As published in the New York Times, June 27, 2006.New Notions
on Pregnant Women With Cancer
By Roni Rabin
Amy Langford was utterly surprised when, at 42, she found out she was
pregnant. Her joy dissipated a few weeks later, when she and her husband
were told that a suspicious lump in her right breast was cancerous.
"The doctor came back and said he had 'not very good news,' "
recalled Amy's husband, Gregg. "His second words were, 'Of course, this
means you will have to terminate your pregnancy.' "
But the Langfords, of League City, Tex., did some research and found
a group of physicians who specialize in treating pregnant women with
breast cancer at the University of Texas M. D. Anderson Cancer Center in
nearby Houston. Mrs. Langford underwent amniocentesis, followed by
breast-conserving surgery and four courses of chemotherapy. On May 23,
2005, she delivered Bryan, a healthy 6-pound-12-ounce baby boy.
Radiation treatment was done only after that.
"I had no hair when he was born," Mrs. Langford said, "but he had a
head full of hair." For many years, the consensus in much of the medical
community has been that pregnant women with breast cancer cannot undergo
treatment without harming their babies — and must make a dreadful
choice. That assumption is being challenged by the results of a small
observational clinical trial carried out at M. D. Anderson, which found
that women with invasive breast cancer may undergo surgery and
chemotherapy during pregnancy and still have healthy babies.
Under the protocol studied, chemotherapy is postponed until after the
first trimester of pregnancy and radiation until after the birth.
"We can now say that the ethical dilemma has been eliminated," said
Dr. Richard Theriault, a professor of medicine in the department of
breast medical oncology at M. D. Anderson, who presented the findings at
an American Medical Association news briefing in Manhattan recently. "We
can safely and successfully treat the disease with a positive outcome
for both the patient and the baby."
Dr. Theriault is the senior author of a paper about the trial, which
he said had been accepted for publication in a medical journal. Dr.
Karin Hahn, Mrs. Langford's physician, is the first author.
Though small, the study is important, said Dr. Carolyn D. Runowicz,
president of the American Cancer Society and moderator of the news
briefing. Each year, breast cancer is diagnosed in about 3,000 pregnant
American women, but pregnant women are usually excluded from clinical
trials for ethical reasons.
"This is a big leap forward, with a reasonable follow-up period and
with pregnancy outcomes, so women and their doctors can feel reassured
that there is some data to base their decision on," Dr. Runowicz said.
A 1999 study from M. D. Anderson reported on the treatment of 24
pregnant patients. Dr. Larry Norton, medical director of the Evelyn H.
Lauder Breast Center at Memorial Sloan-Kettering Cancer Center, agreed
that there is no need to terminate a pregnancy.
"Chemotherapy can be used safely as long as you avoid certain
agents," he said. Treatment remains controversial because of ethical
questions about the use of chemotherapy during pregnancy, as well as
uncertainty about the baby's long-term health and the possibility that
the baby could be left motherless, Dr. Theriault said.
"Some people think we're a little crazy," he said. But, he added,
"Not as much of the chemotherapy is delivered to the baby as to the
mother." And Dr. Theriault dismissed concerns that high hormone levels
during pregnancy may accelerate cancer growth, saying most of his
patients have estrogen receptor-negative tumors.
The trial examined the outcomes of 57 women and 57 live births. The
babies were slightly smaller than average, with a mean birth weight of
6.4 pounds. And they had a slightly increased risk of neonatal
complications, with 37 percent requiring ventilator support compared
with an average of 29 percent of babies born at large tertiary-care
hospitals, Dr. Theriault said.
Several of the babies were born with anomalies, but none was
attributed to the chemotherapy regimen. One had Down syndrome, one was
born with a club foot, and one had a not uncommon disorder called
congenital bilateral ureteral reflux. Though one mother died of a
pulmonary embolism after a Caesarean section, 43 of the mothers, or 75
percent, are currently healthy and cancer-free, Dr. Theriault said.
Researchers have continued to monitor the health of the children. Of
40 children, range from 2 to 15 years old, 39 are developing normally,
according to parents and guardians interviewed, the sole exception being
the baby with Down syndrome.
The Langfords' son just celebrated his first birthday. His mother
worries about his long-term health. But, she said, he has just started
walking, follows his 7-year-old sister everywhere and "is just the
sweetest thing." |
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