Health Care for Women International

ISSN: 0739-9332 (Print) 1096-4665 (Online) Journal homepage: https://www.tandfonline.com/loi/uhcw20

A Qualitative Analysis of Reproductive Issues

Raised by Young Australian Women with Breast
Cancer

Shirley Connell , Carla Patterson & Beth Newman

To cite this article: Shirley Connell , Carla Patterson & Beth Newman (2006) A Qualitative
Analysis of Reproductive Issues Raised by Young Australian Women with Breast Cancer, Health
Care for Women International, 27:1, 94-110, DOI: 10.1080/07399330500377580

To link to this article: https://doi.org/10.1080/07399330500377580

Published online: 20 Aug 2006.

Submit your article to this journal

Article views: 342

Citing articles: 63 View citing articles

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=uhcw20
Health Care for Women International, 27:94–110, 2006
Copyright © Taylor & Francis, Inc.
ISSN: 0739-9332 print / 1096-4665 online
DOI: 10.1080/07399330500377580

A Qualitative Analysis of Reproductive Issues

Raised by Young Australian Women with
Breast Cancer

SHIRLEY CONNELL, CARLA PATTERSON, and BETH NEWMAN

Centre for Health Research—School of Public Health, Queensland University
of Technology, Australia

Available literature concentrates on infertility concerns of young

women with breast cancer, while attention to psychosocial issues
related to maintained or regained fertility is scarce. As part of a
longitudinal, qualitative study of experiences of young women with
breast cancer (diagnosed at 40 years or younger); (n = 13), con-
cerns about fertility, contraception, pregnancy, and breastfeeding
after breast cancer were expressed. Using semistructured, one-to-
one interviews over three time phases, we explored these women’s
experiences. Perceptions of fertility changed over time. Contracep-
tion issues were raised together with recurrence fears related to
pregnancy and breastfeeding after breast cancer. Decisions related
to unplanned pregnancies and breastfeeding were described as par-
ticularly onerous.

BACKGROUND

The most frequently diagnosed cancer in Australian women is breast cancer,

with 11,791 cases recorded in 2001 (Australian Institute of Health and Wel-
fare [AIHW], & Australasian Association of Cancer Registries [AACR], 2004).
Breast cancer is clearly an important women’s health issue with public health
implications. Approximately 6% (674 cases) of diagnoses were recorded for

Received 7 September 2004; accepted 2 September 2005.

Co author Associate Professor Carla Patterson died from breast cancer on the August 31,
2005.
We thank Trish Gould, research assistant, from the Centre for Health Research—School of
Public Health, Queensland University of Technology, for her assistance in coding verification
of participants’ responses for triangulation purposes.
Address correspondence to Shirley Connell, PhD candidate, Centre for Health Research—
School of Public Health, Queensland University of Technology, Victoria Park Rd., Kelvin
Grove, 4059. QLD. Australia.

94
 Reproductive Issues After Breast Cancer 95

women aged 39 years or younger (AIHW & AACR, 2004). Younger women
with breast cancer therefore compose a subgroup deserving special attention
for a range of reasons.
Younger women report similar breast cancer-related issues as older
women, although the literature suggests that they experience these more
negatively and intensely (Mor, Malin, & Allen, 1994; Trief & Donohue-Smith,
1996). Some issues and concerns of young women with breast cancer are
unique, however, such as those surrounding reproduction, including fertility,
contraception, pregnancy, and breastfeeding.
Infertility is a major issue for some young women with cancer as they
can be thrown into early menopause due to cancer treatment (Bloom &
Kessler, 1994; Dunn & Steginga, 2000; Schaefer, Ladd, Lammers, & Echenberg,
1999; Siegel, Gluhoski, & Gorey, 1999; Singer & Hunter, 1999). Approximately
50% of women under age 40 will retain their ovarian function following
cancer treatments; hence future pregnancies remain a possibility (Reichman
& Green, 1994). Despite this, information for these women regarding fertility
and menopause is considered insufficient or unavailable (Thewes, Meiser,
Rickard, & Friedlander, 2003). As more women delay childbearing (Dow,
Harris, & Roy, 1994; Gemignani & Petrek, 2000), as indicated by the trend
in Australia of increasing age at first birth (AIHW, 1997, 2001), so too does
the possibility that more young female breast cancer survivors will desire
children.
The literature advises that a pregnancy should not be attempted for
2 years following a breast cancer diagnosis, due to recurrences occurring most
often in that period (Isaacs, 1995; Petrek, 1994b). According to a review of
the breast cancer and pregnancy literature, avoiding pregnancy in the short
term brings forth a “quagmire of issues related to contraceptive methods”
(Puckridge, Saunders, Ives, & Semmens, 2003, p. 502). Despite availability of
little concrete evidence, nonhormonal contraceptive methods are preferred
(International Planned Parenthood Federation [IPPF], 1999).
The general consensus in the literature is that a pregnancy following
a breast cancer diagnosis does not increase the risk of mortality from the
disease or of recurrence (Blakely et al., 2004; Collichio, Agnello, & Staltzer,
1998; Kroman, Jensen, Wolfahrt, & Mouridsen, 1997; Mueller et al., 2003;
Velentgas et al., 1999). There is evidence to suggest, however, that young
women experience fear and anxiety regarding a pregnancy after breast can-
cer, in part related to the possibility of such recurrence and its consequences.
Concerns regarding difficulty in finding important breast changes in a
pregnant/lactating breast (Dow, 1994; Schover, Rybicki, Martin, & Bringelsen,
1999), fear and anxiety concerning passing on a breast cancer gene to an
unborn child (Saunders & Baum, 1993; Siegel, Gorey, & Gluhoski, 1997)
and possible abnormalities in the child due to treatment effects (Siegel
et al., 1997) all have been noted. Stress due to caring for the child after
breast cancer has been expressed as well; nevertheless, possible positive
96 S. Connell, C. Patterson, and B. Newman

effects, such as the return to normalcy, also have been found (Siegel et al.,
1997).
Two issues have been identified as important for women who breast-
feed after breast cancer: the mechanical ability to breastfeed after radiation
treatment (Petrek, 1994a) and breast surgery (Neifert, 1992), and the risk of
further breast cancer activation due to breastfeeding (Schover, 1991), despite
literature indicating the contrary (Collaborative Group on Hormonal Factors
in Breast Cancer, 2002; McTiernan & Thomas, 1986). Small case studies have
documented women successfully breastfeeding from an affected breast while
stating some difficulties were experienced, such as the infant favouring the
nonaffected breast and low milk supply (Higgins & Haffty, 1994; Neifert,
1992; Tralins, 1995; Varsos & Yahalom, 1991; Wobbes, 1996).

PURPOSE AND SIGNIFICANCE OF STUDY

Much emphasis has been placed on infertility as a consequence of cancer

treatment (Bloom & Kessler, 1994; Dunn & Steginga, 2000; Schaefer et al.,
1999; Siegel et al., 1999; Singer & Hunter, 1999). In contrast, literature relating
to fertility among young women with breast cancer, dealing with personal
experiences of contraception, pregnancy, and breastfeeding, is scarce. A lon-
gitudinal, qualitative study was conducted among women with breast cancer
diagnosed before age 41 years, in order to better understand their concerns
and needs. At each of the three interviews, infertility and maintained or re-
gained fertility after breast cancer were highlighted as important issues, and
this article focuses on the changing views of reproductive issues that were
reported by the participants over a 12–18-month period.

THEORETICAL FRAMEWORK

This study was guided by constructionist epistemology, using an interpreta-

tive approach. Social constructionism, which is underpinned by the philoso-
phy of phenomenology (Cheek, Shoebridge, Willis, & Zadoroznyj, 1996) and
allows the everyday lived experiences of the participants to be captured, was
the theoretical framework used. The interpretative approach encompasses
“how people make sense of their lives; and how they define their situation”
(Jackson, 1998, p. 9). Hence, as well as reporting on various psychosocial as-
pects of these women’s experiences, this study also sought to interpret how
the participants’ experiences were constructed thus allowing the issues that
shape the participants’ reproduction-related perceptions and experiences to
be explored.
 Reproductive Issues After Breast Cancer 97

STUDY PROCEDURES AND PARTICIPANTS

The overarching aim of this study was to explore the issues and concerns
of young women with breast cancer over time. Recruitment for the baseline
interview (first phase) was achieved via convenience sampling; that is, “re-
quests for participants” flyers were placed at various breast cancer events
and at venues where young women with breast cancer were likely to visit,
such as at breast cancer support groups. Thirty-five eligible participants vol-
unteered for the study. The inclusion criteria for the study were an adult
female diagnosed with breast cancer at 40 years or younger and English
speaking. The exclusion criteria were women diagnosed with breast cancer
more than 4 years ago, suffering extreme distress, in palliative care, or all
of these. The follow-up participants (n = 13) were selected, via purposeful
sampling, from the 35 study participants on the basis that the greatest unmet
need they reported was related to support, an issue that had the potential
to change over the short term. Hence the criterion for participation in the
follow-up interviews was not directly related to the theme of reproductive
concerns.

Ethics
This study was given full ethical approval by the Queensland University of
Technology University Human Research Ethics Committee. All participants
signed a consent form after reading an information package prior to any data
collection. Throughout the interview process ongoing consent was verified.

Data Collection
Data were collected three times over a 12–18-month period using one-to-
one, semistructured interviews. The average time per interview was 1 hour,
and interviews were conducted as close as possible to 6 months apart to
capture changes over a short time frame. All interviews were conducted
by a single interviewer (SC) either in participants’ homes or by telephone
where necessary. Due to relocation, one participant left the study prior to the
final interview. The use of one-to-one interviews was considered a powerful
way to acquire insights into the participants’ experiences (Creswell, 1998;
Seidman, 1991).
Some lines of inquiry initiated in the first interview were followed
throughout the study, such as participants’ greatest unmet needs, major
present concerns, and how they were feeling about the breast cancer at
each phase. As new issues emerged from the data, they too were followed.
Questions about reproduction centred on perceptions of participants’ fertility
status, if that status had changed, together with any changes or issues that
98 S. Connell, C. Patterson, and B. Newman

arose. Issues of contraception, pregnancy, termination, and breastfeeding af-

ter breast cancer, and the participants’ feelings about related decisions and
experiences, also were explored. Typical questions relating to pregnancy af-
ter breast cancer were, “What sort of breast changes did you experience dur-
ing the pregnancy? How did you feel about that?” The full interview schedule
is available upon request.

Data Analysis
All data analyses were conducted by the principal investigator (SC), unless
otherwise stated. All audiotape recorded interviews were transcribed verba-
tim, most by an independent transcriber and the remainder by the principal
investigator (SC). A quality check was performed on the first two transcripts
against audiotapes, a face-to-face interview, and a telephone interview, be-
fore the independent transcriber continued. Analyses of the data were per-
formed in accordance with basic analytical principles of data reduction, data
display, and drawing conclusions (Miles & Huberman, 1994).
Data reduction. A summary of each participant’s story was developed.
Following the first data collection, the data were coded into literature-derived
themes, and further categorisation was undertaken where appropriate. Subse-
quent data collected were divided first into themes derived from the interview
phase, and then subdivided and categorised where appropriate.
Data display. A table of major issues and concerns was developed docu-
menting major concerns, greatest unmet needs, and perceptions of the illness
over time. Additional tables were developed for specific emerging themes,
such as issues related to infertility, fertility, contraception, and pregnancy.
Drawing conclusions. The data in these tables were compared and con-
trasted across time phases for each participant and then across all participants.
As this study was longitudinal, movement backward and forward between
data reduction, data display, and drawing conclusions was constant.
Further data reduction. Further subdivision and deeper analysis of the
data were assisted by the use of NUD*IST (N6) qualitative software. The
data were subdivided into three levels: that is, first level main categories, to
second level sub categories, and so on. Two layers of summaries for each of
these categories were formulated, deepening the analysis.
Further data display. Additional tables were developed and previous
tables updated.
Further conclusions drawn. Deeper levels of conclusions then emerged.

Quality Assurance
The rigour of data analysis and the trustworthiness of the study’s findings
were enhanced by attending to a number of recommendations made by
qualitative researchers (Guba & Lincoln, 1989; Miles & Huberman, 1994).
 Reproductive Issues After Breast Cancer 99

Data dependability was achieved in each subsequent interview by confirm-

ing details and verifying the principal investigator’s (SC) understanding of
participants’ descriptions of previously reported experiences. In addition,
field notes recorded the interviewer’s perceptions of the interview process,
noting any specific elements that may have influenced the responses given
by participants, for example, a partner within hearing distance throughout
the interview. Analysis steps were documented to provide an audit trail, in-
cluding sufficient data to allow readers to judge the interpretation presented
(Guba & Lincoln, 1985; Mays & Pope, 2000; Miles & Huberman, 1994).
Investigator triangulation was established with the use of coding checks
performed on portions of the raw data by an independent, experienced re-
searcher (TG), with an inter-rater reliability of 90% for the first level of codes
and 82.5% for the subsequent levels (Miles & Huberman, 1994). Credibility
was further enhanced as participants and experts in the breast cancer field
provided feedback on the study’s findings (Guba & Lincoln, 1989; Patton,
1999). This validated, to a point, the conclusions drawn. Due to the nature
of the illness, and the design of the study, changes did occur in how the
participants perceived their illness trajectories. Theoretical validity, with re-
gards to the use of a theoretical framework suitable to the task, enhanced
the findings’ validity (Miles & Huberman, 1994). Moreover, several findings
from this study are consistent with those found in the literature; hence
transferability/fittingness added to this credibility. Many new insights
evolved, however, due to the focus on young women and the longitudinal
nature of the study.

Participants
Participants resided in various states and territories of Australia. The me-
dian age at diagnosis of the 13 follow-up participants was 37 years (range
29–40 years). By design, women were eligible if they had been diagnosed
within the previous 4 years to gain insight into the wide range of experi-
ences following breast cancer; the median time lag since diagnosis was 26
months (range 5–37 months) at first interview. The self-reported nature of
the data did not allow the severity of participants’ cancer to be checked
against medical records. Two of the follow-up participants reported be-
ing diagnosed with metastatic cancer, however, one prior to the first phase
and one by the second phase. Along with other relevant demographic de-
tails, the education level and occupation of the participants are displayed in
Table 1, giving an indication of their socioeconomic status. Although ethnic-
ity was not specifically recorded, the women in the participant pool were
representative of mainstream Australia; that is, 80% of the Australian popula-
tion’s ancestry is Australian, English, and Irish (Australian Bureau of Statistics,
2001).
100
TABLE 1 Demographic Details of Follow-up Participants

Age at Time since Number

diagnosis diagnosisa Education Main of Ages of
Code (Years) (Months) level Occupation surgery children childrenb

P1 32 24 No reply Business owner/manager Lumpectomy 1 21 months

P4 34 11 Collegec Professional Lumpectomy 2 4 and 7 years
P8 39 37 College Business owner/manager Mastectomy 2 12 and 14 years
P9 34 21 College Other/nonspecific Lumpectomy 0
P10 40 6 Up to year 12 Physical job Mastectomy 2 16 and 17 years
P11 38 12 College Professional Mastectomy 1 18 months
P15 33 30 College Professional Mastectomy 0
P16 39 31 Collegec Professional Lumpectomy 0
P18 33 26 Up to year 12 Administration/public servant Mastectomy 0
P27 37 26 Technical school Trade Mastectomy 2 13 and 16 years
P34 37 33 Technical school Home duties Mastectomy 2 6 and 7 years
P35 37 28 Collegec Professional Lumpectomy 1 3 years
P38 29 5 Up to year 12 Business owner/manager Lumpectomy 0
a Time since diagnosis at first interview.
b Ages of children at first interview.
c Postgraduate education (i.e., master’s or doctorate degree).
 Reproductive Issues After Breast Cancer 101

FINDINGS

Reproduction as a crucial issue for young women with breast cancer not only
hinges on potential infertility caused by treatment but also on uncertainty of
fertility status; suitable, safe, and reliable contraception; and pregnancy and
subsequent breastfeeding.

Fertility
Over time not only did changes occur in fertility status of various participants
but also in their perceptions of infertility as an issue. For some participants,
infertility concerns remained constant, while other participants, who had in
earlier interviews stated infertility was not an issue for them, had a change
in perspective by the last interview. Such changes were centred around re-
gret that fertility-preserving choices in early diagnosis had not been utilized.
The quote below depicts a participant’s deepened level of regret by the last
interview. (Participant code in parentheses.)

Time 3: You don’t think that further out . . . that’s my biggest regret be-
cause I could’ve had eggs frozen. . . . It’s as time goes by and as life
becomes a little bit more back to normal, as it can be, and you see the
holes, big holes that are left. (P15, age 32)

Other participants, who thought they were not fertile, found out they
were when unexpected, and in some cases unwanted, pregnancies occurred.
Unpartnered participants held a different view over time, as expressed below:

Time 3: My periods came back to normal, and as far as I understand, I

have as much chance of conceiving as anyone else. . . . You don’t know
until you try and I haven’t tried. . . . That would be a big deal to me if I
couldn’t conceive. (P38, age 29)

Contraception
Safe, reliable contraception became a concern for some participants as they
did not want more children nor did they want their partners to have a vasec-
tomy in case the participants were to die. Permanent sterilization on the part
of some participants was a consideration, although with reservation. When
participants became pregnant, hence their fertility confirmed, contraception
after delivery became an issue. Below is a quote from such a participant:

Time 2: It really is incredibly difficult. . . . You don’t want your husband to

go and have a vasectomy because if you’re going to die [laughs] anyway
. . . and so there’s no way you’ll force them to go and have one. . . . You go
102 S. Connell, C. Patterson, and B. Newman

and have a tubal ligation because it’s a nonhormonal form of contracep-

tion and you’re going to die anyway [laughs], . . . but you’re menopausal
anyway, why go through a tubal ligation which has some inherent risks.
(P35, age 37)

These participants did not wish to take any hormone-based contracep-

tion regardless of how safe professionals may say it is. Below is a quote from
a participant who was pregnant at the second interview:

Time 2: Well, it’s risky, isn’t it. . . . It’s just my personal belief, I suppose,
it won’t matter what people in the medical field say to me, like they say
that you can take certain types of pills and things like that, and I just
don’t want to have anything that’s hormone altering and I mean, that’s
why it was a risk to get pregnant because there’s nothing more hormone
altering than pregnancy. . . . So I have the belief that anything like that is
tempting fate. (P1, age 32)

It should be noted that some participants were surprised to become

pregnant, due to contraceptive use together with not expecting to be fer-
tile as a consequence of treatment. Failed contraception for this group of
women is about more than the possibility of an unwanted pregnancy, it is
also about their fear and anxiety of possible recurrence. Below is a quote
from a participant who experienced failed contraception prior to the last
interview:

Time 3: I was horrified at the thought of being pregnant, really didn’t

want to be pregnant because of the breast cancer. . . . I really just thought
that being pregnant would be a very bad idea. (P4, age 34)

Pregnancy
Pregnancies occurred among participants during the study. Most participants
were elated they were pregnant, whereas some participants encountered
initial trepidation, debating whether to terminate the pregnancy. Below is a
quote from a participant who was pregnant at the first interview although
did not disclose this as she was deciding if she would terminate:

Time 2: I probably was in the early stages [of pregnancy at first interview],
but it was very difficult for me . . . because I really didn’t know what I was
going to do, or whether it was going to be something that I was going
to keep. It [the pregnancy] wasn’t something that was planned or was
supposed to happen. I really didn’t know if I was going to go through
with it. (P35, age 37)
 Reproductive Issues After Breast Cancer 103

Not only were fears of recurrence expressed in relation to the mortality

of the participants, but also of being selfish having another child when their
lifespan may be compromised:

Time 2: Not being alive in five year’s time, having a child . . . are you
being selfish bringing a child into the world when you have got this
cloud? (p35, page 37)

All participants who became pregnant reported fears that a pregnancy

could either cause or accelerate further cancer although professionally in-
formed otherwise:

Time 2: I don’t think I’d want to risk it again [pregnancy] even though
I felt that I would take that risk to have a second child, I don’t think I
would again. I mean, two is lucky. (P1, age 32)

A specific concern of the participants was the inability to detect any

significant breast changes during pregnancy:

Time 2: Checks don’t really help. As your breast gets bigger and fuller and
everything, it’s harder to find stuff. . . . When I found this lump [original
diagnosis] I went off and had a mammogram and that didn’t see anything
and then I had an ultrasound, and that didn’t see it. I could feel it. It was
like a bloody olive in my breast but they couldn’t see it on the ultrasound
because I was breastfeeding. So, I mean, that’s a bit of a worry, so if
they’re trying to find something little, the chances are they’re not going
to find it. (P11, age 38)

Such fears carried across all interview phases once participants became
pregnant. Even so, balancing out the negative emotions associated with a
pregnancy after breast cancer were positive emotions, including closing the
book on the breast cancer as well as having something positive to focus on
and look forward to:

Time 2: That’s one thing pregnancy does, it makes you think more about
living than the other. . . . Really that’s been the rock, that it just all of a
sudden shocks you into, listen, you can’t dwell on it, you’ve got to go
forward. . . . You’ve really got to live and plan. (P35, age 37)

Breastfeeding
All participants who had viable pregnancies during the course of the inter-
views wanted to breastfeed their new babies. Yet participants did not want
lactation to occur/continue in their affected breasts:
104 S. Connell, C. Patterson, and B. Newman

Time 2: I spoke to a lactation consultant . . . and she said that she has
known some people who will get, even after radiation, they will have
some milk come in. . . . I said I do not want anything happening at all on
that side [forced laugh]. I just have an aversion to it. . . . I just wouldn’t
feel comfortable breastfeeding from that affected breast. (P1, age 32)

Some breastfeeding decisions changed over time. Reasons to breastfeed

were numerous, such as convenience factors and various benefits for the
infant; social expectations, such as beliefs about what they should do; and
wanting to experience breastfeeding. The two quotes below display how
one participant’s desire to breastfeed her infant changed over time:

Time 2: I’d like to breastfeed. . . . I mean it’s very good to breastfeed ob-
viously. There are a lot of reasons why I should be doing it. I don’t know
about supply and all that sort of stuff, whether I’d have to complementary
feed or whatever. (P11, age 38)

Time 3: I was very positive about it [breastfeeding], but I’m going to try
and feed for the first couple of weeks, do the colostrum business but,
no, I think, . . . I’ve discussed it with my husband and as much as I feel
that I should, I think, it’s important to get past that and go off and have
a mammogram. (P11, age 38)

Pregnant and breastfeeding participants also reported major concerns

related to the difficulty of detecting a breast cancer in a lactating breast, and
that usual breast checks could not continue until the breasts were back to
the nonlactating state. The fear of recurrence was so great in one participant
she decided, very late in her pregnancy, to only breastfeed her baby for a
few weeks so she could get her breast tissue back to the nonlactating state
to continue usual breast checks. The quote below carries on from the quote
presented above by Participant 11 at time 3 interview:

Time 3: If I breastfeed for another 6 months, that’s going to be a period

of time that I won’t be able to [have regular breast checks], I mean you
can have mammograms but they don’t show anything. (P11, age 38)

The decision to breastfeed was straightforward for one participant al-

though with elements of caution, while for others the decision was onerous.
Having to make a decision about whether to breastfeed or not was difficult
for some participants as their pre-breast cancer attitudes toward breastfeeding
were often in conflict with post-breast cancer fears.

Time 2: I’ll probably be a one-sided feeder. . . . I’m not sure whether

I want to take that risk since I developed breast cancer feeding last
time,. . . but I haven’t quite decided on that because I’m a staunch
 Reproductive Issues After Breast Cancer 105

follower of nursing mothers. . . . I mean I was one of the real converts, so

it’s going to be difficult. (P35, age 37)

Even so, the decision to breastfeed was not as great a stressor to partic-
ipants as the decision whether to terminate a pregnancy.

DISCUSSION

The life-changing experience of breast cancer encroaches on postdiagnosis

events of fertility, pregnancy, and breastfeeding. As fertility status can change
over time, due to treatment routines, so too can fertility concerns (Thewes
et al., 2003). Confusion over fertility status is evident. The discussions re-
garding possible ovarian failure may contribute to this, particularly for those
who do not ultimately experience premature menopause. Young women
may not deem subsequent fertility a priority during life-saving treatments and
surgeries; however, as life returns to normal, infertility can become a major
concern (Thewes et al., 2003). Conversely, too much fertility also generates
anxiety, raising interest in suitable, safe, and reliable contraception. Perma-
nent sterilization of the couple may be a viable option for some, although
other participants did not want their partners to undergo a vasectomy, and
do not themselves want to undergo any further surgery. Social acceptability
of permanent sterilization may be an issue here, but also personal concerns
about a partner’s future happiness and the participant’s own physical well-
being were evident. Trust in, and desirability of, hormonal and nonhormonal
methods of contraception appear to be minimal, producing additional anx-
iety regarding the management of fertility. Furthermore, consistent with the
findings of others (Dow, 1994; Ives, Semmens, Saunders, & Pickridge, 2002;
Schover et al., 1999), concern about what hormonal changes of pregnancy
and lactation could do to the risk of breast cancer recurrence was expressed
by participants, despite no firm evidence in the literature that would endorse
such fears (Collichio et al., 1998; McTiernan & Thomas, 1986; Mueller et al.,
2003). This suggests that health professionals need to communicate such
findings clearly to help quash unnecessary concerns of young women with
breast cancer.
Some participants perceive the experience of having a child as clos-
ing the door on the cancer and of having a future to look forward to, a
finding confirmed by Dow (1994) and Siegel et al. (1997). However par-
ticipants’ interpretations of the news of a pregnancy were influenced by
their fears of breast cancer recurrence or metastasis, as suggested by others
(Ives et al., 2002; Schover et al., 1999). A diagnosis of breast cancer dur-
ing pregnancy is usually coincidental (rather than caused by the pregnancy)
(Collichio et al., 1998; McTiernan & Thomas, 1986; Mueller et al., 2003),
hence it tends to occur at a later stage when prognosis is worse. This is
106 S. Connell, C. Patterson, and B. Newman

due in part to pregnancy/lactation-related physiologic changes in the breast,

reducing sensitivity of imaging modalities, such as mammography (Talele,
Slanetz, Edmister, Yeh, & Kopans, 2003). Participants were acutely aware of
this.
Participants who had fertility concerns or pregnancies reported mixed
feelings about wanting a child. The thought of bringing a child into the world
with a mother who may have a compromised lifespan was equated with
feelings of guilt and selfishness, further supporting the findings of Siegel
and Colleagues (1997). The socially prescribed role of motherhood may
be responsible for the anxiety these women experienced (Hartrick, 1997);
hence this may be an issue that needs addressing by counsellors, helping
these women come to terms with their new life as a breast cancer sur-
vivor rather than fretting over their pre-breast cancer life expectations and
beliefs.
The literature neglects perceptions of young women with breast can-
cer related to breastfeeding experiences following diagnosis and treatment,
concentrating instead on the physiological ability to breastfeed from an af-
fected breast (Higgins & Haffty, 1994; Neifert, 1992; Tralins, 1995; Varsos &
Yahalom, 1991; Wobbes, 1996). The decision to breastfeed, for this group
of young women, was fringed with fear and anxiety of further breast can-
cer activation and difficulty in detecting breast cancer, as noted above for
pregnancy. Furthermore, breastfeeding firmly is entrenched within current
Western culture as the most desirable method of infant feeding (Murphy,
1999; Van Esterik, 1997). Hence it is not surprising that the participants’
fears of recurrence being caused or accelerated by breastfeeding conflicts
with wanting to be a good mother and doing the right thing, which is
largely a social construction (Hartrick, 1997) and is consistent with Schmied
and Lupton’s (2001) findings. Regardless of how young women feel about
breastfeeding after breast cancer, it is obvious from these findings and others
(Neifert, 1992) that they are in need of support, encouragement, and relevant
information.

IMPLICATIONS

More psychosocial and psychological information on all topics related to

reproduction after breast cancer, including breastfeeding, is needed not only
by the young women who are diagnosed with breast cancer but also by
the medical and allied health professionals who interact with these women,
including nurses, lactation consultants, counsellors, and social workers. Such
information could ultimately benefit breast cancer survivors by increasing
their ability to make informed decisions.
The anxiety and fear these women experience also need specific at-
tention; hence a broader understanding of these women’s experiences and
 Reproductive Issues After Breast Cancer 107

reproductive issues could raise the awareness of various health profession-

als, specifically those who work in the fields of breast cancer, reproduction,
assisted fertility, and child health. Such awareness may help these profes-
sionals to be better equipped to assist and advise such young women of
their reproductive and breastfeeding options. Concurrently, appropriate re-
ferrals to trained counsellors may be important for the subset of women
experiencing extreme fear and anxiety. Support services and networks, in-
cluding those focused on breast cancer as well as more general cancer or-
ganisations, also could benefit from raised awareness of reproductive and
breastfeeding issues and concerns of young women with breast cancer.
In addition, breast cancer and breastfeeding-related websites could contain
information, or links to information, regarding these reproductive matters.
Young women with breast cancer who decide not to breastfeed also need
support.

LIMITATIONS

As this participant pool was small, Australian, and well educated, some results
may not be generalisable to other groups of young women with breast cancer,
such as those who have different cultural norms, beliefs, and practices related
to fertility, contraception, pregnancy, and breastfeeding, and those who are
less educated. The findings provide other researchers and medical and allied
health professionals, however, with some deeper understanding of the needs
of this group of women. Findings, in part, may be transferable to other groups
of young women who suffer from life-threatening illnesses but who retain
their fertility.

CONCLUSION

As fertility status can change over time for young women with breast cancer,
so too can their perspectives on fertility. With the continuance, or return, of
fertility after breast cancer treatment comes the issue of safe, effective, and
reliable contraception as the occurrence of failed contraception raises serious
issues, not only that of bearing an unplanned (or unwanted) child, but also
the fear of further breast cancer. Rather than concentrating solely on the bi-
ological possibilities of the affected breast to lactate, important psychosocial
issues need to be explored further. These include the social expectation that
breastfeeding equates to good mothering, as well as the breasts again being
a focal point amplifying mortality fears. This study extends understanding
of the reproductive issues of young women with breast cancer, in particu-
lar concerns related to contraception and breastfeeding after diagnosis and
treatment.
108 S. Connell, C. Patterson, and B. Newman

REFERENCES

Australian Bureau of Statistics. (2001). AusStats: 0 Australia. 2001 Census Basic Com-
munity Profile and Snapshot. Retrieved August 14, 2005, from http://www.
abs.gov.au/Ausstats/abx@census.nsf
Australian Institute of Health and Welfare (AIHW). (1997). Older mothers, shorter
hospital stays. (Media Release.) Retrieved January 29, 2002, from http://www.
aihw.gov.au/inet/media/1997/mr970619.html
Australian Institute of Health and Welfare (AIHW). (2001). One in ten first-
time mums age 35+. (Media Release.) Retrieved January 29, 2002, from
http://www.aihw.gov.au/media/2001/mro11217.html
Australian Institute of Health and Welfare (AIHW) & Australasian Association of Can-
cer Registries (AACR). (2004). Cancer in Australia 2001. AIHW cat. no. CAN 23,
Canberra, Australia: AIHW (Cancer Series no. 28).
Blakely, L. J., Buzdarm, A. U., Lozada, J. A., Shullaih, S. A., Hoy, E., Smith, T. L., et al.
(2004). Effects of pregnancy after treatment for breast carcinoma on survival
and risk of recurrence. Cancer, 100(3), 465–469.
Bloom, J. R., & Kessler, L. (1994). Risk and timing of counselling and support interven-
tions for younger women. Journal of the National Cancer Institute Monographs,
16, 199–206.
Cheek, J., Shoebridge, J., Willis, E., & Zadoroznyj, M. (1996). Sociology and health:
Social theory for health workers. Melbourne, Australia: Longman.
Collaborative Group on Hormonal Factors in Breast Cancer. (2002). Breast cancer
and breastfeeding: Collaborative reanalysis of individual data from 47 epidemi-
ological studies in 30 countries, including 50 302 women with breast cancer and
96 973 women without the disease. Lancet, 360, 187–195.
Collichio, F. A., Agnello, R., & Staltzer, J. (1998). Pregnancy after breast cancer: From
psychosocial issues through conception. Oncology, 12(5), 759–769.
Creswell, J. W. (1998). Qualitative inquiry and research design: Choosing among five
traditions. Thousand Oaks, CA: Sage.
Dow, K. H. (1994). Having children after breast cancer. Cancer Practice, 2(6), 407–
413.
Dow, K. H., Harris, J. R., & Roy, C. (1994). Pregnancy after breast-conserving surgery
and radiation therapy for breast cancer. Journal of the National Cancer Institute
Monographs, 16, 131–137.
Dunn, J., & Steginga, S. K. (2000). Young women’s experience of breast cancer.
Psycho-Oncology, 9, 137–146.
Gemignani, M. L., & Petrek, J. A. (2000). Pregnancy-associated breast cancer: Diag-
nosis and treatment. The Breast Journal, 6, 68–73.
Guba, E., & Lincoln, Y. (1985). Effective evaluation improving the usefulness of evalu-
ation results through responses and naturalist approaches. San Francisco: Jossey-
Bass.
Guba, E., & Lincoln, Y. (1989). Fourth generation evaluation. Newbury Park, CA:
Sage Publications.
Hartrick, G. A. (1997). Women who are mothers: The experience of defining self.
Health Care for Women International, 18(3), 263–278.
 Reproductive Issues After Breast Cancer 109

Higgins, S., & Haffty, B. G. (1994). Pregnancy and lactation after breast-conserving
therapy for early stage breast cancer. Cancer, 73(8), 2175–2180.
International Planned Parenthood Federation (IPPF). (1999). IMAP statement on con-
traception for women with medical disorders. IPPF Medical Bulletin, 33(5), 1–3.
Isaacs, J. H. (1995). Cancer of the breast in pregnancy. Surgical Clinics of North
America, 75, 47–51.
Ives, A., Semmens, J., Saunders, C., & Puckridge, P. (2002). A growing dilemma—
Breast cancer and pregnancy. Australian Family Physician, 31(10), 1–4.
Jackson, W. (1998). Methods: Doing social research. Ontario: Prentice Hall Canada
Inc.
Kroman, N., Jensen, M., Wolfahrt, J., & Mouridsen, H. (1997). Should women be
advised against pregnancy after breast-cancer treatment? Lancet, 350, 319–322.
Mays, N., & Pope, C. (2000). Assessing quality in qualitative research. British Medical
Journal, 320(7226), 50–52.
McTiernan, A., & Thomas, D. B. (1986). Evidence for a protective effect of lactation
on risk of breast cancer in young women: Result from a case control study.
American Journal of Epidemiology, 124, 353–358.
Miles, M. B., & Huberman, M. (1994). An expanded sourcebook: Qualitative data
analysis. (2nd ed.). Thousand Oaks CA: Sage.
Mor, V., Malin, M., & Allen, S. (1994). Age differences in psychosocial problems
encountered by breast cancer patients. Journal of the National Cancer Institute
Monographs, 16, 191–197.
Mueller, B. A., Simon, M. S., Deapen, D., Kamineni, A., Malone, K. E., & Daling,
J. R. (2003). Childbearing and survival after breast carcinoma in young women.
Cancer, 98 (6), 1131–1140.
Murphy, E. (1999). “Breast is best”: Infant feeding decisions and maternal deviance.
Sociology of Health & Illness, 21(2), 187–208.
Neifert, M. (1992). Breastfeeding after breast surgical procedure or breast cancer.
NAACOG’s Clinical Issues, 3(4), 673–682.
Patton, M. Q. (1999). Enhancing the quality and credibility of qualitative analysis.
Health Services Research, 34(5), 1189–1208.
Petrek, J. A. (1994a). Breast cancer during pregnancy. Cancer, 74, 518–527.
Petrek, J. A. (1994b). Pregnancy safety after breast cancer. Cancer, 74, 528–531.
Puckridge, P. J., Saunders, C. M., Ives, A. D., & Semmens, J. B. (2003). Breast cancer
and pregnancy: A diagnostic and management dilemma. Australian and New
Zealand Journal of Surgery, 73, 500–503.
Reichman, B. S., & Green, K. B. (1994). Breast cancer in young women: Effect of
chemotherapy on ovarian, fertility and birth defects. Journal of the National
Cancer Institute Monographs, 16, 125–129.
Saunders, C., & Baum, M. (1993). Breast cancer and pregnancy. Journal of the Royal
Society of Medicine, 86, 162–165.
Schaefer, K. M., Ladd, E. C., Lammers, S. E., & Echenberg, R. J. (1999). In your skin
you are different: Women living with ovarian cancer during childbearing years.
Qualitative Health Research, 9, 227–242.
Schmied, V., & Lupton, D. (2001). Blurring the boundaries: Breastfeeding and ma-
ternal subjectivity. Sociology of Health & Illness, 23(2), 234–250.
110 S. Connell, C. Patterson, and B. Newman

Schover, L. R. (1991). The impact of breast cancer on sexuality, body image, and
intimate relationships. CA: Cancer Journal for Clinicians, 41, 112–120.
Schover, L. R., Rybicki, L. A., Martin, B. A., & Bringelsen, K. A. (1999). Having children
after cancer: A pilot survey of survivors’ attitudes and experiences. Cancer,
86(4), 697–709.
Seidman, I. E. (1991). Interviewing as qualitative research. New York: Teachers Col-
lege Press.
Siegel, K., Gluhoski, V., & Gorey, E. (1999). Age-related distress among young
women with breast cancer. Journal of Psychosocial Oncology, 17, 1–20.
Siegel, K., Gorey, E., & Gluhoski, V. (1997). Pregnancy decision making among
women previously treated for breast cancer. Journal of Psychosocial Oncology,
15(1), 27–42.
Singer, D., & Hunter, M. (1999). The experience of premature menopause: A thematic
discourse analysis. Journal of Reproductive and Infant Psychology, 17, 63–78.
Talele, A. C., Slanetz, P. J., Edmister, W. B., Yeh, E. D., & Kopans, D. B. (2003).
The lactating breast: MRI findings and literature review. Breast Journal, 9(3),
237–241.
Thewes, B., Meiser, B., Rickard, J., & Friedlander, M. (2003). The fertility- and
menopause-related information needs of younger women with a diagnosis of
breast cancer: A qualitative study. Psycho-Oncology, 12, 500–511.
Tralins, A. H. (1995). Lactation after conservative breast surgery combined with ra-
diation therapy. American Journal of Oncology, 18(1), 40–43.
Trief, P. M., & Donohue-Smith, M. (1996). Counselling needs of women with breast
cancer: What the women tell us. Journal of Psychosocial Nursing, 34(5), 24–29.
Van Esterik, P. (1997). The politics of breastfeeding. In C. Counihan & P. Esterik
(Eds.), Food and culture (pp. 370–383). New York: Routledge.
Varsos, G., & Yahalom, J. (1991). Lactation following conservation surgery and ra-
diotherapy for breast cancer. Journal of Surgical Oncology, 46, 141–144.
Velentgas, P., Daling, J. R., Malone, K. E., Weiss, N. S., Williams, M. A., Self, S. G., et al.
(1999). Pregnancy after breast carcinoma: Outcomes and influence on mortality.
Cancer, 85(11), 2424–2432.
Wobbes, Th. (1996). Effect of a breast saving procedure on lactation. European
Journal of Surgery, 162, 419–420.