Breast cancer is the most common cancer diagnosed during pregnancy. In fact, 5 percent of invasive breast cancers occur in women less than 40 years of age, and 7 to 14 percent of premenopausal breast cancers occur in pregnant women.
Harrington and other surgeons in 1943 felt that the prognosis was so poor for pregnant women with breast cancer that radical mastectomy was not justified. As women delay both marriage and childbearing for careers and other reasons, the mean age of a women’s first pregnancy is older than it was for our mothers, likely responsible for the increased number of cases of cancer diagnosed during pregnancy. Incidentally, cancer during pregnancy occurs in 1 per 1000 pregnancies.
During my fellowship training in maternal-fetal medicine, after completing my residency in obstetrics and gynecology, I met three women who changed the course of my career and my life.
One was diagnosed with melanoma on her thigh and could not find a surgeon willing to operate on her due to pregnancy. She also needed a nuclear medicine injection to highlight any significant lymph nodes in her groin so the surgeon could remove just these and not cause the possible side effects of swelling by just arbitrarily removing all of them. After speaking with both the nuclear medicine physician and surgeon, I was able to reassure them that performing this type of surgery in pregnancy was safe for the fetus and vital for the mother.
Next, I met a patient with Hodgkin’s lymphoma at ten weeks of pregnancy, whose oncologist sent her for a nuclear medicine study as a baseline for heart function before she could start chemotherapy. The radiologist would not do the study before she terminated the pregnancy, risk management of the hospital as well as the oncologist also felt it best for her to terminate. She did not wish to. I found some case reports and small series showing that pregnant women with Hodgkin’s lymphoma did not have worse survival compared to non-pregnant women. How could I advise her to terminate? However, I did not want her to save the pregnancy, just to sacrifice herself (as many women offer to do all over the world with various medical conditions). I looked for a way to save both, especially with such cancer that normally has such a high cure rate such as Hodgkin’s lymphoma, not having chemotherapy for nine months was not an option. At the time, there were a few case reports showing that pregnant women who received chemotherapy for Hodgkin’s lymphoma during pregnancy and their children appeared fine at birth.
As an OB/GYN, I believed if chemotherapy was started after all the organs starting forming in the first trimester, I would not expect to find birth defects, but was looking at the infant only at birth long enough to appreciate any other consequences? After all, the brain does continue to grow and develop longer during pregnancy than the other organs. This couple was also told that if she underwent chemotherapy treatment in pregnancy, the developing child’s gonads (testes or ovaries) would be affected by chemotherapy and he or she would not go through puberty normally, let alone have children of their own. This was based on fear, not facts.
Then I found what we really needed to convince the ethics board and the oncologist that she could safely undergo chemotherapy during pregnancy. I found a study in Mexico that reported on children whose mothers were treated for leukemia and lymphoma during pregnancy, and they followed the children beyond just the newborn period, even reporting some children going through puberty normally, all with normal intelligence, neurologic exams, and normal responses to childhood infections. The ethics board convened and after presenting my findings, all agreed she could undergo chemotherapy and preserve the pregnancy. I had the privilege of following her son’s growth and development. Her son has just graduated from college.
After these two patients, I decided a liaison between oncologists and obstetricians was warranted to help learn the safest way to treat cancer during pregnancy, and this is the birth of the Cancer and Pregnancy Registry, an international collection of women diagnosed with cancer during pregnancy, and their children. A patient enrolled after a diagnosis of breast cancer. Her son, whom she named David because he “fought Goliath,” was exposed as a fetus to chemotherapy, and he was followed annually in the registry, as is his beautiful mother. Both are healthy, and the work has come full circle. I was so excited to learn that David just became a father, and his mother a grandmother. His little daughter is healthy and well and just adorable. Something I was told was not possible for children exposed to chemotherapy in utero. Women diagnosed with cancer during pregnancy can be treated and remain healthy to become a mother, and yes, a grandmother too.
My office walls are now covered in pictures of women who experienced cancer during pregnancy and their smiling children. Over 400 women have enrolled in the ongoing observational cohort and are followed annually, as are their children. I cannot think of a more gratifying direction to have had my life’s work steered to by these brave women, fighting for the health of their unborn child as they fight to save their own lives with cancer therapy.
Elyce Cardonick is an obstetrician-gynecologist.
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