Dr. M.B. Agarwal, MD – Mumbai – November 2007
ND a 24 year old married woman was first seen by us on 2nd of January 2006 for Chronic Myeloid Leukemia – chronic phase (CML-CP). She had been experiencing skeleto-muscular pain and fatigue for a month. Her treating physician detected an enlarged spleen and subsequent blood reports confirmed CML-CP. The patient and the family couldn't believe that she could have blood cancer at such young age. She was just married for a year and she was working as a fashion designer. After repeat investigations including marrow cytogenetics to show Ph chromosome and RT-PCR to show bcr-abl translocation (100%), they accepted the diagnosis.
One of her brothers was found to be fully matched with her with respect to HLA typing and hence she had options of taking drug therapy (Imatinib) vs going for a transplant. She visited the Max Foundation and understood that she could qualify for Novartis' GIPAP donation programme and receive uninterrupted supply of Glivec without cost throughout her life. She also visited a transplant centre and understood all aspects of BMT (positive and negative). She was also explained about hydroxyurea and interferon therapy which are no more the front-runners in the treatment of CML.
Eventually she chose to take interferon therapy and I was surprised. After a couple of counseling sessions, the truth came out which was that she badly desired to be a mother. She had understood that a transplant may totally jeopardize her chances of pregnancy and while on imatinib, the baby may be born may be defective. She was also aware the same may happen with hydroxyurea and only interferon had been successfully used during pregnancy without significant problems.
I had no reason to disrespect her emotions and desire. She began treatment with interferon. Initial course was stormy as the adverse effects were unbearable. With her determination, she fought all of them. The almighty was also on her side and by October 2006, she achieved a complete cytogenetic response. Throughout these ten months, she tried hard to become pregnant but in vain. She saw two eminent infertility specialists and pursued their advice but with no luck. She was disheartened.
Finally, in October 2006, she felt that enough is enough and she would rather go for the transplant. By now, she had spent a fortune on interferon therapy and she fell short of funds for the transplant. She fixed her transplant after six months so that she could gather adequate funds. She switched over from interferon to Glivec through Max Foundation so that she did not have to look for funds on her medical therapy. Her transplant was fixed in April 2007. She was put on 400 mg/day of Glivec from 15th October 2006. In February 2007, she developed a GI upset which was first attributed to a mild gastroenteritis and subsequently considered to be an adverse effect of Glivec. Despite stopping Glivec for a week, she still felt some uneasiness in her stomach and hence saw a gastroenterologist who ordered for a sonography. A huge surprise was in store for her ! She was pregnant and found out she had an eight week foetus in her womb. All her symptoms were due to morning sickness. No attention was paid to her amenorrhea as she had been having irregular periods throughout the preceding one year. She was delighted. However, all her delight vanished and she was deeply saddened when she was suggested to undergo medical termination of pregnancy as she was on Glivec. She was told, in unequivocal terms that due to ongoing Glivec during conception, there was a possibility she may deliver a defective baby with multiple congenital abnormalities. She took some time to decide and returned next week with the decision that she will like to stop Glivec and continue pregnancy. I was again shocked by her decision as there was a strong chance that her leukaemia will relapse, once she stops Glivec. However, she just would not listen to anyone including her husband and all her family members.
The decision was made. The pregnancy would be continued. She was ready to go off Glivec. Her transplant appointment was cancelled. Three months later, the sonography revealed a healthy baby with no evidence of detectable congenital defects. However, CBC revealed that the white cell count had become 40,000/cmm. FISH studies for bcr-abl showed 89% positivity. She was again counseled and explained the consequences. She was determined not to take Glivec in the interest of baby. She was offered interferon but the dreaded adverse effects which she had gone through earlier, made her avoid that as well.
She remained off treatment throughout her pregnancy and delivered in September 2007. She gave birth to a baby boy weighing 3.2 kg with absolutely no evidence of any congenital malformations. Her white cell count on the day of delivery was 2,40,000/cmm.
Now that her dream of becoming a mother was fulfilled, she is back to treatment. Within a month of starting Glivec, she has achieved complete haematological response and FISH has shown bcr-abl positivity of only 11%. She has decided to forgo the transplant as now she is in no mood to take slightest risk of death. I am sure (or rather hopeful) that she will achieve a complete molecular response with Glivec and probably live forever with her baby. This was her dream which was closer to her heart than her own life. Her desire to become a mother was more important to her than anything else including her life. She has almost achieved both.
(The author is consultant hematologist at Bombay Hospital, Mumbai and the story has been publishedwith the consent of the patient who desire to remain anonymous. Hence, even the initials have been changed).