A lot rushes into your mind when you hear the words "breast cancer" come out of a doctor's mouth. Not the least of it is your own mortality.
For 30-year-old Bree Ruzzi, another thought surfaced:
"Oh, my God, I'm never going to have kids."
That realization in December 2004 scared the Virginia Beach woman more than anything. Somewhere after the words "breast cancer" came words such as surgery, chemotherapy, five years of oral medications.
"I'm not doing anything... " she thought, "... until I find out how I can have kids."
Bree didn't just want to save her own life.
Survival rates for people with cancer have improved dramatically during the past few decades. Techniques of reproductive medicine also have advanced at the same rapid pace. Those two trends are allowing people to beat cancer and hang on to their prospects of bearing children.
The Jones Institute for Reproductive Medicine at Eastern Virginia Medical School counsels several patients a month about preserving fertility in the face of disease.
Some patients are sent from Children's Hospital of The King's Daughters, where they're undergoing treatment for leukemia or Hodgkin's disease. Others arrive from the offices of oncologists, who refer young women with breast and other types of cancer.
The common treatments for those diseases -- chemotherapy, radiation therapy, stem cell transplants -- can damage eggs, sperm and reproductive organs. But people who can mentally catapult themselves past the disease often have their eggs or sperm removed before cancer treatment begins.
One of the most successful options is to retrieve eggs and fertilize them with sperm in a lab to form embryos that are then frozen.
Dr. Laurel Stadtmauer, a Jones Institute fertility specialist, said oncologists sometimes are reluctant to talk with their patients about preserving fertility. They might think it's too overwhelming for the patient to take on another layer of decisions.
Some fertility options also can be at odds with the battle against cancer, such as delaying treatment while eggs are retrieved.
Stadtmauer, however, said more doctors are referring patients earlier, and more patients, particularly women, are seeking options on their own. Rather than being an added stress, she said, "it's been a comfort for them, because they're thinking of the future, they're thinking, 'I'm going to get over this.' "
Dr. Christy Russell, a California oncologist who chairs the American Cancer Society's breast cancer advisory panel, said that while some oncologists might not be happy to delay treatment, they're obligated to inform their patients about fertility issues and the available options to help them weigh the risks and benefits.
The issue surfaces depending on the age of the patient and the type and treatment of cancer, but one of the more common discussions arises with breast cancer patients. Retrieving their eggs requires both a delay in treatment and the use of fertility medications, which usually have estrogen that can spur cancer growth.
"I feel there are three partners -- the patient, myself and the fertility specialist," Russell said. "How long is it safe to delay? What is the potential risk of giving her fertility medication? What if not enough eggs are retrieved? What if they don't get fertilized? Do we delay again?"
There are other options, such as suppressing the ovaries during chemotherapy to protect egg cells from getting damaged.
Dr. William Owen, a CHKD pediatric oncologist, said protocols have been developed over the past decade to address fertility issues and other "late effects" of cancer in children, who have enjoyed some of the fastest-improving survival rates.
And as time has gone on, more techniques have become available. For instance, during the past five years, Owen has referred some young female cancer patients to the Jones Institute, where their ovarian tissue has been frozen. The technique is still considered experimental, but the idea is to re-implant the tissue when the patient is cancer-free, with the hope of producing eggs.
Owen's work sometimes involves advising girls and their families of the possibility of early menopause, so childbearing can be done in their 20s.
Bree's focus on fertility was simply about holding fast to an idea she'd been thinking about for years. The school librarian had married her husband, Joe, eight months earlier, and had been trying to get pregnant since their honeymoon. In December 2004, she felt a lump near her armpit.
But before she started any treatment, she plied the Internet with the search words "cancer" and "fertility."
She called the New Hope Center for Reproductive Medicine in Virginia Beach and was told there was a six-month waiting list. But since she'd been diagnosed with cancer, the founder of the center, Dr. Robin Poe-Zeigler, saw her the next day to go over her options.
In January 2005, she had surgery to remove the tumor and 13 lymph nodes. While she was still in the hospital, her husband gave her the first injection of medications to spur her egg production.
Typically, the injections are high in estrogen, but since that hormone could worsen the type of cancer Bree had, she was given a lower dose. Friends helped give her the daily injections for several weeks until the February day she went to have her eggs retrieved.
Eight of her eggs "took," as they say, and Bree breathed a sigh of relief. "Then I could focus on taking care of myself, " she said.
Four months of intravenous chemotherapy followed. Her friends hosted head-shaving parties for her when her hair fell out, with her husband and several other men shaving their heads, too. Her last treatment in the summer of 2005 brought an "end of chemo" party.
Then came six more months of IV medication. The last step of her treatment was taking oral medications for five years.
That's when she and her husband ran into a difference of opinion. Bree wanted to take a break from the meds to have the embryos implanted in her womb.
Joe -- and her oncologist -- disagreed with the idea.
The type of cancer Bree had is "estrogen-driven," raising concerns that a break from the oral meds, coupled with hormonal changes brought on by pregnancy, would increase the risk of cancer returning.
She complained to her friends and family that her husband didn't want her to carry the pregnancy. They told her they didn't think she should, either.
Bree struggled with the notion of not carrying her baby herself. Joe asked her to think from the perspective of a husband and a child left without her.
By early 2007, however, Bree had come around, and the couple started looking for a woman to carry the baby.
New Hope hooked the couple up with a woman named Allyson last summer. She doesn't want her last name used in this story because she doesn't want questions to arise about insurance coverage of her pregnancy.
The three hit it off immediately. Allyson had two children of her own, now 9 and 10, and had carried twin babies for another couple two years earlier.
That made the Ruzzis feel she was a safe bet in terms of holding firm to her commitment.
Two embryos were implanted in late August. On Bree's 33rd birthday, in September 2007, she and Joe went with Allyson to see the first ultrasound.
That's when they found out they were having twins. "They looked like two pieces of rice," Bree recalled.
On the way home, Bree stopped at a bookstore and bought, "What to Expect When You're Expecting." She read the parts about the stages of fetal development and skimmed the pregnancy parts that didn't apply to her.
Bree kept up with Allyson by phone and e-mail, and spent time with Allyson while she was in the hospital on bed rest. Bree also pitched in by going to Allyson's house to help her children and do some household chores.
Early in the pregnancy, Allyson had some bleeding and had to be on bed rest for a few weeks. The bleeding stopped, but then, with the babies still a couple of months from their due date, she started having contractions.
This time, Allyson spent several weeks on bed rest, then three more in the hospital. Bree took leave from her job to be with Allyson.
Bree might have been free from the pain of contractions, but not the mental anguish.
"I felt helpless," Bree said. She felt grateful to Allyson, and at the same time, guilty -- and even angry at herself -- for not being the one carrying the babies.
Finally, on April 22, 6-pound Ava arrived, followed by 5-pound Brian, with Allyson doing the pushing, and Bree and Joe watching the birth of their children.
It was a perspective few mothers experience.
"I sat there and I cried," Bree said. "All these emotions all came at once. It's amazing to see your babies born."
Bree, Joe and Allyson would not discuss the financial terms they agreed upon in a 42-page legal document that outlined the arrangement.
Web sites devoted to the subject of surrogacy say their average fee, not including medical and legal costs, can run from $15,000 to $30,000.
Bree said the general public has a perception that it's scandalous to pay someone to bear your child, but she asks for consideration for all Allyson had done.
"Before she started carrying them, she had a month of injections," Bree explained. "Then nine months of housing them, feeding them, going to doctors' appointments that kept her from doing things with her children. For 10 months, she put my children before her children. How do you put a price on that?"
Bree has two more years of oral medication in her cancer treatment. She has scans every three or four months to check for cancer; the scans so far have been clear.
And she and Joe have two babies who are a fine -- and noisy -- distraction from all of that.
It's a far cry from the day Bree heard the words "breast cancer" in a hospital exam room. "This is the happiest I can remember being, ever," she said, the two babies sleeping quietly in a crib a few feet from her. "I am happy when they're sleeping and when they're awake. Even in the middle of the night, changing their diapers. I've been looking forward to it for so long. I have waited and wanted them for a long, long time."
Though the couple knows that Bree, like any cancer survivor, lives with the shadow of the disease, it's not something she spends time worrying about.
If Bree could think past it at the beginning, she can think past it now.
So can her husband.
"You can get hit by a bus tomorrow," Joe said. "You have to live today for today."
Elizabeth Simpson, (757) 446-2635, elizabeth.simpson@pilotonline.com To see more of the The Virginian-Pilot, or to subscribe to the newspaper, go to http://www.pilotonline.com. Copyright (c) 2008, The Virginian-Pilot, Norfolk, Va. Distributed by McClatchy-Tribune Information Services. For reprints, email tmsreprints@permissionsgroup.com, call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.
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