Headlines
As reported by 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."