As a nonpartisan organization, the American Cancer Society has an overarching goal to improve the lives of patients with cancer and their families. We believe all individuals should have an equitable opportunity to prevent, find, detect, and survive cancer, irrespective of geography.
The June 24 decision by the U.S. Supreme Court to overturn the nearly 50-year precedent of Roe v Wade, which conferred a federal constitutional right to an abortion, shifted the authority to determine abortion rights to individual states. The Supreme Court’s ruling will have animmediate and potentially unintended detrimental impact on access to timely, effective cancer care.
As described in our public statement1 and in our position statement in collaboration with ASCO and the Leukemia and Lymphoma Society (https://www.fightcancer.org/sites/default/files/cancer-care-and-reproductive-health-v4.pdf), we believe it is our organization’s responsibility to educate the public and policymakers nationwide about the impediments to cancer care resulting from the Dobbs v JacksonWomen’s Health Organization (Dobbs) decision. Our concern arises from the following observations.
Cancer During Pregnancy Is Increasing
Up to 1 in 1,000 pregnant women in the United States have a co-occurring cancer diagnosis.2-4 Based on the trend of increasing age of pregnancy for mothers in the United States, along with the increased risk of cancer with aging, this number is expected to increase.5 Even in the present state, cancer is the second most common cause of death for women of childbearing age,6 and in pregnant women who develop cancer, diagnosis is often delayed as a result of similar symptoms that include anemia, nausea, and fatigue.7
Since it is well established that early intervention across cancer types is associated with improved outcome, access to immediate, effective cancer care is essential for pregnant individuals with cancer to maximize their chance of survival. It is this very imperative that is threatened in the aftermath of the Dobbs ruling.
Limitations to Cancer Care During Pregnancy
For pregnant individuals with a cancer diagnosis, therapeutic options are significantly limited if the intent is to maintain a successful pregnancy, given the potential or likely impact of cancer therapy on a growing fetus.7,8 Whereas surgical resection is considered a generally safe option during pregnancy, most other treatment options are not recommended. Radiation therapy is not advised in pregnant patients with cancer, irrespective of the site of the cancer that threatens the life of the mother. And most cytotoxic chemotherapies are also avoided during the first trimester in patients who have cancer and are currently pregnant. Resulting delays in treatment have significant potential for reducing the chances of survival for the mother, particularly in the case of aggressive cancers.
“Cancer affects us all, with one in two men and one in three women expected to receive a cancer diagnosis over their lifetime.”— Karen E. Knudsen, MBA, PhD
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As oncology care has moved beyond the era of surgical resection, radiotherapy, and cytotoxic chemotherapy as the only options for cancer care, and improved survival through the discovery and implementation of targeted therapy and immunotherapy, options for pregnant patients with cancer are even more limited. The most commonly diagnosed cancer of pregnant women is breast cancer, yet often hormone therapies, including tamoxifen and anastrozole, cannot be used in these patients.
Other targeted agents known to extend life, such as imatinib for the treatment of chronic myeloid leukemia, have been associated with inadvertent induction of spontaneous abortion and cannot be used in pregnant patients. Similar concerns exist with immuno-oncology agents, which have largely not been tested in pregnant patients and are not recommended, despite known life-extending activity in cancer types of prominence in pregnant patients with cancer. Some immunotherapies are known to cross the placenta and would likely cause direct, unintended toxicity to the fetus. The divide between what can be safely administered to a pregnant patient with cancer vs one who is not or is no longer pregnant will continue to grow, as pregnant patients are largely excluded from clinical trials, for good reason. On balance, the limited cancer care options that can be delivered to a patient if the goal is to maintain a successful pregnancy raise a significant threat to the survival of the mother.
Creating Greater Inequity in Cancer Care
It is also important to note that narrowing cancer care options available to pregnant patients have a disproportionate impact on persons of color. Across most cancer types, Black men and women have the highest cancer mortality rate and the shortest survival of any racial or ethnic group in the United States.9 The breast cancer disparity alone is striking—Black women suffer from a 41% higher death rate than their White counterparts.9
Inflammatory breast cancer is more common in Black women and represents an aggressive cancer type for which rapid treatment is critical. Concomitant to the increased frequency of aggressive breast cancers, Black women are challenged by reduced access to highly effective contraception compared with White women and, as a result, experience a higher rate of unintended pregnancies. Thus, increased barriers of cancer care for pregnant individuals have the potential to impact communities of color even more deeply in areas of the United States where reproductive rights are further restricted.
Impact of Governmental Insertion Into the Cancer Care Discussion for Pregnant Patients
Co-occurrence of pregnancy with a cancer diagnosis creates a heartbreaking dilemma for the patient with cancer. Prior to the Dobbs ruling, care decisions involved a thoughtful discussion between the pregnant patient and her oncology team. This patient-centered approach has not historically been interfered with through government policy and allowed for fulsome consideration of all possible options.
Care plans developed between any patient and her oncologist require careful assessment of risks, benefits, and repercussions for both quality of life and overall survival. For a pregnant patient, such considerations also include the implications for continuation or discontinuation of a pregnancy. In the aftermath of the Dobbs ruling, women living in areas with restrictions on reproductive health have the potential to be adversely affected by the exclusion of therapies that can be life-saving.
“Toward the goal of improving the lives of patients with cancer and their families, it is essential for patients to receive timely, effective, unimpeded access to cancer care.”— Karen E. Knudsen, MBA, PhD
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Put simply, states that have enacted or have proposals to enact laws classifying fertilized eggs, zygotes, embryos, and fetuses as having full legal protections from conception create a likely barrier for a subset of pregnant women to receive immediate, effective cancer care. This governmental policy creates, for the first time in the modern era of oncology, insertion of government into the cancer care decision-making for pregnant patients.
In addition to the narrow range of options for pregnant patients to receive cancer care without the potential danger of fetal harm, fear of legal prosecution on the part of the oncology team in the event of inadvertent spontaneous abortion resulting from treatment may result in a hesitancy to treat patients with cancer. This is especially of concern in states where exceptions are statutorily defined as the life of the mother and medical emergencies rather than the health of the mother.
Looking to Precedents for the Consequences of Abortion Bans on Cancer Care
Precedents in other areas of the world underscore these concerns, wherein hesitancy to treat pregnant patients with cancer is a reality. For example, women and girls in Nicaragua have been unable to access cancer care that can be potentially life-saving if they are pregnant. In that country, medical professionals can be sentenced for up to 6 years in prison for providing care that even unintentionally leads to an abortion.10
In the Dominican Republic, where a right to life is inviolable from the moment of conception to death, cancer care for even young girls has been denied due to a co-occurring pregnancy.11 And in Poland, where there is a total ban on abortion, pregnant women diagnosed with aggressive cancer have resorted to leaving the country to receive care.12
These situations are at odds with the ethical principle of the “dual effect” in medicine, wherein after careful consideration between patients and clinicians, it is permissible to experience a negative outcome if the primary intention is well reasoned, including but not limited to saving the mother’s life, and risks of the negative outcome are minimized as much as possible. This principle is particularly critical during times of patient extremus and in decisions surrounding complex cancer cases and prioritizes the intentionality of the patient and the oncology team.
Impact of Dobbs Ruling on Fertility Preservation for Patients With Cancer
In addition to creating impediments to effective cancer care, we continue to monitor the impact of proposed new legislation on fertility preservation for patients with cancer wishing to plan for future families after the completion of their cancer treatment. Currently, guidelines recommend providing an option for fertility preservation for all patients with cancer of childbearing age.
Research has shown that cancer survivors commonly regret lack of fertility preservation to the extent that the absence of options negatively affects quality of life.13 The need for fertility preservation is significant, since more than 80,000 young adults between the ages of 20 and 39 receive a cancer diagnosis each year in the United States.14
Critically, proposed new legislation is likely to create challenges toward effective fertility preservation, since the most effective approach for patients with cancer is through the creation and freezing of fertilized embryos for implantation after treatment. Multiple such embryos are created during this process, toward the goal of ensuring the success of future pregnancies. After the Dobbs ruling, it is uncertain how embryos not considered viable (eg, because of non–life-sustaining malformations) or that exceed the needs of the cancer survivor’s family will be treated in response to shifting state laws around reproduction.
There is reasonable concern on the part of patients, their families, and oncology teams related to potential new financial, civil, and criminal penalties that have not for 5 decades interfered in this critical patient/clinician discussion.
Providing Information to States on the Consequences of Restricting Options for Pregnant Women With Cancer
Taken together, there are significant concerns about the implications of the Dobbs ruling for patients with cancer and their families. Cancer affects us all, with one in two men and one in three women expected to receive a cancer diagnosis over their lifetime.15 Through the American Cancer Society Cancer Action Network, we are committed to working with states to provide needed information about the consequence(s) of reproductive legislation on access to care for pregnant patients with cancer, access to fertility preservation for all patients with cancer of childbearing age, and any other implication with the potential to influence cancer survivorship.
Toward the goal of improving the lives of patients with cancer and their families, it is essential for patients to receive timely, effective, unimpeded access to cancer care.
DISCLOSURE: Dr. Knudsen reported having stock and other ownership interests in Genomic Health and Pfizer; has received honoraria from CellCentric and Sanofi; has served as a consultant or advisor to Atrin Pharmaceuticals, CellCentric, Context Therapeutics, and Sanofi; has received research funding from Celgene; and has received reimbursement for travel, accommodations, and expenses from Genentech and Sanofi.
REFERENCES
1. American Cancer Society: The American Cancer Society Highlights Impact of Dobbs v. Jackson Ruling on Cancer Patients and Their Families. June 24, 2022. Available at http://pressroom.cancer.org/SCOTUS-2022. Accessed August 3, 2022.
2. Donegan WL: Cancer and pregnancy. CA Cancer J Clin 33:194-214, 1983.
3. Nieminen U, Remes N: Malignancy during pregnancy. Acta Obstet Gynecol Scand 49:315-319, 1970.
4. Smith LH, Danielsen B, Allen ME, et al: Cancer associated with obstetric delivery: Results of linkage with the California cancer registry. Am J Obstet Gynecol 189:1128-1135, 2003.
5. Morse A: Fertility Rates: Decline for Younger Women, Increased for Older Women. Stable Fertility Rates 1990–2019 Mask Distinct Variations by Age. United States Census Bureau, 2022. Available at https://www.census.gov/library/stories/2022/04/fertility-rates-declined-for-younger-women-increased-for-older-women.html?utm_campaign=20220406msacos1ccstors&utm_medium=email&utm_source=govdelivery. Accessed August 3, 2022.
6. Siegel RL, Miller KD, Jemal A: Cancer statistics, 2019. CA Cancer J Clin 69:7-34, 2019.
7. Silverstein J, Post AL, Chien AJ, et al: Multidisciplinary management of cancer during pregnancy. JCO Oncol Pract 16:545-557, 2020.
8. Hepner A, Negrini D, Hase EA, et al: Cancer during pregnancy: The oncologist vverview. World J Oncol 10:28-34, 2019.
9. American Cancer Society: Cancer Facts & Figures for African American/Black People 2022–2024. Available at www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-facts-and-figures-for-african-americans/2022-2024-cff-aa.pdf. Accessed August 3, 2022.
10. Hutchison C: Nicaragua’s Anti-Abortion Policy Endangers Women, Criminalizes Doctors, Experts Say. ABC News, February 25, 2010. Available at Nicaragua’s Anti-Abortion Policy Endangers Women, Criminalizes Doctors, Experts Say-ABC News (go.com). Accessed August 3, 2022.
11. Romo R: Dominican Republic abortion ban stops treatment for pregnant teen with cancer. CNN, July 25, 2012. Available at Dominican Republic abortion ban stops treatment for pregnant teen with cancer CNN. Accessed August 3, 2022.
12. Bennhold K, Pronczuk M: Poland Shows the Risks for Women When Abortion Is Banned. The New York Times, June 26, 2022. Available at https://www.nytimes.com/2022/06/12/world/europe/poland-abortion-ban.html. Accessed August 3, 2022.
13. Benedict C, Thom B, Kelvin JF: Young adult female cancer survivors’ decision regret about fertility preservation. J Adolesc Young Adult Oncol 4:213-218, 2015.
14. Pinelli S, Basile S: Fertility preservation: Current and future perspectives for oncologic patients at risk for iatrogenic premature ovarian insufficiency. Biomed Res Int 2018:6465903, 2018.
15. Hayat MJ, Howlader N, Reichman ME, et al: Cancer statistics, trends, and multiple primary cancer analyses from the Surveillance, Epidemiology, and End Results (SEER) Program. Oncologist 12:20-37, 2007.
Dr. Knudsen is Chief Executive Officer of the American Cancer Society and the American Cancer Society Cancer Action Network.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.
