Case Study: Cancer and Maybe a Baby?

Abstract

Mary N, a thirty-five-old, premenopausal woman, was diagnosed in June five years ago with inflamatory ductal carcinoma of her left breast. Between July and December she received six cycles of chemotherapy, to which she responded very well - both lymph node and breast masses regressed nearly completely. To complete her treatment, from January to March she underwent radiotherapy. In the four years since she completed the treatment there has been no evidence of her disease recurring. When her cancer was first diagnosed, Mary N and her husband, Jason, had been trying to start a family, having postponed having children for several years. Because of the breast cancer Mary's gynecologist had cautioned her against ever becoming coming pregnant, but she and Jason very much want a family. As a result of the systemic chemotherapy she recieved however, Mary no longer ovulates. The couple's only hope of achieving a pregnancy is to go through in vitro fertilization with a donated ovum and her husband's sperm. Because she is prematurely menopausal Mary will require hormone therapy to prepare her uterus for the fertilized ovum. They are willing to undergo IVF to have a child. The infertility specialist Mary and Jason consulted is concerned, however. While women who retain ovarian function after treatment for breast cancer seem, clinically, to be able to go on to have children without affecting the woman's prognosis from the cancer or harm to the child, Mary's infertility specialist questions whether she should undergo IVG. She is not certain that Mary and Jason fully understand Mary's prognosis with respect to the cancer or the uncertainties involved in the hormone stimulation she will have to receive. In view of such concerns, should Mary and Jason N attempt IVF? How important ought Mary's likely prognosis be to their decision? Should the infertility clinic accept them as clients? Mary's situation will become ever more common. As we diagnose more breast cancer, at an earlier stage, and are more likely to use multiagent chemotherapy to treat even patients with good prognoses, there will be young women who have become menopausal but have excellent prognoses for long-term survival. Mary has at least two strong incentives for wanting children. She and Jason had waited to have children for years, only to have her cancer discovered just as they began trying to start their family. In addition, when facing a potentially fatal illness many people, especially young people, consider how they might leave a permanent mark on the world. Having children is one way to leave such a legacy. But is it good for Mary (and Jason) to fulfill these desires? Are there other factors she should consider? How should her physician advise her? Mary's physician should not simply take her expressed wishes as her actual wishes in the name of autonomy. The physician must work with Mary to make sure she knows what she wants and that what she wants forms a consistent life vision. This is what autonomy truly means and this is what is required of the compassionate physician. To this end, the physician should pursue (at least) the following four issues. First, on factual matters, do Mary and Jason fully understand her chance of recurrence and her prognosis? The physician must be sure that the couple understands that studies of inflammatory breast cancer show five-year survival rates under 40 percent and that in cases where the mass does not completely regress the prognosis is even worse. Second, the physician must make sure that Mary and Jason are aware of the fact that while none of the existing studies suggests that women who get pregnant after breast cancer have a higher rate of recurrence, these conclusions are based on case reports and a handful of studies with fewer than 1,000 patients overall. More importantly, very few of the women studied have had inflammatory breast cancer and there are only two cases reported of women with breast cancer receiving IVF and exogenous estrogens. …