Abstract
Purpose
To evaluate fertility preservation outcomes in breast cancer women with different hormonal receptor profiles before oncological treatment.
Methods
The study population included women with a diagnosis of breast cancer who underwent fertility preservation from 2009 until 2018 at a university-affiliated tertiary hospital. Stimulation parameters and fertility preservation outcomes were compared among the following receptor-specific profile groups: (1) estrogen receptor positive (ER+) versus estrogen receptor negative (ER−), (2) triple-negative breast cancer (TNBC) versus estrogen and progesterone receptor positive (ER+/PR+), and (3) TNBC versus non-TNBC. Primary outcome was the total number of mature oocytes. Secondary outcomes included the number of retrieved oocytes, the peak estradiol level, and the number of follicles > 14 mm on the final oocyte maturation trigger day.
Results
A total of 155 cycles were included in the final analysis. These were divided into the exposure groups of ER+ (n = 97), ER− (n = 58), ER+/PR+ (n = 85), TNBC (n = 57), and non-TNBC (n = 98). Cycle outcomes revealed similar number of retrieved oocytes and follicles > 14 mm on the trigger day. Women with TNBC had significantly lower number of mature oocytes compared with those with ER + PR+ (7 (5–11) versus 9 (7–15); p = 0.02) and non-TNBC (7 (5–11) versus 9 (7–16); p = 0.01) status. Triple-negative breast cancer profile was associated with a significant reduction in the chance of developing over 10 mature oocytes (OR 0.41; 95% CI 0.19–0.92).
Conclusion
Among the different hormonal receptor profiles in breast cancer, the TNBC subtype has a negative effect on fertility preservation outcomes.
Keywords: Triple-negative breast cancer, Fertility preservation, Number of oocytes, Estrogen receptor, Progesterone receptor
Introduction
The typing and prognostication of cancers have traditionally been a function of their histological analysis, namely, the stage and grade of the neoplasm [1]. In the era of modern therapeutics, molecular analysis, and immunohistochemistry, other tumor characteristics have also proved to be of value [2]. Breast cancer is the most salient example, whose hormonal receptor profile, in addition to its grade and stage, provides important information about its aggressiveness and evolution [3, 4]. In particular, the presence of estrogen receptors (ER), progesterone receptors (PR), or human epidermal growth factor receptors 2 (HER2) has implications on the prognosis and therapeutic modalities available to treat this condition [5, 6]. Indeed, the classification of breast tumors into ER+ and ER− subtypes is a critical distinction in the treatment of breast cancer. ER− tumors are in general more clinically aggressive than their ER+ counterparts [7], and ER+ tumors are routinely treated using anti-hormonal therapies such as selective estrogen receptor modulators (SERM) and aromatase inhibitors [5, 8]. Patients whose tumors express ER and/or PR receptors have better prognosis than those without such expression [9, 10]. Triple-negative breast cancer (TNBC), which lacks expression of the ER, PR, and HER2, has a poorer prognosis than the more common ER+ tumors [7, 11, 12].
Breast cancer remains the most common malignancy in women of reproductive age, with survivals up to 85–90% in young women [13]. As survival increases, womens’ desire to ensure future childbearing becomes an important consideration of the therapeutic plan, in which physicians must engage in prior to initiating treatment. Not surprisingly, women with breast cancer represent the majority of cases of oocyte and embryo cryopreservation today [13, 14].
Most common and well-established female fertility preservation options refer to the process whereby either oocytes or embryos are retrieved and cryopreserved for future attempts at conception [14, 15]. Though fertility preservation has seen an increase in use for social reasons [16, 17], its primary utility remains in women undergoing gonadotoxic treatments, such as chemotherapy and radiation, for a number of different malignancies, including breast cancer [18, 19].
Given the potential different combinations of grade, stage, and hormonal receptor profile a breast cancer patient can present with, it is imperative to provide comprehensive and personalized counseling to those who wish to undergo fertility preservation. Studies have shown that cancer [20–24] and an advanced cancer grade particularly [25] may apply a negative effect on the ovarian stimulation response and the fertility preservation outcome. Specifically, for breast cancer, the underlying breast cancer susceptibility gene 1 (BRCA1), which is associated with TNBC status and poorer ovarian stimulation outcomes, has also been associated with occult primary ovarian insufficiency [26]. However, the impact of different hormonal receptor profiles in breast cancer tumors on the ovarian response during controlled hyperstimulation remains unknown.
The objective of our cohort study was to determine whether specific receptor profiles affect the fertility preservation outcome in women with breast cancer.
Material and methods
Study population
We collected information on all women who underwent fertility preservation at McGill University Health Centre following a diagnosis of breast cancer between 2009 and 2018. We evaluated baseline demographic information, oncologic information about the tumor including hormonal profile, and reproductive parameters such as ovarian reserve measures, fertility preservation modality and characteristics, and number of retrieved immature and mature oocytes.
The following inclusion criteria were used: women aged between 18 and 38 years, a confirmed diagnosis of breast carcinoma, and use of the gonadotropin-releasing hormone (GnRH) antagonist protocol for the ovarian stimulation. If more than one stimulation cycle was performed, only the first one was included in the analysis. The exclusion criteria consisted of cases of recurrent cancer, previous chemo- and/or radiotherapy, previous ovarian surgery, and known ovarian pathology.
Estrogen and progesterone receptor status was determined through immunohistochemistry staining. Human epidermal growth factor receptor 2 status was determined but not individually analyzed as a subgroup in this study. Instead, the HER2 status was used to adequately classify women into the TNBC group. The McGill University Health Centre Research Ethics Board approved the study (MUHC 2018–4279).
Study groups
All women with breast cancer were stratified according to ER and PR status (positive or negative). Women with ER−/PR−HER2− status were categorized into the TNBC group. The study group comparisons were performed as follows: (1) ER+ versus ER−, (2) TNBC versus ER+/PR+, and (3) TNBC versus non-TNBC (either ER+ or PR+).
Study outcomes
The primary outcome was the total number of mature oocytes. The secondary outcomes included the number of retrieved oocytes, serum estradiol levels, and number of follicles > 14 mm on the day of final oocyte maturation trigger. We also evaluated factors significantly associated with good fertility preservation outcome defined as over 10 mature oocytes.
Stimulation protocol
We performed ovarian stimulation using a standard GnRH-antagonist protocol that has been previously described [27, 28]. We administered recombinant follicular-stimulating hormone (rFSH) (Gonal-F, Merck-Serono, Geneva, Switzerland) or urinary human menopausal gonadotropin (HMG) (Repronex, Ferring Pharmaceuticals, NY, USA) within 48 to 96 h of initial consultation.
Transvaginal ultrasound was performed on alternate days to assess the follicular growth. A total of 0.25 mg of GnRH-antagonist ganirelix (Orgalutran, MSD Organon, Oss, Netherlands) or 0.25 mg cetrorelix (Cetrotide, Merck-Serono, Geneva, Switzerland) was added when the lead follicle measured > 12 mm. All women were likewise prescribed an aromatase inhibitor, letrozole (Femara, Novartis, NJ, USA) at a daily dose of 5 mg [29]. Subcutaneous injection of 0.25 mg recombinant hCG (Ovidrel, EMD Serono, MA, USA) or 1 mg of GnRH-agonist buserelin (Suprefact, Sanofi-Aventis, QB, Canada) was administered for the final oocyte maturation when 2–3 follicles reached 17 mm in diameter. Ultrasound-guided oocyte retrieval was performed under conscious sedation after 36 h. All the oocytes collected were either cryopreserved or fertilized. Vitrification as a cryopreservation method was used for all mature oocytes and resulting embryos [30, 31].
Statistical analysis
We used a Shapiro-Wilk test to assess data distribution. Data that was normally distributed is presented as mean ± standard deviation (SD) and comparisons carried out using Student’s t test. Non-parametric data was presented as median (with inter quartile range), and the Mann–Whitney U test was used for statistical comparison. Chi square test was used for categorical data.
We performed univariate analysis to evaluate factors associated with the result of over 10 mature oocytes. We then identified variables whose p values were < 0.1 in the univariate analysis, and adjusted for them as confounders in the multivariate logistic regression in order to identify factors associated with favorable fertility preservation outcomes. If we observed a high correlation between variables, only one of them was included in the final multivariate model. The logistic regression yielded odds ratios (OR) with 95% confidence intervals (95% CI). A p value < 0.05 was considered as statistically significant. Statistical analyses were performed using the JMP Pro 13.2.0 software (SAS Institute Inc., USA).
Results
We performed 187 stimulation cycles for fertility preservation in women with biopsy-confirmed breast cancer. After inclusion and exclusion criteria were applied, a total of 155 cycles were included in the final analysis (Fig. 1). These were divided into the exposure groups of ER+ (n = 97), ER− (n = 58), ER+/PR+ (n = 85), TNBC (n = 57), and non-TNBC (n = 98). Tables 1, 2, and 3 describe individual group comparisons. Age, body mass index (BMI), smoking status, and antral follicle count (AFC) were similar between groups in all comparisons. Stimulation cycle parameters including timing of stimulation start, gonadotropic agent for stimulation, rate of recombinant luteinizing hormone (rLH) use, start and total FSH dose used, and stimulation duration and agent used for triggering were also similar between the groups (Tables 1, 2, 3).
Fig. 1.
Flowchart of patient selection process. GnRH, gonadotropin-releasing hormone; ER, estrogen receptor; PR, progesterone receptor; TNBC, triple-negative breast cancer
Table 1.
Comparison of breast cancer women with ER+ and ER- status
| ER+ status (n = 97) | ER− status (n = 58) | p value | |
|---|---|---|---|
| Age (years) | 32 (28–35) | 31 (26.8–34) | 0.34 |
| BMI (kg/m2) | 23.5 (21.6–25.1) | 22.5 (21.8–23.6) | 0.17 |
| Smoking (n (%)) | 6 (6.2%) | 8 (13.8%) | 0.11 |
| AFC (n) | 12 (10–20) | 15 (10–20) | 0.51 |
| Stimulation start | 0.09 | ||
| Early follicular phase | 40 (41.2%) | 32 (55.2%) | |
| Random | 57 (58.8%) | 26 (44.8%) | |
| Stimulation (n (%)) | 0.87 | ||
| rFSH | 64 (66.0%) | 39 (67.2%) | |
| HMG | 33 (34.0%) | 19 (32.8%) | |
| rLH addition (n (%)) | 8 (8.3%) | 5 (8.6%) | 0.94 |
| Total FSH dose (IU) | 1800 (1450–2400) | 2000 (1313–2700) | 0.70 |
| FSH start dose (IU) | 200 (150–300) | 200 (150–263) | 0.33 |
| Days of stimulation | 8 (7–9) | 8 (7–10) | 0.43 |
| Trigger (n (%)) | 0.11 | ||
| hCG | 56 (57.7%) | 41 (70.7%) | |
| GnRH agonist | 41 (42.3%) | 17 (29.3%) | |
| Estradiol on trigger day (pmol/L) | 1000 (591–1806) | 833 (500–1076) | 0.007 |
| Follicles > 14 mm on trigger day (n) | 5 (3–10) | 5 (2–8) | 0.26 |
| Number of collected oocytes (n) | 13 (8–18) | 10 (8–14) | 0.12 |
| GV at collection (n) | 2 (0–5) | 1 (0–3) | 0.09 |
| MI at collection (n) | 1 (0–2) | 1 (0–2) | 0.08 |
| Maturation rate of GV and MI oocytes (mean %) | 35.9% | 38.6% | 0.91 |
| Total number of mature oocytes (n) | 9 (7–15) | 7 (5–13) | 0.06 |
Data are median (quartiles) unless stated otherwise
ER Estrogen receptor, BMI Body mass index, AFC Antral follicle count, rFSH Recombinant follicle-stimulating hormone, HMG Human menopausal gonadotropin, rLH Recombinant luteinizing hormone, hCG Human chorionic gonadotropin, GnRH Gonadotropin-releasing hormone, GV Germinal vesicle, MI Metaphase I
Table 2.
Comparison of breast cancer women with TNBC and ER+/PR+ status
| TNBC (n = 57) | ER+/PR+ (n = 85) | p value | |
|---|---|---|---|
| Age (years) | 31 (26.5–34) | 32 (28–35) | 0.16 |
| BMI (kg/m2) | 22.5 (21.8–23.7) | 23.5 (21.6–24.8) | 0.45 |
| Smoking (n (%)) | 8 (14.0%) | 6 (7.1%) | 0.17 |
| AFC (n) | 15 (10–20) | 12 (10–20) | 0.44 |
| Stimulation start | 0.14 | ||
| Early follicular phase | 32 (56.1%) | 37 (43.5%) | |
| Random | 25 (43.9%) | 48 (56.5%) | |
| Stimulation (n (%)) | 0.81 | ||
| rFSH | 38 (66.7%) | 55 (64.7%) | |
| HMG | 19 (33.3%) | 30 (35.3%) | |
| rLH addition (n (%)) | 4 (7.0%) | 8 (9.4%) | 0.62 |
| Total FSH dose (IU) | 2000 (1274–2700) | 1850 (1500–2500) | 0.83 |
| FSH start dose (IU) | 200 (150–263) | 300 (188–300) | 0.08 |
| Days of stimulation | 8 (7–9) | 8 (7–10) | 0.36 |
| Trigger (n (%)) | 0.09 | ||
| hCG | 41 (71.9%) | 49 (57.7%) | |
| GnRH agonist | 16 (28.1%) | 36 (42.3%) | |
| Estradiol on trigger day (pmol/L) | 847 (500–1038) | 1061 (640–2324) | 0.001 |
| Follicles > 14 mm on trigger day (n) | 5 (2–8) | 5 (3–9) | 0.28 |
| Number of collected oocytes (n) | 10 (8–14) | 12 (7–17) | 0.15 |
| GV at collection (n) | 1 (0–3) | 2 (0–3) | 0.37 |
| MI at collection (n) | 1 (0–3) | 0 (0–2) | 0.07 |
| Maturation rate of GV and MI oocytes (mean %) | 38.6% | 35.9% | 0.90 |
| Total number of mature oocytes (n) | 7 (5–11) | 9 (7–15) | 0.02 |
Data are median (quartiles) unless stated otherwise
TNBC Triple-negative breast cancer, ER Estrogen receptor, PR Progesterone receptor, BMI Body mass index, AFC Antral follicle count, rFSH Recombinant follicle-stimulating hormone, HMG Human menopausal gonadotropin, rLH Recombinant luteinizing hormone, hCG Human chorionic gonadotropin, GnRH Gonadotropin-releasing hormone, GV Germinal vesicle, MI Metaphase I
Table 3.
Comparison of breast cancer women with TNBC and non-TNBC status
| TNBC (n = 57) | non-TNBC (n = 98) | p value | |
|---|---|---|---|
| Age (years) | 31 (26.5–34) | 32 (28–35) | 0.26 |
| BMI (kg/m2) | 22.5 (21.8–23.7) | 23.5 (21.6–25.1) | 0.17 |
| Smoking (n (%)) | 8 (14.0%) | 6 (6.1%) | 0.10 |
| AFC (n) | 15 (10–20) | 12 (10–20) | 0.42 |
| Stimulation start | 0.08 | ||
| Early follicular phase | 32 (56.1%) | 40 (40.8%) | |
| Random | 25 (43.9%) | 58 (59.2%) | |
| Stimulation (n (%)) | 0.97 | ||
| rFSH | 38 (66.7%) | 65 (66.3%) | |
| HMG | 19 (33.3%) | 33 (33.7%) | |
| rLH addition (n (%)) | 4 (7.0%) | 9 (9.2%) | 0.64 |
| Total FSH dose (IU) | 2000 (1274–2700) | 1800 (1475–2400) | 0.74 |
| FSH start dose (IU) | 200 (150–263) | 200 (150–300) | 0.33 |
| Days of stimulation | 8 (7–9) | 8 (7–9) | 0.79 |
| Trigger (n (%)) | 0.09 | ||
| hCG | 41 (71.9%) | 56 (57.1%) | |
| GnRH agonist | 16 (28.1%) | 42 (42.9%) | |
| Estradiol on trigger day (pmol/L) | 847 (500–1038) | 1000 (591–1770) | 0.005 |
| Follicles > 14 mm on trigger day (n) | 5 (2–7.5) | 5 (3–10) | 0.19 |
| Number of collected oocytes (n) | 10 (8–14) | 13 (8–18) | 0.08 |
| GV at collection (n) | 1 (0–3) | 1 (0–2) | 0.07 |
| MI at collection (n) | 1 (0–3) | 1 (0–2) | 0.08 |
| Maturation rate of GV and MI oocytes (mean %) | 38.6% | 35.7% | 0.84 |
| Total number of mature oocytes (n) | 7 (5–11) | 9 (7–16) | 0.01 |
Data are median (quartiles) unless stated otherwise
TNBC Triple-negative breast cancer, BMI Body mass index, AFC Antral follicle count, rFSH Recombinant follicle-stimulating hormone, HMG Human menopausal gonadotropin, rLH Recombinant luteinizing hormone, hCG Human chorionic gonadotropin, GnRH Gonadotropin-releasing hormone, GV Germinal vesicle, MI metaphase I
With regard to cycle outcomes, no differences were found in any comparison group regarding the number of follicles > 14 mm on trigger day and totally collected oocytes as well as the number and maturation rate of immature (germinal vesicle (GV) and metaphase I (MI)) oocytes. On the other hand, average serum estradiol levels at trigger day were consistently higher in the presence of ER+ tumors (Tables 1, 2, 3). A significantly lower total number of mature oocytes was observed in the TNBC group compared with that of women with ER + PR+ (p = 0.02) and non-TNBC (p = 0.01) profiles (Tables 2, 3).
Univariate analysis of factors potentially associated with good fertility preservation outcome (over 10 mature oocytes) is shown in Table 4. Multivariate analysis (Table 5) reveals that the factors predictive of over 10 mature oocytes include an increasing AFC (OR 1.12; 95% CI 1.06–1.18; for every increase in 1 follicle) as well as a potentially significant association with ER+ status (OR 2.13; 95% CI 0.98–4.64). Triple-negative breast cancer status was associated with a significant reduction in the chance of developing over 10 mature oocytes (OR 0.41; 95% CI 0.19–0.92).
Table 4.
Univariate analysis of factors potentially associated with the result of over 10 mature oocytes
| > 10 mature oocytes (n = 59) | ≤ 10 mature oocytes (n = 96) | p value | |
|---|---|---|---|
| Age (years) | 30 (26–35) | 32.5 (29–35) | 0.04 |
| BMI (kg/m2) | 23.5 (21.8–25.1) | 23 (22.5–24.5) | 0.77 |
| Smoking n (%) | 4 (6.8%) | 8 (8.3%) | 0.73 |
| AFC (n) | 18 (12–25) | 11 (9–14) | 0.0001 |
| Stimulation start | 0.42 | ||
| Early follicular phase | 25 (42.4%) | 47 (49.0%) | |
| Random | 34 (57.6%) | 49 (51.0%) | |
| Stimulation (n (%)) | 0.09 | ||
| rFSH | 44 (74.6%) | 61 (63.5%) | |
| HMG | 15 (25.4%) | 35 (36.5%) | |
| Total FSH dose (IU) | 1850 (1500–2250) | 1750 (1237–2381) | 0.22 |
| Days of stimulation | 8 (7–9) | 8 (7–10) | 0.56 |
| Trigger (n (%)) | 0.002 | ||
| hCG | 33 (55.9%) | 76 (79.2%) | |
| GnRH agonist | 26 (44.1%) | 20 (20.8%) | |
| Estradiol on trigger day (pmol/L) | 1076 (600–2386) | 650 (500–1110) | 0.0003 |
| Follicles > 14 mm on trigger day | 9 (6–13) | 4 (2–6) | 0.0002 |
| ER positive breast cancer (n (%)) | 42 (71.2%) | 55 (57.3%) | 0.05 |
| Triple-negative breast cancer (n (%)) | 15 (25.4%) | 42 (43.8%) | 0.02 |
Data are median (quartiles) unless stated otherwise
BMI Body mass index, AFC Antral follicle count, rFSH Recombinant follicle-stimulating hormone, HMG human menopausal gonadotropin, rLH Recombinant luteinizing hormone, hCG Human chorionic gonadotropin, GnRH Gonadotropin-releasing hormone, ER Estrogen receptor
Table 5.
Multivariate analysis of factors associated with the result of over 10 mature oocytes
| Factor | OR | 95% CI |
|---|---|---|
| AFC | 1.12* | 1.06–1.18* |
| Triple-negative breast cancer | 0.41 | 0.19–0.92 |
| ER positive breast cancer | 2.13 | 0.98–4.64 |
| Trigger (GnRH-agonist versus hCG) | 1.53 | 0.71–3.32 |
| Stimulation type (rFSH versus HMG) | 1.26 | 0.57–2.78 |
*OR and 95% CI per unit change in parameter
AFC Antral follicle count, ER Estrogen receptor, GnRH Gonadotropin-releasing hormone, hCG Human chorionic gonadotropin, rFSH Recombinant follicle-stimulating hormone, HMG Human menopausal gonadotropin
Discussion
The purpose of our study was to evaluate the effect of different hormonal receptor profiles in breast cancer women on stimulation cycle parameters and fertility preservation outcomes. We found that among the different hormonal receptor profiles in breast cancer, the TNBC subtype has a negative effect on fertility preservation outcomes.
There is an interesting parallel that these findings evoke. Indeed, among all different hormonal receptor profiles in breast cancer, TNBC confers the worst prognosis in oncological terms as well [7, 11]. While the mechanism is unclear, we can postulate why TNBC has poorer outcomes with regard to both oncological prognosis and fertility preservation. It is well-established that any cancer growth is accompanied by progressive infiltration, invasion, and destruction of the surrounding tissue causing activation of the systemic inflammatory response. Circulating levels of cytokines, matrix metalloproteinases, plasminogen activators, and other pro-inflammatory substrates are proportional to tumor burden and aggression [32–34]. Given that the ovary is exquisitely sensitive to inflammation and gonadotoxic injury, it falls within reason to assume that more aggressive cancers, such as TNBC, might reduce the ovarian reserve and hinder the ovarian response to hormonal stimulation [35–37].
Regarding individual group comparisons in our cohort, several postulations might help elaborate our findings. Relative to the absence of estrogen receptors, ER+ tumors in general have better prognosis [38]. This is in large part due to the availability of hormonal and endocrine therapies that have been shown to reduce recurrence within the first 5 years of therapy [39]. The expression of ER or PR in the tumor is not constant and changes with disease progression. Typically, the number of cells expressing ER and/or PR progressively decreases with disease progression [40]. As such, any survival benefit conferred by ER+ status is lost after 5 years [41]. In our study, we did not find individual differences in fertility preservation outcomes in this comparison group since women had just been recently diagnosed and no therapy had been initiated (Table 1). We could reasonably expect that as ER− tumors progress faster, they would likely confer a worse prognosis than their ER+ counterparts following ovarian stimulation once treatment had been initiated. However, given that the delay between diagnosis and initiation of treatment is typically short, we can reasonably expect that the gonadotoxic effect of the oncological treatment is what impacts ovarian reserve the most [18].
We also conducted the evaluation of TNBC versus ER+/PR+ (Table 2) and versus non-TNBC (Table 3) tumors. As mentioned previously, from an oncological point of view, TNBC tumors confer the worst prognosis, whereas ER+/PR+ have the best prognosis [9, 10]. TNBC has an aggressive natural history, accounting for 15% of cases but 25% of deaths [42]. Compared with other breast cancer subtypes, TNBC tumors are frequently larger and less differentiated, and 2.5-fold more likely to metastasize within 5 years of diagnosis [38, 43, 44]. A leading theory for the enhanced ability of TNBC to metastasize has to do with the overexpression of epidermal growth factor receptor (EGFR), whose random somatic mutations lead to its constant activation, which produces uncontrolled cell division [45]. A normal EGFR activation has been implicated in the normal ovarian steroidogenesis and oocyte maturation pathways [46]. It is therefore conceivable that an overexpression of EGFR might lead to a poorer ovarian response, as seen in Tables 2 and 3.
Although the aforementioned hypotheses could explain why the differences were observed, multivariate analysis of factors associated with the result of over 10 mature oocytes (Table 5), much like in the non-oncologic population undergoing fertility preservation, reveals that the most important factor to ensure a good ovarian response is the AFC prior to undergoing stimulation [47]. All parameters being equal, TNBC significantly reduces the ovarian response and was also associated with a significant reduction in the chance of developing over 10 mature oocytes (OR 0.41; 95% CI 0.19–0.92). Previous studies demonstrated the correlation between the number of mature oocytes and live birth rate [48, 49]. In our multivariate analysis, the threshold of 10 mature oocytes was used, as a high cumulative live birth rate of 50% was reported when over 10 oocytes were achieved in 18–38 age group women.
To the best of our knowledge, our study is the first analysis addressing the impact of breast cancer hormonal receptor profiles on fertility preservation outcomes and has a number of strengths. We compared women with different receptor profiles, which are clinically relevant and consistent with modern oncologic classification of breast cancer women. Likewise, the cycle stimulation protocol used is standardized, and the facilities used to undergo the cycle stimulations are state-of-the-art, indicating that any differences found are likely to be related to the underlying hormonal profile (the exposure) and not on any treatment allocation differences. Finally, we used an appropriate clinical outcome, namely, the total number of mature oocytes, which represents the pool of frozen oocytes and a future fertility potential of women with cancer who will return to use frozen gametes or embryos.
On the other hand, this study has several limitations as well. Though our comparison groups were made up as a function of the receptor profile prevalence observed clinically, we did not account for all potential subtypes that could exist (e.g., ER−/PR+/HER2+, or ER−/PR−/HER2+, among others). Additionally, only 38.1% (n = 59) of included women underwent fertilization of achieved oocytes and only 18.6% (n = 11) of them had embryo transfer. This is in agreement with previous studies demonstrating a low number of patients return to use frozen oocytes/embryos [50, 51]. Although the pregnancy outcome was not evaluated, the correlation model between the number of mature oocytes and the live birth rate [48, 49] was used in our study to assess the factors associated with the result of over 10 mature oocytes.
Breast cancer susceptibility gene 1 (BRCA1) mutations have been shown to lead to occult ovarian insufficiency, which may explain why their ovarian stimulation response is not as robust [26]. Moreover, a high prevalence (11–30%) of BRCA mutations was found among women with TNBC [52, 53]. In our study, we were not able to evaluate a correlation between TNBC and BRCA mutation, as only 11 women underwent genetic tests for BRCA status. Given the predilection of BRCA+ status for TNBC, we cannot ascertain beyond a reasonable doubt what confounding effect the BRCA status has on stimulation outcomes in our population. That said, if future studies point towards the TNBC status alone as the primary culprit, more intense stimulation protocols may be necessary to obtain similar outcomes.
In our study the average number of mature oocytes in TNBC group was 7, which is similar to that in the social fertility preservation group [54]. One can state that similar results reflect a normal retrieval rate in TNBC patients compared with that in healthy women who underwent fertility preservation for social reasons. However, the age of women who underwent elective fertility preservation was significantly higher (37–38 years) compared with that of population from our study (31–32 years). After the age adjustment, the reported number of mature oocytes in the social fertility preservation group was over 30% higher compared with that in the TNBC group from our study [54, 55].
Of note, correction for multiple analyses using methods such as the Bonferroni correction is conducted in cases where numerous outcomes are studied in an individual exposure comparison to decrease the random chance of type 1 error [56]. In keeping with the temporal relationship of breast cancer diagnosis—ovarian stimulation outcomes, we studied 4 different main outcomes, namely, peak serum estradiol level, number of follicles > 14 mm on the day of final oocyte maturation trigger, number of collected oocytes, and total number of mature oocytes. Applying the Bonferroni correction and dividing the standard p value of 0.05 by 4, we obtain a corrected p value threshold of 0.0125. Using this p value level, our conclusions regarding the comparison between TNBC and non-TNBC remain significant regarding the estradiol level at trigger day, as well as the total number of mature oocytes retrieved.
In conclusion, among different hormonal receptor profiles in breast cancer, the TNBC subtype has a negative effect on the fertility preservation procedure outcomes. Our results are useful in counseling of women with breast cancer undergoing fertility preservation and in decision-making process about the stimulation protocol intensity. Future studies should determine if a negative effect on the stimulation results can be explained by TNBC subtype or by a combination with other factors such as BRCA status.
Acknowledgments
The authors express their appreciation to the embryologists, nurses, and other team members of McGill University Reproductive Centre. We especially appreciate the contribution of Nancy Lamothe for managing the database.
Author contributions
All authors contributed to the study conception and design. Material preparation was performed by Togas Tulandi, William Buckett, Hananel Holzer, and Alexander Volodarsky-Perel. Data collection was performed by Naama Steiner, Guy Shrem, and Alexander Volodarsky-Perel. Data analysis was performed by Jacques Balayla, Togas Tulandi, and Alexander Volodarsky-Perel. The first draft of the manuscript was written by Jacques Balayla and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
Footnotes
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