Chemo in pregnancy? Yes, it can be done, study says. It’s an undeniable trend: across the world, a rising number of women today are choosing to delay pregnancy, even in the once-traditional societies of East, South and West Asia.
For the most part, the decision is a good one: it grants women the time, energy and power to build their careers and finances, and prepare for a more financially and emotionally stable family.
Many extraordinary advances in medicine, too, have made it easier for women to get pregnant and have a safe pregnancy later in life. But women of advanced maternal age still have a higher risk for difficult pregnancies and labor, miscarriage, placenta problems, and high blood pressure and diabetes, than younger women.
They also have a higher risk for cancer.
For many years, pregnant women, as well as their families and doctors, have struggled with the dilemma: to undergo chemotherapy or not?
On one hand, most drugs—be they chemotherapy drugs or simple headache remedies—can raise the chance of a baby being born with defects when these are taken by pregnant women in the first trimester or 12 weeks of pregnancy, when the baby’s organs are still forming.
How would fetuses fare against the onslaught of toxic cancer drugs and radiation treatments? Was it even safe to continue pregnancy when a woman had cancer?
And while doctors in the last decade or so have been more willing to use chemotherapy after the first trimester, many still worry that the child’s brain and heart could suffer damage.
On the other hand, putting off the treatment could allow the cancer to spread.
Right now, only about one in 1,000 pregnant women face this dilemma. But numbers are bound to climb, as more women are delaying having children until they’re older, when they also face a higher cancer risk.
Chemo: yes, it’s possible
Now comes reassuring news from a new, groundbreaking study: pregnant women with cancer need worry no more about how chemotherapy will affect their babies.
While it still stands that chemotherapy shouldn’t be given during the first trimester, a new study published in the journal Lancet Oncology on Feb. 10 suggests that mothers who undergo cancer drug treatment during pregnancy don’t appear to have babies that suffer from physical or mental problems.
In the Belgian-led study, researchers followed the progress of 70 children in Europe who were exposed to chemotherapy while they were in the womb and found that the treatment had not harmed their development.
Researchers found that children born to women undergoing cancer drug treatment show normal results in tests on their hearts, IQ and general health—done at birth, at 18 months, and at either five, eight, nine, 11, 14 or 18 years.
In thinking and reasoning capacity, these “cancer-treatment-exposed” children were similar to other children, researchers said. In growth, behavior, hearing and general health, the children did as well as any others, too. Their heart size and function was also found to be normal.
Began in 2005, the study recruited some children retrospectively and following others from birth. The children ranged in age from 18 months to 18 years.
Writing in Lancet Oncology, the researchers said, “Fetal exposure to chemotherapy was not associated with increased central nervous system, cardiac or auditory morbidity, or with impairments to general health and growth compared with the general population.”
“Many (doctors) aren’t keen to give chemotherapy to pregnant women and may even recommend termination,” the study’s lead author, Dr. Frederic Amant of the Leuven Cancer Institute in Belgium, tells the Associated Press.
“But treating a pregnant woman with cancer doesn’t have to be so different from treating a cancer patient who isn’t pregnant,” he concludes.
For the study, researchers looked at 68 pregnancies, producing 70 children, during which 236 cycles of cancer drugs were administered.
Premature deliveries no good
But some of the children who were born prematurely had lower development scores than those who were brought to term, and researchers warned that this was primarily because they were delivered early. Lower developmental scores are similarly seen in all very premature babies, whether or not these are carried by women on cancer treatment, they note.
In general—with a few differences brought by age, sex and country of birth—a child’s IQ is 12 points higher for every extra month he or she spends in the womb.
But sometimes, doctors of pregnant women with cancer go on to deliver the baby early in order to begin the mother’s cancer treatment sooner.
“Prematurity was common and was associated with impaired cognitive development. Therefore, iatrogenic preterm delivery should be avoided when possible,” Dr. Amant advised.
“We show that children who were prenatally exposed to chemotherapy do as well as other children,” the authors conclude in their paper.
“The decision to administer chemotherapy should follow the same guidelines as in non-pregnant patients. In practice, it’s possible to administer chemotherapy from 14 weeks gestational age onwards with specific attention to prenatal care,” the researchers say.
But the researchers admit that they can’t be certain that there will be no effects from the cancer drugs on the children in the years to come.
Follow-up of a larger group of children and for a longer period is needed to be sure that there are no adverse effects from the cancer drugs, Dr. Amant and colleagues say. In particular, more studies need to investigate if children exposed to cancer drugs in the womb will not have impaired fertility as adults or be more likely to get cancer themselves, they add.
“Only time will inform us of the full consequences, including fertility and secondary malignancies (especially if DNA damaging drugs are used), of fetal exposure to chemotherapy,” they sum up.
Changing clinical practice
“The study by Amant and colleagues has the potential to affect clinical practice,” writes Dr. Elyce Cardonick of the obstetrics and gynecology department at Rowan University’s Cooper Medical School in New Jersey in an editorial published in Lancet Oncology to accompany the study. “If we can present this reassuring data to pregnant women with cancer, women might be more likely to accept treatment during pregnancy when indicated.”
“These data don’t say that chemotherapy is completely safe, but the baby is better off being in (the mother) as long as possible,” Dr. Catherine Nelson-Piercy, an obstetric physician and spokeswoman for Britain’s Royal College of Obstetricians and Gynecologists tells the Associated Press. Nelson-Piercy was not connected to the study, but often works with pregnant women diagnosed with cancer or other illnesses.
She said this would hopefully change the treatment of pregnant women with cancer. “Doctors will often err on the side of caution and deliver a baby early to avoid the effects of chemotherapy,” she notes.
Dr. Richard Theriault, a professor of medicine at the MD Anderson Cancer Center in Texas who heads a program to treat pregnant women with cancer, says he hopes the papers would change how doctors treat pregnant cancer patients.
“Terminating a pregnancy isn’t always necessary,” says Dr. Theriault, even as a minority of pregnant women with cancer still gets abortions.
The placenta seems to act as a kind of filter for chemotherapy drugs, restricting their effects on the fetus, he tells the Associated Press. The study “seems to suggest not as much gets to the baby as we thought.”
The study was funded by the Belgian institutions: Research Foundation-Flanders, Research Fund-K U Leuven, Agency for Innovation by Science and Technology, Stichting tegen Kanker, Clinical Research Fund-University Hospitals Leuven, and Belgian Cancer Plan, Ministery of Health.
Together with the study by Dr. Amant’s team, a series of similar studies were also published on Feb. 10 in the journals Lancet and Lancet Oncology, AP reports.
Other key contributions to the clinical practice of cancer treatment in pregnant women from these studies are:
• After the first trimester, chemotherapy in pregnant women is possible. Extra ultrasounds could be used to ensure the baby is developing properly.
• Radiation therapy is best done in the first two trimesters, when the baby is small enough to be covered with a lead blanket, according to another study, a review of previous studies, led by Dr. Amant’s team.
• Ending the pregnancy doesn’t improve the mother’s chances, the same study found.
• The type of cancer seems to matter. Pregnant women with blood cancers can’t delay chemotherapy and may want to terminate a pregnancy, an Israeli analysis of past research suggests. But in cervical or ovarian cancers, doctors should aim to preserve the pregnancy, another review of previous studies by French and American researchers concludes.