As abortion bans take effect in the contiguous South, cancer doctors are grappling with how new state laws will affect their discussions with pregnant patients about what treatments they can offer.
Cancers co-occur with approximately 1 in 1,000 pregnancies, the most common being breast cancer, melanoma, cervical cancer, lymphoma and leukemia. But drugs and other treatments can be toxic to the developing fetus or cause birth defects. In some cases, hormonal overload during pregnancy can fuel cancer growth, putting patients at greater risk.
While new abortion restrictions generally allow exceptions based on “medical emergencies” or “life-threatening medical conditions,” cancer doctors describe the legal term as unclear. They fear misinterpreting the law and falling into Dilemma.
For example, brain cancer patients have traditionally opted for abortion if pregnancy could limit or delay surgery, radiation, or other treatment, says brain cancer surgeon at the Winship Cancer Institute at Emory University in Atlanta Dr. Edjah Nduom said.
“Is this a medical emergency requiring an abortion? I don’t know,” Nduom asked, trying to parse out the medical emergency exception in the new Georgia law. “And then you end up with an overzealous prosecutor saying, ‘Hey, this patient had a medical abortion; why do you need to? this way? ‘” he said.
Pregnant patients with cancer should receive treatment similar to non-pregnant patients when feasible, although care is sometimes adjusted in terms of timing of surgery and other aspects, according to Overview of a study published in Current Oncology Reports in 2020.
For breast cancer patients, surgery can be performed early as part of treatment, deferring chemotherapy until later in pregnancy, according to the study. Cancer Specialist It is generally recommended to avoid radiation therapy throughout pregnancy, as well as most chemotherapy drugs in the first trimester.
However, for some cancers, such as acute leukemia, the recommended drugs are known to have a risk of toxicity to the fetus , and Dr. Gwen Nichols, chief medical officer of the Leukemia and Lymphoma Society, said time is not on the patient’s side.
“You need urgent care,” she said. “You can’t wait three months or six months to complete pregnancy. “
Another life-threatening situation involved a patient who was diagnosed with spreading breast cancer early in her pregnancy and was tested by Debra Oncologist in Austin, Texas. This suggests that cancer growth is stimulated by estrogen, said Dr. Debra Patt, who estimates she has cared for more than two dozen pregnant breast cancer patients.
“Pregnancy is a A state of elevated estrogen levels. It actually actively causes the cancer to grow more all the time. So I think it’s an emergency,” said Pat, who is also executive vice president of policy and strategic initiatives for Texas Oncology, a statewide practice of more than 500 physicians.
When cancer strikes an individual One challenge is that malignancies tend to be more aggressive during the reproductive years, says Dr. Miriam Atkins, an oncologist in Augusta, Georgia. Another reason, she says, is that some Whether the new cancer drug could affect the fetus.
While hospital ethics committees may be consulted about specific treatment dilemmas, this is the agency’s opinion on state ethics committee experts, University of Arkansas School of Medicine, Little Rock Abortion laws may prevail, said Micah Hester, chair of the humanities and bioethics department.
“Let’s be honest,” he said. “The legal environment is in many states conducive to What you can and can’t do set pretty strong parameters. “
It is difficult to fully assess how doctors plan to handle this dilemma and discuss bans in states that are almost exclusively abortions. Several large medical centers contacted for this article said their doctors were not interested in the subject or unable to speak.
Other physicians, including Nduom and Atkins, said the new law would not change their discussions with patients about the best treatment, potential effects of pregnancy or whether abortion is an option.
“I will always be honest with my patients,” Atkins said. “Oncology drugs are dangerous. You can give a [pregnant] cancer patient some medicines; there are a lot of things you can’t do. “
Some insist that when cancer threatens someone’s life, terminating treatment is still a critical and legitimate part of care.
New Orleans Ochsner Health System Joseph Biggio Jr., Ph.D., chair of maternal-fetal medicine, wrote in an email that patients “are informed about the best treatment options and the potential impact on their pregnancy and future fertility.” “Under state law, to save the life of the mother, Termination of pregnancy is legal. “
Likewise, Pat said, physicians in Texas can counsel pregnant cancer patients about the procedure, for example, to treat patients who carry a documented risk of birth defects. Therefore, physicians They can’t be recommended, and abortions can be offered, she said.
“I don’t think there’s any controversy about it,” Pat said. “Unabated cancer could pose a serious risk to life. “
Patt has been educating physicians in Texas oncology on NSW law and shared the JAMA Internal Medicine editorial, which provides detailed resources on abortion care.” I feel very strongly about this, that knowledge is power,” she said.
Still, the vague terminology of Texas law complicates doctors’ ability to determine legally permitted care, Prof. Joe Anna Grossman, of SMU’s Dedman School of Law, said the statute doesn’t tell doctors “how much of a risk it needs to be before we can legally label it ‘life-threatening.’
According to medical ethicist Hester, that meant she had “tremendous choices.” She had to address the following issues: “For her, it was best for her to follow the medically recommended time frame for her cancer.” Treatment,” he said, “or delaying cancer treatment to maximize fetal health benefits? ? “
Abortions outside Georgia may not be possible for patients with limited cash or no backup child care or sharing a car with extended families,” Atkins said. “I have a lot of patients who can barely travel to get chemotherapy.
Dr. Charles Brown, an Austin maternal-fetal medicine physician who retired this year, said he was more vocal than his practicing colleagues. Brown, who has cared for pregnant women with cancer, said the scenarios and related unanswered questions The problems are almost innumerable. The “fetal personality” in its laws, like Georgia. What if a cancer patient can’t have an abortion, Brown asks, and the treatment has known toxic effects?
” if she said , ‘Well, I don’t want to delay my treatment — give me the medicine anyway,'” Brown said. “And we know the medicine can harm the fetus. Am I now responsible for harm to the fetus because it is a human? “
Whenever possible, physicians always strive to treat a patient’s cancer and preserve the pregnancy,” Brown said. When those goals conflict, he said, “these pregnant women have to make painful tradeoffs.” trade-offs. “If termination is not possible,” you have removed one of the options for managing her illness. ”