15th Milan Breast Cancer Conference
Breast cancer patient autonomy and effects on treatment
Dr Fedro Peccatori - European Institute of Oncology, Milan, Italy
We are used to applying ethical frameworks in our everyday job. Requests from patients have changed very much; we have transitioned from a phase of paternalism to a phase in which a patient’s autonomy is much more valued. Of course this poses some questions and sometimes it’s difficult to answer those questions that come from patients. One of the big issues is the fact that the patient’s autonomy entails also the fact that the decisions can sometimes not be shared among physicians and patients and this sometimes can be problematic in choosing what is best for the patient.
In my job I treat patients, young patients, with tumours which occur during a reproductive age and the so-called reproductive autonomy is a big issue because patients ask for the possibility of having a pregnancy also after having received chemotherapy. Sometimes they put the pregnancy desire and their reproductive issues first in their priorities. Of course it’s kind of difficult to balance what may be important by the treating point of view for treating cancer and the right that every woman has to decide upon her reproduction. In oncology this poses a further problem because of the prognosis and because of the effect of treatment on fertility. So we are doing a big effort to offer these women also something that can preserve their fertility before undergoing treatment. Now the technology is mature enough to have effective fertility preservation methods for patients who undergo chemotherapy.
What are some of the important factors when informing the patients?
One of the most important things when we approach young patients with cancer is information to the patients. Also in the recently updated guidelines of the American Society of Clinical Oncology and in our guidelines, the guidelines of the European Society of Medical Oncology which I participated in writing, we put discussion information as the first step in approaching those patients. Of course a decision can be made only if it is an informed decision which means that the patients must have all the options on the table and then deciding accordingly but after all the options are there and they have been explained thoroughly. So this is very, very important in the decision tree. There are also other factors, of course the availability of the fertility preservation technique, the fact that some of the techniques are standard techniques and other techniques are still experimental techniques. This is particularly important not to raise too many expectations in women where the rate of success remains anyhow around 30%.
Where should patients be referred to in Italy?
It’s very important that the patients are referred to centres which have a keen interest in this kind of procedural counselling and have set up a network with the assisted reproductive technology centres to refer the patients. One of the most important things is that the referral to the ART, the assisted reproductive technology centres, should be early in the trajectory of the disease because if you wait too much then you do not have the time to do all these procedures that in women take around ten days, 10-15 days. The technology has helped now because we can start the ovarian stimulation which is the main means of fertility preservation. We harvest oocytes after ovarian stimulation in any phase of the menstrual cycle so we do not have to wait until the next menstruation to start the ovarian stimulation. That’s very good, actually, it’s something new that we have at our disposal. The other point is that the network must be an efficient network which means that if I have a patient and I have to refer her to the reproductive endocrinologist he or she should be very prompt in replying, so to accept the patient and to evaluate the patient in a very short time.