SURVIVAL, TIMES TWO
When cancer strikes during pregnancy, improving the odds demands teamwork
Only six weeks after discovering she was pregnant with her second child, a doctor gave Tracy Hartman more big news.
"I could just tell from the look in her eyes that something was wrong," she recalls.
Hartman had cervical cancer, a diagnosis that in many cases demands a radical hysterectomy, chemotherapy and radiation treatment.
"My first thought was, what about the baby?" she says.
From that moment forward, Hartman's hope for an uneventful pregnancy became an ongoing struggle to decide how best to improve the chances both for herself – and her growing fetus.
Radiation treatment is not recommended during pregnancy, and some chemotherapy drugs may harm a fetus. Chemotherapy treatment during pregnancy also can result in low birth weight and increase the risk of the child developing cancer. Anesthesia required for surgery can increase the chance of premature birth, and in some cases surgery can effectively terminate a pregnancy altogether.
Fortunately, Hartman's agonizing scenario is rare. A study based on data from the California Cancer Registry found about one in a thousand women have cancer when they give birth, and most don't know it until after they've delivered, says Lloyd Smith, an author of the study and chair of obstetrics and gynecology at UC Davis.
"They're very complex and challenging cases," Smith says, "for both the doctors and the patient."
Pregnant women aren't any more likely to get cancer than others their age, and the malignancies most common in mothers-to-be – cancers of the breast, thyroid and cervix, melanoma and Hodgkin's disease – tend to be the most common cancers among young women.
Gary Leiserowitz, a specialist in gynecologic oncology at UC Davis, puts it this way: "Pregnancy happens to women who also sometimes get cancer."
And when it does, malignancies can be missed because pregnancy may obscure the diagnosis. Leiserowitz says that's because some symptoms of cancer, such as rectal bleeding, also are common during pregnancy.
Or doctors may miss signs of cancer for other reasons. "Doctors don't want to believe that a pregnant woman may have a life-threatening malignancy, and they often overlook symptoms or findings that they should be following up on," says Smith. "Doctors don't want to think about cancer in a young woman who's pregnant."
As pregnant women with cancer go, Hartman was lucky. Symptoms surfaced even before she knew she was pregnant. After two abnormal Pap smears, a vaginal ultrasound and two biopsies, she learned she had an early-stage cervical cancer. Exams uncovered a golf ball-sized lesion covering her cervix, which raised concerns about spread to her lymph nodes.
Hartman was being seen by doctors in San Ramon, who recommended she undergo a radical hysterectomy – an option that would have given Hartman the best chance for a cure, but would have ended the pregnancy.
"If I hadn't been pregnant, it would have been a pretty easy decision," says Hartman, who now lives in El Dorado Hills. "But I really wanted to do whatever I could to have the child."
To better understand the risks and options for women like Hartman, UC Davis researchers have carried out a series of studies in recent years on cancer in mothers-to-be. They've looked at breast, thyroid, cervical, ovarian and colorectal cancers, as well as melanoma, gathering data about when pregnancy-associated cancer is diagnosed and how patients fare.
What they've learned is that there are a lot of options for effectively fighting cancer in a pregnant woman without harming her baby, and that such cases require a multidisciplinary approach, with input from high-risk pregnancy and cancer specialists.
The best way to treat cancer diagnosed during pregnancy depends on the kind of cancer, how advanced it is, and how far along the patient is in her pregnancy, says Anne Rodriguez, a specialist in gynecologic oncology at UC Davis.
"It's really important that a pregnant woman in this situation does not make the decision to terminate because she thinks she can't have treatment. She may be able to," Rodriguez says, adding, however, that some women do choose to end a pregnancy in order to maximize their options for treatment, and increase their chance of survival.
If the disease is not very advanced, it may be possible to postpone treatment without affecting the mother's prognosis – either until she gives birth at the end of a fullterm pregnancy, or until the baby is old enough to survive a planned early delivery that will allow the mother to begin treatment as soon as possible.
Pregnant women also can undergo surgery with little risk to the fetus, Rodriguez says, ideally early in the second trimester to minimize risks associated with anesthesia.
Hartman decided against a radical hysterectomy, instead opting for a lymphadenectomy – surgical removal of lymph nodes suspected of being cancerous.
The young mother knew going into surgery that her now 3½-monthold fetus still could be in jeopardy. "The oncologist asked me, ‘If we find a lot of positive lymph nodes, do I have permission to go ahead with the complete hysterectomy?'"
"I said, ‘I really want this baby.' She said, ‘We'll do the best we can.'"
When she awoke from surgery, Hartman searched frantically for a nurse to ask if she was still pregnant. Indeed, she was. Back home, and with an eightinch abdominal incision, Hartman again was faced with life-and-death decisions, after her doctor called to say that two of the nodes removed were positive for cancer. Again, the oncologist recommended the hysterectomy – and said it should be done quickly.
After a night of intense prayer, Hartman told her doctor she would not have a procedure that would end the pregnancy. Her husband, Tom, supported the decision. Instead, she agreed to undergo chemotherapy treatment, and to have an early, planned surgical delivery.
Some chemotherapeutic drugs can be used in expectant women, although the timing is important.
"Generally we don't give anything during the first trimester," says Helen Chew, who heads the clinical breast cancer program at UC Davis. The first three months of pregnancy are crucial to the development of a baby's organs, and women are advised to steer clear of even common, over-thecounter medications, Chew says.
Hartman had three courses of chemotherapy later in her second trimester, and took steroids because of concerns that the baby might not be growing adequately.
Doctors had warned Hartman that her newborn might be small, because of everything she'd gone through. Just before the planned delivery, tests revealed that her baby's lungs weren't sufficiently developed, so they waited a few more weeks.
Morgan arrived a healthy 6 pounds by Caesarean section, nearly at term, in a room crowded with some 25 doctors, nurses and technicians. In addition to the delivery, doctors took out her cervix and uterus and repaired a hernia. Because she was only 35 years old, they spared her ovaries. Six weeks later, Hartman had more chemotherapy and also radiation treatments.
The prognosis for women like Hartman who have cancer while pregnant is the subject of considerable debate, and research findings vary in terms of how well pregnant women fare compared with cancer patients who aren't expecting.
One UC Davis study on breast cancer found that women who had the disease when they were pregnant were slightly more likely to die of it than women who weren't pregnant, and not only because pregnant patients tended to have more advanced disease at diagnosis – another of the study's findings.
"That is an interesting finding," says Leiserowitz. "However, most studies on cancer in pregnancy show that a patient's prognosis is usually dependent on the stage of the cancer and the response to treatment."
Hartman, who now sees UC Davis gynecological oncologist John Dalrymple for follow-up care, is in remission, and free to focus on raising her children.
Morgan is now 8. She has long known that her Mom had been sick when she was a baby. But it was only recently, after the family participated in a bike ride to raise money for pediatric cancer research, that Hartman revealed to Morgan that it had been cancer.
"We both teared up," Hartman says. "She said, ‘Mommy, could you have died?' I said, ‘What kept me going was that I really wanted you. I wanted you so badly.'"
Faced with the same situation today, Hartman says, she'd do it again. "I can't imagine my life without her."