Dr. Janice Walshe:

I thank the Chairman and members of the committee for the invitation to express my opinion as a medical oncologist on the proposed heads of the 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 to 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, haematological cancers such as lymphoma or leukaemia, gynaecological and skin cancers are the most frequently encountered. As there are many gynaecologists 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.

When considering the implications of this Bill for cancer in pregnancy, two main questions arise. 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.

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 haematology 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 foetal maturity rather than just foetal viability.

There are risks with chemotherapy administration in every trimester for mother and foetus. 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 foetal 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 foetus but this has implications for the mother when immediate chemotherapeutic intervention is required. Organogenesis occurs during weeks 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 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, regardless of the country where 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 the 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 - for example two consultant medical oncologists or consultant haematologists, as they would have the medical expertise to advise and guide in this difficult area.