As abortion bans go into effect , cancer physicians are wrestling with how new state laws will influence their discussions with pregnant patients about what treatment options they can offer.
Cancer coincides with roughly 1 in 1,000 pregnancies, most frequently breast cancer, melanoma, cervical cancer, lymphomas, and leukemias. But medications and other treatments can be toxic to the developing fetus or cause birth defects. In some cases, hormones that are supercharged during pregnancy fuel the cancer鈥檚 growth, putting the patient at greater risk.
Although new abortion restrictions often allow exceptions based on 鈥渕edical emergency鈥 or a 鈥渓ife-threatening physical condition,鈥 cancer physicians describe the legal terms as unclear. They fear misinterpreting the laws and being left in the lurch.
For instance, brain cancer patients have traditionally been offered the option of abortion if a pregnancy might limit or delay surgery, radiation, or other treatment, said Dr. Edjah Nduom, a brain cancer surgeon at Emory University鈥檚 Winship Cancer Institute in Atlanta.
鈥淚s that a medical emergency that necessitates the abortion? I don鈥檛 know,鈥 Nduom asked, trying to parse the medical emergency exception . 鈥淭hen you end up in a situation where you have an overzealous prosecutor who is saying, 鈥楬ey, this patient had a medical abortion; why did you need to do that?鈥欌 he said.
Pregnant patients with cancer should be treated similarly to non-pregnant patients when feasible, though sometimes adjustments are made in the timing of surgery and other care, according to , published in 2020 in Current Oncology Reports.
With breast cancer patients, surgery could be performed early on as part of the treatment, pushing chemotherapy to later in the pregnancy, according to the research. Cancer experts typically recommend avoiding radiation therapy throughout pregnancy, and most chemotherapy drugs during the first trimester.
But with some cancers, such as acute leukemia, the recommended drugs have known toxic risks to the fetus, and time is not on the patient鈥檚 side, said Dr. Gwen Nichols, chief medical officer of the Leukemia & Lymphoma Society.
鈥淵ou need treatment urgently,鈥 she said. 鈥淵ou can鈥檛 wait three months or six months to complete a pregnancy.鈥
Another life-threatening scenario involves a patient early in her pregnancy who has been diagnosed with breast cancer that鈥檚 spreading, and tests show that the cancer鈥檚 growth is spurred by the hormone estrogen, said Dr. Debra Patt, an oncologist in Austin, Texas, who estimated she has cared for more than two dozen pregnant patients with breast cancer.
鈥淧regnancy is a state where you have increased levels of estrogen. It鈥檚 actually actively at every moment causing the cancer to grow more. So I would consider that an emergency,鈥 said Patt, who is also executive vice president over policy and strategic initiatives at Texas Oncology, a statewide practice with more than 500 physicians.
When cancer strikes individuals of child-bearing age, one challenge is that malignancies tend to be more aggressive, said Dr. Miriam Atkins, an oncologist in Augusta, Georgia. Another is that it鈥檚 unknown whether some of the newer cancer drugs will affect the fetus, she said.
While hospital ethics committees might be consulted about a particular treatment dilemma, it鈥檚 the facility鈥檚 legal interpretation of a state鈥檚 abortion law that will likely prevail, said Micah Hester, an expert on ethics committees who chairs the department of medical humanities and bioethics at the University of Arkansas for Medical Sciences College of Medicine in Little Rock.
鈥淟et鈥檚 be honest,鈥 he said. 鈥淭he legal landscape sets pretty strong parameters in many states on what you can and cannot do.鈥
It鈥檚 difficult to fully assess how physicians plan to handle such dilemmas and discussions in states with near-total abortion bans. Several large medical centers contacted for this article said their physicians were not interested or not available to speak on the subject.
Other physicians, including Nduom and Atkins, said the new laws won鈥檛 alter their discussions with patients about the best treatment approach, the potential impact of pregnancy, or whether abortion is an option.
鈥淚鈥檓 going to always be honest with patients,鈥 Atkins said. 鈥淥ncology drugs are dangerous. There are some drugs that you can give to [pregnant] cancer patients; there are many that you cannot.鈥
The bottom line, maintain some, is that termination remains a critical and legal part of care when cancer threatens someone鈥檚 life.
Patients 鈥渁re counseled on the best treatment options for them, and the potential impacts on their pregnancies and future fertility,鈥 Dr. Joseph Biggio Jr., chair of maternal-fetal medicine at Ochsner Health System in New Orleans, wrote in an email. 鈥淯nder state laws, pregnancy termination to save the life of the mother is legal.鈥
Similarly, Patt said that physicians in Texas can counsel pregnant patients with cancer about the procedure if, for instance, treatments carry documented risks of birth defects. Thus, physicians can鈥檛 recommend them, and abortion can be offered, she said.
鈥淚 don鈥檛 think it鈥檚 controversial in any way,鈥 Patt said. 鈥淐ancer left unabated can pose serious risks to life.鈥
Patt has been educating physicians at Texas Oncology on , as well as sharing a JAMA Internal Medicine editorial that . 鈥淚 feel pretty strongly about this, that knowledge is power,鈥 she said.
Still, the Texas law鈥檚 vague terminology complicates physicians鈥 ability to determine what鈥檚 legally permissible care, said Joanna Grossman, a professor at SMU Dedman School of Law. She said nothing in the statute tells a doctor 鈥渉ow much risk there needs to be before we label this legally 鈥榣ife-threatening.鈥欌
And if a woman can鈥檛 obtain an abortion through legal means, she has 鈥済rim options,鈥 according to Hester, the medical ethicist. She鈥檒l have to sort through questions like: 鈥淚s it best for her to get the cancer treatment on the time scale recommended by medicine,鈥 he said, 鈥渙r to delay that cancer treatment in order to maximize the health benefits to the fetus?鈥
Getting an abortion outside Georgia might not be possible for patients with limited cash or no backup child care or who share one car with an extended family, Atkins said. 鈥淚 have many patients who can barely travel to get their chemotherapy.鈥
Dr. Charles Brown, a maternal-fetal medicine physician in Austin who retired this year, said he can speak more freely than practicing colleagues. The scenarios and related unanswered questions are almost too numerous to count, said Brown, who has cared for pregnant women with cancer.
Take as another example, he said, a potential situation in a state that incorporates 鈥渇etal personhood鈥 in its law, such as Georgia. What if a patient with cancer can鈥檛 get an abortion, Brown asked, and the treatment has known toxic effects?
鈥淲hat if she says, 鈥榃ell, I don鈥檛 want to delay my treatment 鈥 give me the medicine anyway,鈥欌 Brown said. 鈥淎nd we know that medicine can harm the fetus. Am I now liable for harm to the fetus because it鈥檚 a person?鈥
Whenever possible, physicians have always strived to treat the patient鈥檚 cancer and preserve the pregnancy, Brown said. When those goals conflict, he said, 鈥渢hese are gut-wrenching trade-offs that these pregnant women have to make.鈥 If termination is off the table, 鈥測ou鈥檝e removed one of the options to manage her disease.鈥