Contraceptive Needs Fertility Intentions of Women with Breast Cancer in Cape Town
Project ended 30 June 2020
A/Prof Jane Harries
- Women’s Health Research Unit, School of Public Health and Family Medicine, Health Sciences Faculty, University of Cape Town
Title of the project
Contraceptive needs and fertility intentions of women with breast cancer in Cape Town: a qualitative exploratory study.
Breast cancer remains the commonest cancer among women globally with nearly 1.7 million new cases diagnosed in 2012 (WCRF, 2012). Breast cancer survival rates vary greatly worldwide, ranging from 80% in North America, Sweden and Japan to around 60% in middle-income countries and below 40% in low-income countries.
In South Africa, breast cancer is the most common cancer in women, with an age-standardised incidence rate of 26.9 per 100 000 women (NCR 2005), and a major cause of cancer mortality, accounting for 15.6% of cancer deaths among women (Bradshaw et al, 2006). Late presentation and hence diagnosis and treatment of breast cancer further compounds the problem (Moodley et al, 2016). Breast cancer is an important women’s health issue, and premenopausal women with breast cancer comprise a special subgroup with unique concerns regarding contraception, early menopause, infertility, and future fertility options. Despite women’s needs for information on these issues, their levels of knowledge are considered insufficient compounded by limited counselling available to women (Karaöz, et al, 2010; Guthrie et al, 2015).
Limited data on contraceptive counselling and choices in women with breast cancer has been reported in developing countries and none in South Africa (Connell et al, 2006; Maslow et al, 2014; Guth et al, 2015). Contraception is challenging for women with cancer, particularly those with breast cancer, who are limited to non-hormonal methods notably the copper T380A intrauterine device (IUD) as hormonal contraception is usually contraindicated and therefore discontinued in women with breast cancer (Maslow et al, 2014; Guth et al, 2015). Contraceptive counselling in young breast cancer patients is complex and involves different decisions and choices during the continuum of care throughout breast cancer treatment including contraceptive counselling at the time of breast cancer diagnosis, preventing pregnancy during treatment, contraceptive counselling post-treatment and avoiding hormonal contraceptives (Connell et al, 2006).
Pregnancy during breast cancer treatment is contraindicated as chemotherapy administered during the first trimester results in increased congenital malformations (RCOG, 2011). Most clinicians recommend a delay of at least two years to allow aggressive breast cancer to become manifest before considering pregnancy underlining the need for effective, long-acting non-hormonal contraceptive methods (Guth et al, 2015).
When a woman is diagnosed with breast cancer, initial consultations with the oncologist focus predominantly on issues such as the implication of the cancer diagnosis itself, multimodal cancer therapy and coping with a life-threatening disease leaving little room and time for contraceptive counselling (Guth et al, 2015) and as most oncologists are not experienced in the field of contraception refer patients to gynaecologists (Gorman et al 2011; Guth et al 2015. However, little is known what happens once women are referred or whether they receive the most suitable contraceptive method and/or continue with the method.
Infertility after treatment is a major concern for young women with breast cancer particularly as it relates to opportunities for future childbearing influencing treatment intentions (Peate et al, 2009; Peate et al, 2011). Research in developed country contexts with more comprehensive programs has highlighted concerns amongst breast cancer patients that their concerns around fertility options are not adequately addressed, and noted women’s frustration with the paucity of information available (Thewes et al, 2003). A qualitative study amongst young Australian women with breast cancer highlighted a multiplicity of factors influencing decisions around contraception and the uncertainty of future fertility and childbearing options throughout care and treatment. Moreover, psychosocial issues emerged around mortality and survivorship (Connell et al, 2006).
No known reported studies have been undertaken in South Africa exploring the contraceptive and fertility needs and preferences of women of reproductive age diagnosed with breast cancer. Following discussion with doctors involved in the treatment of breast cancer patients at GSH, contraceptive and fertility counselling are not addressed in a comprehensive manner. Women are referred to public sector facilities for the non-hormonal IUD. However, access to the non-hormonal IUD is extremely limited at most health care facilities in the Western Cape and throughout South Africa (SADH, 2012; Hoke et al, 2014).
Intervention strategies that have been proposed in developing country contexts have suggested developing referral networks of fertility specialists and ensuring psychosocial support, improving patient-provider communication and assisting oncologists with guidelines and information around suitable contraceptive methods early in the treatment plan so as to be able to make informed decisions based on the best available evidence.
How the project was of value in the struggle against cancer
This is the first study undertaken in South Africa exploring the contraceptive and fertility needs and preferences of women diagnosed with breast cancer. No other studies to our knowledge have been conducted in South Africa and Sub Saharan Africa. This study is something totally new for women of reproductive age with breast cancer whose fertility and contraceptive needs have not been fully met. It will also provide information and support to oncologists and other providers for women diagnosed with breast cancer fertility and sexual health needs.
Future plans for this research project
There is a need for improved information and counselling regarding the impact of treatment on contraceptive and feasible fertility options. It is important that health care providers provide timely and ongoing information regarding fertility options and communicate with breast cancer patients about their fertility concerns prior to treatment and throughout the treatment trajectory including survivorship. The development of evidence-based information tools via print and social media platforms could facilitate patient-provider communication and address knowledge gaps especially for younger patients desiring more children. Information tools could also facilitate discussion between not only providers and patients but also wider social networks including family, friends, partners and support groups.