By Mikkael A. Sekeres / Special To The Washington Post
My patient, a 30-year-old woman in her second trimester of pregnancy, was undergoing a routine fetal ultrasound when the radiology technician saw something unexpected; a mass growing out of her kidney, near the uterus. She underwent a biopsy, was diagnosed with acute lymphoblastic leukemia and was sent immediately to my hospital’s leukemia service to be treated.
I can only imagine the roller coaster of emotions she must have gone through, from excitement at a glimpse of her future baby to a devastating diagnosis of cancer.
Acute leukemia is considered a medical emergency; it’s a cancer that grows fast. If left untreated, patients die within weeks, and sometimes within days or even hours. When a person has acute leukemia, the bone marrow cannot produce the normal components of blood. With low red blood cells, people can become profoundly anemic; with fewer platelets, people are prone to excessive bleeding; and with dysfunctional white blood cells, people can suffer life-threatening infections.
By definition, people with leukemia have compromised immune systems. Pregnancy also affects the immune system, and the combination of the two can make people even more vulnerable to infections.
Soon after she arrived, I sat at the edge of her hospital bed and had the conversation that both patients and oncologists dread. Should she try to keep the fetus, knowing the risks, or should she undergo an abortion?
Certain chemotherapy drugs, including the ones needed to treat her leukemia, could cross the placenta and cause irreparable harm or death to the fetus. The drugs also could cause infection or bleeding in my patient, lowering her blood counts further, which would lead to similar side effects in the fetus. My patient also would be at a higher risk of death herself.
When I met her, almost two decades ago, before Dobbs v. Jackson Women’s Health Organization upended the abortion rights guaranteed through Roe v. Wade, this was a hard discussion. Now, in some states, we can add this complexity: opting for an abortion could be illegal.
She was quiet after I posed the question, and so poised as she answered, “This is my first baby. I know the risks of trying to keep it. But I still want to try.”
And try we did.
We started chemotherapy the next day and asked the obstetrics team to perform daily ultrasounds on the fetus. For the first few days, my patient looked great, even teasing us and telling jokes. The fetus was doing wonderfully, too. She taped the ultrasound photos on her hospital wall, which buoyed our spirits and reminded us of what was at stake.
Then she spiked a fever. That morning, she looked worried for the first time since we had met.
“Something’s wrong,” she told me. “Something’s really wrong.”
Her blood pressure had started to falter, and we suspected that she had started to develop sepsis; the body’s extreme response to infection that can lead to death.
“We’ll take care of you,” I told her, trying to reassure her as much as myself. But I was worried.
We gave her antibiotics immediately, but within two hours she had to be transferred to the intensive care unit because her blood pressure had dropped further. Within eight hours, she had been placed on a ventilator. Twelve hours after the fever started, the fetus died. By hour 18, my patient died, too.
Cancer is unusual in pregnant people, affecting approximately 1 in 1,000 pregnancies. This is estimated to translate to about 6,000 cases each year in the United States, and accounts for about 0.1% of all malignant tumors. Pregnancy in and of itself is not thought to be a risk factor for developing cancer, although theories abound regarding whether the hormonal changes or suppressed immune system during pregnancy could encourage tumor growth. The co-occurrence is probably just a rotten happenstance. The most common malignancies that occur in pregnant people include cervical cancer, breast cancer, melanoma, lymphoma and leukemia.
Every oncologist I know has at least one story of treating a patient who was pregnant. I have a few.
My patient chose not to undergo an abortion, and both she and her fetus died. Others have made the same decision, and both mother and baby survived; I have the snapshots of those babies with yearly updates. They had a better outcome because they had a different type of leukemia, or were treated at a different stage of fetal development, or were just lucky and did not have an infection or bleeding complication.
Some of my patients chose to undergo an abortion and went into remission from their cancers. Others, with slower-growing cancers, were able to delay chemotherapy just long enough to deliver their child.
In all of these scenarios, my patients could make independent choices, weighing the risks and benefits of maintaining or terminating a pregnancy.
But the Supreme Court decision to overturn Roe has introduced complications for future cases.
Thirteen states have “trigger bans” on abortion that have gone into effect, with exceptions for protecting the life of the mother that are too vague to know when they can be invoked. My own state of Florida bans abortions after 15 weeks of pregnancy, with a similar exception. (This was blocked temporarily by a Florida judge and reinstated July 5.)
As physicians who have taken an oath to provide the best care to our patients, my colleagues and I need guidance on what constitutes an immediate threat to the life of a pregnant person. A patient who is bleeding profusely from the pregnancy certainly is in grave danger. And I would argue that a pregnant patient with cancer who is about to receive chemotherapy also has an immediate health threat that would be greatly raised because of side effects.
This guidance would help us engage in a better informed consent process with particularly vulnerable patients for receiving chemotherapy that includes risks, benefits and possible legal consequences.
My patient’s story still haunts me. Would she be alive today if she had undergone an abortion? Perhaps. But I take some comfort in knowing she had the freedom to make that choice.
Mikkael A. Sekeres is chief of the hematology division and professor of medicine at the Sylvester Comprehensive Cancer Center at the University of Miami, and author of “When Blood Breaks Down: Life Lessons From Leukemia” and of the forthcoming book “Drugs and the FDA: Safety, Efficacy, and the Public’s Trust.”