As abortion bans take effect across a contiguous area in the South, cancer doctors are wrestling with how the new state law will affect their discussions with pregnant patients about what treatment options they can offer.
Cancer occurs in about 1 in 1,000 pregnancies, most commonly breast cancer, melanoma, cervical cancer, lymphomas, and leukemia. But drugs and other treatments can be toxic to the developing fetus or cause birth defects. In some cases, extra-charged hormones during pregnancy fuel cancer growth, putting the patient at greater risk.
Although the new abortion bans often allow exceptions based on “medical necessity” or “life-threatening physical conditions,” cancer doctors describe the legal terms as vague. They fear misinterpreting the law and get left out.
For example, brain cancer patients have traditionally been given the option of abortion if pregnancy could limit or delay surgery, radiation or other treatments, said Dr. Edjah Nduom, a brain cancer surgeon at Emory University’s Winship Cancer Institute in Atlanta.
“Is it a medical emergency that requires an abortion? I don’t know,” Nduom asked, trying to analyze the medical emergency exception in Georgia’s new law. “Then you end up in a situation where you have an overzealous prosecutor who says, ‘ Hey, this patient had a medical abortion; why did you need to do that?'” she said.
According to a research overview published in Current Oncology Reports in 2020, pregnant patients with cancer should be treated in the same way as non-pregnant patients when possible, although the timing of surgery and other care is sometimes adjusted.
With breast cancer patients, surgery may be performed earlier as part of treatment, pushing chemotherapy to later in pregnancy, according to the study. Oncologists generally recommend avoiding radiation therapy during pregnancy and most chemotherapy drugs during the first trimester.
But with some cancers, such as acute leukemia, recommended drugs have known toxicity risks for the fetus, and timing is not on the patient’s side, said Dr. Gwen Nichols, chief medical officer of the Leukemia and Lymphoma Society.
“You need urgent treatment,” she said. “You can’t wait three months or six months to complete a pregnancy.”
Another life-threatening scenario involves a patient diagnosed early in pregnancy with breast cancer that has spread, and tests show that cancer growth is stimulated by the hormone estrogen, said Dr. Debra Pate, an oncologist in Austin, Texas. It is estimated that he has cared for more than two dozen pregnant patients with breast cancer.
“Pregnancy is a condition where your estrogen levels are elevated. It’s actually actively causing the cancer to grow every moment. So I would consider it an emergency,” said Pat, who is executive vice president of policy and strategic initiatives at Texas Oncology, an organization with more than 500 physicians. State wide practice
When cancer strikes people of childbearing age, one challenge is that malignancies tend to be more aggressive, says Dr. Miriam Atkins, an oncologist in Augusta, Georgia. Another is that it is unknown whether some new cancer drugs will affect the fetus, he said.
While hospital ethics committees may be consulted about doubts about a particular treatment, it’s the legal interpretation of a state’s abortion law facility that will likely prevail, said Micah Hester, an ethics committee expert who chairs the university’s department of medical humanities and bioethics. Arkansas for Medical Sciences College of Medicine in Little Rock.
“Let’s be honest,” he said. “The legal landscape sets pretty strong parameters in many states on what you can and can’t do.”
It is difficult to fully assess how physicians plan to handle such dilemmas and discussions in states with almost complete abortion bans. Several major medical centers contacted for this article said their physicians were either unwilling or unavailable to talk about the matter.
Other doctors, including Nduom and Atkins, said the new law would not change their discussions with patients about the best treatment options, the potential effects of pregnancy or whether abortion is an option.
“I’m always going to be honest with patients,” Atkins said. “Oncology drugs are dangerous. There are drugs you can give [pregnant] cancer patients; There’s a lot you can’t.”
The bottom line, to maintain something, is an important and legal part of hospice care when cancer threatens someone’s life.
Patients are “counseled about the best treatment options for them and the possible effects on their pregnancy and future fertility,” Dr. Joseph Biggio Jr., chair of maternal-fetal medicine at Ochsner Health System in New Orleans, wrote in an email. “Under state law, termination of pregnancy to save mother’s life is legal.”
Similarly, Pate said doctors in Texas can counsel pregnant patients with cancer about the procedure if, for example, the treatments carry a documented risk of birth defects. Thus, doctors cannot recommend them and abortion can be offered, he said.
“I don’t think it’s controversial at all,” Pat said. “Cancer left untreated can pose a serious risk to life.”
Pat has been educating physicians at Texas Oncology about the new state law, as well as sharing a JAMA Internal Medicine editorial that provides details about abortion care resources. “I feel pretty strongly about it, that knowledge is power,” he said.
Still, the vague terminology of Texas law complicates physicians’ ability to determine what is legally permissible care, said Joanna Grossman, a professor at the SMU Dedman School of Law. The law, he said, does not say how much risk a doctor needs to pose before he is “legally labeled as ‘life-threatening’.”
And if a woman can’t get an abortion legally, she has “serious options,” according to Hester, the medical ethicist. She must choose between questions such as: “Is it better for her to treat the cancer on the time scale recommended by medicine,” he said, “or to delay the cancer treatment to maximize the health benefits of the fetus?”
For patients having abortions outside of Georgia, limited cash or backup childcare or those who share a car with extended family may not be possible, Atkins said. “I have many patients who can rarely travel to receive their chemotherapy.”
Dr. Charles Brown, a maternal-fetal medicine physician in Austin who retired this year, said he can speak more freely than colleagues practice. Caring for pregnant women with cancer, Brown says, the situation and related unanswered questions are almost too numerous to count.
Take, as another example, a possible situation in a state that includes “fetal personhood” in its laws, such as Georgia, he said. What if a patient with cancer can’t have an abortion, Brown asked, and the treatment has toxic effects?
“If he says, ‘OK, I don’t want to delay my treatment — give me the medicine anyway,'” Brown said. “And we know that drugs can harm the fetus. Am I now responsible for harming the fetus because it is a person?”
Whenever possible, doctors have always tried to treat a patient’s cancer and preserve the pregnancy, Brown said. When these goals conflict, she said, “these are gut-wrenching trade-offs that these pregnant women have to make.” If termination is off the table, “you’ve removed one of her disease management options.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Along with policy analysis and polling, KHN is one of the three main operating programs of the KFF (Kaiser Family Foundation). KFF is a non-profit organization that provides health information to the nation.
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