Motherhood after breast cancer

Bavina Sookdeo

A breast-cancer diagnosis can feel like a devastating halt to a woman’s dreams – particularly for those hoping to start or grow their families.

But Dr Rajen Rampaul, breast oncologist and reconstructive surgeon, says motherhood after breast cancer is not only possible but increasingly safe, thanks to advances in treatment and fertility preservation.

In a career of nearly three decades, Rampaul has dedicated much of his life to women’s health and breast cancer care. As the medical director at Pink Hibiscus Breast Health Specialists, he leads one of the region’s foremost centres for breast-related care.

What sets him apart in the Caribbean landscape is his pioneering work in radioactive and oncoplastic breast surgeries – procedures widely regarded as the gold standard internationally.

But beyond the cutting-edge technology and surgical precision, Rampaul’s message is one of compassion and empowerment.

“Your life does not end with breast cancer. It can be successfully treated and cured. You can be a mother, you can have a family – and we (medical practitioners) can help you with that.”

While breast cancer itself doesn’t directly affect a woman’s ability to have children, Rampaul explained that treatment choices can make a significant difference.

“Developing breast cancer does not affect her reproductive potential. However, there are other conditions, such as developing endometrial cancer or ovarian cancer, that can.”

He said in the case of breast cancer, it’s the treatment that affect whether a woman can have children.

“…That is where we have to pay attention, to help protect her so that she can have the chance for children later in life.”

How treatment affects fertility

Rampaul described the effect of various treatments:

Surgery (a primary mode of treatment) – “Surgery will not affect her fertility, that is her reproductive potential or the ability to have children.”

Chemotherapy agents act by preventing the growth and causing the death of rapidly developing or multiplying cells.

“However, ovarian cells, which go on to produce hormones and are also going to produce the egg, fall within this category,” said Rampaul. “Therefore, these cells within the ovary are affected by chemotherapy.”

Radiation, he said, will not affect her fertility, as radiation is directed to the breast and will not be administered to her ovaries.

Hormone therapy, however, will affect a woman’s fertility.

“This takes the form in breast cancer treatment (of) hormone blockers or oestrogen receptor blockers. So naturally, when these drugs are given, it will lower the activity or the efficacy of oestrogen in the body…Oestrogen is one of the most important hormones that play a role in fertility and in pregnancy and thus having children.”

Preserving fertility

Asked about preserving fertility, Rampaul explained this is a highly individualised decision, depending on the woman’s reproductive health, her wishes, the type of breast cancer she’s been diagnosed with and what is available to help her.

For patients with hormone-negative cancers, he said options are broader, since they are not prescribed oestrogen blockers. These women may consider ovarian suppression – using medication to temporarily pause ovarian function – or freezing ovarian tissue for future use.

While embryo harvesting is possible, he cautioned that it is often too time-consuming when treatment must begin quickly.

“Time is of the essence in treating breast cancer, and therefore this is not an ideal option.”

For women with hormone-positive cancers, the options are more limited, as ovarian stimulation is not advised, but tissue freezing or ovarian suppression remain viable. Rampaul said these fertility-preservation methods are available locally.

Pregnancy after breast cancer

While women may have a strong desire to become pregnant, Rampaul advised patience and careful medical supervision.

Asked how long after completing breast cancer treatment he would advise a patient to wait before getting pregnant, he said there are no definitive guidelines, but it would be safe to consider a minimum of five years.

“Naturally, you also have to take into consideration the age of the patient – in the older patient, waiting five and ten years can put her in an age range where she would not be able to carry the pregnancy (due to advanced maternal age pregnancy) without increasing risk.”

Rampaul added that the risks associated with pregnancy after breast cancer treatment depend largely on the type of cancer. In cases of hormone-positive or oestrogen-positive breast cancer, pregnancy can increase the risk of recurrence, or metastasis, since the high-oestrogen environment of pregnancy may stimulate cancer cell growth.

He stressed that women with this diagnosis must receive thorough counselling before trying to become pregnant.

However, for those with hormone-negative breast cancer, he said this risk does not apply, and their concerns would instead focus on the usual considerations of pregnancy itself.

Is breastfeeding possible?

For many mothers, breastfeeding is a deeply emotional experience – one they hope to share even after treatment. But Rampaul cautioned that the ability to breastfeed after breast cancer depends on the type of surgery and whether radiation was involved.

For instance, when it comes to mastectomy (the removal of the breast), “If she had bilateral mastectomies, she would not be able to breastfeed at all.

“However, if she had one breast removed, she would be able to breastfeed on the normal, remaining breast.”

Lumpectomy, he noted, is similar.

“Having surgery on the breast to remove a part of it can affect the milk duct system, where scarring and removal can prevent the milk from reaching the nipple.

“However, even if that did not happen, but she received radiation to the breast, that would definitely have an impact on the breast to be able to breastfeed, so that ability would be diminished or absent completely.”

But he stressed, “I would remind readers that none of this affects a woman’s ability to become pregnant or to deliver a normal baby.”

Rampaul explained that there are generally no significant risks of breastfeeding after breast cancer treatment for either the mother or the child.

The only potential concern arises if a woman has had breast reconstruction with an implant. In such cases, developing mastitis (swelling and redness (inflammation) of breast tissue) in the remaining, natural breast could indirectly affect the implant on the opposite side.

He stressed that there are no risks to the child, as breast milk is safe once treatment has ended.

“Naturally, breastfeeding would not occur during chemotherapy, and so the child would not be at risk of chemotherapy (drugs) being present in the milk.”

Seeking support

Asked what advice he would give to women who are concerned about balancing breast cancer, survivorship and the desire to start or expand a family, he said, “My advice is to understand their risk if they were to have a family. But in the modern era, we as doctors can help support their need and expectations for a family.”

He stressed that emotional and psychological support is just as vital as medical care.

“I personally believe it is very important to help my patients have a full and beautiful life, and having a family is part of that. I believe it is our duty as doctors and nurses to be able to educate, support and provide extra care so they can have their family and remain safe.”

Support systems for breast-cancer survivors in TT are growing in number, and Rampaul said many of them can be accessed online.