An examination of how a doctor should counsel a pregnant woman through the ethical and medical challenges of being diagnosed with stage II cervical cancer.
Commentary by Watson A. Bowes, Jr., MD
Mrs. Smith arrived at the clinic nearly 30 minutes late. Patty, the nurse at the front desk, watched her enter. Mrs. Smith's 10-year-old daughter was whining and grasping at her sides while her adolescent son ineffectually instructed the little girl to "stop it or else." When Mrs. Smith came into full view, it was obvious that she was pregnant.
Learning Objective Understand the ethical issues raised by the presence of stage II cervical cancer in a pregnant woman and how a physician should counsel that patient.
Dr. Daniels quickly glanced over Mrs. Smith's chart before entering the exam room and saw that her last recorded visit was a routine postpartum care appointment nearly one decade prior.
Dr. Daniels greeted Mrs. Smith with a warm smile that had come to be one of her trademarks. "What brings you to clinic today?" she began.
"Well, now, isn't that pretty clear?" Mrs. Smith said jovially while patting her belly. A large smile spread across her face. "I'm probably almost five months along!"
Throughout the course of the interview, it became clear to Dr. Daniels that this pregnancy meant a great deal to Mrs. Smith. She had recently remarried and was carrying the child of her new husband, who was also extremely excited about the recent developments. When Dr. Daniels probed to find if Mrs. Smith had been receiving any form of health care since her last clinic visit, Mrs. Smith disclosed sheepishly that she had been battling unemployment intermittently and had only recently regained her health insurance.
Dr. Daniels then finished the interview. "Today we'll draw blood, do a urinalysis, and perform a Pap smear along with your exam. Then we'll schedule an ultrasound to confirm your dates and ensure that the pregnancy is proceeding normally. Do you have any questions or concerns for me?"
Mrs. Smith did not.
They proceeded with the physical exam. Dr. Daniels was alarmed to find several suspicious lesions involving the cervix, so she told Mrs. Smith that in addition to the Pap smear she would likely need to biopsy these sites.
A week later, Mrs. Smith found herself again in the obstetrician's office-this time alone. Dr. Daniels began to explain that the Pap smear and biopsies showed clear evidence of abnormal cells.
"What do you mean, 'abnormal cells?' Are you saying that I have cancer?" interrupted Mrs. Smith. "How will that affect my baby?"
"Well," began Dr. Daniels, "if a pregnant woman is found to have very early stage disease, most physicians are comfortable delaying interventions until after delivery regardless of how far along in the pregnancy you are. For late stage cancers, we generally recommend that treatment-which might include hysterectomy-begin immediately, again, regardless of the stage of pregnancy. I'd like to do a few more tests today, and we'll go from there."
One week later Dr. Daniels had to deliver the news to Mrs. Smith that she had stage II cancer and discuss with Mrs. Smith her treatment options and their affect on her pregnancy.
Mrs. Smith states that she believes she is "probably almost five months along," and there is no data given about the results of the ultrasound performed by Dr. Daniels to confirm gestational age of the fetus. For purposes of this discussion I will assume that the gestational age is 20 weeks. At this time Mrs. Smith has also been found to have stage II cancer of the cervix, which means that the cancer has spread beyond the cervix but has not reached the pelvic side walls or extended beyond the upper one-third of the vagina. The five-year survival rate for this stage of cancer in nonpregnant women managed with either radical hysterectomy or radiation therapy (both of which are considered standard of