In a study reported in The New England Journal of Medicine, Ann H. Partridge, MD, MPH, of Dana-Farber Cancer Institute, and colleagues found that temporary interruption of adjuvant endocrine therapy to attempt pregnancy was not associated with increased short-term risk of breast cancer events among women with hormone receptor–positive early breast cancer.1
As stated by the investigators: “Prospective data on the risk of recurrence among women with hormone receptor–positive early breast cancer who temporarily discontinue endocrine therapy to attempt pregnancy are lacking.”
In the multicenter International Breast Cancer Study Group study, 516 women aged ≤ 42 years with stage I to III disease who had received adjuvant endocrine therapy for 18 to 30 months and desired pregnancy were enrolled between December 2014 and December 2019. The study protocol specified that patients have a 3-month washout period after discontinuing endocrine therapy before attempting pregnancy. The duration of interruption of endocrine therapy could be up to 2 years. Fertility assessment was strongly encouraged if pregnancy did not occur after 1 year.
Ann H. Partridge, MD, MPH
The primary endpoint was the number of breast cancer events—defined as local, regional, or distant recurrence of invasive breast cancer or new contralateral invasive breast cancer—during follow-up. The primary analysis was to be performed after 1,600 patient-years of follow-up; the prespecified safety threshold was occurrence of 46 breast cancer events during this period. Breast cancer outcomes in the study population were compared with those in an external control cohort of 1,499 women with hormone receptor–positive disease (from the SOFT and TEXT trials) who met age, disease stage, and duration of endocrine therapy entry criteria for the current study.
Among the 516 women, the median age was 37 years, the median time from breast cancer diagnosis to enrollment was 29 months, and 93.4% had stage I or II disease. Among 497 women who provided information on pregnancy status, 368 (74.0%) had at least one pregnancy, and 317 (63.8%) had at least one live birth; in total, 365 babies were born, including 335 singletons and 15 sets of twins. Among the 368 women with at least one pregnancy, 93 (25.3%) had miscarriages, 16 (4.3%) had elective abortions, 1 (0.3%) had a stillbirth, and 1 (0.3%) had a neonatal death.
With 1,638 patient-years of follow-up (median = 41 months), 44 patients experienced a breast cancer event, a number not exceeding the safety threshold of 46 events. The hazard ratio for a breast cancer event to be associated with pregnancy was 0.53 (95% confidence interval [CI] = 0.27–1.04).
Analysis using a bootstrap-matching method for the study population vs the control cohort showed that the 3-year incidence of breast cancer events was 8.9% (95% CI = 6.3%–11.6%) in the study cohort vs 9.2% (95% CI = 7.6%–10.8%) in the control cohort (absolute difference = −0.2 percentage points; 95% CI, −3.1 to 2.8 percentage points; hazard ratio [HR] = 0.81, 95% CI = 0.57–1.15). The 3-year incidence of distant recurrence was 4.5% (95% CI = 2.7%–6.4%) vs 5.8% (95% CI = 4.5%–7.2%; absolute difference = −1.4 percentage points, 95% CI = −3.5 to 1.0 percentage points; HR = 0.70, 95% CI = 0.44–1.12). Results were similar when a direct comparison method was used for the unadjusted study and control cohorts.
Logistic-regression analysis showed that younger age was the only factor substantially related to successful pregnancy; pregnancy occurred in 85.7% of patients aged < 35 years, 76.0% of those aged 35 to 39 years, and 52.7% of those aged 40 to 42 years. A total of 43.3% of women reported using assisted reproductive technology. The cumulative incidence of first pregnancy was 28.8% at 6 months from enrollment, 53.6% at 12 months, and 70.5% at 24 months.
A total of 41 women with at least one pregnancy (11.1%) reported at least one pregnancy complication, most commonly hypertension or preeclampsia (3.8%), diabetes (2.4%), and placental abnormalities (1.6%). Adverse birth outcomes among the 365 babies born included low birth weight (< 2,500 g) in 7.9% and birth defects in 2.2%. Among 317 women with at least one live birth, breastfeeding was reported by 61.8%.
Among 415 patients who were disease-free for at least 2 years, 304 (73.3%) resumed endocrine therapy during the study period; approximately half resumed therapy within 26 months after treatment interruption. Among 111 women who had not resumed endocrine therapy at time of the database lock, 88 (79.3%) reported they were currently attempting to become pregnant, actively, or recently pregnant, or actively or recently breastfeeding. A total of 15.4% had not resumed endocrine therapy by 48 months after treatment interruption.
The investigators concluded: “Among select women with previous hormone receptor–positive early breast cancer, temporary interruption of endocrine therapy to attempt pregnancy did not confer a greater short-term risk of breast cancer events, including distant recurrence, than that in the external control cohort. Further follow-up is critical to inform longer-term safety.”
DISCLOSURE: The study was funded by the European Thoracic Oncology Platform and International Breast Cancer Study Group Partners Foundation and others. Dr. Partridge is a member of the ASCO Board of Directors; Vice Chair of Medical Oncology at Dana-Farber Cancer Institute; and has received royalties from UpToDate. For full disclosures of the study authors, visit nejm.org.
1. Partridge AH, Niman SM, Ruggeri M, et al: Interrupting endocrine therapy to attempt pregnancy after breast cancer. N Engl J Med 388:1645-1656, 2023.