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Pregnant with cancer

Author: Laurie Wertich

Jackie Malena was seven months pregnant when she was diagnosed with stage II hepatocellular carcinoma (HCC ). The uncomfortable pain she had originally chalked up to pregnancy was actually the result of a football-sized tumor that was hanging off of her liver. “Suddenly, I had a 2-pound baby girl and a 2-pound tumor fighting for the same space,” she explains.

At the time, HCC was considered somewhat of a silent killer because by the time it appeared on scans, it was nearly impossible to treat. The only treatment option was surgery. Suddenly, Jackie was thrust into a flurry of decisions she never expected to encounter. Should she have surgery while she was pregnant, or should she wait? The tumor was growing quickly—was there time to wait? How would surgery affect her growing baby? If doctors had to make a choice during surgery, who should they save—her or the baby?

Jackie’s was a crash course in cancer and its treatment. Just four days after the diagnosis, she underwent groundbreaking surgery that successfully removed the tumor while keeping her baby in utero. Two months later she delivered a healthy baby girl.

Cancer and pregnancy

It seems like an impossible juxtaposition that cancer and pregnancy can coexist, but they can and they do. In fact, about one pregnant woman in 1,000 is diagnosed with cancer each year in the United States. That means approximately 3,500 women per year face the most ironic twist of fate: their bodies are fighting to grow new life in the midst of an invasion of deadly cancer cells. While cancer during pregnancy is still considered rare, the incidence appears to be on the rise—possibly because more women are delaying childbirth until they are older. In 2009 Swedish researchers found that the incidence of breast cancer diagnosed during pregnancy more than doubled between 1963 and 2002, partly because of an older age at conception.1

The most common cancers diagnosed during pregnancy are breast cancer, cervical cancer, lymphoma, and melanoma. Interestingly, the cancer itself rarely harms the baby, and some of the treatments are even considered safe for a growing fetus. Like Jackie, many pregnant women experience the ultimate happy ending: cancer survival and motherhood.

Diagnosing cancer during pregnancy

Diagnosing cancer during pregnancy can be tricky. On the one hand, pregnancy sometimes serves as an opportunity to uncover cancer because women are undergoing more checkups and ultrasounds. In fact, there is some evidence that widespread use of ultrasound during pregnancy has led to the detection of asymptomatic ovarian cancer.2,3

On the other hand, pregnancy can often serve to mask symptoms of cancer because women either do not notice the changes in their bodies or they mistakenly attribute any new or unusual symptoms to the pregnancy. Ironically, the signs and the symptoms of breast cancer can be similar to the changes in a woman’s body during pregnancy.

Furthermore, women become singularly focused during pregnancy—with all attention on their growing baby. As a result, they may be more hesitant to address any other health concerns that could affect the pregnancy. Any delay in diagnosing cancer can be risky because it gives the cancer time to grow and spread. Early-stage cancer is always more treatable than later-stage cancer.

Treating cancer during pregnancy

Cancer treatment for pregnant women has come a long way in a short time. Historically, doctors recommended terminating the pregnancy to deliver the best treatment and chance of a cure to the mother. Now we know better.

Today physicians take a two-pronged approach to treating pregnant women— their goal is to treat the cancer while protecting the baby. “Cancer during pregnancy presents a challenging clinical situation because the well-being of the mother and the fetus need to be taken into account,” explains Sagun Shrestha, MD, a hematologist-oncologist and medical oncologist at Cancer Treatment Centers of America® (CTCA ) in Tulsa, Oklahoma. “It is important to have good communication between the obstetrician and the oncologist, so all the care is well coordinated,” Dr. Shrestha says. I n most cases, physicians treat the cancer in the same way they would if the patient were not pregnant—with some safeguards in place.

Safety and cancer treatment during pregnancy

It seems counterintuitive: women take extra care during pregnancy to avoid things like caffeine, alcohol, tobacco, and even sushi, yet if they are diagnosed with cancer, they may end up undergoing chemotherapy. How can that be safe? Though some drugs do have “blackbox warnings” forbidding their use during pregnancy because of their toxicity, it turns out that certain types of chemotherapy are considered safe during pregnancy because the drug molecules are too large to pass through the placenta and are thereby prevented from reaching the baby.

Despite the proven safety of these drugs, delivering chemotherapy during pregnancy can be tricky. Dr. Shrestha explains, “There are certain physiologic changes during pregnancy that change the way the body handles the chemotherapy.”

Physicians take great care to deliver the right chemotherapy at the right time to offer the best treatment for the patient while keeping the baby safe. “The timing and the period of exposure to chemotherapy is critical,” explains Dr. Shrestha. “The greatest risk of congenital abnormality is during the first trimester of pregnancy.”

Often chemotherapy may not be directly harmful to the growing fetus but can be indirectly harmful as a result of side effects experienced by the mother, such as malnutrition or anemia.

In addition to chemotherapy, most women can tolerate surgery well. The bottom line is that with extra precautions in place, pregnant women can be successfully treated, carry their babies to term, and give birth to healthy babies.

Delivering a healthy baby

Cancer may seem to steal the spotlight from the pregnancy, but ultimately both mother and doctor are always focused on the health of the baby and plans for a successful delivery.

Dr. Shrestha notes, “The timing of delivery in relation to chemotherapy administration should be carefully considered. Delivery should occur following a time when the mother’s white blood count and platelet count are within normal limits to prevent infections and bleeding.”

Jackie’s pregnancy was just 27 weeks along when the tumor was removed, and she recounts the heroic efforts of doctors to ensure that she did not go into labor during or after surgery. “They staffed a nurse to sit by my bed in the IC U,” she recalls. “At any minute something could go wrong, and they were dealing with two people, not just one.”

Jackie spent two weeks in the hospital before she was discharged. “I went home with 30 staples down my pregnant belly and with a very active baby who was kicking a lot,” she remembers. Jackie recovered from surgery, and her healthy, 7-pound daughter was born just three weeks early.

From cancer to motherhood

It can be a shocking transition to endure cancer treatment and then face the challenges that come with motherhood. “I had newborn trauma and cancer trauma,” Jackie recalls. “The surgery took care of the cancer and then— boom—I was a new mom. My whole world changed when I became a mom.”

All new mothers are overwhelmed and exhausted, but new moms who have just survived cancer experience a unique emotional journey: they face the same exhaustion coupled with medical questions and fears. “Late at night was when I most feared the cancer’s coming back,” Jackie admits.

In addition to the fear, these moms may still have to cope with the very real side effects of treatment. The things most of us take for granted may not be possible in the face of cancer. For example, mothers who are still undergoing treatment may have to forgo breastfeeding because although cancer cells cannot pass through breast milk, chemotherapy drugs can.

Finally, even if initial treatment is effective, women who are diagnosed with cancer while they are pregnant must continually monitor their health after they give birth and, sometimes, must manage the reality of a recurrence. In Jackie’s case, cancer recurred several years after the initial diagnosis, at which point she underwent treatment at CTCA in Tulsa.

There is no doubt that cancer and pregnancy are strange bedfellows, characterized by the contrasts between stress and joy, fear and elation. But this once-impossible situation is now surmountable. And, of course, surviving cancer makes the joy of motherhood even sweeter.

No case is typical. You should not expect to experience these results.

References

  1. Andersson TM, Johansson AL, Hsieh CC , et al. Increasing incidence of pregnancy-associated breast cancer in Sweden. Obstetrics & Gynecology. 2009;114(3):568–72.
  2. Behtash N, Zarchi MK, Gilani MM, et al. Ovarian carcinoma associated with pregnancy: a clinicopathologic analysis of 23 cases and review of the literature. BMC Pregnancy and Childbirth. 2008;8(3). doi:10.1186/1471-2393-8-3.
  3. Zanotti KS, Belinson JL, Kennedy AW. Treatment of gynecologic cancers in pregnancy. Seminars in Oncology. 2000;27:686–98.

Disclaimer: CTCA is a proud sponsor of Jackie Malena’s book, Surviving Cancer 101 (Purpose Driven Publishing, 2010; $19.99).

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