• Paths of Progress Spring/Summer 2012

    Pregnancy and Breast Cancer: Making it Through

    By Saul Wisnia

     

    Rebecca Byrne had waited years for a doctor to tell her: "You are pregnant." She never imagined that just a few months after she first heard those words, she would hear four more: "You have breast cancer."

    Byrne still tears up when telling the story, but then smiles when her 20-month-old daughter, Emelia, leaps into her lap. Emelia is the happy outcome of a painful period of Byrne's life, when the joys of pending and early motherhood were shadowed by chemotherapy treatments, hair loss, radiation, and uncertainty.

    It's a combination that seems too cruel to be true, but every year in the U.S., one in 3,000 women will be diagnosed with breast cancer during pregnancy. Many obstetricians and oncologists have never dealt with these dual challenges, but Dana-Farber/Brigham and Women's Cancer Center in Boston has become a leader in achieving healthy outcomes for patients and their babies.

    The key is to look at each case individually, explains Ann Partridge, MD, MPH, director of Dana-Farber/Brigham and Women's Cancer Center's Program for Young Women with Breast Cancer.

    The program assists women in their early 40s and younger before, during, and after cancer treatment, and works in collaboration with the reproductive endocrinology and high-risk pregnancy centers at partnering Brigham and Women's Hospital (BWH), where individuals like Byrne can consider their reproductive options.

    Depending on the type of breast cancer and the stage of pregnancy at which it is diagnosed, the Dana-Farber/Brigham and Women's Cancer Center team may choose among chemotherapy regimes that can be given safely, without clear harm to the fetus or the patient.

    Rebecca at home with Emelia.Rebecca at home with Emelia. 

    In Byrne's case, she knew exactly when she had conceived. After years of trying to get pregnant, she and her husband, Larry, had undergone in vitro fertilization, with implantation taking place on Christmas morning in 2009.

    In her first trimester, she felt a lump in her breast, but waited until her 12-week ultrasound to tell her OB-GYN. The doctor said it was "probably nothing," but suggested that Byrne have it checked at a hospital near her Framingham, Mass., home.

    At the time, Byrne says, she gave little thought to the worst-case scenario. She was only 34, had no family history of breast cancer, and didn't even know pregnant women could develop the disease. But a few days later, doctors told Byrne that she should seriously consider terminating her pregnancy and having a mastectomy.

    A radiation oncologist was more emphatic, telling Byrne she needed a mastectomy and radiation right away. "I remember asking, 'So, it's my boob or my baby?'" says Byrne. "And the doctor said 'yes.' They wanted me to make a decision within a couple of days."

    She and Larry are both engineers, so they attacked the problem analytically, looking online to find anything they could about chemotherapy, mastectomy, and radiation treatment during pregnancy. Byrne also considered the ultimate horror: "What if I get through the pregnancy, have a baby, and then die a month later?"

    Her physicians mentioned a Dana-Farber/Brigham and Women's Cancer Center doctor who they felt had more experience and could offer other options. Soon thereafter, Byrne met with Partridge.

    "The first thing Dr. Partridge told me was, 'Take a breath; you don't need to decide today, and you don't need to have surgery today,'" says Byrne, recalling her initial visit. "She had cared for other patients in my situation, and she said that terminating the pregnancy wouldn't change my cancer outcome or my treatment."

    Because Byrne was in her second trimester, when the baby was more developed, Partridge said this would be the safest time during pregnancy to have both chemotherapy and any needed surgery.

    Partridge also reassured Byrne that her type of breast cancer, HER2-positive invasive ductal carcinoma, was very responsive to a chemotherapy regimen that she could handle while pregnant.

    This new information convinced the couple they should keep the baby. Partridge recommended a lumpectomy as a first surgery, rather than a mastectomy. In April 2010, Byrne had two lumpectomies to remove tumors in the breast, along with some surrounding breast tissue.

    Before and after each surgery, clinicians let her hear the baby's heartbeat.

    Katherine Economy, MD, and Ann Partridge, MD, MPH. 

    A month later, Byrne started treatment with chemotherapy medications taken every three weeks for a 12-week cycle. Partridge referred her to the high-risk pregnancy center at BWH, where obstetrician Katherine Economy, MD, and her colleagues team with Dana-Farber/Brigham and Women's Cancer Center oncologists to provide specialized care for patients in this delicate situation. Byrne could consult with both Partridge and Economy.

    Through it all, Byrne was determined to have as normal a pregnancy as possible. She shaved her head right before her hair started falling out, got a wig, and wore it to Lamaze class, where she and Larry kept their difficult situation private.

    Although the couple had days when they didn't mention cancer, Byrne longed to connect with someone who could understand her emotional struggles. Through an online cancer forum, she found another woman in her mid-30s who had gone through breast cancer while pregnant and now has a healthy young daughter.

    "She gave me hope," Byrne says.

    Byrne had been originally due to deliver on September 13, the same day her sister, Sarah, was due to give birth. But Byrne's delivery date was moved up to early August to accelerate her next round of chemotherapy and radiation. In the end, events occurred even more rapidly; Byrne's water broke two weeks before her scheduled labor induction, and she was rushed from work for a Caesarean section at BWH.

    Emelia weighed 3 pounds, 9 ounces, when born on July 30, and spent her first 26 days in the neonatal intensive care unit (NICU) at BWH. Shortly thereafter, Byrne began a new 12-week chemotherapy cycle.

    On days when she was scheduled for chemo infusion, she'd spend her mornings snuggling with the baby in the NICU, then head over to Dana-Farber/Brigham and Women's Cancer Center for treatment. Because she couldn't produce safe breast milk during chemo, friends with infants provided their own to feed Emelia.

    Byrne was on maternity leave from her longtime job with a company that manufactures mammography equipment and other devices used by women undergoing cancer treatment – "How's that for irony?" she jokes now – but kept busy away from the hospital.

    When it was time for radiation, her care team arranged for Byrne to receive treatment near her home, about 20 miles from Boston.

    "We've started a working group combining the high-risk center at BWH and the breast oncology team at Dana-Farber/Brigham and Women's Cancer Center – including medical oncologists, surgeons, radiation oncologists, social workers, radiologists, and nurses – to develop standards and coordinate the care of such patients, as well as conduct research in this area," says Partridge. "We'd love for more women like Rebecca to have this type of outcome."

    Byrne's year of chemotherapy treatment ended in August 2011, and she is now focused fully on her family and career. Emelia is a healthy, happy, mile-a-minute toddler, and the garage in which Byrne sat and cried after hearing her diagnosis now holds strollers and diapers.

    When she comes to see Partridge at Dana-Farber/Brigham and Women's Cancer Center once every four months for a checkup, she always stops by BWH and says hello to Emelia's NICU nurse. The walk between the two hospitals is much easier now.

    "Dr. Partridge wants me to wait until March 2013 to start trying to have another baby, since that will be three years since my diagnosis," says Byrne. Then she beams at Emelia.

    "I'm not sure I can wait."

    Paths of Progress Spring/Summer 2012 Table of Contents

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