After Row, pregnant women diagnosed with cancer may face wrenching choices

Last April, Rachel Brown received a call from an oncologist with the bad news that, 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 to have a baby with her fiancé.

She always said she would never have an abortion. But the choice she faced was agonizing. If she had the chemotherapy she needed to prevent the spread of the cancer, she could have harmed her baby. If she wasn’t there, the cancer might have spread and killed her. She had two children, aged 2 and 11, who could have lost their mother.

For Ms. Brown and other unfortunate women who are diagnosed with cancer during pregnancy, the Supreme Court’s decision in June that struck down the constitutional right to abortion may seem like a slap in the face. If the life of the fetus is paramount, pregnancy may mean that a woman cannot receive effective treatment for her cancer. One in a thousand women who become pregnant each year is diagnosed with cancer, meaning that thousands of women face a serious and possibly fatal illness while they are expecting a baby.

Even before the Supreme Court decision, a pregnant woman with cancer was already “entering a world with huge unknowns,” the doctor said. Clifford Hadis, Chief Executive Officer of the American Society of Clinical Oncology. Now the patients, as well as the doctors and hospitals that treat them, face the added complication of the abortion ban.

“If the doctor cannot give the medicine without fear of harming the fetus, will this affect the results?” Dr. Hudis asked. “It’s a whole new world.”

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

About 40 percent of women who are pregnant and have cancer have breast cancer. But other types of cancer also occur in pregnant women, including blood cancer, cervical and ovarian cancer, gastrointestinal cancer, melanoma, brain cancer, thyroid cancer, and pancreatic cancer.

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

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

Some oncologists say they’re not sure what’s legal when a woman lives in a state like Michigan, where most abortions are criminalized but allowed to save the mother’s life. Is leukemia a reason for an abortion to save her life?

“It’s still so early that we don’t know the answer,” the doctor said. N. Lynn Henry, oncologist at the University of Michigan. “We cannot prove that the medication caused problems for the child, and we cannot prove that not taking the medication would have a negative outcome.”

In other words, doctors say pregnancy complications — miscarriage, premature birth, birth defects, or death — can occur regardless of whether a woman with cancer is taking medication. If she was left untreated and her cancer developed into a malignant tumor that would kill her, that too could happen even if she was given cancer medication.

The University of Michigan Medical System Administration does not interfere with decisions about cancer treatment in pregnant women, stating that “medical decisions and management should be made by physicians and patients.”

I. Glenn Cohen, professor of law and bioethicist at Harvard, is seriously concerned.

“We’re putting doctors in a terrible position,” Cohen said. “I don’t think signing up for a doctor should mean signing up for a prison term,” he added.

Oncologists are usually part of the hospital system. According to Cohen, this creates additional difficulties for doctors treating cancer in states where abortion is illegal. “Whatever their personal feelings,” he asked, “what risks will the hospital system face?”

“I don’t think oncologists ever thought that day would come for them,” Cohen said.

Behind the doctors’ confusion and anxiety are the stories of women like Ms. S. Brown.

She had a large tumor in her left breast and cancer cells in her axillary 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 cancer was one of the worst prognosis for breast cancer. Then targeted treatment, trastuzumab or Herceptin, completely changed the picture. Women with HER2 tumors now have one of the best prognosis compared to other types of breast cancer.

But trastuzumab should not be given during pregnancy.

Mrs. Brown’s first visit was to an oncology surgeon, 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 treatment in the second trimester will be a mastectomy to remove all of the lymph nodes in her left armpit, which would increase the risk of lymphedema, an incurable collection of fluid in her arm. She could start chemotherapy in the second trimester, but she 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, told her that while she could have a mastectomy in the first trimester, before chemotherapy, it’s not optimal. Usually, oncologists give cancer medication before a mastectomy to shrink the tumor, allowing for a less invasive operation. If the treatment did not lead to the destruction of the tumor, oncologists after the operation would have tried to use more aggressive drug treatment.

But if she had had a mastectomy before chemotherapy, it would have been impossible to know if the treatment was helping. What if the drugs didn’t work? She was worried that her cancer could become fatal without her knowledge.

She was afraid that if she tried to keep the pregnancy, she might sacrifice her life and ruin the lives of her children. And if she hesitated to make a decision and then had an abortion later in her pregnancy, she was afraid that the fetus might feel pain.

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

With great sadness, they made the decision that she would have a medical abortion. She took pills one morning when she was six weeks and one day pregnant and cried all day. She wrote a eulogy for a child that could have been. She was convinced the baby would be a girl and named her Hope. She kept the ultrasound of Hope’s heartbeat.

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

After she terminated the pregnancy, M. Brown was able to start treatment with trastuzumab along with a cocktail of chemotherapy drugs and radiation. She had a mastectomy and there were no signs of cancer at the time of the operation – a great prognostic sign, Dr. Wilson. Carey said. She did not need to have all of her lymph nodes removed and did not develop lymphedema.

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

But after going through this debilitating treatment, she also wondered how she could even handle a newborn baby and two other children to take care of.

“My bones hurt. I couldn’t walk more than a few steps without gasping for breath. It was difficult to get nutrients due to nausea and vomiting,” she said.

The decision of the Supreme Court hit her hard.

“I felt like the reason I did what I did was irrelevant,” she said. “My life didn’t matter, and the lives of my children didn’t matter.”

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