In response to the U.S. Supreme Court decision in Dobbs v Jackson Women’s Health Organization overturning Roe v Wade, eliminating the constitutional right to an abortion and returning the power to regulate reproductive health for women to the states, ASCO, the American Cancer Society Action Network, and the Leukemia & Lymphoma Society issued a joint brief on reproductive health and cancer care.1 The brief provides background on reproductive health, including medication access and fertility preservation, as it relates to cancer care and outlines the organizations’ advocacy principles and priorities regarding these issues.
ASCO has also issued a policy brief on Fertility Preservation and Cancer,2 which outlines the Society’s support for access to fertility preservation for patients with cancer, which may become more difficult as the full implication of the laws banning abortion and their potential impact on in vitro fertilization becomes known.
In addition, ASCO has published a link to an Abortion in the U.S. dashboard (https://www.kff.org/womens-health-policy/dashboard/abortion-in-the-u-s-dashboard), a third-party resource from KFF, which tracks current state abortion policies and litigation across the United States. Currently, about 26 states are expected to enact outright bans on abortion or impose gestational limits on the procedure.
Julie R. Gralow, MD, FACP, FASCO
In a wide-ranging interview with Julie R. Gralow, MD, FACP, FASCO, Chief Medical Officer and Executive Vice President of ASCO, Dr. Gralow discussed the potential consequences abortion bans will have on the clinical care of pregnant patients with cancer and how ASCO is mobilizing its resources to help clinicians navigate this new cancer care terrain and educate policymakers on the dire outcome abortion bans can have on pregnant women with cancer.
Assessing the Effect of Abortion Bans on Oncology Care for Women
What is your assessment on how the Supreme Court’s decision to overturn Roe v Wade is impacting oncology care for pregnant women with cancer?
So far, the main impact has been extreme uncertainty and confusion about what the real ramifications are. We must watch 50 different sets of laws take effect, and there is a lot of vagueness in the laws limiting or outlawing abortion in terms of exceptions made for the life of the mother. So, to date, I can’t say we have seen specific examples of harm to a pregnant patient with cancer, but we are seeing the uncertainty, the confusion, the fear, and the undermining of the doctor/patient relationship.
We are regularly communicating with our state societies and with our members and asking them whether and when they are comfortable to provide us with specific examples of how abortion bans or restrictions are impacting cancer care. Having specific examples will be incredibly helpful to understand what is happening in real-world practice, and we have not yet received such examples. That may be because either the provider or the patient does not want to talk about it. The silence does not mean patients or providers are not being impacted.
Providing Life-Saving Treatment for Pregnant Patients
The most common cancers that occur during pregnancy include breast cancer, cervical cancer, lymphoma, ovarian cancer, leukemia, colorectal cancer, and melanoma. Please talk about how the treatments for these cancers may result in harm to the fetus and how bans on abortion may impact care that may be contraindicated in pregnancy yet lifesaving for the patient.
Of those cancers, an acute leukemia is one where we generally admit the patient and start treatment as soon as the diagnosis is made; disease progression can happen very, very quickly, so this is one cancer where you do not have a lot of time to make decisions. You get the best chance for a cure if you admit the patient and start treatment right away. Usually, very high white blood cell counts and frequently low red blood cell counts and platelet counts go along with some of these acute myeloid leukemias; you cannot wait 3 months until the second trimester of a pregnancy, when there may be less harm to the fetus, to start treatment.
For breast cancer, you can perform breast surgery during pregnancy. Radiation therapy, even with shielding, is generally not recommended during pregnancy. Certainly, radiation therapy for more advanced cervical cancer is a big part of the treatment, and you cannot radiate in that area during pregnancy. So, every one of these cancers has different treatment modalities.
“For the newer targeted therapies and immunotherapies, we just do not have any data about their safety during pregnancy....”— JULIE R. GRALOW, MD, FACP, FASCO
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For many chemotherapies, we have decades worth of evidence to determine which ones are safe to give once a patient is in her second and third trimester and which ones are not. However, for the newer targeted therapies and immunotherapies, we just do not have any data about their safety during pregnancy, and there is great fear, just based on how they work, that they should not be used during pregnancy.
In breast cancer, for example, what we have learned over time is that the HER2 receptor is critical for fetal heart development. Thus, blocking HER2, which is incredibly effective in improving outcomes of early- or advanced-stage HER2-positive breast cancer, may adversely affect heart development in a fetus.
Educating the Public and Policymakers on Dangers of Abortion Bans for Patients
Recently, ASCO, the American Cancer Society (ACS), and the Leukemia & Lymphoma Society (LLS) issued a joint statement on cancer care and reproductive health, which outlined these organizations’ opposition to legislation banning abortion and that reduce patients’ ability to have timely access to life-saving cancer treatments.1 What is ASCO, ACS, and LLS doing to educate the public and policymakers on the dangers these bans may place on patients with cancer and the physicians who treat them?
We have already issued a policy brief on Fertility Preservation and Cancer.2 It is intended to be a tool for policymakers and emphasizes the importance of preserving the ability to have children for individuals facing cancer. We have convened a working group to develop new guidelines on the management of pregnancy in the context of cancer, and that will be published soon. Now, practice guidelines are generally for our clinicians and our members, whereas policy statements are generally for policymakers. However, we will use what we develop out of that pregnancy management guideline to inform how we present the information to our policymakers as well. We are also working with our state affiliates to educate policymakers at the state level on reproductive health and cancer care.
Fertility preservation in female patients with cancer is a complicated process and can involve egg, embryo, or ovarian tissue freezing. When states define personhood as the union of a sperm and an egg, that really complicates the in vitro fertilization process and embryo creation.
Addressing How Abortion Restrictions Impact Fertility Care
How might personhood laws that consider an embryo a human impact embryonic genetic testing for inheritable cancers? Will it be unlawful for families to discard embryos with a cancer gene mutation?
These laws will clearly impact our patients with cancer, as well as our society more broadly. There is a lot of uncertainty around this issue. Although there are no laws on the books yet prohibiting the destruction of embryos created for in vitro fertilization, there is a lot of concern about what may happen in the future if, for example, embryos are created, but the law changes before they can be implanted.
At ASCO, we feel we should stay involved in addressing how abortion restrictions impact our patients with cancer and the relationship between clinicians and their patients, and who is making the decision when it comes to the cancer care of pregnant patients, including their fertility care, both in the pre- and posttreatment settings.
Exacerbating Health Disparities Among -Vulnerable Patient Populations
A recent interview with medical recruiters found that obstetricians-gynecologists, internists, and medical students are refusing to move to conservative states to practice medicine.3 Are you hearing from ASCO members practicing in these states about whether to continue practicing there? How will oncologists’ migration out of these states decrease access to cancer care and increase health disparity among minority patient populations?
We are clearly hearing these same concerns through social media. I am unaware that we have heard directly from an ASCO member, student, or trainee who has specifically stated they have refused to move to one of these states. Now, we have not asked them either, but we are hearing about their concern. We are seeing the social media discussions, and I think we will see the ramifications of these laws with the number of applications to medical schools, residencies, and fellowships, as well as what happens with the workforce in these states.
Time will tell how much of an issue this is, but we are aware of broad concern among trainees and among those in the workforce about not wanting to be in these states. We are closely following developments.
We do know there will be health disparities, no question about it. Many of these states are states that are already dealing with a lot of disparities in access to care.
Navigating the New Medical and Legal Terrain
How is ASCO helping its members living in the states with abortion bans to navigate the new medical and legal climate?
We have mobilized our staff and our volunteers in these states to help keep us updated and navigate the fast-changing situation. We are looking at the implications of some of these laws and how to best support members by issuing clinical guidance statements or education programs or even helping with advocacy in these states.
This is new territory for us, but we have our own working group, which spans all our different departments, and we are getting expertise, both internally and externally, from a very multidisciplinary group. That group is keeping us updated and helping us stay nimble in our response, as situations regarding abortion restrictions change.
DISCLOSURE: Dr. Gralow is a member of the steering committee and data safety monitoring committee at Roche/Genentech; a member of the data safety monitoring committee and advisory board at AstraZeneca; a member of the advisory board at Puma Biotechnology; a member of the data safety monitoring committee at Novartis; a member of the data safety monitoring board at Immunomedics; and a consultant at Seagen.
REFERENCES
1. American Cancer Society’s Cancer Action Network, Leukemia & Lymphoma Society, and ASCO: Cancer care and reproductive health. Available at www.fightcancer.org/sites/default/files/cancer-care-and-reproductive-health-v4.pdf. Accessed October 17, 2022.
2. ASCO: Fertility preservation and cancer. Policy Brief. Available at www.asco.org/sites/new-www.asco.org/files/content-files/advocacy-and-policy/documents/2022-Fertility-Preservation-Brief.pdf. Accessed October 17, 2022.
3. Rowland C: A challenge for antiabortion states: Doctors reluctant to work there. The Washington Post. August 6, 2022. Available at www.washingtonpost.com/business/2022/08/06/abortion-maternity-health-obgyn/. Accessed October 17, 2022.
