ABSTRACT: This narrative review addresses how evidence on treatment-related fertility risk, fertility-preservation strategies, inequities in access, and post-treatment reproductive outcomes can be integrated into individualized and equitable care for young women with breast cancer. Its objective is not to restate existing guideline recommendations, but to identify where their implementation fails in routine practice and to synthesize clinically actionable strategies across the care continuum, from diagnosis to survivorship.
Fertility preservation (FP) has emerged as a critical component of comprehensive care for young women diagnosed with breast cancer. Advances in reproductive technologies, including oocyte and embryo cryopreservation, alongside growing evidence on ovarian protection strategies and prospective trials such as the POSITIVE (Pregnancy Outcome and Safety of Interrupting Therapy for Women with Endocrine-Responsive Breast Cancer) study, have expanded both counseling and reproductive options for survivors.
Observational data and meta-analyses consistently demonstrate that pregnancy after breast cancer is generally safe, including in hormone receptor-positive disease and among BRCA mutation carriers, without increasing recurrence risk when appropriately timed. Nevertheless, substantial disparities persist in FP access, influenced by socioeconomic status, race/ethnicity, insurance coverage, and geographic location. System-level interventions – such as automatic referrals to oncofertility specialists, dedicated FP navigation programs, and mandated or publicly funded coverage – have improved uptake and patient satisfaction. Psychosocial interventions and structured decision aids further reduce decisional conflict and regret, supporting informed reproductive choices.
Emerging challenges include understanding the impact of newer oncologic therapies, such as PARP (Poly (ADP-ribose) polymerase) inhibitors, immune checkpoint inhibitors, and antibody-drug conjugates, on fertility potential. By bringing together evidence that is usually dispersed across oncology, reproductive medicine, health-services research, and survivorship studies, this review highlights practical actions for clinicians: early risk-based counselling, prompt referral, multidisciplinary coordination, navigation support, and attention to financial and geographic barriers. Long-term survivorship registries capturing ovarian reserve, FP utilization, pregnancy outcomes, child health, and psychosocial metrics are essential for evaluating real-world effectiveness and equity. Integrating FP into routine breast cancer care requires a dual strategy: implementation of evidence-based clinical pathways and system-level support, combined with research to refine guidance as therapies evolve. This approach has the potential to safeguard reproductive potential, reduce psychosocial burden, and enhance quality of life for young breast cancer survivors.

Impact statement: This review highlights clinically actionable strategies for timely fertility counselling and preservation in young women with breast cancer, addressing treatment-related risks, access disparities, and reproductive outcomes to improve survivorship care.

Key words: Fertility preservation; breast cancer; oncofertility; reproductive outcomes; health disparities.