Last April, Rachel called Brown’s oncologist with bad news — at age 36, she had an aggressive form of breast cancer. She found out she was pregnant the next day after trying for a baby with her fiancé for almost a year.
She had always said she would never have an abortion. But the choices she faced were painful. If she had the chemotherapy she needed to stop her cancer from spreading, she could harm her baby. If she didn’t have it, the cancer could spread and kill her. She had two children aged 2 and 11 who could lose their mother.
For Ms Brown and others in the hapless sisterhood of women diagnosed with cancer during pregnancy, the Supreme Court’s June decision ending constitutional abortion rights may seem like a slap in the face. When the life of a fetus is of paramount importance, pregnancy can mean that a woman cannot receive effective treatment for her cancer. One in a thousand women who become pregnant each year is diagnosed with cancer, meaning thousands of women face a serious and potentially fatal illness while expecting a baby.
Before the Supreme Court decision, a pregnant woman with cancer was already “entering a world of tremendous unknowns,” said Dr. Clifford Hudis, Chief Executive Officer of the American Society of Clinical Oncology. Now both patients and the doctors and hospitals that treat them are affected by the added complications of the abortion ban.
“If a doctor can’t give a drug without fear of harming a fetus, will that affect the results?” asked Dr. Hudis. “It’s a whole new world.”
Cancer drugs are dangerous for fetuses in the first trimester. Although older chemotherapy drugs are safe in the second and third trimesters, the safety of the newer and more effective drugs is unknown and doctors are reluctant to give them to pregnant women.
About 40 percent of women who are pregnant and have cancer have breast cancer. But other types of cancer also occur in pregnant women, including blood cancer, cervical and ovarian cancer, gastrointestinal cancer, melanoma, brain cancer, thyroid cancer, and pancreatic cancer.
Women with some cancers, such as acute leukemia, often cannot go ahead with a pregnancy if the cancer is diagnosed in the first trimester. They need immediate treatment within days, and the necessary medications are toxic to a fetus.
“In my view, the only medically acceptable option is termination of the pregnancy so that life-saving treatment can be given to the mother,” said Dr. Eric Winer, the director of the Yale Cancer Center.
Some oncologists say they’re not sure what’s legal when a woman lives in a state like Michigan that criminalizes most abortions but allows them to save the mother’s life. Is leukemia a reason for an abortion to save her life?
“It’s so early that we don’t know the answer,” said Dr. N. Lynn Henry, oncologist at the University of Michigan. “We cannot prove that the medication caused a problem for the baby, and we cannot prove that withholding the medication would have adverse consequences.”
In other words, doctors say that complications of pregnancy — miscarriage, premature birth, birth defects, or death — can occur whether a woman with cancer takes the drugs or not. If she is left untreated and her cancer turns into a malignancy that kills her, that could have happened too, even if she had been given the cancer drugs.
University of Michigan medical system administrators do not intervene in cancer treatment decisions about treating cancer in pregnant women, saying “medical decision-making and management lies between physicians and patients.”
I. Glenn Cohen, Harvard law professor and bioethicist, is deeply concerned.
“We’re putting doctors in a terrible position,” Mr Cohen said. “I don’t think signing up as a doctor should mean signing up for jail time,” he added.
Oncologists are typically part of a hospital system, Mr Cohen said, adding another complication for doctors treating cancer in states that ban abortion. “Whatever their personal feelings may be,” he asked, “what risks will the hospital system face?”
“I don’t think oncologists ever thought that day would come for them,” said Mr. Cohen.
Behind the doctors’ confusion and concern are the stories of women like Ms. Brown.
She had a large tumor in her left breast and cancer cells in her forearm lymph nodes. The cancer was HER2 positive. Such cancers can spread quickly without treatment. About 15 years ago, the prognosis for women with HER2-positive cancer was among the worst breast cancer prognosis. Then a targeted treatment, trastuzumab or Herceptin, changed the picture completely. Now, women with HER2 tumors have one of the best prognosis compared to other types of breast cancer.
However, trastuzumab must not be administered during pregnancy.
Ms Brown’s first visit was to a surgical oncologist who, she said, “made it clear that my life would be in danger if I kept my pregnancy because I might not be able to get treatment until the second trimester.” He told her that himself her cancer would spread to distant organs and become fatal if she waited those months.
Her treatment in the second trimester would have been a mastectomy to remove all the lymph nodes in her left armpit, which would have put her at risk for lymphedema, an incurable fluid buildup in her arm. She was able to start chemotherapy in her second trimester, but was unable to receive trastuzumab or radiation.
Her next consultation was with Dr. Lisa Carey, a breast cancer specialist at the University of North Carolina, who told her that while she can have a mastectomy in the first trimester, it’s not optimal before chemotherapy. Typically, oncologists give anticancer drugs before a mastectomy to shrink the tumor and allow for less invasive surgery. If treatment didn’t eradicate the tumor, oncologists tried more aggressive drug treatment after surgery.
But if she had a mastectomy before chemotherapy, there would be no way of knowing if the treatment helped. And what if the drugs didn’t work? She worried that her cancer might become fatal without her realizing it.
She feared she would sacrifice her own life and ruin her children’s lives if she tried to maintain her pregnancy. And if she delayed her decision and had an abortion later in the pregnancy, she feared the fetus might feel pain.
She and her fiancé discussed their options. This pregnancy would be his first biological child.
It was with great sadness that they made their decision – she would have a medical abortion. She took the pills one morning when she was six weeks and a day pregnant and cried all day. She wrote a eulogy for the baby that could have been. She was convinced the baby would be a girl and had named her Hope. She recorded the ultrasound of Hope’s heartbeat.
“I don’t take this little life lightly,” Ms. Brown said.
After terminating her pregnancy, Ms Brown was able to begin treatment with trastuzumab along with a cocktail of chemotherapy drugs and radiation. She had a mastectomy, and at the time of her surgery there was no evidence of cancer — a great prognostic sign, said Dr. carey She did not require all lymph nodes to be removed and did not develop lymphedema.
“I feel like it took a lot of courage to do what I did,” Ms Brown said. “As a mother, your first instinct is to protect the baby.”
But after going through this grueling treatment, she also wondered how she would ever have managed to take care of a newborn baby and her two other children.
“My bones hurt. I couldn’t walk more than a few steps without getting out of breath. It was difficult to get nutrients because of the nausea and vomiting,” she said.
The Supreme Court decision hit her hard.
“I felt like the reason I was doing what I was doing didn’t matter,” she said. “My life didn’t matter, and my children’s lives didn’t matter.”
“It didn’t matter if I lost my life because I was forced to conceive,” she said.