Cancer Care Connections
Cancer Care Connections
Fertility After a Breast Cancer Diagnosis
How can young women facing breast cancer preserve their dreams of motherhood? Discover the essential insights from Dr. Nina Balanchivadze of Virginia Oncology Associates as she shares her profound expertise in oncofertility and the critical importance of preserving ovarian function amidst cancer treatments. Dr. B delves into the rising trend of younger women being diagnosed with breast cancer and the unique challenges they encounter regarding fertility preservation. She offers a heartfelt discussion on the compassionate care needed to guide patients through their treatment and survivorship journey, ensuring their reproductive health remains a priority.
Uncover the latest breakthroughs in breast cancer treatment with Dr. B, highlighting the move towards more personalized therapies. These innovations boost survival rates and minimize side effects, allowing patients to maintain a better quality of life. Dr. B's insights ensure that while cancer may change lives, it doesn't define them, empowering women to continue thriving in their roles as mothers, partners, and professionals. Join us for an episode that promises to enlighten and inspire, offering hope and practical advice for those navigating the complexities of breast cancer.
Dr. Nina Balanchivadze is passionate about caring for patients with cancer and providing personalized, state-of-the-art, compassionate care to all her patients. She specializes in the treatment of patients with a breast cancer diagnosis.
Dr. B has extensive experience in leadership and education, having gained experience in her role as core clinical faculty/Assistant Professor of Clinical Medicine at Grand Strand Medical Center, Myrtle Beach, SC, where she served as the Chief of Medicine for the 369-bed acute care hospital.
During her residency and fellowship, she presented her research work at numerous national and international conferences and has published many abstracts and manuscripts. She was recognized multiple times and has been presented with many Resident of the Year awards, and Teaching Attending Physician and Mentor of the Year awards. She was named Fellow of the Year at Henry Ford Cancer Institute and has won the Robert A. Chapman Outstanding Fellow Award two years in a row. Her research activities have been recognized many times with one of her projects securing first place in a hospital-wide resident/fellow research competition at the Henry Ford Medical Education Forum. In addition, Dr. Balanchivadze was granted multiple travel awards to present at national conferences.
On a national level, Dr. Balanchivadze served on the American Society of Hematology (ASH) Trainee Council, has been an active member of multiple committees, and has facilitated many different educational sessions. She is a Fellow of the American College of Medicine (ACP) and is an active member of ACP, American Medical Association, American Society of Clinical Oncology, and ASH.
Thank you for listening! If you're interested in hearing more from Virginia Oncology Associates, make sure to subscribe to Cancer Care Connections on Apple Podcasts, Spotify, or anywhere podcasts are available, or listen online at cancercareconnections.buzzsprout.com.
Cancer Care Connections is the official podcast of Virginia Oncology Associates. For more information, visit us at VirginiaCancer.com. or find us on Facebook or Instagram at Virginia Oncology Associates.
Episode 11: Preserving Fertility After a Breast Cancer Diagnosis with Dr. Nina Balanchivadze
Intro
00:07
On this episode of Cancer Care Connections, Cheryl spoke with Dr. Nina Balanchivadze, a medical oncologist and hematologist with Virginia Oncology Associates. Dr. B specializes in the care of patients with a breast cancer diagnosis. During this interview, she shares her expertise on oncofertility and the critical importance of preserving ovarian function in women undergoing breast cancer treatment.
Cheryl
00:36
Dr. Nina Balanchivadze arrived at Virginia Oncology Associates in 2022. She specializes in breast cancer. She has extensive experience in leadership and education, and she has presented her research work at numerous national and international conferences. Dr. B. is passionate about caring for patients with cancer and providing personalized, state-of-the-art, compassionate care to all of her patients. Dr B., thanks so much for talking with us today.
Dr. Balanchivadze
01:01
Thank you for having me, and thank you for your kind introduction.
Cheryl
01:06
What encouraged you to specialize in breast cancer, specifically?
Dr. Balanchivadze
01:12
I think one of the biggest factors was my passion for women's care, you know, and women's health. And overall, how women manage their diagnosis, and how women deal with their diagnosis. Additionally, there is so much research ongoing in cancer care and, in particular, in breast cancer. There are personalized approaches, and outcomes have improved, and we can offer so much for these women.
Cheryl
01:51
I've noticed too in recent years this focus on women's health, which has been really exciting, and, as a woman, it's been really fun to see just this focus on how we can grow older and understand our bodies better.
Dr. Balanchivadze
02:02
Yes, absolutely. There have been a lot of talks about women being underdiagnosed or misdiagnosed in various conditions because some complaints may not be taken seriously from women. So it's very refreshing to see that in cancer care we are taking things serious. And, we're very passionate and forward-thinking for rapid diagnosis and treatment of women with cancer and breast cancer.
Cheryl
02:20
It ties in really well with the topic that we want to talk about today, as we're talking about fertility after a breast cancer diagnosis. It sort of makes me think about how the women that you're dealing with, do have to think ahead as far as that next generation if we're talking about fertility. I wanted to ask you a question about some of the trends you're seeing regarding breast cancer diagnosis in women. Are you noticing that there's a trend toward younger women?
Dr. Balanchivadze
03:00
Yes, Interestingly, there has been an increasing trend of younger women being diagnosed with breast cancer, and there have been some studies that have demonstrated that. Breast cancer is the most common malignancy among women of reproductive age and it accounts for about 30% of new cancer diagnoses worldwide among those that are aged 40 or younger. As we advance in treatment options and we see that there have been reductions in breast cancer mortality, we are seeing that there is increased emphasis on survivorship. So treating breast cancer and curing patients or achieving long-term remission is as important as care afterward, which is survivorship. And fertility is a very important aspect of this path and of this step.
Cheryl
04:02
Absolutely. So what are some of the challenges that these younger women face with a diagnosis?
Dr. Balanchivadze
04:07
Great question. So we'll just hone in on fertility challenges because younger women in general face multiple challenges in regards to treatment and diagnosis. Sometimes, doctors or other care providers do not believe women can get breast cancer at the age of 22 or 23 and oftentimes there are delays in diagnosis. Then there are issues with physical appearance and body changes. Oftentimes our treatments affect women's sexuality. As we're talking about fertility, fertility is being affected by various treatments that we offer and since we've seen the age of first pregnancy rising in general among women, women are, you know, having children at an older age due to career advances and such, there is an increasing percentage of women that are being diagnosed with breast cancer prior to having children. So this term, oncofertility, or fertility after breast cancer diagnosis, becomes even more relevant as we see a rise in women who get breast cancer before they even get a chance to have a child.
Cheryl
05:31
Right To even know whether they want to have a child someday in the future.
Dr. Balanchivadze
Exactly, yeah.
Cheryl
05:32
So let's talk more about oncofertility. I've not heard that before. Can you talk more about that and what the steps are for that?
Dr. Balanchivadze
05:43
Yeah, sure. So oncofertility is almost like an umbrella term.
So when we talk about women who are facing a cancer diagnosis and treatment and how it affects their fertility, there are multiple steps that we have to go through. Every time I meet a young woman who comes into my office with a new diagnosis of breast cancer, I always set aside time to address issues around fertility and how it may affect their journey.
The first step is talking about what are the risks of premature ovarian failure or early menopause with the treatment that we are proposing. As you can imagine, it's overwhelming. I not only have to tell them, okay, you may need chemotherapy, you may need XYZ treatment, but then I have to tell them this is what the risks of these particular treatments affecting your ovarian reserve and affecting your future ovarian function. That's kind of first step, because even if women are not interested in having children, most women are interested in preserving their ovarian function because we know that estrogen can be protective for many organs and systems in our body; our heart, our bone, and our cognitive function. A lot of the time our treatments may affect this ovarian reserve and ovarian function and women can be diagnosed with premature ovarian failure after cancer diagnosis.
Cheryl
07:31
So you have some really serious conversations about the future when you have a breast cancer diagnosis for a woman, really of any age.
Dr. Balanchivadze
07:39
Yes, absolutely. And speaking of age...so age at the time of receiving these treatments...we call them cytotoxic treatment, meaning chemotherapy treatments...so age, type, and the duration of the treatments are the main determinants that determine how much ovarian reserve can be affected. There's no magic number and really nobody knows. We can have two women whose cases are identical; cancers, age, everything but may have different outcomes. There have been studies that show certain chemotherapy regimens are more likely to cause ovarian function suppression, so oncologists should have these discussions as this might be an important determinant when choosing what is the right chemotherapy for the patient.
Cheryl
08:37
Right. Let's talk more about the fertility aspect and, in terms of chemotherapy, how that affects a woman who is of childbearing age.
Dr. Balanchivadze
08:48
Yes, so chemotherapy can reduce ovarian function and therefore can affect the ability to become pregnant and have a successful pregnancy. We do have data about the standard chemotherapy regimens that have been around for decades, but there are newer drugs now, like immunotherapy, targeted therapy, and what we call antibody-drug conjugates. There is not much data available, so we don't know how, in the future, these treatments can affect fertility. After I discuss the risks, I then proceed to give my patients some options. What can be done in regards to one, preserve ovarian function, so these women do not go into early menopause or how do we prevent early menopause? And then number two, how do we preserve fertility? So if one is interested in having a child or is thinking maybe they sometime in the future might be interested in becoming pregnant, then they have that option down the road.
Cheryl
10:04
What are some of the other options available for fertility preservation?
Dr. Balanchivadze
10:08
Yes, great question. So the most commonly utilized option is assisted reproductive techniques, where a patient visits a reproductive endocrinologist and undergoes a phase of stimulation, and then oocytes or eggs, in common language, are harvested and then frozen or cryopreserved for future use. Another option is to, rather than cryopreserve the oocytes or eggs, women, if they have a partner, can preserve embryos. The chances of successful pregnancy are higher if you have frozen embryos rather than oocytes. So those are the two options.
It does take about two to three weeks for this entire process. These women receive medications that stimulate the ovaries to produce extra follicles so the oocytes can be harvested. This requires time, so women get anxious about how this is going to affect their cancer journey because most women, and anybody really once they're faced with a diagnosis of cancer just want the cancer out as soon as possible or treat it if a treatment is required. There are certain types of really aggressive forms of cancer where there is not enough time or one doesn't have that two or three weeks.
So apart from those two options, oocyte and embryo preservation (cryopreservation), there are possibilities of actually harvesting ovarian tissue which would require surgery. This needs to be done at centers with expertise in harvesting ovarian tissue and cryopreserving ovarian tissue. That would be a third option. A fourth option is to just preserve ovarian function. This doesn't truly preserve fertility. But if you're thinking somebody is very young, let's say, age 35 or younger, or even 30 or younger, what we do is we put their ovaries to sleep. We give them medication. They're called gonadotropin-release hormone analogs, and what these drugs do, they basically freeze the ovaries, and that in turn halts things in time. We find that doing so reduces the risk of premature ovarian failure. Obviously it does not guarantee fertility, but it does reduce early menopause.
Cheryl
13:16
It seems like these young women are dealing with so much. They're getting the diagnosis and then understanding that time is of the essence, but then they've got this other thing to think about in terms of fertility, depending on the age when they receive this diagnosis. How do you help them through this process, emotionally?
Dr. Balanchivadze
13:33
Yeah, so it really takes a village, and at Virginia Oncology Associates we have that village that it takes. We have physicians who specialize in treating certain cancers like myself. And we have other physicians who treat women with breast cancer specifically. This is what we do every day. We also have a group of social workers, case managers, and nurses. We partner with local fertility clinics, as well as universities, and we find pathways and channels to try to get these patients to reproductive endocrinologists as soon as possible.
I can remember very few times when we didn't get these patients in on the same day. I'm talking either the same day or the next day they're meeting with a fertility specialist and talking through the options. It is challenging because it's emotionally challenging. Plus, a lot of these women don't even have partners, or those who have partners, the partner might not be certain if they want to have children down the road. Then there is the financial aspect of it because these treatments can be expensive. Thankfully, there are various grants available. So we have support systems in place where we can connect these patients to possibly available grants where they can receive assistance for some of the medications that help in the process.
Cheryl
15:30
Thank you, and you're right, it does take a village and it helps to hear about all the people who can play a role. So thank you for that. I wanted to talk about the...I guess the process; maybe the best way to describe it. So let's say, a woman makes that decision to do something to preserve, how soon after can chemotherapy take place?
Dr. Balanchivadze
15:50
Actually one can start chemotherapy the same day as the oocytes are collected. Obviously, I talk to the fertility specialist to make sure there are no complications, like bleeding, or typically the risk of infection is very low. But I touch base with the fertility physician. The same day or the next day treatment can start, so it really moves pretty fast. That initial two or three weeks for the stimulation and then once the oocytes are collected, patients are ready to go, so they start chemotherapy right away.
Cheryl
16:30
As far as regularity, as far as a woman's cycle, when does that return after chemotherapy?
Dr. Balanchivadze
16:39
It depends on the age, and what the initial ovarian reserve was. Most women would see the return of their menstrual cycle within months. However, even if their menstrual cycle is irregular, sometimes they can still get pregnant, believe it or not. We see kind of both sides of the coin. Oftentimes we have to counsel these women on proper contraceptives because of the toxicities that are associated with the treatments.
Cheryl
17:14
And speaking of such, how soon can someone get pregnant after breast cancer treatment?
Dr. Balanchivadze
17:21
So it's a trick question in a way. We have to adequately treat the breast cancer. For most run-of-the-mill breast cancer, adequate treatment involves, surgery or radiation and then, if they needed chemotherapy, treatment with chemotherapy and about five years of anti-estrogen treatment if they had hormone-positive breast cancer. That would be the standard of care for breast cancer treatment. There have been studies that are now looking at can these women get pregnant sooner. There was a recent study called a positive trial, just like you would spell out the word positive.
So in this study, they looked at women who had early-stage breast cancer and they had hormone-positive breast cancer and they were age 42 or younger. They must have completed about 18 to 30 months of endocrine therapy and they had to have a desire to get pregnant. They enrolled about 516 patients, and most of these patients were aged less than 41. 47% of these women had stage one disease and most of these women had prior chemotherapy. The researchers followed these patients for about 40 months and they found that, compared to the relapse rate in premenopausal women that is expected with similar types of cancers, the patients who became pregnant and stopped the endocrine treatment sooner, there was no difference in regards to progression of cancer or death. Now we have this mounting evidence in regards to cancer recurrence, it is safe to get pregnant, and if one cannot wait the standard of five years, then maybe getting pregnant sooner is an option. We typically recommend at least two years after the diagnosis prior to getting pregnant.
Cheryl
19:42
That is positive news. Thank you.
Dr. Balanchivadze
19:44
Yeah, it is positive.
Cheryl
19:46
On this podcast, we've had the opportunity to speak with some of your colleagues about advances, about research, about things that they're excited about related to their specialties. Is there anything that you're excited about as you treat women with breast cancer and more and more young women; anything that is exciting?
Dr. Balanchivadze
20:05
Yeah, there is so much to be excited about. I think that we are getting better, not only in regards to treatment and more targeted therapies, but our treatments have become individualized. As these treatments become individualized, they are relevant not only for the survival and treatment of these particular patients. In regards to toxicities, so we're seeing fewer toxicities. No woman or patient should now be throwing up for the duration of the treatments. We've gotten so much better at treating toxicities. And women are very outspoken about the quality of life. I tell my patients cancer is life-changing but it's not life-defining. Life goes on. These women are mothers, they are partners, they are friends. They are CEOs, they are leaders, and they need to go on with their lives. I'm excited to see that we are able to help women achieve and get back to their lives as quickly as possible after their cancer diagnosis.
Cheryl
21:35
Dr. B., thank you so much for your time.
Dr. Balanchivadze
21:38
Thank you for having me.
21:40
That’s all for this episode of Cancer Care Connections. Stay tuned for our next episode where Cheryl will sit down with Dr. Ligeng Tian, a medical oncologist and hematologist with Virginia Oncology Associates. Dr. Tian discusses what one can do for themselves to reduce their risk of cancer; stressing that a healthy diet, physical activity, and vaccination against certain diseases play a tremendous role.
Don't forget to subscribe to our podcast via Apple Podcast, Spotify or anywhere podcasts are available, or listen online at cancercareconnections.buzzsprout.com. Cancer Care Connections is the official podcast of Virginia Oncology Associates. For more information, visit us at virginiacancer.com or find us on Facebook or Instagram at Virginia Oncology Associates.