As abortion bans take effect in a controversial region of the South, cancer doctors are grappling with how the new state laws will affect their conversations with pregnant patients about what treatment options they offer. can do
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, supercharged hormones during pregnancy can increase cancer growth, putting the patient at greater risk.
Although the new abortion restrictions often allow exceptions based on a “medical emergency” or a “life-threatening physical condition,” cancer physicians describe the legal terms as unclear. They fear that the rules will be misinterpreted and they will be left out.
For example, brain cancer patients are traditionally offered the option of abortion if pregnancy would limit or delay surgery, radiation, or other treatments, said Dr. Adjah Andoum, Emory in Atlanta. brain cancer surgeon at the University’s Winship Cancer Institute.
“Is this a medical emergency that requires an abortion? I don’t know,” Nduom asked, trying to parse the medical emergency exception in Georgia’s new law. “Then you’re faced with a situation where you have an enthusiastic prosecutor who’s saying, ‘Hey, this patient had a medical abortion. Why did you have to do that?'” he said. said
Pregnant patients with cancer should be treated the same as non-pregnant patients when possible, although sometimes with adjustments to the timing of surgery and other care, according to a research review published in 2020 in Current Oncology Reports. has happened
With breast cancer patients, surgery may be done earlier as part of treatment, which moves chemotherapy later in pregnancy, according to research. Cancer specialists generally recommend avoiding radiation therapy throughout pregnancy, and most chemotherapy drugs during the first trimester.
But Dr. Gwen Nichols, chief medical officer of the Leukemia and Lymphoma Society, said that with some cancers, such as acute leukemia, the drugs prescribed are known to have toxic risks for the fetus, and the timing is not for the patient.
“You need immediate treatment,” she said. “You can’t wait three months or six months to carry a pregnancy to term.”
Another life-threatening scenario involves a patient who is diagnosed early in her pregnancy with breast cancer that is spreading, and tests show that the cancer is caused by the growth hormone estrogen, Dr. said Debra Pate, an ophthalmologist 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 you have elevated estrogen levels. It actually causes the cancer to actively grow every moment. So I would consider it an emergency,” said Pete, who He is also executive vice president of policy and strategic initiatives at Texas Oncology, a statewide practice with more than 500 physicians.
When cancer strikes people of childbearing age, one challenge is that the lesions tend to be more aggressive, said Dr. Miriam Atkins, an ophthalmologist in Augusta, Georgia. Another is that it is not known whether some of the new cancer drugs will affect the fetus, she said.
Although hospital ethics committees may be consulted about a particular treatment dilemma, it is the facility’s legal interpretation of state abortion law that will likely prevail, said Micah Hester, an ethics committee expert at the University Head of the 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 in many states sets pretty strong parameters for what you can and can’t do.”
It’s hard to fully predict how doctors plan to handle such dilemmas and conversations in abortion-ban states. Several major medical centers contacted for this article said their physicians were not interested or available to discuss the topic.
Nduom and other physicians, including Atkins, said the new rules would not change their discussions with patients about the best treatment regimen, possible pregnancy outcomes, or whether abortion is an option.
“I will always be honest with patients,” Atkins said. “Oncology drugs are dangerous. There are certain drugs you can give. [pregnant] Cancer patients; There are many that you cannot do.”
The bottom line, something to maintain, is that termination remains an important and legal part of care when cancer threatens someone’s life.
Dr. Joseph Biggio Jr., chief of maternal-fetal medicine at Ochsner Health System in New Orleans, wrote in an email, patients should be “educated about the best treatment options for them, and the potential impact on their pregnancy and future fertility.” Advised.” “Under state law, termination of pregnancy to save the life of the mother is legal.”
Similarly, Pate said physicians in Texas can counsel pregnant patients about cancer procedures if, for example, the treatment has documented risks of birth defects. As such, doctors may not recommend them, and abortion may be offered.
“I don’t think it’s controversial in any way,” Pete said. “Cancers left unchecked can be life-threatening.”
Pat has been educating doctors at Texas Oncology about the new state law, as well as sharing a JAMA Internal Medicine editorial detailing abortion care resources. “I feel very strongly about this, that knowledge is power,” he said.
Still, the vague wording of the Texas law complicates doctors’ ability to determine legally justified care, said SMU Dedman School of Law professor Joanna Grossman. He said nothing in the law tells a doctor “how much of a risk there has to be before we can legally label it ‘life-threatening’.”
And if a woman can’t obtain an abortion by legal means, she has “serious options,” according to Hester, a medical ethicist. He’ll have to sort through questions like: “Is it better for him to treat the cancer on the timescale prescribed by the drug,” he said, “or to maximize the health benefits to the fetus?” Delaying cancer treatment?
Abortions outside of Georgia may not be possible for patients who have limited cash or no backup childcare or who share a car with extended family, Atkins said. “I have many patients who can barely travel to get their chemotherapy.”
Dr. Charles Brown, a maternal-fetal medicine physician in Austin who retired this year, said he can talk more freely with fellow practitioners. Brown, who cares for pregnant women with cancer, said the scenario and the unanswered questions surrounding it are almost too numerous to count.
Another example, he said, is a possible situation in a state that incorporates “fetal personhood” into its statute, such as Georgia. Brown asked what if a cancer patient could not have an abortion, and the toxic effects of the treatment were known.
“What if she says, ‘Well, I don’t want to delay my treatment — give me the medicine anyway,'” Brown said. “And we know that medicine can harm the fetus. Am I now responsible for harming the fetus because it’s 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 taken away one of her options for managing her illness.”
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