With Child, With Cancer
LIZETTE IRVIN, HEAVILY PREGNANT, reclined on a hospital bed, relaxed, considering the circumstances. A bag of fluid dripped into her blood through an IV line as Irvin sucked on ice cubes, trying to pass the time. The ice helped to minimize the metallic taste and heat in her mouth from 5-fluorouracil, an antimetabolite, which entered her bloodstream via a catheter inserted in her chest. It was June 16, Irvin’s fourth round of chemotherapy. She was 32 weeks pregnant and had breast cancer.
Before she left the chemo suite at the M. D. AndersonCancer Center in Houston, Irvin, who is 36 years old, was hooked up to a portable pump that slowly released doxorubicin — “the red devil,” a drug so toxic it can cause third-degree burns — into her body over the next 72 hours. During that time, her daughters, Madeline, 4, and Noelle, 2, stayed at her in-laws in part because Irvin feared that Noelle, “the clingy one,” might accidentally tear out her IV.
It was Noelle’s clambering on her mother that first alerted Irvin to a tender lump in her left breast last November. Irvin nearly called off her mammogram appointment when a home pregnancy test showed up positive in December. Because pregnant women typically experience enlargement and tenderness of their breasts, they often ignore early signs of cancer. Unfortunately, this means pregnant women learn of their breast cancer 2 to 15 months later than nonpregnant women and are two and a half times more likely to be told they have advanced-stage cancer. (Irvin’s cancer was Stage IIB; she had three smalltumors in one breast and the cancer had begun spreading to her lymph nodes.) Doctors are discovering more and more breast cancers at Stage 0 and I in nonpregnant women, but as one oncologist, Dr. Clifford Hudis, chief of breast-cancer medicine at Memorial Sloan-Kettering Cancer Center, put it, “In pregnant women, breast cancer is more likely to be the old-fashioned, 19th-century, ‘look at this big thing that’s developed.’ ”
In Irvin’s case, a breast specialist was concerned enough by an initial ultrasound that Irvin had a biopsy and mammogram right away. For the next few days, she focused intently on her daughters’ play dates, Madeline’s upcoming birthday party and “pushing the negative away.” On the fifth day, a nurse called and asked her to come in — and to bring her husband. “It doesn’t take a rocket scientist,” Irvin told me, but when the surgeon told them she had cancer, “I went completely blank.”
The question of how to handle cancer during pregnancy has long troubled the medical profession. In 1880, Samuel Gross, a pioneering American surgeon and the subject of the celebrated Thomas Eakins painting “Gross Clinic,” noted that when breast cancer was associated with pregnancy, “its growth was wonderfully rapid and its course excessively malignant.” In 1943, after treating 20 pregnant patients for breast cancer, doctors atColumbia-Presbyterian Hospital concluded that pregnancy made the disease inoperable. Ten years later, the consensus was that termination of the pregnancy was essential and even improved patient survival.
Breast-cancer treatment has made huge strides since then, and a considerable amount of research shows that termination does not improve a pregnant woman’s prognosis. Yet many pregnant women are still refused treatment unless they abort. “Some doctors may be concerned about hurting the baby or the mother,” says Dr. Richard Theriault, an oncologist at M. D. Anderson, where he oversees a team specializing in the treatment of pregnant women with breast cancer. “Or they’re concerned there will be some medical catastrophe and they’ll be liable. Some just don’t want to tackle the issue because it’s complicated.”
Though still relatively rare (the rate of pregnancy-associated cancer is about 1 in 1,000 pregnancies), the incidence of pregnancy-associated breast cancer is considered to be on the rise. Cancer is primarily a disease of aging, and in the case of breast cancer — the most common cancer diagnosed during pregnancy — age works against women in two ways. First, studies show that women who give birth for the first time at younger ages are less likely to get breast cancer. (The best, perhaps only, argument in favor of teenage pregnancy is that women who get pregnant before age 20 are two to three times less likely to develop breast cancer than women who get pregnant for the first time after 30.) Second, as women increasingly conceive for the first time in their 30s and 40s, their likelihood of developing cancer while pregnant increases. Only 2 percent of breast-cancer cases occur in women under 35, but 1 in 5 are diagnosed in women between the ages of 35 and 49. It’s at these ages that cancer and pregnancy are most likely to collide. One study showed that among women 35 and younger with cancer, 14 percent were pregnant when their illnesses were diagnosed; another study of women under 45 found that 7 percent were pregnant at the time of diagnosis.
All this takes place against the backdrop of a massive biological shift. Only 150 years ago, girls got their first period at 15 or 16 and went through menopause in their late 30s and 40s. Today, girls begin puberty as early as 9, and menopause generally occurs around 50. We have also increasingly begun tinkering with our bodies, pushing the limits of our fecundity through an array of assisted reproductive technologies. The period in which women’s bodies go through a series of tremendous hormonal shifts is extending ever longer, increasing both our fertile years — and our chances of getting breast cancer.
Lizette Irvin hadn’t even planned to get pregnant. Twelve weeks in, when her cancer was diagnosed, she fleetingly considered terminating the pregnancy. “But it wasn’t really an option,” Irvin said, citing her Catholicism. The breast specialist she initially consulted was surprisingly optimistic. “Despite what you might think, chemo is an option,” she was told.
As best they can, oncologists try to hew closely to the level of care a nonpregnant woman would receive. “The decisions you have to make when a woman has cancer are difficult enough,” Dr. Ann Partridge, an oncologist at Dana-Farber Cancer Institute in Boston, says. “Throw in the fact that she’s pregnant, and now we have another party to think about, the fetus.” Most oncologists advise strongly against chemotherapy in the first trimester when the fetus’s organs are developing. Irvin, like nearly all pregnant breast-cancer patients, had a mastectomy and then started chemo at 23 weeks. She was determined to be aggressive. “I was ready to get rid of both breasts, but they told me it wasn’t really necessary at that point.” The doctors also wanted to keep her underanesthesia for as little time as possible.
“People can fathom what it’s like having two children under 5,” Irvin said. “They can fathom being tired because you’re pregnant. They can even fathom what it’s like having cancer. But they cannot fathom all three at the same time.”
IN 1997, WHEN Dr. Elyce Cardonick, a perinatologist, was a research fellow at Cooper University Hospital in Camden, N.J., she met with a pregnant patient who had been told by her oncologist to terminate after learning she had Hodgkin’s disease. “She was afraid not to be treated for cancer, but she was afraid to expose her fetus to drugs,” Cardonick recalled when I spoke to her recently. It was perhaps the ultimate maternal conflict: choosing between the biological imperatives for self-preservation and procreation.
“We had to figure out what we could do to protect the fetus, but also what to do to protect the mother so that that baby had one,” Cardonick said. She did some research and found that pregnant patients had been treated with chemotherapy in Mexico, with what appeared to be remarkable success. In 1973, while still a resident, Dr. Agustin Avilés, a senior researcher at the Instituto Mexicano del Seguro Social in Mexico City, saw his first pregnant patient with acute leukemia. This woman became the impetus for Avilés’s groundbreaking study on the effects of chemo while pregnant, the first of 84 patients who received chemotherapy during pregnancy between 1973 and 2003, 58 of them during the first trimester. For most, termination wasn’t an option. Up until recently, medical abortions were rarely permitted in Mexico. Delaying treatment wasn’t viable, either. All 84 had acute leukemia, advanced Hodgkin’s or malignant lymphoma. Forestalling chemotherapy for even a few days could cost both mother and fetus their lives.