As has often been written, “Cancer is the greatest equalizer.” It tends to strike its victims regardless of their financial status. In low- and middle-income countries, however, the impact of poverty on the treatment of cancer is strikingly conspicuous. It is the major catalyst for delay in seeking timely medical care, and consequently many patients in poverty-stricken areas present with locally advanced or metastatic stages of cancer.1
Subeera Khan, MD
I learned this the hard way, suffering through a great deal of distress after realizing that many women in low- and middle-income countries, with curable stages of cancer, did not show up for treatment. This was after being advised about a treatment plan with a battery of investigations that were beyond their financial abilities.
Cancer During Pregnancy: No Longer Rare
Our forefathers in oncology were lucky enough to declare that cancer associated with pregnancy was extremely rare. Today, however, the trend among young women to give birth later in life, along with an age-dependent increase in cancer,2 has led to a scenario where we can only exclaim that the situation, albeit infrequent, is definitely not rare anymore.
The diagnosis of cancer during pregnancy poses a dilemma, not just to the expectant mother, but also to the treating oncologist, who is forced into a corner, unable to bank upon any level 1 evidence. We often scurry back to the literature, only to find sparse data in the form of retrospective reviews, case reports, and anecdotal experiences.
The strain of shouldering responsibilities for two lives at once, making tough calls that might result in the termination of an unborn and innocent life along the way, is extremely difficult to handle and takes a toll on our mental health. The residual moral distress left behind by these cases can linger for long periods, often being rekindled when we see even a remotely similar circumstance. While treating women with locally advanced and metastatic cancer coupled with pregnancy, however hard we try, the silver lining is truly difficult to see.
‘Life Finds A Way’
Despite having grown up on a steady dose of Steven Spielberg’s movies, I never really understood the significance of what Dr. Malcolm meant in the movie Jurassic Park when he said, “Life finds a way,” until I met this 32-year-old woman. She was undergoing adjuvant radiation therapy to her left chest wall and taking tamoxifen.
During her third week of radiotherapy, she approached me saying that her menstrual cycle had not resumed after completion of chemotherapy. I assured her this was quite common and could be chemotherapy-induced amenorrhea, gently reminding her about taking all the contraceptive precautions we had advised before the beginning of treatment. I advised her to take a urine pregnancy test at home so she wouldn’t lose sleep overthinking about this.
The very next day, she was waiting for me in the clinic with the positive stick in her hand, basically echoing, “Life finds a way.”
A viability scan revealed she was in her eighth week of pregnancy, and there was strong cardiac activity in the fetus. I immediately informed my professor, and we took action right away. We went back into her history, determined the probable date of conception, and established that her cumulative abdominal surface dose was much higher than 0.4 Gy. At this juncture, she was just halfway through her radiation treatment (the health consequences to the fetus can be severe with exposure at doses greater than 0.5 Gy).3
The patient ultimately underwent termination of pregnancy as advised4 and completed radiotherapy. But it was not what she wanted, and she was not the same cheerful young woman who greeted me anymore. Even though life had found a way, I believe we had muffled its echo, literally and figuratively.
‘No Way!’
A 27-year-old woman presented for management of multiple brain metastases. The caveat was she was in the early half of her second trimester of pregnancy and undergoing chemotherapy for breast cancer.
There were a lot of deliberations over deciding the line of further treatment, with most colleagues raising concerns about the risks to the fetus from radiation therapy. The only thing everyone agreed upon was that treatment of the patient’s brain metastases could not wait until the completion of term. Given her poor prognosis, she was advised to terminate the pregnancy and start whole-brain radiotherapy at the earliest possibility.
Despite multiple counseling sessions, she said, “No way!” and outright refused the option of terminating the pregnancy. Putting aside the technicalities and precautions we took to keep the dose to the abdomen as low as reasonably achievable, she delivered a healthy baby boy and died a few months after his birth. However, her last months were spent in peace.
I believe that because this patient had wrestled with her decision and opted not to terminate the pregnancy, she had somehow reconciled with her cancer.
To Breastfeed or Not to Breastfeed
A 29-year-old woman, expecting her first child, was diagnosed with right-sided, locally advanced triple-negative breast cancer in week 37 of her pregnancy. An immediate delivery was advised, and she gave birth to a healthy baby girl. Citing the need to breastfeed her child, she refused neoadjuvant chemotherapy. It took me almost a week to convince her that her baby would be just fine without breast milk, using myself as a personal example of how bottle-fed babies turned out pretty well, too.
“As enthusiastic clinicians, we are so preoccupied with whether ‘we can’ that sometimes we don’t stop to think about whether ‘we should’ impose our decisions on our patients.”— Subeera Khan, MD
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Helping her get placed on the track of standard-line chemotherapy brought me a little joy in this otherwise gloomy scenario. But the joy, unlike the cancer, was short-lived. A routine clinical exam post third cycle revealed a small lump in the opposite breast. Imaging revealed that the disease had progressed like a storm, and the patient’s lungs and liver were now studded with metastases.
When I informed her about the poor prognosis, she told me with great anguish that because she was dying anyway, it would have been better if I had just allowed her to stick with her gut instinct of refusing chemotherapy, so as to reap the immense satisfaction of breastfeeding her little baby girl, whom she could no longer hold in her arms because of the toxicity of the (apparently futile) treatment. I had absolutely no words to comfort her and will always have the gnawing feeling that she did not die at peace. Despite my good intentions, I had denied her the final closure she needed in the form of breastfeeding her child.
Whose Moral Compass to Follow?
A 32-year-old woman presented with locally advanced cervical cancer coupled with a pregnancy of 16 weeks. Having dealt with great emotional difficulty in the preceding case scenarios without batting an eyelid, I assumed this young mother also would want to avoid termination of her pregnancy.
I yearned to flash a little light at the end of her seemingly dark tunnel. Mustering up enough courage, backed with literary evidence, I extensively counseled her about the relative safety of chemotherapy in the second and third trimesters.5 I recommended for her to start with and continue chemotherapy until fetal maturity, deliver the baby, and then proceed with definitive radiation therapy.
Contrary to my presumptions, she wanted to terminate her pregnancy. In fact, she had gone to her obstetrician for an abortion but had been diagnosed with cervical cancer instead. I stopped myself from enquiring what had made her wait for 16 weeks before going to an obstetrician, because I knew the answer would always revolve around financial destitution.
She had been running from pillar to post to get her pregnancy terminated but faced rejection everywhere due to the cancer complicating her case scenario. Almost all obstetricians she approached told her that they couldn’t go ahead with a vaginal route for delivery, because the tumor was large and almost filling up her vagina.
She was thin, frail, and weak from the burden of cancer as well as the pregnancy. She had also been on antiretroviral therapy for the past 3 years and was told that even a classic cesarean section would come with a high risk of bleeding and intraoperative mortality.
The moral residue of previous experiences, when none of the mothers had wanted an abortion (despite being advised), had blinded me so much that I was adamant on starting this mother on chemotherapy, failing to look at things from her perspective and wishes. The irony here is that, as a radiation oncologist, I have been trained to look at and treat the same tumor or problem from different angles, different beams, and a different beam’s-eye (point of) view!
My colleagues offered her a second option of therapeutic radiation with the baby in utero.6 The patient asked for a day to ponder the option of radiation and returned the very next day to begin pelvic radiation therapy. The fetus lost cardiac activity at 36 Gy; she delivered her abortus vaginally at 38 Gy.
I secretly desired to see the abortus with some type of malformation or anomaly, to at least justify its supposed annihilation to my own conscience, but alas, I learned the fetus was completely normal physically, just weighed a little less for its gestational age.
I could find comfort in the fact that the patient continued radiation therapy and had a complete response.
Even though we had aimed all our beams at treating these patients, no one was beaming at the outcomes. Since, deep down, we wanted to save both lives at stake. Despite the four case scenarios discussed here, there were eight lives hanging in the balance. Cancer really proved to be the equalizer here too, claiming four lives and leaving us with four.
Lessons Learned
After advising and giving the ailing mother all her options to choose from, if she decides to go against your advice, stay calm, put down your ego, and respect her wishes.
It will be less haunting and distressing for you as an oncologist to know that the patient was at peace with herself and that you did your best to warn her and were there for her regardless.
As enthusiastic clinicians, we are so preoccupied with whether “we can” that sometimes we don’t stop to think about whether “we should” impose our decisions on our patients. In poor-prognostic settings, involving patients in steering their own disease management may give them more peace moving forward than any treatment can. Sometimes, facilitating closure is all we have to offer. And often, that’s more than enough.7
DISCLOSURE: Dr. Khan reported no conflicts of interest.
REFERENCES
1. Sathwara JA, Balasubramaniam G, Bobdey SC, et al: Sociodemographic factors and late-stage diagnosis of breast cancer in India: A hospital-based study. Indian J Med Paediatr Oncol 38:277-281, 2017.
2. Donegan WL: Cancer and pregnancy. CA Cancer J Clin 33:194-214, 1983.
3. International Atomic Energy Agency (IAEA). Radiation protection of pregnant women in radiology. Available at https://www.iaea.org/resources/rpop/health professionals/radiology/pregnant-women. Accessed February 18, 2020.
4. Kal HB, Struikmans H: Radiotherapy during pregnancy: Fact and fiction. Lancet Oncol 6:328-333, 2005.
5. Pereg D, Koren G, Lishner M: Cancer in pregnancy: Gaps, challenges and solutions. Cancer Treat Rev 34:302-312, 2008.
6. Sood AK, Sorosky JI: Invasive cervical cancer complicating pregnancy: How to manage the dilemma. Obstet Gynecol Clin North Am 25:343-352, 1998.
7. Bair H: Dear Rachel. J Clin Oncol 37:2171-2174, 2019.
Dr. Khan is a senior resident in the Department of Radiation Oncology at the Government Medical College and Hospital in Nagpur, Maharashtra, India.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views
of ASCO or The ASCO Post.
