The one between pregnancy and treatment is not a crossroads in which one of the two things excludes the other. It’s not an either/or, not even when there’s a tumor involved. These days, faced with the death of the young Azzurra Carnelos, the question is burning. When it comes to health, each story is a case in itself and there are no a priori statements that apply to everyone, but the reality in general is very different from the narrative according to which discovering a tumor during pregnancy immediately means finding oneself in the most difficult and painful ethical dilemma for a woman: choosing between her own life and that of the child she is carrying. “Fortunately, in most cases this is not the case and for women knowing this is always a great relief,” she explains Lucia Del Mastro, coordinator of the Breast Unit of the San Martino Polyclinic Hospital in Genoa, expert in pregnancy tumors, funded by the Airc Foundation for her research for over 30 years. Her unit has a specific expert in this field and has treated many women, even from outside the region, with breast cancer but also with cervical cancer. «You recently gave birth to a woman with Hodgkin’s lymphoma. They always send me a photo of the babies as soon as they are born”, smiles the doctor. “They told her that she could only start treatment after giving birth,” she adds. And instead. “Instead you haven’t been a dramatic either/or for at least twenty years.”
Let’s start from the beginning. Are pregnancy and treatment mutually exclusive in the case of cancer?
Fortunately, no, these are not mutually exclusive situations. Although clearly we cannot ignore specifying which tumor we are talking about, the moment of pregnancy we are in, whether the tumor is in an initial or metastatic stage. In many cases, however, it is possible to carry out treatments even during pregnancy, it is not true – as was once said – that one must wait until the end of the pregnancy and therefore bring the birth as early as possible to start the treatments. The point is that these situations must be managed by a multidisciplinary team: there is not only the oncologist, but it is necessary to work in collaboration with the gynecologist, the neonatologist, the anesthetist… all the figures, together, discuss the therapeutic approach improve. For this reason, when there is cancer during pregnancy, it is essential to contact a center that knows how to manage these cases. They are complex cases: not because they are difficult to manage, but because management requires multiple skills.
How many women in Italy need treatment for cancer during pregnancy?
Every thousand pregnancies, one is complicated by the presence of a tumor. And in most cases we are talking about breast cancer, which alone accounts for approximately 40% of tumors in pregnancy.
Which treatment is compatible with pregnancy? When? With what precautions?
For many tumors – breast cancer is one of these – it is possible to carry out treatments even during pregnancy. Surgery can be done at any time, while chemotherapy must wait until the second trimester because in the first trimester the risk of malformation of the fetus is too high. From the second trimester, however, we know that exposure to chemo during intrauterine life does not increase the risk of malformations: we now have a large series of cases, which extends over more than twenty years of research and work.
Which treatments are not compatible with pregnancy?
Radiotherapy cannot be done during pregnancy. Not even biological therapies. And frankly we don’t have a lot of data on immunotherapy yet. Obviously if we are in the presence of a tumor such as uterine cancer, which requires the removal of the uterus… this is incompatible with the continuation of the pregnancy. The cases in which the pregnancy is incompatible are not that they don’t exist, but they are relatively few, thanks to the knowledge we have today about drugs, about which drugs we can use and which we can’t, about when we can use them and when we have to stop them. Let’s not forget that these women give birth with a planned birth: and today we know that giving birth to them early causes more harm to the baby than the potential harm caused by chemotherapy.
Therefore, starting from the second trimester of pregnancy, a woman can be treated with relative peace of mind, because chemotherapy does not increase the risk of malformations in the baby. However, what does this time of postponing treatment and waiting mean compared to the effectiveness of the therapy?
Here too there is no clear answer. In breast cancer I can wait until the woman enters the second trimester but I cannot do this, for example, in acute leukemia. In some cases it is possible to wait, without this compromising the effectiveness of the therapy or accepting that it compromises it minimally, but other times I cannot wait two months. In these cases we talk to the woman, explain the pros and cons, so that she can choose. In some cases we have recommended therapeutic abortion to people at the beginning of pregnancy, in cases where waiting could compromise the prognosis, because the tumor could go from localized to metastatic. In these cases we have frozen a part of the ovary. The woman is always reassured that, if she decides to continue the pregnancy despite knowing that waiting could compromise the treatment, she will still receive the treatment. It is certainly a great relief for women to know that they can take care of themselves during pregnancy, that they do not have to choose between having an abortion and treatment. The woman generally wants to carry on with the pregnancy, but at the same time she is terrified of not being able to get treatment. Some women already have other children, in addition to the one they are expecting. When a woman knows that she doesn’t have to choose, that she can treat herself and carry on with her pregnancy at the same time… she is reborn. Having understood that we can treat the woman without harming the child has been an advance in knowledge that in many cases has resolved this difficult dilemma.
Previously you said that it is essential to contact a center that knows how to manage these cases. But what are the centers specialized in cancer during pregnancy?
The advice is to contact the Brest units that also have a research activity, they are generally equipped to handle these situations. Our centre, in Genoa, has been working in this direction for twenty years. But I also think of Professor Peccatori at the IEO in Milan, of the Pascale of Naples with Professor De Laurentiis or of the Cro of Aviano and Professor Puglisi.
Could other centers, however, still suggest the clear alternative between abortion and postponing treatment until after the birth?
Unfortunately. And with this in mind, they anticipate giving birth to start treatment as soon as possible. However, in this way they do double damage: they delay the mother’s therapy and do more damage to the child than chemo would have done. It is necessary to explain from time to time the extent of the risk associated with waiting, but knowing that you have to wait two or three months, not the end of the pregnancy.
Photo by Anastasiia Chepinska on Unsplash