Contraceptive Use Declines After Breast Cancer Diagnosis

Sharon Worcester, MA

October 21, 2022

Contraceptive use declined significantly after treatment for early breast cancer, according to a prospective analysis of nearly 3000 premenopausal women.

More specifically, at diagnosis, more than half of women reported using contraceptives — but at 1 year, that percentage had declined to less than 40%.

The findings, published online last month in JAMA Network Open, point to an unmet need for targeted contraceptive counseling in this population, especially among women who do not wish to become pregnant, the authors said.

The June 24 US Supreme Court ruling overturning Roe v Wade adds another layer of concern about contraceptive use and access for those with cancer. Restrictive to very restrictive abortion laws in about 26 states further limits patients' options if they were to become pregnant.

The Supreme Court's ruling puts "an added weight" on women with cancer who become pregnant or who are diagnosed with cancer during pregnancy, said Maryam Lustberg, MD, MPH, chief of breast medical oncology at Yale Cancer Center, New Haven, Connecticut.

"All women, including breast cancer survivors, need to have full access to reproductive health choices, which includes education about contraception and access to the full spectrum of gynecological services," Lustberg wrote in an editorial accompanying the study.

In recent years, "some concerning signals have emerged" suggesting that many pregnancies among breast cancer survivors are unintended, which explains, at least in part, "the high rate of induced abortions described among breast cancer survivors," study author Matteo Lambertini, MD, PhD, of the University of Genova, Italy, and colleagues wrote.

Given this, Lambertini and colleagues wanted to better understand contraceptive use among women with breast cancer.

The current analysis used data from the CANTO study, which included 2744 women diagnosed with stage I-III breast cancer in France between March 2012 and December 2017. The researchers analyzed data collected at different time points "to provide distinct insights on contraceptive use and factors associated with contraceptive use over time."

At the time of diagnosis, more than half of women (54.2%) reported contraceptive use, 63% of whom used hormonal birth control. Participants were a mean age of 43 years. Primary treatment included chemotherapy in about 71% of participants, and endocrine therapy in about 80%.

The use of contraception significantly decreased 1 year after diagnosis to nearly 39% of patients (911 of 2342) and 2 years after diagnosis to 41% of women (808 of 1961). Most patients at year 1 (94.2%) and year 2 (95.3%) reported use of nonhormonal methods, including reversible mechanical methods, such as copper intrauterine devices and male condoms.

At 1 year after diagnosis, 45% of patients reported consulting with a gynecologist during the prior year, and at year 2, almost two thirds of patients reported doing so.

After adjustment for numerous variables, factors significantly associated with contraceptive use at 1 year included contraception use at diagnosis (adjusted odds ratio [aOR], 4.02), younger age (aOR, 1.09 per decreasing year of age), better sexual function (aOR, 1.13), already having children (aOR, 4.21), the presence of leukorrhea (aOR, 1.32), treatment with single-agent tamoxifen (aOR, 1.39), and consulting with a gynecologist during the prior year (aOR, 1.29).

Similar factors were associated with contraceptive use at 2 years, but at that time, still being partnered was also significantly associated with contraceptive use (aOR, 1.61), the authors noted.

The findings are notable given earlier diagnoses and longer lifespans among cancer survivors, which make future pregnancies and reproductive health in general more relevant than in the past.

"Among premenopausal patients, reproductive health is an important component of survivorship care," the authors wrote. "These data support the clinical utility of promoting a more structured referral network that links oncologists and gynecologists, which may ensure not only access to fertility preservation strategies but also provide comprehensive long-term follow-up care."

The current results also "highlight the importance of specialized comprehensive contraceptive counseling to aid in the selection of reliable methods and decrease the risk of unintended pregnancies."

Lustberg agreed, adding that the "findings underscore the need to protect women by making conversations about contraceptive choices a priority."

Contraceptive choices are already limited after cancer because hormonal contraceptives are often not an option, she explained.

For women who do wish to become pregnant later, it is important to plan ahead. "It takes planning and resources, and [these discussions] need to be more ingrained in the care of these women," she said.

And although CANTO is a French study, the findings "very much resonate in terms of what happens in the United States," Lustberg said.

"A more structured and coordinated system that links oncologists, gynecologists, and primary care clinicians is essential to providing long-term follow-up care to the increasing number of breast cancer survivors," she added.

The CANTO study is supported by grants from the Investment for the Future program of the National Research Agency of France. Lambertini reported receiving personal fees from AstraZeneca, Eli Lilly and Co, Gilead Sciences, Merck Sharp & Dohme, Novartis, Pfizer, Roche, and others and served as an advisor for some of these companies outside the submitted work. Lustberg reported no conflicts of interest.

JAMA Network Open. Published online September 23, 2022. Full text; Editorial

Sharon Worcester, MA, is an award-winning medical journalist based in Birmingham, Alabama, writing for Medscape, MDedge and other affiliate sites. She currently covers oncology, but she has also written on a variety of other medical specialties and healthcare topics. She can be reached at sworcester@mdedge.com or on Twitter: @SW_MedReporter

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