Why would a woman withhold chemotherapy from her child with lymphoma?

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One of the main issues that I’ve written about quite a bit is the issue of what the state should have the power to do when a child has cancer or another life-threatening disease and the parents choose quackery over scientific medicine when the disease is potentially (or even highly) treatable or curable with standard treatment. Most of the time, this has come in the context of patients like Abraham Cherrix, who, with his parents support chose the quackery that is the Hoxsey therapy over chemotherapy, or Katie Wernecke, whose parents chose high dose vitamin C and other woo, over effective anticancer therapy. In this case, Abraham’s doing pretty well thus far, thanks to his willingness to accept low dose radiation therapy as part of his “alternative” therapy regimen, while when last I checked Katie was not doing well at all, and I now wonder if she is even still alive anymore. (I do know that a year ago her parents were suing the State of Texas for trying to save her life.) I also tend to write about cases where a family’s religious beliefs lead them to favor prayer over medicine and thereby deny their children life-saving treatment, letting them die in most unpleasant ways. Such cases disturb me more than any others.

This case has nothing to do with quackery or extreme religious beliefs, but it brings up the same issues. It’s also an instructive comparison to cases in which religion or faith in “alternative” medicine leads a parent to rely on prayer or quackery instead of scientific medicine. In that it may even be more disturbing in a way than the cases mentioned above:

SALEM — A mother has been charged with failing to give her 8-year-old son his cancer medication, a decision prosecutors say caused the boy’s cancer to return in an untreatable form.

Because of Kristen Anne LaBrie’s failure to medicate her child, “in all likelihood, Jeremy Fraser will not see his ninth birthday,” prosecutor Kate MacDougall said during LaBrie’s arraignment yesterday in Salem District Court.

LaBrie, 36, who moved recently from Salem to Beverly, pleaded not guilty to reckless child endangerment. She refused comment as she left court with her lawyer.

The boy’s father, Eric Fraser, who now has full custody of his son, said he is outraged not only about what happened to his son, but that LaBrie was able to walk out of court yesterday without posting any bail.

“I’m pretty disgusted about the whole justice (system) and DSS,” Fraser said. “Now my son’s going to die.”

Jeremy was diagnosed with non-Hodgkin’s lymphoma in 2006. As I’ve mentioned before, lymphomas are among the most treatable of childhood cancers, and assuming the police report is correct oncologists estimated Jeremy’s chances of survival at the time of diagnosis to be in the range of 85-90%. Jeremy underwent initial chemotherapy and had a good response; the drugs drove his tumor into remission.

To understand why his mother’s not given Jeremy the proper medications, a little bit about the treatment of lymphoma needs to be explained. When lymphoma is diagnosed, there are usually three main phases to its treatment, the induction phase, the consolidation phase, and then the maintenance phase. The induction phase, as you might imagine, is the initial shot at the tumor with chemotherapy. That’s where oncologists usually hit the tumor hard and heavy with big gun chemotherapy in order to drive it into remission. If there’s one thing about cancer, it’s that the first shot at it is almost always the best shot at curing it. Once the tumor is in remission, however, it’s known that there is a very high rate of recurrence without additional treatment, and once a recurrence occurs the odds of driving the tumor into remission again fall dramatically, and long term survival follows it, plunging to the 10-20% range.

That’s why chemotherapy regimens were developed that included additional phases, and the consolidation phase is additional chemotherapy designed to sustain a remission. Consolidation is often used for the treatment of leukemias. After that, there is maintenance chemotherapy, which is lower dose chemotherapy given over a long period of time to assist in prolonging a remission. Because Jeremy was apparently on maintenance chemotherapy, I’m guessing that he probably had lymphoblastic lymphoma, which is usually treated with a full course of induction, consolidation, and maintenance chemotherapy, while nonlymphoblastic lymphoma usually does better with a shorter, more intense pulsed therapy. For localized lymphoblastic lymphoma, prolonged disease-free survival is around 60% without maintenance chemotherapy but rises to 90% with it. Reading between the lines, I’m guessing that Jeremy was probably on maintenance methotrexate, which is a drug that can be taken in oral form. He may have also been receiving what’s known as “CNS prophylaxis.” Because lymphoma can relapse in the central nervous system, one strategy to prevent that is to give periodic doses of intrathecal methotrexate. (Intrathecal means using a lumbar puncture to introduce the drug right into the cerebrospinal fluid.) Reading between the lines again, I’m guessing that the missed appointments were for administering intrathecal chemotherapy, probably mixed with appointments for routine checkups and blood work, possibly with some additional IV chemotherapy:

According to the police report by Salem detectives Peter Baglioni and Lt. Thomas Griffin, Jeremy was first diagnosed with non-Hodgkin’s lymphoma in 2006. The child underwent a five-phase regimen of chemotherapy, including some drugs that were supposed to be given to him at home by his mother.

The detectives said LaBrie had canceled at least a dozen appointments for chemotherapy treatments and had failed to pick up the medications from a pharmacy.

“Due to Ms. LaBrie’s failure to provide Jeremy with lifesaving cancer medication, his cancer has returned,” the detectives wrote.

Fraser said his ex-wife picked up Jeremy’s medication for about a month after he came home from the hospital. Then she just stopped.

Jeremy didn’t receive anywhere near his full doses of maintenance chemotherapy, and so his lymphoma recurred, putting him in the group with only a 10%-20% chance of survival. Given that his oncologist says he only has a 10% chance, I’m inferring that Jeremy’s recurrence is bad. My guess is that it’s either widespread or in the CNS, either of which portend a poor prognosis. The mother’s neglect will, with 90% certainty, kill her child. In actions, she is no better than the “alternative medicine” cultists or religious loons who sacrifice their children to their beliefs. When Jeremy dies, it’s 90% certain it was because of her neglect. (I’m in a generous mood and granting her the 10% chance that Jeremy would have died even if treated completely according to the standard of care.)

But why did she do it?

There are two factors to consider. First, she and her husband were supposedly involved in a very bitter divorce. On the other hand, it was a physician who reported her to Child Protective Services:

Because of ongoing disputes with his ex-wife and her boyfriend, Fraser said, he cut off contact with her and with his son for some months. Then he got a call from LaBrie’s sister, who told him Jeremy was back in the hospital and things didn’t look good.
Fraser, a full-time UPS delivery driver, was on the road delivering packages a few weeks later when his son’s doctor called.

“The doctor said, ‘You need to pull over,'” Fraser said.

The doctors and a DSS worker “said Kristen basically stopped giving him his medicine,” Fraser said. “She missed four IV chemo appointments and rescheduled 13 of them.”

“It comes out to about a year that she didn’t continue with the treatment,” Fraser said. “They basically said if Jeremy got his at-home chemo he would not have relapsed. The doctor was very shocked that he was back in there so quickly.”

Then the doctor told him they couldn’t let Jeremy go home with LaBrie. “It’s either you or foster care,” Fraser recalled being told. The choice was clear.

There’s one other thing: Jeremy is autistic.

Could it be that the combination of divorce, Jeremy’s autism, and other factors led to Kristen Ann LeBrie’s wanting, either consciously or unconsciously, to be rid of Jeremy, to see him dead? it’s nothing more than speculation, but it’s not entirely unreasonable speculation. Add to that a desire to hurt her husband, who appears to truly love his son, and who knows? I also don’t find the father entirely blameless here. Whatever the circumstances of his divorce, he let himself be kept away from his son. He may have had no choice, or he may have let it happen. It’s not clear which is closer to the truth, and if the divorce was truly ugly his wife may have made it virtually impossible for him to visit his son. It may not have made a difference, anyway.

Whatever the case, it’s entirely appropriate that charges be brought against the mother. What’s disturbing is that there was not a better mechanism for detecting earlier that Jeremy wasn’t getting all of his chemotherapy drugs, while there was still time to correct the situation and take action earlier. What’s even more disturbing is the likelihood that, if Kristin Ann LeBrie were a religious extremist who refused chemotherapy for her child in favor of prayer or an “alternative medicine” cultist who thinks that some concoction based on a paste from a plant that some guy in the 1800’s claimed to cure a horse’s cancer would be more likely to cure her child than chemotherapy, the law would likely indulge her, thanks to laws that exclude religion-inspired neglect from child-neglect laws or that give a parent essentially unlimited rights to choose quackery. From my perspective, failing to provide a child with life-saving treatment is gross negligence, whatever the reason for it. From my perspective, whatever the reason, woo, religion, personal difficulties, or spite, a parent may have a right to make herself a martyr, but she does not have the right to make her child into one.