Lack of Access to Abortion Has Had a Negative Impact on Cancer Care

Since the US Supreme Court overturned Roe v Wade last year, restrictions limiting access to abortion have had a negative impact on cancer care.^1-5 

Patients with cancer have been forced to travel out of their home states to terminate pregnancies, delaying the start of cancer treatment and increasing the patients’ risk of death.^3-6 

Patients have also experienced treatment delays due to legal battles, and they have been forced to receive less effective cancer treatment due to abortion restrictions in their state, according to Melanie Sheen, MD, a medical oncologist at Ochsner Medical Center in New Orleans, Louisiana.

Dr Sheen treated a pregnant patient with metastatic gastrointestinal cancer who could not receive standard therapy due to the abortion restrictions in Louisiana. The standard treatments carry significant risks of fetal toxicity, and the patient was unable to terminate the pregnancy, so the only option was to receive non-standard cancer treatment. 

In Louisiana, abortion was previously allowed up to 20 weeks post-fertilization.⁷ Now, abortion is banned except when used to “prevent the death or substantial risk of death due to a physical condition, or to prevent the serious, permanent impairment of a life-sustaining organ” of a pregnant patient.^8,9

Another of Dr Sheen’s patients had relapsed acute myeloid leukemia, and the patient’s request for an abortion was “tied up in legal debate,” increasing the patient’s risk of death. 

“Without an abortion, the patient herself would not have survived to 20-week gestational age without treatment, and the fetus would not have survived the induction therapy, as it carries a high embryo-fetal toxicity,” Dr Sheen explained.

“Louisiana already has the fifth highest maternal mortality rate in the country and the tenth highest cancer mortality rate, and I fear that the intersection of maternal mortality and cancer mortality will only be magnified the longer restrictions to abortion remain,” Dr Sheen said.^10,11 

Cancer Treatment in Pregnancy 

Research suggests that cancer affects approximately 1 in 1000 pregnancies, and 9% to 28% of patients choose to terminate the pregnancy.¹²

“Pregnant individuals with cancer face difficult choices — whether to initiate, delay, or continue life-saving cancer treatment, or whether to terminate their pregnancy,” said Julie R. Gralow, MD, chief medical officer and executive vice president of the American Society of Clinical Oncology (ASCO). 

“These medical decisions are complex, in part because timely cancer treatment improves a person’s likelihood of survival, but every patient should be able to maximize their chance for survival by receiving recommended care promptly.” 

When treating pregnant women with cancer, clinicians must balance the health of the patient and the fetus, said Katherine Van Loon, MD, associate professor of clinical medicine at the University of California, San Francisco, and director of the Global Cancer Program at the UCSF Helen Diller Family Comprehensive Cancer Center.

Clinicians must consider the patient’s diagnosis, the type of treatment required, the urgency of treatment, and the safety of treatment based on the gestational age of the fetus, Dr Van Loon said. 

“The consideration of a termination is only relevant when the fetus is not yet viable, the mother needs urgent therapy for her cancer, and the proposed therapies are likely to be teratogenic,” Dr Van Loon noted. “In these cases, if the cancer treatment is delayed, the mother could die.”

A meta-analysis published in 2020 showed that the mortality risk among patients with cancer increased by as much as 13% with each month that treatment was delayed.⁵ 

Concerns About Cancer Treatment in a Post-Roe Era

The Dobbs v Jackson ruling, which overturned Roe v Wade, “empowers states to determine access to abortion and will disproportionately impact female cancer patients of child-bearing age,” said Kriti Mittal MD, an assistant professor at UMass Chan Medical School in Worcester, Massachusetts. 

“As my colleagues and I outline in our recent editorial in JCO Oncology Practice, delicate conversations about treatment planning between patients and physicians will now move from the clinic to the state house,” she added.¹³

Although many states with tight abortion restrictions allow exceptions when termination of a pregnancy is necessary to protect the life of the pregnant patient, the rules on how to apply these exceptions are unclear.^2,14 

“With such uncertainty, clinicians will fear criminalization and may not act in the best interest of the patient,” Dr Van Loon said. “Clinicians in every state need to be protected and empowered to provide timely care that protects the life of the mother.”

Dr Gralow said ASCO has received many inquiries from oncologists who are worried about the impact of the Dobbs decision on patients. 

“Some of our members are concerned about maintaining the ability to provide evidence-based care while navigating the complexities of the legal system, given the quickly changing legal landscape and the subsequent ethical and legal concerns across medicine following the Dobbs decision,” Dr Gralow explained. 

“They are worried about whether their patients can get the care they need in a timely manner, and they are worried about the ethical and legal uncertainties in the post-Roe era and whether providers could face prosecution for providing high-quality, evidence-based cancer care,” she added.

Dr Van Loon anticipates that many clinicians and cancer patients affected by restrictive abortion laws in “hostile states” will be apprehensive about discussing their experiences in the post-Roe era. 

“One of the projects that we are considering is to develop a formal way to anonymously interview patients and their doctors so that we can learn more about the impacts” of the ruling, Dr Van Loon said. 

Another potential issue is that oncologists with expertise in treating pregnant patients may not feel comfortable treating patients in more restrictive states, said Eleonora Teplinsky, MD, head of breast medical oncology at Valley Health System in Paramus, New Jersey, and clinical assistant professor of medicine at the Icahn School of Medicine at Mount Sinai in New York, New York.

Dr Teplinsky noted that the number of oncologists with this expertise is already limited, and these experts may feel forced to leave states where patients need them the most.

Help for Clinicians and Patients

“On an individual level, oncologists must be able to counsel pregnant patients on all of their options, regardless of geographic location, and we must support our colleagues in states with abortion bans who face challenges in how they can treat pregnant patients with cancer,” Dr Teplinsky said. 

“One of the ways we can do this as an oncology community is to provide guidance on clinical situations that are life-threatening and should be free from legal prosecution — such as a pregnant patient with newly diagnosed leukemia, for example.” 

Dr Teplinsky said one resource that can help guide treatment in these cases is the Advisory Board on Cancer, Infertility and Pregnancy, an international board that provides expert advice to doctors treating pregnant patients with cancer.¹⁵

Another resource is ASCO’s guidance for navigating cancer care in states with abortion restrictions.¹⁶ The guidance includes recommendations for oncologists and their institutions. For example, the guidance recommends that oncologists:

• Inform patients about the benefits and risks of all treatment options available within the United States and do not omit medically and scientifically accurate information
• Ensure patient safety and privacy, being sensitive to patients who can’t legally access abortion in their state and are unable to travel.

The guidance also recommends that institutions “protect clinicians who appropriately inform their patients about all standard treatment options for their disease” and “establish safe and rapid mechanisms for referral and transfer of patients who require abortion care related to cancer treatment.”

Such mechanisms could help meet the transportation needs of patients seeking abortions outside of their home state, but whether patients can afford that transportation, or whether their insurance will cover it, is another consideration.

“Transportation barriers are especially high for those patients not covered under private insurance, since Medicaid patients and patients treated on insurance plans provided by the ACA exchange may be limited to their in-state providers,” said Sunita D. Nasta, MD, professor of clinical medicine at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia.  

“Because federal law only allows the use of federal funds for abortion in cases of rape, incest, or life endangerment of the pregnant person, in most states, Medicaid coverage for abortion is limited to these circumstances,” Dr Nasta added. “However, 16 states do go beyond this limit and use state funds to cover other abortions for people enrolled in Medicaid.”¹⁷

There is a need to enact “legislation permitting travel for abortion services, or the current restrictions on abortion care in the states limiting abortion need to be loosened for management of cancer patients,” Dr Nasta said.

“In terms of advocacy, I think we need to make sure that our policy makers understand the potentially devastating consequences of denying a pregnant woman the oncologic care that she requires,” Dr Van Loon said. 

Dr Gralow said ASCO is committed to ensuring timely access to high-quality, equitable, evidence-based care for cancer patients who are pregnant or may become pregnant during treatment, regardless of where they live, as well as advocating for policies that allow the provision of such care. 

“No court decision, regulation, or legislation should deprive patients of potentially life-saving, life-extending, or palliative treatment,” Dr Gralow said. “Furthermore, no oncologist should have to choose between their professional duties and ethical commitments to patients, obeying the law, and their individual conscience or fear criminal prosecution for providing evidence-based, high-quality care to their patients.”

Disclosures: The clinicians interviewed for this article reported that they have no relevant disclosures.

References

1. Abortion in the United States dashboard. KFF. Updated April 14, 2023. Accessed May 3, 2023.

2. State policies protecting or restricting legal status of abortion. KFF. Updated July 27, 2022. Accessed May 3, 2023.

3. Luthra S. State abortion bans are preventing cancer patients from getting chemotherapy. The 19th. Published October 7, 2022. Accessed May 3, 2023.

4. Grey H. How strict abortion laws are delaying cancer treatment. HealthLine. Published October 27, 2022. Accessed May 3, 2023.

5. Ungar L and Hollingsworth H. Despite dangerous pregnancy complications, abortions denied. Associated Press. Published November 20, 2022. Accessed May 3, 2023.

6. Hanna TP, King WD, Thibodeau S, et al. Mortality due to cancer treatment delay: systematic review and meta-analysis. BMJ. 2020;371:m4087. doi:10.1136/bmj.m4087

7. Abortion in Louisiana. June Medical Services v. Russo. Center for Reproductive Rights. Accessed May 3, 2023.

8. Status of State Abortion Bans, as of April 6, 2023, Louisiana. State Profiles for Women’s Health. KFF. Accessed May 3, 2023.

9. Human Life Protection Act. RS 40:1061. Chapter 5. Health Provisions: Abortion. Louisiana State Legislature. Accessed May 3, 2023.

10. Maternal deaths and mortality rates per 100,000 live births. KFF. Accessed May 3, 2023.

11. Cancer mortality by state. US Centers for Disease Control and Prevention. Updated February 28, 2022. Accessed May 3, 2023.

12. Silverstein J and Van Loon K. The implications of the Supreme Court decision to overturn Roe v Wade for women with pregnancy-associated cancers. JAMA Oncol. 2022;8(10):1394-1395. doi:10.1001/jamaoncol.2022.3785

13. Mittal K, Sheen M, Wheelden M, Faramand R, Teplinsky E, Joshi M. Dobbs v Jackson– rewriting women’s autonomy in cancer care. JCO Oncol Pract. Published online January 18, 2023. doi:10.1200/OP.22.00610

14. Harris LH. Navigating loss of abortion services – a large academic medical center prepares for the overturn of Roe v. Wade. N Engl J Med. 2022;386(22):2061-2064. doi:10.1056/NEJMp2206246

15. Advisory Board on Cancer, Infertility and Pregnancy. Ask for Advice. https://www.ab-cip.org/ask-for-advice

16. Spence RA, Hinyard LJ, Jagsi R, et al. ASCO ethical guidance for the US oncology community where reproductive health care is limited by law. J Clin Oncol. Published online March 29, 2023. doi:10.1200/JCO.23.00174

17. State funding of abortions under Medicaid. KFF. Updated May 1, 2022. Accessed May 3, 2023.