Download Dr Janice Walshe, consultant medical oncologist, St Vincents

Good evening, Mr Buttimer and members of the Committee
I would like to thank you for the invitation to express my opinion as a Medical
Oncologist on the proposed Heads of Bill as presented for cancer in pregnancy. I am a
Consultant Medical Oncologist in both St Vincent’s University Hospital and the
Adelaide and Meath Hospital Tallaght.
Cancer is a disease of increasing age so while cancer during pregnancy is encountered;
it is rare. International data suggest that it complicates approximately 0.1% of all
pregnancies, therefore in the absence of published Irish data we estimate there are
approximately 60-70 cases diagnosed in Ireland per year. However, with increasing
age of childbearing, it is likely that this number will increase. In pregnancy, a variety
of cancers occur but breast cancer, haematologic cancers such as lymphoma or
leukaemia, gynaecological and skin cancers are the most frequently encountered. As
you have many gynecologists who can comment on surgical cancer treatment on the
panel, my focus is the administration of drugs during pregnancy. Agents used in
Medical Oncology include traditional cytotoxic chemotherapies, biological therapies
and anti-hormonal agents which for convenience I will refer to as “chemotherapy”
going forward.
When considering the implications of this bill for cancer in pregnancy. Two main
questions arise:
1. Does the pregnancy confer a worse outcome to the pregnant mother with
cancer and if so, will a termination of pregnancy improve her outcome? The
literature here is consistent in demonstrating a lack of evidence to suggest that
termination will abrogate mortality risk in pregnant women with cancer.
Dr Janice Walshe
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5/3/2017
2. Does the administration of chemotherapy in the pregnant woman put that
woman’s life at risk in a way that is not experienced in the non pregnant
woman?
In clinical practice, we in the hematology and medical oncology field not
infrequently navigate this challenging scenario. In the vast majority of cases,
chemotherapy will be administered to the pregnant woman as curative or life
prolonging therapy without significant modification as per international
guidelines. We work very closely with our obstetric colleagues to identify the
optimum time for delivery of the baby (striving for fetal maturity rather than just
fetal viability).
There are risks with chemotherapy administration in every trimester for mother
and fetus, however available evidence suggests that many of the agents used in
the treatment of cancer have a safe profile particularly if initiated after the first
trimester thereby minimising risk to the unborn. As doctors, a challenge for us is
balancing the risk of fetal abnormalities in the unborn as a result of the
administration of chemotherapy during the first trimester or its deferral until a
potentially safer time for the fetus but this has implications for the mother when
immediate chemotherapeutic intervention is required. Organogenesis occurs
during week’s five to ten of gestation. The administration of chemotherapy may
have unintended complications, requiring intensive care unit management
potentially threatening the life of the mother. May a termination be required to
save the life of the mother in this circumstance, it is possible but these situations
are exceedingly rare.
In answering these questions, I do acknowledge a dearth of large prospective
randomised trials investigating each question here but through retrospective cohort
studies, case series and case reports the results achieved reach similar conclusions
Dr Janice Walshe
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regardless of what country the study was performed. It is universally recognised that
treatment recommendations in pregnant women with cancer will always rely on
limited evidence.
My only comment in appraising the Heads of Bill is that should a situation arise where
the life of the mother is at significant risk, it would be advisable that two medical
practitioners on the Specialist Register with expertise in this area be involved in the
certification process with the Consultant Obstetrician e.g. two Consultant Medical
Oncologists or Consultant Haematologists as they would have the medical expertise to
advise and guide in this difficult area.
Thank you
Dr Janice Walshe
M.B., B.Ch., B.A.O, MRCPI
Dr Janice Walshe
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