While watching TV last August, Clara Pablo felt a lump on her right breast.
Having two aunts who had breast cancer, Pablo made sure she checked herself monthly. At the recommendation of friends, she went to the Miami Cancer Institute at Baptist Health South Florida, where a biopsy revealed she had invasive ductal carcinoma (IDC), the most common type of breast cancer.
The following month, Pablo, who was 36 at the time, had a lumpectomy and her lymph nodes removed, followed by reconstructive surgery and radiation for the Stage 1 cancer.
“All of my doctors were saying: 'You’re very young, have you thought about fertility?”” said Pablo, who lives in downtown Miami.
Pablo says she wasn’t thinking about fertility — she just wanted to be cancer-free.
“I just wanted to get this tumor out of my breast and continue on with my life,” said Pablo, who works as the head of talent relations at Univision. “But you have to think about your future at some point. Your doctors are telling you that you’re going to have a future. You have to think about it.”
Keeping her options open
Pablo decided she wanted the option of having kids.
“When they tell you that you might not be able to get pregnant because of the radiation or the hormones you’re on, you’re kind of like, “Okay, I think I want to have kids.”
Since her oncologists were already watching her closely post-procedure, they recommended she start fertility treatments after she recuperated, and referred her to an outside IVF specialist. She started fertility preservation in November of last year, via egg freezing.
But there are some risks associated with fertility preservation during cancer treatment. Radiation uses high-energy rays to kill cancer cells, but the rays can damage a woman's eggs and ovaries, as well as men’s sperm.
“Not everyone is a candidate,” said Dr. John P. Diaz, lead physician of clinical trials in gynecologic oncology at the Miami Cancer Institute, part of Baptist Health South Florida. “Some people are too sick to undergo preservation, or their cancer treatment can’t be delayed. Instead, we minimize damage to the ovaries or to the sperm during treatment."
If a patient is going to receive radiation therapy, depending on where the radiation will be delivered, “possible shielding of the ovaries,” would be an option, he said.
Diaz was one of the pioneers who published a study leading to the “radical trachelectomy” becoming standard practice. The procedure is used to treat cervical cancer but allows the uterus to be preserved, thus, allowing women to become pregnant. Before the radical trachelectomy, doctors removed the uterus if a woman had cervical cancer, erasing any possibility of pregnancy.
“It can be performed as minimally invasive or via robotic approach,” said Diaz. “Patients are able to carry term pregnancy and not be at an increased risk for cervical cancer recurrence.”
Cervical cancer is the third most commonly diagnosed cancer and the fourth-leading cause of cancer-related mortality in women.
Fertility preservation isn’t cheap. The cost of harvesting eggs from the ovaries is about $10,000, and that doesn’t include the storage fee of about $500 a year. IVF, where the eggs are thawed, fertilized and implanted in the uterus, costs about $5,000. It’s usually not covered by insurance, even when the patient has cancer. By contrast, the cost to collect and freeze sperm is often less than $1,000.
There are programs that help offset the financial burden, like the LIVESTRONG Foundation, which has helped almost 10,000 people in providing fertility preservation discounts and medicines free of charge to those who have cancer.
UHealth, the University of Miami Health System, offers a one-stop shop where everything from cancer diagnosis to fertility treatments and preservation are done.
“It’s an inter-disciplinary approach. The oncology people work with fertility specialists in the same place,” said Dr. George Attia, director to both the UHealth Reproductive and Fertility Center and the Division of Reproductive Endocrinology and Infertility.
Attia explains how hormones affect fertility preservation during cancer treatments.
“When you develop breast cancer, estrogen is the main hormone that that we’re concerned about that can affect the progression of the disease,” he said. “There’s a lot of different hormonal treatments and methods we use to manage and keep this hormone under control, to not worsen the diagnosis in those patients.”
Dr. Estelamari Rodriguez is the chair of Mount Sinai’s Women’s Centered Care Program and is a longtime advocate of women’s health issues. She says it’s understood in the oncology field that fertility preservation is important to young women who are diagnosed with cancer and that it’s an important part of survivorship.
Her typical clients include young women with breast cancer and young men with lymphoma.
Rodriguez says psychosocial support is imperative for patients who wish to preserve their fertility.
“It’s good to have a psychosocial provider because it’s a lot of stress from getting the diagnosis and thinking about fertility,'' she said. "You’re thinking you’re going to die from cancer and at the same time we’re telling you that you might not be able to plan the life that you wanted to have. I think that it requires reassurance from the physician perspective but it also requires enough people on the team who are guiding you through that fear and the emotions that you go through.”
Pablo said that doing the fertility preservation after she healed helped prepare her for a future — and for life after cancer.
“I didn’t even realize that while doing this, I was preparing for a future. I was telling myself subconsciously that I was going to live through this,” said Pablo. "A fertility treatment is so much more than just freezing eggs. It’s telling yourself, 'I got this. I’m going to have a future and I’m going to live.”'