In a pregnant patient with cancer, how do you save the life of the mother?

Photo by DIGITALE on Unsplash

A recent publication from Tufts University suggests that ancient viruses left behind pieces of their DNA in human DNA. These pieces, called HERVs (Human Endogenous RetroViruses), now make up about 8% our genome and are found in the DNA of other primates like chimpanzees and gorillas.

These ancient viruses, researchers hypothesize, infected the germ cells (eggs and sperm) which meant the viral DNA was passed on to their offspring who passed it on to their offspring and so on and so on until it got to us. Scientists have suggested that one of these viral genes, syncytin, was instrumental in our transition from egg-laying reptiles to milk producing mammals.  

Syncytin codes for a protein that is critical in the development of the placenta, the fused layer of blood vessels that provides nutrients and communication between the mother and fetus. 

Who needs conspiracy theories when you have science?  Mammalian reproduction is so cool.

---

Some of the hardest conversations that I have been a part of have happened around how to care for a pregnant person with cancer.  Balancing two colonies of rapidly dividing cells, both of which are sucking the life out of the host, is difficult. For the patient, the doctors, the nurses, the family. It is just hard.

As the war over abortion continues and in the context that human pregnancy may have been made possible by something as random as a pre-historic viral infection, I invite you to consider this piece, parts of which were originally published under the title Pink Crocs by Evocations Review where it won the 2022 Fall Non-Fiction Award.

---

I watched the shadows of the pregnant patient’s mammogram pass across the large screen followed by the pink and purple slides of her traitorous ducts. The young woman felt a mass in her breast and brought it to the attention of her doctor. With further work up it was determined that the cancer had already spread to the lymph nodes under her arm.

It might have already spread to the rest of her body. But we couldn’t tell. The radiation exposure of the PET scan would be hazardous to the 7-week-old prenate she carried. Still grieving over a previous miscarriage, the patient was determined to carry this pregnancy to term and was not interested in other options, the nurse navigator warned. Surgery without anesthesia was out of the question. Chemotherapy could only be given in the second trimester – an unacceptable 5 weeks away.

We stared at each other across the conference room table – sure of the decision that needed to be made, but wondering who would say it first. The aggressive nature of her cancer necessitated urgent treatment. As a multidisciplinary team, we outlined a plan – abortion, staging scans, chemotherapy then surgery – to save the life of this mother from the other interloper she now carried. In an uncommon moment of silence, we paused, contemplating as parents, children, and humans what this meant for her -- our patient, this mother.

As we relayed the plan to her, the patient sat alone on the paper covered exam table, quietly twisting her hair, looking down at her pink Crocs. I could barely imagine what she was feeling as each bullet of our plan tore through her. We were fortunate that everything could be done locally. She left our clinic holding a paper filled with appointments and a heart broken by unwanted answers. Our usually bustling doctor’s workroom was eerily quiet as we finished our documentation and headed back to our respective clinics.

I am struck now on what we would have done if she would have needed to travel hours to have an abortion. Would the extra few weeks (if it could have been arranged at all) have allowed her cancer time to spread? Would we have modified our plan out of fear? Would we have been able to live with ourselves if we had? If we had not?

---

Cancer, most commonly breast cancer and melanoma, occurs in one of every 1,000 pregnancies. The signs of pregnancy mask the symptoms of cancer, so diagnosis is often delayed. Potential danger to the fetus of the usual imaging studies and interventions lead to further delays in care.

• Prenatal radiation exposure causes birth defects, intellectual delays, growth restriction and even death.

• Anesthesia and surgery in the first trimester increase the risk of miscarriage, premature labor, and low birth weight.

• Chemotherapy given during the first trimester is associated with a risk of major fetal deformities, many of which are fatal.

Brave pregnant people in the US diagnosed with breast cancer already face one of the highest maternal mortality rates in the developed world and add these additional worries to their already heavy load.

In an amicus brief addressing the Supreme Court in response to the Dobbs vs Jackson Women’s Health case, the American College of Obstetrics and Gynecology was joined by twenty-four medical professional organizations representing all provider groups and specialties. In cancer specifically, all major professional organizations – the American Society of Clinical Oncology (ASCO), the American College of Surgeons (ACS) and the American Society of Therapeutic Radiation Oncology (ASTRO) -- concurred.

Speaking for over 45,000 oncology professionals, the largest of these groups, ASCO, stated unequivocally “Every patient should have the ability to pursue, in partnership with their oncologist, all treatment options that offer the best chance of a successful outcome for their cancer.”

Restricting choice in the setting of cancer binds the hands of oncologists unnecessarily in a situation where the consequences of delay or carrying a pregnancy during cancer treatment may be deadly. A state-by-state approach further stratifies the care of pregnant patients with cancer into an impractical patchwork - particularly in rural areas where 60% of hospitals closed between 2015 and 2019.

Cancer like pregnancy is the growth of rapidly dividing cells and its treatment, which mothers’ consent to every day, poses more physical risks to the mother than medical or surgical abortion.

---

In this electrified moment, how do we measure the “life of a mother”?

Is it living 12 months with metastatic breast cancer, knowing she will not live to see her child walk?

Or is it sitting in a chair as chemotherapy drips into her veins, sobbing over the loss of a desperately wanted pregnancy?

And what of physician mothers?

The atmospheric shift of a post-Dobbs world reveals the ultimate personal sacrifice that our Hippocratic Oath now requires. The intrusive, anti-privacy approach to the doctor patient relationship adopted by some states now allows interstate prosecution of physicians. Others offer a bounty on our brains.

Shall I be ripped away from my family for giving medical advice that I am licensed and trained to provide?

If I recommended care against my employer’s policy, will I be fired and unable to provide for my family?

With oncologists in jail, what tumor goes untreated?

Those who have all the answers must answer these: Whose life matters most? And who gets to choose?

The layered complexities of the doctor-patient relationship do not fit into the straight lines of constitutional originalism or political strategy. And yet, uninvited guests draw up chairs, crowding the space between doctor and patient, shouting about what should be done and legislating what can be done. 

What they do not see, however, is that an overcrowded exam room only pushes the two of us closer together.  Doctor and patient look at each other with even more compassion and resolve. A quiet understanding passes, no matter the political leanings of either, that this is a sacred space.

We do not have the luxury of judgement in these moments. We trust each other and push back on those who, with their own agendas, try to distract us from the heavy decision at hand. I support you, I say. It is, after all, about the life of the mother.

On My Mind…