Something felt wrong in Leila Sadat's right breast. The Washington University law professor tried to ignore the nagging worry about a hard spot that mammograms did not detect. Doctors thought it was nothing more serious than a blocked milk duct. It couldn't be cancer. Sadat was pregnant.
As many as one in 1,000 pregnant women will be diagnosed with cancer. Doctors expect that number to rise as more women delay childbirth into their 30s and 40s, because cancer risk increases with age.
Pregnant women with cancer must make life-and-death decisions times two.
"That tension is more poignant because here it's my life versus my baby's life," said Dr. James Bartelsmeyer, director of maternal-fetal medicine at St. John's Mercy Medical Center in Creve Coeur, where doctors treat cancer in five to 10 pregnant women each year. "What's good for the mother is often at conflict with what's good for the baby."
Terminating the pregnancy was once seen as the only option to save the mother's life. Some women with very aggressive cancers that are discovered early in the pregnancy still choose that option.
But now, starting chemotherapy during pregnancy is becoming more common since doctors have learned that babies exposed to chemotherapy during the second or third trimester have virtually no greater risk of birth defects than those not exposed to it. Chemotherapy in the first trimester has been shown to cause birth defects such as cleft palates at rates three times the average.
Radiation therapy can cause mental retardation and other birth defects and is avoided during pregnancy -- except in the rare instance of brain tumors. Surgeries such as mastectomies, along with the anesthesia, are usually considered safe.
TAKING ACTION
"If you're pregnant, the only wrong answer is to do nothing about it," said Dr. Jennifer Litton, an oncologist at the M.D. Anderson Cancer Center in Houston, considered a leader in treating pregnant women. "There is a choice to both treat you and keep the baby safe."
For Sadat, a precautionary biopsy confirmed her worry: What doctors initially thought was an infection of the breast tissue was actually a tumor. A tumor that grew quickly.
Her uncle, a doctor in his 80s, told her she had to have an abortion or she would die.
Her oncologist, obstetrician and other doctors at Siteman Cancer Center at Barnes-Jewish Hospital assured her the cancer was treatable and the baby was not at risk.
Sadat, who was 45 at the time, practices yoga, eats organic food and had never been seriously ill. It was difficult to reconcile that with pumping toxic chemicals through her blood.
"I was a pregnant happy mom. All of a sudden you're a cancer patient, and my whole essence fought that," she said. "I think I just knew that I had to wake up and do what they told me to do because I had to be there for my kids."
She fought the disease "bald and pregnant and getting chemo."
Because it was her third pregnancy, Sadat felt the baby was growing and kicking normally. In addition, she had weekly ultrasounds, something typically performed in high-risk pregnancies such as hers.
REASSURING DATA
A growing body of research also helps reassure mothers. Litton and her colleagues in Texas manage a registry of women diagnosed with breast cancer while pregnant. They follow the cases of 75 patients who have given birth, with the oldest child now 19.
All of the children in the registry were exposed to chemotherapy in the second or third trimesters. None of the children has developed cancer. One was born with Down syndrome, which is genetic and unrelated to the mother's cancer. The separate birth defects of kidney reflux and club foot were noted in two children, although it is unclear whether they are related to the cancer drugs. Another child had bleeding in the brain at birth but recovered fully.
Dr. Elyce Cardonick of Cooper University Hospital in New Jersey runs another nationwide database of 224 women who were diagnosed with any type of cancer while pregnant.
Like the Texas study, Cardonick didn't find a higher rate of birth defects compared with the general population. The findings give her confidence that pregnant women can be treated safely, particularly with older chemotherapy drugs with which doctors have more experience.
"Let's find out how you would be treated if you weren't pregnant, and then let's discuss if it's possible to do the same during pregnancy," she said.
RUNNING RISKS
The list of foods and drugs any pregnant woman should avoid is long: Bacteria in raw fish, soft cheeses and deli meats can cause miscarriages. Alcohol, some over-the-counter cold medicines and certain prescription drugs such as the acne medication Accutane can cause serious birth defects.
With chemotherapy, not much is known about how the babies escape harm even as the toxins cause the mother to lose weight, become anemic and lose her hair and fingernails.
"We don't even know if the chemo is getting through the placenta, and if it is, if the placenta is pumping it back out," Litton said.
Also unknown are the long-term effects of exposure to chemotherapy. Of particular concern are the children's hearts and reproductive systems, both known to be susceptible to damage in adult cancer patients. With future grant money, the doctors plan tests to detect any developmental abnormalities as the children grow up. They will compare results with siblings who were not exposed to the chemicals.
As for the mothers, they seem to do as well after treatment as women who are diagnosed at the same age and cancer stage but aren't pregnant.
Some doctors and patients theorize that pregnancy hormones, particularly estrogen, hasten the growth of tumor cells just as they help to grow and multiply cells in the developing fetus. But because there's no evidence that terminating the pregnancy improves the outcome for the mother, that theory doesn't seem to hold. And breast tumors were probably growing for months or years before the pregnancy, doctors say.
DIAGNOSIS IS VITAL
The biggest threat to pregnant women with any kind of cancer is a delay in getting diagnosed. Symptoms of cancer can easily be dismissed as typical side effects of pregnancy: aches and pains, swollen breasts, rectal bleeding. Plus, most obstetricians might see only one or two women with cancer in their careers, so they're not on the lookout.
That was the case for Angela Powell, whose doctors figured a lump in her breast was an enlarged milk duct. A biopsy to confirm the benign mass instead found the cancer. Powell, then 28, was three months pregnant.
Worrying about her baby's health more than her own helped Powell, of Marthasville, endure a mastectomy and five rounds of chemotherapy during the pregnancy. She lost 50 pounds while pregnant because of the stress and the drugs.
"It was a daily nightmare sitting there and knowing they were injecting me with all these medicines," Powell said. "They could reassure me all they wanted to, but until I saw him and counted fingers and toes and looked in those eyes, I didn't believe it."
Tyler weighed a healthy 7 pounds, 1 ounce when he was born July 1 of last year -- under the astrological sign of Cancer.
"He's been through everything with me," she said. "He is the one who really saved my life."
The cancer treatments and complications don't end when the baby is born. Women usually have further rounds of chemotherapy and radiation. Even if they didn't have mastectomies, they miss out on breast feeding because the drugs can pass through the milk. They are often thrust into early menopause, reducing their chances of having more children.
Sadat knew this pregnancy would be her last, making the fight to keep her and the baby healthy all the more critical. She became anemic and protein deficient. All food tasted terrible. After four rounds of chemotherapy, she was too sick to walk around the block.
Sadat's doctors decided to deliver early so they could start radiation treatments. They injected Sadat with steroids to pump up the baby's lungs in preparation for the premature birth. Emily was born six weeks early, weighing 4 pounds, 4 ounces.
Today Emily is a smart, happy and healthy 22-month-old, and Sadat is cancer-free.
"She seems very grateful for what she has," Sadat said of her daughter. "Every baby is always a special miracle, but she seems particularly special."
Copyright (c) 2008, St. Louis Post-Dispatch
