or male or female sterilisation.
It’s still possible to catch sexually transmitted infections (STIs) after menopause. Condoms are the most effective way of protecting against STIs.
Breast cancer treatment and pregnancy
Some breast cancer treatments are not recommended for women who are pregnant when diagnosed with breast cancer. Some treatments can also affect a woman’s ability to have children in future.
Treatment for breast cancer during pregnancy
If a woman is pregnant when she is diagnosed with breast cancer:
- it’s possible to have breast surgery with only a slight risk of miscarriage; the risk of miscarriage is lower after the first trimester
- radiotherapy is not recommended because it may harm the unborn baby; radiotherapy can be given after the baby is born
- chemotherapy is not recommended during the first trimester because it may harm the unborn baby; chemotherapy is often given during the second and third trimesters, when the risk of harm is lower
- hormonal therapy and trastuzumab (Herceptin®) are not recommended.
Pregnancy during treatment for breast cancer
It’s recommended that women do not become pregnant during treatment for breast cancer. Treatments such as chemotherapy and radiotherapy can harm the unborn baby.
Women should use contraception if it’s possible that they could become pregnant during treatment, even if periods become irregular or stop during treatment.
Effects of breast cancer treatment on fertility
Some treatments for breast cancer can affect a woman’s fertility. Once treatment has finished there’s no reliable test to find out if a woman will be able to fall pregnant in future.
Women who were planning to have children before their breast cancer diagnosis should speak to their oncologist before starting treatment for breast cancer. It may be possible to see a fertility specialist to discuss the available options.
Find out more
Tips for making decisions
Women can be fully involved in all decisions about their treatment for breast cancer. Everyone has the right to a second opinion at any time.
Tips for making decisions about treatment
- Ask your doctor about the possible benefits and side effects of each treatment.
- A diagnosis of breast cancer can be overwhelming. You’ll be given lots of information and you may find it difficult to remember everything. Ask your doctor to repeat things or write things down for you.
- Ask for time to read about different treatments or to talk to family and friends if you feel you need to.
- It’s OK to take a week or two to decide about treatment. This can allow time to choose which treatment is right for you and to make practical arrangements. Taking a week or two to decide will not affect the treatment outcome.
- If you have been diagnosed with breast cancer and would like to talk to someone else about your treatment options, ask your GP or specialist to refer you to another doctor. You may decide after seeing another doctor that you would prefer the original doctor to manage your treatment. The fact that you have seen someone else should not affect how the first doctor manages your treatment.
- After weighing up the benefits and side effects, you may decide not to have a particular treatment. Discuss your decision with your healthcare team and those close to you.
Questions to ask
Listed below are some general questions that may be helpful when first talking about treatment for breast cancer. Questions about individual treatments are listed in the relevant treatment section.
- Will I need to travel for treatment?
- What impact will being pregnant have on the timing of my treatment?
- Can I have a second opinion?
- Can I bring a friend/family member to my appointments?
- Do you mind if I tape record our discussion?
- Can you write down what you have told me?
Information for health professionals about the MammaPrint® test for early breast cancer
What is the MammaPrint® (70 gene signature) test?
MammaPrint® is a gene profile test (a genomic test of breast cancer tumour cells). It examines 70 different genes to look for changes associated with a higher risk of breast cancer recurrence after treatment. The aim of the MammaPrint® test is to help inform decisions about whether to use chemotherapy after local treatment for early breast cancer.
What did MSAC conclude about the MammaPrint® test?
MSAC did not support public (Government) funding for the MammaPrint® test in Australia. This conclusion was based on a review of the safety, clinical effectiveness and cost-effectiveness.
Why did MSAC reach the conclusion not to support public funding of the MammaPrint® test in Australia?
MSAC based its conclusion on its appraisal of a study known as the MINDACT trial which investigated the use of the MammaPrint® test in a clinical trial setting.
The trial aimed to show whether information provided by the MammaPrint® test could be added to existing clinical information to inform decisions about the use of adjuvant chemotherapy for early breast cancer. The trial showed that, overall, breast cancer outcomes were poorer in women who did not have chemotherapy based on the MammaPrint® test, compared with those who received chemotherapy.
“As a result, MSAC had little confidence that the MammaPrint® test could be used to justify withholding chemotherapy without negatively impacting upon important outcomes, including overall survival.”
http://www.msac.gov.au/internet/msac/publishing.nsf/Content/1376.1-public
Does this MSAC conclusion apply to other gene profile tests?
MammaPrint® is one gene profile test that has been considered by MSAC for public funding. A number of such tests have been developed to assess the risk of breast cancer recurrence after initial treatment, in order to guide a patient’s decision about the use of chemotherapy.
To date, none of the tests reviewed by MSAC has been considered to provide sufficient evidence of benefit to be approved for public funding in Australia. However, gene profile tests are an active area of research. MSAC’s conclusion in relation to this particular test (MammaPrint®) does not necessarily mean that the Committee would reach the same conclusion for other gene profile tests in the future.
Is the MammaPrint® test available in Australia?
Currently no gene profile tests, including MammaPrint® for use in early breast cancer, are publicly funded in Australia, however patients can choose to personally pay for such a test.
Patients who choose to undertake the MammaPrint® test after being informed about the MSAC findings, should be made aware that there is an out of pocket cost for the test. This is called informed financial consent. Patients should also be made aware that breast cancer tissue is sent overseas for testing.
What should I tell a patient considering having the MammaPrint® test?
A clinician’s role is to provide advice about treatment options relevant to the individual patient. This advice should consider clinical and patient characteristics and include the potential benefits and risks of treatments. The consideration of the MammaPrint® test should be in the context of providing a clear explanation of the MSAC conclusion based on the MINDACT trial.
http://www.msac.gov.au/internet/msac/publishing.nsf/Content/1376.1-public
Current clinical practice involves the use of patient and tumour criteria to determine if chemotherapy is recommended. Patients who choose to undertake the MammaPrint® test after being informed of the MSAC conclusion, should be advised of the out of pocket costs, as part of informed financial consent and the fact that samples are currently sent overseas for testing.
What should I tell a patient who has had the MammaPrint® test?
Inform the patient that treatment decisions are based on the best available information at the time. There are many factors considered in the decision about whether or not to have chemotherapy, including specific clinical and tumour characteristics.
Recent assessment undertaken by MSAC of the MammaPrint® test considered the results of a randomised controlled trial, the MINDACT trial. Based on the study, MSAC concluded that withholding chemotherapy on the basis of the MammaPrint® test led overall to poorer breast cancer outcomes for some patients. Further details can be found in the MSAC Public Summary Document at http://www.msac.gov.au/internet/msac/publishing.nsf/Content/1376.1-public
If you are not the treating specialist, encourage the patient to discuss any concerns they have associated with the use of the MammaPrint® test with their specialist treating clinicians.
What should I do if I treated patients who have had the MammaPrint® test?
If you have treated a patient who decided not to have chemotherapy after using the MammaPrint® test, consider the need to contact the patient and counsel them based on the MSAC conclusion with respect to the particular circumstances of the patient.
For more information on MSAC’s conclusion in relation to the MammaPrint® test, visit the MSAC website at
http://www.msac.gov.au/internet/msac/publishing.nsf/Content/1376.1-public
and supporting information.
