After Roe, pregnant women with cancer may face heartbreaking choices

In April last year Rachel Brown’s oncologist called with bad news – at 36 she had an aggressive form of breast cancer. The very next da...

In April last year Rachel Brown’s oncologist called with bad news – at 36 she had an aggressive form of breast cancer. The very next day, she found out she was pregnant after nearly a year of trying with her fiancé to have a baby.

She had always said she would never have an abortion. But the choices she faced were heartbreaking. If she received the chemotherapy she needed to prevent the spread of her cancer, she could harm her baby. If she didn’t have it, the cancer could spread and kill her. She had two children, aged 2 and 11, who could lose their mother.

For Ms Brown and other members of the unlucky sorority of women who are diagnosed with cancer while pregnant, the Supreme Court’s decision in June ending the constitutional right to abortion may seem like a slap in the face . While the life of a fetus is paramount, pregnancy can mean a woman cannot get effective treatment for her cancer. One in a thousand women who become pregnant each year is diagnosed with cancer, which means that thousands of women face a serious and life-threatening illness while expecting a baby.

Before the Supreme Court’s decision, a pregnant woman with cancer was “already stepping into a world filled with huge unknowns,” said Dr. Clifford Hudis, chief executive of the American Society of Clinical Oncology. Today, patients as well as the doctors and hospitals that care for them are caught up in the added complications of abortion bans.

“If a doctor can’t administer a drug without fear of harming a fetus, will that compromise the results?” asked Dr. Hudis. “It’s a whole new world.”

Cancer drugs are dangerous for fetuses in the first trimester. Although older chemotherapy drugs are safe in the second and third trimesters, the safety of newer, more effective drugs is unknown, and doctors are reluctant to give them to pregnant women.

About 40% of pregnant women with cancer have breast cancer. But other cancers also occur in pregnant women, including cancers of the blood, cervix and ovary, gastrointestinal cancer, melanoma, brain cancer, thyroid cancer and pancreatic cancer.

Women with certain types of cancer, such as acute leukemia, often cannot continue with their pregnancy if the cancer is diagnosed during the first trimester. They must be treated immediately, within a few days, and the necessary drugs are toxic to the fetus.

“In my opinion, the only medically acceptable option is to terminate the pregnancy so that life-saving treatment can be given to the mother,” said Dr. Eric Winer, director of the Yale Cancer Center.

Some oncologists say they don’t know what’s allowed if a woman lives in a state like Michigan, which has criminalized most abortions but allows them to save the mother’s life. Is leukemia considered grounds for abortion to save her life?

“It’s so early that we don’t know the answer,” said Dr. N. Lynn Henry, an oncologist at the University of Michigan. “We cannot prove that the drugs caused a problem for the baby, and we cannot prove that refusing the drugs would have a negative outcome.”

In other words, according to doctors, complications from a pregnancy – miscarriage, premature birth, birth defects or death – can occur whether or not a woman with cancer takes the drugs. If she is left untreated and her cancer turns into a malignant tumor that kills her, this too could have happened even if she had received the anti-cancer drugs.

Administrators of the University of Michigan medical system are not involved in cancer treatment decisions about how to treat cancers in pregnant women, saying that “medical decision-making and management rests with physicians and patient”.

I. Glenn Cohen, a Harvard law professor and bioethicist, is gravely concerned.

“We put doctors in a terrible position,” Mr. Cohen said. “I don’t think signing up to be a doctor should mean signing up to do jail time,” he added.

Oncologists are typically part of a hospital system, Cohen said, adding an additional complication for doctors treating cancers in states that ban abortions. “Whatever their personal feelings,” he asked, “what are the risks the hospital system is going to face?

“I don’t think oncologists ever thought this day was coming for them,” Cohen said.

Behind the confusion and worry of doctors lie the stories of women like Ms Brown.

She had a large tumor in her left breast and cancerous cells in her armpit lymph nodes. The cancer was HER2 positive. These cancers can spread quickly without treatment. About 15 years ago, the prognosis for women with HER2-positive cancers was among the worst prognoses for breast cancer. Then a targeted treatment, trastuzumab, or Herceptin, completely changed the picture. Now, women with HER2 tumors have some of the best prognoses compared to other breast cancers.

But trastuzumab cannot be given during pregnancy.

Ms Brown’s first visit was with a surgical oncologist who she said “made it clear that my life would be in danger if I continued my pregnancy because I could not be treated until the second trimester”. He told her that if she waited for those months to pass, her cancer could spread to distant organs and become fatal.

Her second-trimester treatment would be a mastectomy with removal of all the lymph nodes in her left armpit, which would have increased her risk of lymphedema, an incurable buildup of fluid in her arm. She could start chemotherapy in her second trimester, but could not receive trastuzumab or radiation therapy.

Her next consultation was with Dr. Lisa Carey, a breast cancer specialist at the University of North Carolina, who told her that while she could have a mastectomy in the first trimester, before chemotherapy, it was not optimum. Usually, oncologists would administer anticancer drugs before a mastectomy to shrink the tumor, allowing for less invasive surgery. If the treatment failed to eradicate the tumor, oncologists would attempt more aggressive drug treatment after the operation.

But if she had a mastectomy before undergoing chemotherapy, it would be impossible to know if the treatment was helping her. What if the drugs don’t work? She feared that her cancer would turn fatal without her knowing it.

She feared that if she tried to maintain her pregnancy, she might sacrifice her own life and destroy the lives of her children. And if she delayed making her decision and had an abortion later in the pregnancy, she feared the fetus would experience pain.

She and her fiancé discussed her options. This pregnancy would be her first biological child.

With immense sadness, they made their decision: she would have a medical abortion. She took the pills one morning when she was six weeks and a day pregnant and cried all day. She wrote a eulogy for the baby that might have been. She was convinced the baby was going to be a girl and named her Hope. She saved Hope’s heartbeat ultrasound.

“I don’t take this little life lightly,” Ms Brown said.

After terminating her pregnancy, Ms Brown was able to start treatment with trastuzumab, along with a cocktail of chemotherapy and radiotherapy drugs. She underwent a mastectomy and there was no evidence of cancer at the time of her operation – an excellent prognostic sign, Dr Carey said. She did not need all of her lymph nodes removed and did not develop lymphedema.

“I feel like it took a lot of courage to do what I did,” Ms Brown said. “As a mother, your first instinct is to protect the baby.”

But after enduring the grueling treatment, she also wondered how she could have coped with having a newborn baby and her two other children to care for.

“My bones were hurting me. I couldn’t take more than a few steps without getting out of breath. It was difficult to get nutrients because of nausea and vomiting,” she said.

The Supreme Court’s decision hit her hard.

“I felt like it didn’t matter why I did what I did,” she said. “My life didn’t matter, and my children’s lives didn’t matter.”

“It didn’t matter if I lost my life because I was forced to be pregnant,” she said.

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Newsrust - US Top News: After Roe, pregnant women with cancer may face heartbreaking choices
After Roe, pregnant women with cancer may face heartbreaking choices
Newsrust - US Top News
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