In our Q&A: Eighth Amendment Referendum series, we are answering questions our readers have submitted in relation to the upcoming vote on 25 May.
THE QUESTION
A number of people have asked a version of these questions. Here are some of those queries:
THE ANSWER
THE IRISH CANCER Society (ICS) recommends that pregnancy during chemotherapy should be avoided ”in case the drugs harm your baby”.
The organisation notes that many doctors advise women to not get pregnant for two years after their chemotherapy ends as it can increase the risk of miscarriage or birth defects.
Of course, women may unintentionally become pregnant while receiving cancer treatment or shortly afterwards. Others may be diagnosed with cancer while already pregnant.
Pregnant women can receive cancer treatment but the type of treatment they receive will depend on a number of factors including:
Women may undergo chemotherapy (which usually won’t happen until at least the second trimester of the pregnancy), radiation, surgery or another form of treatment. The decision on the best approach to take is made on a case by case basis by a team of doctors, sometimes across more than one hospital.
A spokesperson for the Rotunda Hospital, one of Dublin’s maternity hospitals, noted that “a multi-disciplinary approach” is taken to cancer care during pregnancy.
The spokesperson told TheJournal.ie:
A multi-disciplinary group of obstetricians who are subspecialists in maternal medicine, meets regularly with various non-obstetric specialists, including oncologists, haematologists, paediatricians, radiologists, anaesthetists, pharmacists and surgeons.
They said the hospital would work with staff from the nearby Mater Hospital to provide care for a pregnant woman who is diagnosed with cancer.
“The patient’s clinical history, examination findings, obstetric ultrasound findings, imaging results and laboratory results are reviewed by the team and an individualised care plan is established, with chemotherapy or surgical plans put in place, together with an optimised time for delivery of the baby.
“The experience of this team to date has demonstrated excellent outcomes for both mothers and babies,” the spokesperson told us.
A spokesperson for the Coombe Women & Infants University Hospital said the organisation “doesn’t have specific advice for women diagnosed with cancer who are receiving treatment, or who are about to receive treatment, as no two cases are the same”.
They added that employees from the Coombe work with medical staff from the hospital which is treating the patient for cancer.
Advice
The ICS advises women who become pregnant to discuss all their options with their doctor.
“It may be possible to delay chemotherapy until later in your pregnancy or until your baby is born. In some cases, it is also possible to have chemotherapy and deliver a healthy baby. However, depending on your situation, you may not have a choice,” the organisation notes.
The National Health Service (NHS) in the UK also advises women to not become pregnant while undergoing cancer treatment as “chemotherapy drugs can damage an unborn child”.
“During treatment, and for about one year afterwards, sperm and eggs may not be formed normally, if they are produced at all. Your doctor will be happy to discuss this further with you…
If you know you are pregnant before starting treatment or become pregnant during treatment, you must tell your doctor immediately.
“We are aware that some women may be diagnosed with cancer during pregnancy. If you are in this situation, your specialist doctor will discuss with you the benefits and risks of having chemotherapy.”
‘Chilling effect’
A number of doctors who are in favour of repealing the Eighth Amendment have said it has a chilling effect on their work and can impact the type of treatment (not just for cancer) pregnant women receive.
The case of Michelle Harte, a woman with cancer who had to travel to the UK for a termination in 2010, has come back into the spotlight in recent weeks. She had wanted to undergo a clinical trial but couldn’t due to her pregnancy.
Doctors at Cork University Hospital had advised her to terminate the pregnancy but were unable to do so as there was no ‘immediate’ risk to her life. She received substantial compensation from the State shortly before her death in November 2011.
Medical trials may be an option for people whose cancer can’t be successfully treated by other forms of care. However, they generally stipulate that pregnant women cannot take part due to the increased risk involved.
Professor Louise Kenny, who was involved in Harte’s care, said the type of treatment women receive while pregnant is impacted by the Eighth Amendment.
“There are some exceptionally skilled clinicians in this country, some of the best midwives and obstetricians I’ve ever worked with, and I’ve worked in a number of jurisdictions, are here in Ireland.
“I would say that our maternal mortality rate is as low as it is … because of those skilled clinicians and despite the Eighth Amendment, not because of it,” Kenny told reporters at an Amnesty International Ireland pro-repeal event in Dublin last month.
C v Ireland
The State’s abortion laws have been challenged at European level on a number of occasions. Three women brought a case (A, B, C v Ireland) to the European Court of Human Rights (ECtHR) in August 2005.
The case was taken by three women, supported by the Irish Family Planning Association (IFPA), who travelled abroad for abortion services.
One of the women, referred to as C, was in remission from cancer when she became pregnant. She claimed she could not obtain clear advice about the risks to her health and life, and to the foetus, if she continued her pregnancy to term.
On 3 March 2005, the woman had an abortion in England. She was in her first trimester of pregnancy at the time.
The judgement, delivered in December 2010, notes: “Prior to that, she had been treated for three years with chemotherapy for a rare form of cancer.
She had asked her doctor before the treatment about the implications of her illness as regards her desire to have children and was advised that it was not possible to predict the effect of pregnancy on her cancer and that, if she did become pregnant, it would be dangerous for the foetus if she were to have chemotherapy during the first trimester.
The cancer went into remission and the woman unintentionally became pregnant. She was unaware of this fact when she underwent a series of tests for cancer. When she discovered she was pregnant, she consulted her GP, as well as several medical consultants.
“She alleged that, as a result of the chilling effect of the Irish legal framework, she received insufficient information as to the impact of the pregnancy on her health and life and of her prior tests for cancer on the foetus,” the report states.
The woman researched her options online and went to England for a termination.
The report notes: “She maintained that she wanted a medical abortion (drugs to induce a miscarriage) as her pregnancy was at an early stage but that she could not find a clinic which would provide this treatment as she was a nonresident and because of the need for follow-up. She therefore alleged she had to wait a further eight weeks until a surgical abortion was possible.
On returning to Ireland after the abortion, the third applicant suffered complications of an incomplete abortion, including prolonged bleeding and infection. She alleges that doctors provided inadequate medical care.
In the case of this woman, the ECtHR ruled that her right to privacy under Article 8 of the European Convention on Human Rights had been violated.
In its ruling, the ECtHR stated that it rejected the government’s argument that the woman “failed to exhaust domestic remedies”.
The Court also noted that the “criminal provisions” in legislation regarding abortion, which could lead to a 14-year jail sentence, “would constitute a significant chilling factor for both women and doctors in the medical consultation process, regardless of whether or not prosecutions have in fact been pursued”.
“Both the third applicant and any doctor ran a risk of a serious criminal conviction and imprisonment in the event that a decision taken in medical consultation, that the woman was entitled to an abortion in Ireland given the risk to her life, was later found not to accord with Article 40.3.3 of the Constitution (the Eighth Amendment). Doctors also risked professional disciplinary proceedings and serious sanctions,” the report states.
Eighth Amendment
Dr Peter Boylan, chair of the Institute of Obstetricians and Gynaecologists, previously told the Oireachtas Eighth Amendment Committee: “I don’t think the Constitution is the place to regulate medical practice … [The Eighth] has caused endless problems.”
He added that the Eighth Amendment “gives rise to significant difficulties for doctors practising in Ireland and has caused grave harm to women, including death”.
These sentiments were echoed by Dr Rhona Mahony, the Master at the National Maternity Hospital, who separately told the committee that clinicians need greater flexibility and “shouldn’t have have to wait until a woman is at a substantial chance of dying”, as set out under the Protection of Life During Pregnancy Act 2013.
“There are no other areas where people are charged with making medical decisions under the shadow of a custodial sentence of 14 years. We had a chance to discriminate that in the case of the Protection of Life During Pregnancy Act, and we chose not to do that. And I think that was a mistake,” Mahony said.
‘No effect on treatment’
However, at a Save the 8th campaign last month, Professor Eamon McGuinness, a consultant obstetrician and gynaecologist and former chair of the Institute of Obstetricians and Gynaecologists, said the Eighth Amendment doesn’t impact the type of treatment doctors give pregnant women.
McGuinness is among the doctors who have said the Eighth Amendment has never impacted the care they give pregnant women, noting that the Medical Council’s guidelines oblige doctors to deliver the treatment a patient needs, including in cases where such treatment could harm an unborn child.
When asked about the comments made by Boylan and Mahony to the committee about the Eighth Amendment, McGuinness said: “Well I just want to know where it’s tying their hands, it didn’t tie my hands and, a lot of my colleagues, it didn’t tie our hands.
“We were not restricted in any way … so I don’t know what society they’re working in, possibly different than mine.”
‘Challenging for every physician’
An international study, the results of which were published in The Lancet Oncology in January, found that the use of treatment such as chemotherapy among pregnant women increased by about 10% every five years over the course of a 20-year period.
Researchers said this increase “could be related to a shift in cancer incidence” and the increasing age at which women become pregnant, as well as more doctors feeling comfortable using certain treatments as the level of research in this area increases.
The report notes: “Taking responsibility for a pregnant woman diagnosed with cancer and her unborn child is challenging for every physician.
“Therefore, an expert interdisciplinary team involving gynaecologists, medical oncologists, neonatologists, obstetricians, pathologists, psychologists, and radiotherapists is necessary to achieve the best oncological result for the woman and avoid morbidity for the fetus [sic].
Thanks to interdisciplinary cooperation and progress in oncology and neonatology, there has been a major clinical shift from termination of pregnancy at less than 20 weeks of gestation towards individualised therapy according to cancer type, stage, and patient preference, allowing most pregnancies to be prolonged until fetal maturity [sic].
The report states that “knowledge of the biology of cancer in pregnancy is very poor” and more research needs to be carried out.
The study in question examined the perinatal outcomes after treatment for various cancer types over two decades (1 January 1996 to 1 November 2016).
Some 1,170 women who were diagnosed with or treated for cancer during their pregnancy took part in the research. Some 779 (67%) received treatment during pregnancy. Breast cancer was the most common malignant disease (462/39%).
Admission to neonatal intensive care units (NICU) seemed to depend on the type of cancer – with gastrointestinal cancers having the highest risk and thyroid cancers having lowest risk when compared with breast cancer.
The researchers said that, unexpectedly, the data suggested that abdominal or cervical surgery was associated with a reduced likelihood of NICU admission.
The findings indicate that babies exposed to antenatal chemotherapy might be more likely to develop complications, such as being small for their gestational age and needing to be admitted to the NICU.
Effect on children
On the primary question of perinatal outcome, just over 500 patients in the study could be assessed: 391 of 1170 patients did not receive any oncological treatment during pregnancy, and 95 pregnancies were terminated before oncological therapy.
Among the remaining 684 patients, 89 with breast cancer underwent surgery alone without chemotherapy or radiation. The surgical procedures without subsequent therapy received by patients with thyroid cancer, melanoma or brain tumours would be unlikely to affect pregnancy outcomes.
In patients with acute leukaemia, immediate commencement of chemotherapy is the precondition for women’s survival.
Researchers said the findings of the study “strengthen the need for pregnant women who are treated for cancer to be extensively counselled” on the risks to themselves and the baby.
A 2015 European study examined the impact on children of prenatal exposure to cancer treatment. The 258 children involved were equally split into two groups.
In one group, 96 children (74.4%) were exposed to chemotherapy (alone or in combination with other treatments) during pregnancy, 11 (8.5%) to radiotherapy (alone or in combination), 13 (10.1%) to surgery alone, two (1.6%) to other drug treatments, and 14 (10.9%) to no treatment. They had a median age of 22 months.
The research found that prenatal exposure to maternal cancer with or without treatment did not impair the cognitive, cardiac or general development of the children in early childhood. Prematurity was correlated with a worse cognitive outcome, but this effect was independent of cancer treatment.
The study notes that research in this area is lacking and more needs to be done, particularly looking into the long-term outcome for children who are exposed to maternal cancer.
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