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Pregnant, With Cancer: Doctors Rethink Treatment

Risk of Chemotherapy May Be Lower Than Once Feared; The Pressure to Terminate

By AMY DOCKSER MARCUS
Staff Reporter of THE WALL STREET JOURNAL
May 18, 2004; Page D1

Last December, Vernetta Rolle Smith started chemotherapy to treat breast cancer. But Ms. Smith, a 28-year-old math teacher from Houston, isn't an ordinary cancer patient: She was 24 weeks pregnant at the time.

For years, pregnant women diagnosed with cancer have faced a stark and painful choice: terminate their pregnancy -- as Ms. Smith's doctor originally suggested that she consider -- or risk their babies and their
own lives.

Women who refused to terminate have had a hard time even finding a doctor
to treat them. The worry is that the large doses of chemotherapy and other
treatments often needed might severely damage the unborn child. There has
also been a fear that pregnancy itself -- which increases hormone levels
and blood volume and is undeniably stressful to the body -- might reduce a
woman's chances of survival.

But an important change in thinking is emerging among oncologists. Many are
starting to argue that chemotherapy and other treatments can be
administered in ways that may not harm the mother's prognosis or damage the
fetus, especially if given after the first trimester. At the same time, as
more people survive cancer and can expect to be alive years down the road,
some pregnant women are deciding it's worth the risk of trying to save both
themselves and their babies. This, in turn, is generating more data than
were previously available.

While cases of pregnant women coping with cancer are rare, oncologists say
the numbers are growing as more women are delaying childbearing into their
30s and 40s when the likelihood of cancer is higher. Estimates range
anywhere from one in 1,000 pregnancies to one in 3,000. And these women,
faced with giving up what may be their last chance to have a child, are
looking for alternatives.

Vernetta Rolle Smith of Houston, with her infant son, Paul.

DECLINING RISK

A look at the rate of birth defects in babies of 619 women who received
chemotherapy while pregnant.
With chemo exposure in the first trimester: 19%
When chemo is delayed until second or third trimester: 5.5%
Rate of birth defects in the general population: 5%

Source: University of Oklahoma Registry of Pregnancies Exposed to
Chemotherapeutic Agents

One of the key insights emerging from the growing number of cases is that,
contrary to what was once believed, a woman's survival doesn't appear to
improve if the pregnancy is terminated. Evidence also indicates that among
children exposed to chemotherapy in utero, the risks of stillbirth, birth
defects, low birth weight and other complications are lower than previously
feared. On average, these risks are higher than in the general population,
but research suggests that when chemo is delayed until after the first
trimester, the risks fall considerably.

In Ms. Smith's case, she turned to a program at M.D. Anderson Cancer Center
in Houston after learning the lump in her breast was malignant. Doctors
there run a registry tracking what happens to pregnant women with breast
cancer who go through treatment. Ms. Smith began treatment in her second
trimester, and her son, Paul, was born in March with no apparent
complications. Her treatment is continuing.

Not all oncologists think it is worth taking the risk -- either to the
mother or the baby -- of undergoing cancer treatment while pregnant.
Virtually no long-term data are available on how babies of cancer-treatment
patients fare into adulthood. And pregnancy certainly doesn't make cancer
treatment any easier.

"It's like saying I'm going to get hit by a car and recover from it at the
same time that I have cancer treatment," says Jeanne Petrek, director of
the surgical program at the Lauder Breast Center of New York's Memorial
Sloan-Kettering Hospital. Given that there are still unanswered questions
about the effects of chemotherapy, she says she still recommends patients
consider terminating a pregnancy.

First-Trimester Risk

In a University of Oklahoma registry of 619 pregnant women who had
chemotherapy, director John J. Mulvihill says his analysis shows the rate
of birth defects when the drugs were given in the first trimester was 19%,
compared with a 5% risk in the general population. But the risk went down
to 5.5% when drugs were given only in the second and third trimesters.

There are now at least four such registries tracking the health outcomes of
pregnant women diagnosed with a variety of cancers, as well as children
exposed to chemotherapy drugs in utero.

All chemotherapy drugs are considered potentially dangerous to a fetus. The
drugs have caused defects in animal studies, but no human trials have been
conducted. So oncologists have relied mainly on published reports of cases
to try to determine which drugs are more harmful. For instance, some drugs
that are mainstays in treating particular cancers -- such as
cyclophosphamide, widely used to treat non-Hodgkins lymphoma, breast and
ovarian cancer -- have caused eye abnormalities, absent toes and cleft
palate in children exposed during the first trimester.

RESOURCES

Elyce Cardonick, a maternal-fetal medicine specialist who runs a database
of pregnant women with cancer based at Cooper University Hospital in
Camden, N.J., says she advises using older drugs rather than the newer
agents because at least there is more evidence about their effects on
children who get exposed during pregnancy.

Richard Theriault, who founded the M.D. Anderson pregnancy registry, says
none of the 54 babies in his database has had birth defects, including Ms.
Smith's son. But it's not known if the long-term risks of chemotherapy --
such as an increased susceptibility later in life to cancer, cardiac
problems and fertility problems -- could also affect children exposed in
utero. Dr. Theriault's database is small and the oldest child is still only
14. In some of the other databases, the oldest child is even younger.

"The children are fine so far," says Dr. Theriault, "but no one knows
what's ahead."

New studies may start developing the data that women need to make a more
informed choice about what to do, says Gideon Koren, director of the
Motherisk program at the Hospital for Sick Children in Toronto, which
advises pregnant and lactating women about drug exposure and runs an
international registry of pregnant cancer patients. Dr. Koren says a large
study they did of 200 women diagnosed with breast cancer during pregnancy
had surprising results. When matched by age, treatment, and stage of the
disease with nonpregnant women, the women's survival rates were similar,
Dr. Koren says.

Delaying Radiation

Oncologists say they try to ensure that a pregnant woman's cancer treatment
remains as close as possible to what she would receive if she weren't
pregnant. Some changes are usually required, though. Radiation therapy,
where the patient receives beams of X-rays or other radiation, can cause
birth defects and mental retardation and is generally delayed until after
delivery. But diagnostic scans such as mammograms, which involve low levels
of radiation, have all been successfully used on pregnant cancer patients,
and surgical procedures including mastectomies have been safely performed,
oncologists say.

The Question of Dosage

A debate remains over how much chemotherapy is safe to give. "You do not
want them to be undertreated and get chemo-lite," says Dr. Cardonick. "That
puts the women at risk of recurrence." But Dr. Cardonick adds that not
enough is known about whether pregnant women need to get a different dose
of chemotherapy than women who are similar weights but not pregnant.

These sorts of uncertainties are what can make the choice so overwhelming.

"I felt guilty every time I did chemo," says Juliet Jones, 34, of
Tarrytown, N.Y., who was diagnosed in 2002 with inflammatory breast cancer,
an aggressive form of the disease, when she was 23 weeks pregnant. Each
time she finished a treatment, she would wait anxiously, making sure she
could still feel the baby moving. Her 17-month-old daughter is healthy and
Ms. Jones is currently considered disease-free, but she says she still
worries about both of their futures. "It is so tough to go through the most
horrible thing that has ever happened to me," she says, "and have it be
completely intertwined with the most wonderful thing that has ever happened
to me."


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Pregnancy and Cancer

The following Web sites offer information and resources about fertility
issues and cancer:

Fertile Hope (www.fertilehope.org)
Information involving all aspects of fertility issues arising from cancer
treatment before, after and during pregnancy

Motherisk (www.motherisk.org)
Runs an international registry tracking pregnant women with cancer, advises
pregnant and lactating women about drug exposures

National Cancer Institute (www.cancer.gov)
Information about specific cancer treatments while pregnant

Pregnant With Cancer (www.pregnantwithcancer.org, 1-800-743-6724 x308)
Support group, information about all aspects of being pregnant with cancer

Cancer and Childbirth Registry (Contact: For database: 856-757-7876; For
appointments: 856-342-2491) Run by Elyce Cardonick at Cooper Health, tracking the outcomes of
pregnancies of women with cancer all over the country

Health Outcomes of Pregnancy Database at M.D. Anderson (Contact:
713-792-4124) Database currently comprises women diagnosed with breast cancer while
pregnant

Registry of Pregancies Exposed to Chemotherapeutic Agents (Contact:
Susan-Hassed@ouhsc.edu) Run out of the University of Oklahoma, the database includes 619 cases,
primarily from published reports, including women with diseases other than
cancer who were also exposed to chemo drugs while pregnant

Write to Amy Dockser Marcus at amy.marcus@wsj.com

URL for this article:
http://online.wsj.com/article/0,,SB108482808830513726,00.html

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Richard and Juliet Jones