Racial Differences in Live-Birth Outcomes After a Breast Cancer Diagnosis

Racial and ethnic disparities exist in subsequent live-birth rates after breast cancer.

Abstract

Breast cancer is the most common cancer among young women, and its treatment can compromise future fertility. Although racial and ethnic disparities are well established in cancer outcomes, their effect on postcancer fertility is not well understood. We evaluated racial and ethnic differences in live-birth rates between women diagnosed with breast cancer compared with the general population using linked data from California and the National Center for Health Statistics bridged-race population estimates. Among 25,448 women aged 20–49 diagnosed with stage I–III breast cancer between 2000 and 2012, breast cancer was associated with a 58% reduction in live-birth rate compared with women without cancer (birth-rate ratio 0.42; 95% CI, 0.39–0.47). Reductions varied by race and ethnicity: 61% in non-Hispanic White, 50% in non-Hispanic Black, and 32% in Hispanic women. Non-Hispanic Asian women had increased fertility (birth-rate ratio 2.21; 95% CI, 1.90–2.58). These findings highlight racial differences in reproductive outcomes after breast cancer underscoring the need for further research to identify contributing factors.

Breast cancer is the most frequently diagnosed cancer among women, with more than 300,000 new cases expected in 2024.¹ It is the most common cancer diagnosis among women younger than 45 years old,¹ making family-building considerations central to survivorship.

Racial and ethnic differences in cancer outcomes are well established,² but it remains unclear whether these differences extend to birth outcomes after cancer treatment. Understanding these patterns could help guide fertility counseling and inform targeted support for women at greatest risk of compromised fertility. In this study of women from California, we compared live-birth rates between women diagnosed with breast cancer and the general population to evaluate whether the association between breast cancer diagnosis and subsequent fertility differs by racial and ethnic groups.

METHODS

This study was approved by the University of Texas MD Anderson Cancer Center's IRB (IRB #2022-0953). We used linked California Cancer Registry and California Birth Data, as well as National Center for Health Statistics bridged-race population estimates (Appendix 1, available online at http://links.lww.com/AOG/E412), to calculate age group–specific birth counts and person-time for our two cohorts. The case group included women aged 20–49 years diagnosed with stage I–III breast cancer while residing in California between January 1, 2000, and December 31, 2012. The control group included women of the same age range and study period who had not been diagnosed with cancer. Follow-up began at the date of breast cancer diagnosis (or the corresponding index date for the control group) and continued until death or the end of the study period (December 31, 2012), which is the latest date available for the linked data set. We calculated age group–specific birth rates for Asian, Black, Hispanic, and White women and fit Poisson regression models to estimate the birth-rate ratios associated with a breast cancer diagnosis compared with no breast cancer diagnosis after adjusting for age.³ The likelihood ratio test was used to determine whether the association between breast cancer and live-birth rate differed among racial and ethnic groups, and the analysis was stratified when there was evidence of effect modification (p_interaction<.05). To evaluate the effect of chemotherapy, we conducted a secondary analysis excluding patients who received it in the primary setting.

RESULTS

We identified 25,448 women diagnosed with breast cancer who experienced 915 births over 124,505 person-years. The mean age of the breast cancer cohort was 40.4 years (SD 4.58). Most women were non-Hispanic White (51%, n=12,916), followed by Hispanic (24.6%, n=6,260), non-Hispanic Asian/Pacific Islander (17.1%, n=4,355), and non-Hispanic Black (7.5%, n=1,917). Most patients (70.5%) received chemotherapy. Women without breast cancer had 4,054,063 births over 100,770,670 person-years.

Age group–specific birth rates among indivdiuals in the case (stratified by chemotherapy use) and control groups are illustrated in Figure 1. In the overall cohort, after adjusting for race and age group, breast cancer was associated with a 58% decrease in live-birth rate (birth-rate ratio 0.42, 95% CI, 0.39–0.47) (Table 1). There was heterogeneity in the association between breast cancer diagnosis and fertility by racial and ethnic group (P<.001). A breast cancer diagnosis was associated with a 61% reduction in live-birth rate (birth-rate ratio 0.39, 95% CI, 0.35–0.43) among non-Hispanic White women, a 50% reduction among non-Hispanic Black women (birth-rate ratio 0.50, 95% CI, 0.39–0.65), and a 32% reduction among Hispanic women (birth-rate ratio 0.68, 95% CI, 0.60–0.76). Among non-Hispanic Asian women, a breast cancer diagnosis was associated with higher live-birth rate (birth-rate ratio 2.21, 95% 1.90–2.58). The pattern of associations remained similar after restricting the analysis to patients who did not receive chemotherapy.

Fig. 1. Births per 100 person-years by age group for individuals with breast cancer treated with chemotherapy (green), individuals with breast cancer who were not treated with chemotherapy (orange), and individuals without cancer (blue), stratified by race and ethnicity. Non-Hispanic Asian-Pacific Islander (A), Non-Hispanic Black (B), Hispanic or Latina (all races) (C), and Non-Hispanic White (D).

Abel. Birth Disparities After Breast Cancer. O&G Open 2025.

Table 1.

Associations Between Breast Cancer Diagnosis and Fertility Rate by Race and Ethnicity Group

Race and Ethnicity	All Breast Cancer Patients*	Breast Cancer Patients Who Did Not Receive Chemotherapy*
All patients	0.42 (0.39–0.47)	0.43 (0.35–0.53)
Asian	2.21 (1.90–2.58)	2.63 (1.99–3.47)
Black	0.50 (0.39–0.65)	0.50 (0.29–0.87)
Hispanic/Latina	0.68 (0.60–0.76)	0.88 (0.70–1.10)
White	0.39 (0.35–0.43)	0.39 (0.32–0.48)

^*Adjusted for age group in race group–specific model and age group and race and ethnicity in pooled model.

Data are fertility rate ratio (95% CI).

DISCUSSION

In this population-based cohort study, the association between a breast cancer diagnosis and subsequent live births differed by racial and ethnic groups. Non-Hispanic White women experienced the greatest decline in live-birth rate, followed by non-Hispanic Black and Hispanic/Latina women. Paradoxically, non-Hispanic Asian women showed increased fertility postdiagnosis, potentially reflecting a later average age at first birth⁴ or increased fertility motivation after cancer. Additionally, the association between breast cancer and decreased fertility was observed even among patients who did not receive chemotherapy.

Previous studies suggest that factors such as parity status and tumor characteristics, including hormone receptor status, may influence fertility outcomes.^5,6 The racial differences observed in this study are likely multifactorial, reflecting a complex interplay of biological, socioeconomic, and health care–related factors. This study is limited by the inability to control potential confounders, such as parity and hormonal status. Future research is needed to identify these contributors and inform equitable, targeted survivorship care.