Cancer & Pregnancy : Dilemma Sometimes Pits Survival Against Abortion
The new mother studied the petal-pink baby sleeping beside her.
“I call him my little miracle baby,” Pam Baird said as she gazed at 8-week-old Nathan.
Miracle indeed.
For Baird learned that she had breast cancer not long after she learned that she was pregnant. And a nationally known oncologist urged an immediate abortion, then chemotherapy, as her best chance to survive.
But after consulting more than a dozen specialists and a hospital ethics committee, Baird, like a growing number of pregnant women with cancer, decided to try to beat the disease--and keep her baby.
After a mastectomy, she began an aggressive course of chemotherapy. Every few weeks for most of her pregnancy, Baird reported to the Breast Care Center in Orange for injections of three anti-cancer drugs. Sometimes the powerful toxins made her throw up. Sometimes her blond curls fell out in handfuls. And sometimes--scared for her baby and whether she would live to raise him--she cried.
But once a month, at the obstetrician’s office, Baird was reassured by a black and white ultrasound image that showed a normal baby curled tightly inside her.
In August, about five weeks early, Baird delivered a healthy 5-pound, 4-ounce boy. And this week, after finishing her last chemotherapy treatment, she and her husband Rodger celebrated with champagne.
Baird’s cancer is in remission, her oncologist, David Margileth said, adding, “Here’s a breast cancer patient I feel optimistic about. . . . Here’s a woman I think will be around to raise her baby.”
Cancer is rare in pregnancy. A spokeswoman from the National Cancer Institute estimated that a malignancy occurs once in a thousand pregnancies, with breast cancer once in every 3,500.
But when it does occur, it raises deep emotional and ethical questions for patients and their doctors.
Should the mother-to-be have an abortion? Can she afford to delay cancer treatment until her baby is mature enough for delivery? Will the baby be harmed by chemotherapy? And will the mother live to care for her child?
Twenty years ago, obstetricians and oncologists said, the standard recommendation for breast cancer during pregnancy was an immediate abortion followed by mastectomy, radiation or chemotherapy.
“In the past, an abortion had been recommended because the physician was uncomfortable about doing the treatments necessary for the mother for fear of injuring the fetus,” said Dr. Frankie Ann Holmes, an assistant professor of medical oncology at M.D. Anderson Cancer Center in Houston.
Today, some doctors still advocate abortion, but many others like Holmes are convinced: “You don’t have to terminate.”
Radiation therapy is still considered harmful to the baby during all stages of pregnancy, and diagnostic abdominal X-rays have been associated with a high risk of leukemia after birth and other malignancies, some doctors report.
But chemotherapy is a different story.
Anti-cancer drugs can harm a baby during the first trimester when the heart, lungs and other organs are developing, medical articles show. Though the articles don’t indicate why this is the case, many of the same drugs can be used safely in the second and third trimester, Holmes, other oncologists and obstetricians have reported.
At the Houston center, for instance, four breast cancer patients who had chemotherapy in pregnancy gave birth to normal babies this year, Holmes said.
Still, some doctors admit that they are very uncomfortable when treating a pregnant woman for cancer.
“Everybody kind of wrings their hands a little bit,” said Dr. Robert Dillman, director of the Hoag Cancer Center in Newport Beach. “You really would like to get the fetus out.”
Margileth said that as Baird’s pregnancy continued during the chemotherapy, “I tossed and turned about this. . . . Are we doing the right thing?”
Margileth said he was also concerned that the normally happy experience of pregnancy had become a troubling one because of the cancer. “Here’s this nice, 3-to-4-month pregnant person that you just wish was shopping at South Coast Plaza for maternity clothes--rather than getting Adriamcyin (a chemotherapy agent),” Margileth said.
Another major concern: Doctors around the nation say there is little data showing the long-term effects of chemotherapy on an unborn child. Doctors say they simply don’t know if such children will develop major problems, like infertility and leukemia.
“We worry,” said Dr. Gerald Gilchrist, chairman of pediatrics at the Mayo Clinic in Rochester, Minn., and also chairman of the American Academy of Pediatric’s section on hematology and oncology. He added: “I don’t think anyone knows.”
Baird noticed a lump in her right breast late last January, shortly after she had weaned her first son, Rory, now 17 months. Not long after that, a home pregnancy test and then a visit to Orange obstetrician Peter Anzaldo confirmed that she was pregnant.
Anzaldo suggested that the breast lump might be caused by a clogged milk duct, Baird said, but sent her to the Breast Center for a more detailed exam.
There a biopsy revealed a large, cancerous tumor. And in March, as Baird entered her second trimester, she had a mastectomy. That surgery showed her cancer had spread, invading one lymph node. And so the debate began in earnest. Should Baird abort? Should she continue her pregnancy and have chemotherapy?
Baird wasn’t sure what to do. “I had a 10-month-old son. I didn’t want to die of breast cancer and leave him without a mother. . . . But I didn’t want to have an abortion.”
Margileth began researching the issue, reading journal articles and contacting experts around the country. When his first contact, a renowned breast cancer specialist, emphatically recommended abortion, Baird spent a sleepless week in tears.
But Margileth continued his inquiries, finding many oncologists who thought Baird could continue her pregnancy and start chemotherapy in the second trimester.
Meanwhile, Baird’s family and friends did their own research. Her brother, a medical student, sent copies of the few nationally reported studies on cancer in pregnancy. A friend, an oncology nurse, talked to experts at the National Institutes of Health. Her mother, who was also being treated for breast cancer, talked to doctors.
And her husband, Rodger, , an environmental chemist, asked the National Cancer Institute for a list of reports on pregnant women with cancer, then wrote their authors to see how the babies had fared.
The three doctors who responded offered good news: the babies were normal. Exulted Korean obstetrician Doo Sang Kim: “The bottom line is ‘The baby is now 4 years and 5 months old and very healthy!’ ” Wrote another, Dr. Thomas G. Day Jr., director of gynecologic oncology at the James Graham Brown Cancer Center in Louisville, Ky.: “I would like to reassure you that if chemotherapy is started after 12 to 14 months, it is probably safe.”
The Bairds took one more step. At Anzaldo’s suggestion, they asked St. Joseph Health System’s perinatal bioethics committee to review their case. A 25-member committee that included doctors, a geneticist, a social worker and a priest listened as Anzaldo presented diverse opinions on what to do. The committee provided a forum for the issues, but no recommendation.
Still, Rodger Baird called the meeting “cathartic. They didn’t have any lectures for us. I spent half the time asking technical questions of the geneticist.”
But when it ended, the Bairds had come to a conclusion. Three days later, in her 15th week of pregnancy, Pam Baird received her first dose of chemotherapy.
“The first time I had it, I just cried,” she recalled. “It was scary” to know she was pregnant and yet three powerful, toxic drugs--Adriamycin, Cytoxan and an agent called 5 Fu--were coursing through her veins.
Though she became nauseated and her hair fell out, the treatments never seemed to affect the baby, Baird said. Each month, “I just relied on Dr. Anzaldo that everything was all right. At each visit, he took a sonogram and I could see the baby move.”
Nathan Trilling Baird was born prematurely, by Cesarean section, after Baird’s amniotic fluid began leaking in the eighth month of her pregnancy. Anzaldo said he does not believe that the anti-cancer drugs caused the premature birth or affected the baby.
The Bairds are thankful, and still a little amazed, that chemotherapy didn’t hurt their son. “These are really nasty compounds,” Rodger Baird said. “But the baby’s definitely healthy.”
As for Pam Baird, she is busy caring for cuddly Nathan as well as trying to keep track of Rory, an active toddler.
But if her ordeal is over, Baird has some suggestions for other women who might find themselves pregnant and diagnosed with cancer.
“Don’t just rely on one doctor,” she advised. “Take the initiative to research it. Don’t just go on blind faith.”
The Bairds recently wrote the three cancer specialists they had heard from, thanking them for their responses and reporting that mother and baby were fine.
And Pam Baird said she was considering sending one more letter--and a picture of Nathan--to the prominent breast cancer specialist who had urged an abortion. The note will be brief, Baird said: “This is the baby we wouldn’t have had.”
