It was early fall, 1993 — decision time for Ann Wheeler of Brookline.
She was 42, a self-described “late bloomer,” and she had finally resolved that with or without her boyfriend’s assistance, she was going to get pregnant by spring and have the baby she’d dreamed of for years.
Then her mother died. Two weeks later, Wheeler, a manager at a Boston work force development firm, was diagnosed with breast cancer. The minute her lumpectomy was done, doctors urged her to go on with chemotherapy and radiation.
Wheeler balked, trapped between the need to save her life and what seemed an equally compelling need: to have a baby.
It is an increasingly common dilemma, as thousands of women find themselves caught in that cruel place where the rising age of childbirth meets the age- related risk of breast cancer.
Wheeler knew the old medical party line — that the hormone surges of pregnancy might fuel her breast cancer; that it would be folly to postpone chemo until after a pregnancy; that if she had the treatment and then had a child, there was no way to know whether she’d live long enough to nurture it to maturity.
But almost more than life itself, Wheeler wanted a child, she said last week from a villa in Tuscany where she was on vacation. “I had to make sure I was able to do that.”
So she cajoled her cancer doctor and an in vitro fertilization specialist into a reluctant pact: She would delay chemo for one month, long enough to take hormone injections to stimulate her ovaries to produce extra eggs and to have the eggs harvested, inseminated and frozen.
Three days after the embryos were frozen, Wheeler began treatment, buoyed by the vision of her frozen assets — “I call them ‘the kids.’ I am planning on having these kids.”
This year, 182,000 women will be diagnosed with breast cancer and nearly a quarter of them will, like Wheeler, get the news while still in their childbearing years.
For many, questions about future fertility, even for those who have already had a child, are among the most agonizing: Is it safe to have a baby after breast cancer? Is it possible, if chemo makes monthly periods stop? Is it smart?
The full answers are not yet in, but old dogma is crumbling in the face of new evidence that for some women, especially those whose cancers are caught very early, a subsequent pregnancy may not be nearly as dangerous as once assumed.
“The teaching five or 10 years ago was that it was not safe,” says Dr. Isaac Schiff, chief of obstetrics and gynecology at Massachusetts General Hospital.
In fact, many doctors thought pregnancy was downright crazy because many breast tumors are driven by female hormones, which soar when a woman is pregnant. But “that teaching was based more on intuition than data,” observes Schiff.
The first new data came in 1991, when Dr. David N. Danforth, Jr., a National Cancer Institute surgeon, reviewed a number of studies and found that, taken together, they showed pregnancy does not make the prognosis worse if the cancer was caught early. Since recurrence is most likely right after treatment, he suggested that women wait at least two to three years after treatment before getting pregnant.
Last year, Boston researchers bolstered that view with a small study of 23 breast cancer survivors who later became pregnant, and 23 who did not.
Led by Karen Hassey Dow, now an associate professor at the University of Central Florida School of Nursing, Dr. Jay Harris, clinical director of the Joint Center for Radiation Therapy and Callista Roy, a professor of nursing at BostonCollege School of Nursing, the team matched the women by stage of cancer and found no difference in survival among the two groups.
Furthermore, for many of the women, getting pregnant after breast cancer was an “act of wellness, of life, so these were extremely meaningful events,” says Harris.
Two encouraging studies, of course, hardly clinch the case, especially given sobering data to the contrary, and many doctors, among them Dr. Jeanne Petrek, a surgeon at Memorial Sloan-Kettering Cancer Center, remain leery.
There is no way of knowing, for instance, how many women with breast cancer get pregnant and die — without ever being studied.
And scary evidence on the other side came in a study published last year by Dr. Vincent F. Guinee, a now-retired internist from M.D. Anderson Cancer Center in Houston.
After studying more than 400 women under 30 with breast cancer, Guinee says, “If a woman became pregnant within four years of her diagnosis, survival was affected deleteriously,” regardless of how advanced the cancer was upon diagnosis.
And if a woman was diagnosed with breast cancer while she was pregnant, Guinee adds, she was three times more likely to die of the disease than a woman who had never been pregnant.
But even that worst case scenario is not inevitably a death sentence, as Esterlene Jacks, a 48-year-old Dorchester flight attendant, attests.
Almost 20 years ago, Jacks gave birth to her first son. A week later, she was diagnosed with breast cancer — a clear case of concurrent cancer and pregnancy. She juggled chemo with diaper changes and thought she’d won her battle.
Three years later, her cancer came back, and she was treated again. Four years after that, she felt a lump in her abdomen. This time, though, that lump was a baby, not a tumor, and today, she and her sons, now 19 and 12, are doing fine.
Nor do doctors assume that they cannot offer chemotherapy to a pregnant woman who is diagnosed with breast cancer, says Dr. Michael Greene, director of maternal and fetal medicine at MGH.
“You sure can give her chemotherapy without hurting the baby,” he says. ”We make every effort to avoid it, but on occasion, we do do it and it is remarkably safe,” even though many chemotherapy drugs are targeted at dividing cells, and a fetus is a collection of such cells.
Chemotherapy is not given during the first trimester, when the major organs are forming. And if cancer is diagnosed late in pregnancy, the fetus is delivered by C-section as soon as feasible and the woman is then started on chemotherapy.
“But on occasions where we get caught in the second trimester, where it would be many weeks before the fetus would be safely delivered, . . .we have started chemo,” says Greene, adding he has “come to appreciate how powerful the motivation to have a child is for many women. A lot of women are willing to sacrifice everything to have a child, and it’s not my place to say that’s wrong or foolish.”
So how can you keep your options open if you have breast cancer?
The main risk is from chemotherapy, which can kill developing eggs in the ovaries, so be sure to ask how the drugs you’re getting will affect your ovaries. Some are harsher than others.
If you are in your early 20s, there’s a good chance chemotherapy won’t make you infertile, says Dr. David Rosenthal, chairman of medical affairs for the American Cancer Society, because young women still have so many eggs.
By your late 20s or 30s, however, the risk that chemotherapy will induce a premature but irreversible menopause goes up.
But even for older women, there is growing hope. Recently, doctors have been giving women birth control pills or other hormones called GnRH agonists along with chemotherapy in hopes that these hormones may prevent ovulation and help keep eggs from being damaged.
“It’s a new thing and it’s not guaranteed, but it preliminarily appears to have no downside,” says Dr. Machelle Seibel, director of reproductive medicine at Faulkner Hospital.
The bottom line, as usual, is that each woman has to assess for herself the risks — and ethics — of pregnancy after cancer.
When cancer is confined to the milk duct and has not spread to lymph nodes, there is “no real reason why that person should not get pregnant after treatment,” says Greene.
But if it has spread, or if you were diagnosed during pregnancy, doctors urge caution. Getting pregnant again may be unsafe.
And what of the ethics — and wisdom — of conceiving a child you may not live to raise?
“Any person deciding to become a parent knows they are taking a chance that they may not be around to see the child grow into adulthood,” says Cindy Pearson, program director of the National Women’s Health Network. A woman who has had breast cancer simply “makes that decision in a more extreme way.”
As Wheeler knows.
Despite simultaneous chemo and radiation, Wheeler’s cancer recurred six months after treatment. She also went into irreversible menopause, but she remains undaunted.
“I am still planning to get healthy and to have a surrogate mother have my children,” she says, though she adds, “Clearly, I am not going to go ahead with it unless I completely heal.”
But throughout her ordeal, the chance of having a child has been “the single most important thing to me, along with my family and my boyfriend. . .”
And if worse comes to worst? She has planned for that, too.
“I will donate these embryos to someone else if I am unable to have them.”