As conservative legislatures take the cue from the Supreme Court’s overturn of Roe v. Wade by enacting abortion restrictions, oncologists in many states are scrambling to figure out how to best care for their pregnant patients, said Alice Mims, a hematologist-oncologist at the Ohio State University Comprehensive Cancer Center – James.
“I live in a state now—Ohio—where there’s a six-week abortion ban, unless in case of a medical emergency or no heartbeat detected,” Mims, the OSUCCC-James acute leukemia clinical section head and associate professor in the Division of Hematology, said to The Cancer Letter. “I think the concern is, do you have to wait and get permission?”
The Ohio bill prohibits abortions after six weeks, except in the case of medical emergency or necessity, or if there is no heartbeat. (Experts have pointed out that the term “fetal heartbeat” is not medically accurate—fetuses haven’t yet developed heart valves at six weeks.)
“Who’s making the determination about ‘medical emergency’?” Mims said. “How do you feel confident you’re not going to have your medical license be charged with a felony, versus doing your job to take the best care of the patient, which is more important?”
Almost half of U.S. states—including Ohio—have already banned or heavily restricted abortion. Immediately following the Supreme Court’s June 24 ruling, an Ohio judge dissolved the injunction on the six-week abortion ban.
The American Civil Liberties Union of Ohio, Planned Parenthood Federation of America, and the law firm WilmerHale have filed a lawsuit against the bill—but, at least for now, the ban remains. On July 1, the Ohio Supreme Court rejected a request for an emergency stay on the bill.
“[Cancer] should equate to a medical emergency, but you just don’t know, especially when you have people in the legislature who are trying to draft things—like in Ohio, they have this bill that they were trying to propose to replant ectopic pregnancies,” Mims said. “Fortunately, that didn’t go forward, but if you have people who don’t understand and don’t have a medical background who are trying to make laws, it makes things a lot more complicated in trying to do the best thing for your patients.”
Pregnancy does, in many cases, threaten a cancer patient’s survival. However, pregnant cancer patients undergoing treatment may face more nuanced risks—birth defects to the fetus, for example, or having to accept suboptimal treatment in order to carry the pregnancy to term—that may not qualify as a “medical emergency” (The Cancer Letter, July 1, 2022).
“It’s hard when there are these black-and-white laws from people who don’t understand the nuances of medicine and how it impacts patients,” Mims said. “The people who are trying to put all these regulations in place, unless they personally go through this as human beings or know people who do, they don’t understand it to that level.”
If an Ohio doctor does perform an abortion, they need to provide written rationale in the patient’s medical record for how the abortion will “prevent the death of the pregnant woman or to prevent a serious risk of the substantial and irreversible impairment of a major bodily function of the pregnant woman.” The doctor must keep this written statement for seven years.
“You need to document all the rationale behind it, but who’s going to make the determination that your rationale is good enough?” Mims said.
Failure to comply may result in legal action (The Cancer Letter, July 1, 2022). In Ohio, violating the six-week “heartbeat law” equates to a felony of the fifth degree. Doctors may also incur steep fines.
“The state medical board may assess against a person a forfeiture of not more than twenty thousand dollars for each separate violation or failure of the person to comply with any of the requirements,” the bill reads.
Ohio oncologists are concerned about the consequences not only of performing abortions, but of administering treatment that threatens pregnancy, Mims said.
“What if you treat a patient later in their pregnancy, like second or third trimester, with chemotherapy—when it should be safer, but it’s still not a completely safe thing—and the patient miscarries, and that could potentially be attributed to a side effect of your chemotherapy?” Mims said.
Providing legal justification for an abortion could also take time—something pregnant cancer patients don’t have a lot of, Mims said.
“Sometimes, things happen very quickly with cancer patients, and we don’t have time to call a lawyer, necessarily, and talk to the attorney general in the state to decide about care for our patients,” Mims said. “I think we’re going to run into problems because of that.”
Mims spoke with Alice Tracey, a reporter for The Cancer Letter.
Alice Tracey: I’d love to hear your thoughts on how abortion bans are affecting—or are going to affect—cancer patients and cancer doctors.
Alice Mims: Absolutely. So, I’ll tell you a little bit about my background. I focus on acute leukemias in adults—so, blood cancers. I think that’s where my perspective comes from, because I live in a state now—Ohio—where there’s a six-week abortion ban, unless in case of a medical emergency or no heartbeat detected.
It’s not common that we have patients who come in who are pregnant with acute leukemia, but it has happened, and I have taken care of those patients. Typically, those are medical emergencies, where they need to start treatment very soon or the patients will die.
I think the concern is, do you have to wait and get permission? Who’s making the determination about “medical emergency?” How do you feel confident you’re not going to have your medical license be charged with a felony, versus doing your job to take the best care of the patient, which is more important. It’s very stressful to think about.
It’s something that’s come up with my colleagues, other people who care for these patients, because we’ve had these scenarios arise in the past. The response—it’s been difficult.
We’re not sure about this new legislation. We’ll have to see—[cancer] should equate to a medical emergency, but you just don’t know, especially when you have people in the legislature who are trying to draft things. Like in Ohio, they have this bill that they were trying to propose to replant ectopic pregnancies.
Oh my gosh.
AM: Fortunately, that didn’t go forward, but if you have people who don’t understand and don’t have a medical background who are trying to make laws, it makes things a lot more complicated in trying to do the best thing for your patients.
For our patients, they come in, they have acute leukemia, they’re pregnant, they have complications from their leukemia—they can present with bleeding complications—they’re going to have a high white [blood cell] count and need urgent chemotherapy. Then you have to consult your OB/GYN colleagues.
Are they going to feel comfortable moving forward with the procedure? How do you document it? You need to document all the rationale behind it, but who’s going to make the determination that your rationale is good enough?
Or, what if you treat a patient later in their pregnancy, like second or third trimester, with chemotherapy—when it should be safer, but it’s still not a completely safe thing—and the patient miscarries, and that could potentially be attributed to a side effect of your chemotherapy? It just makes it very difficult to try to do the best thing to care for your patient, when you have that looming over your head.
Absolutely. And from my understanding, sometimes it’s not a life-or-death medical emergency, but there are risks of being pregnant while having cancer or undergoing treatment. So, I’m imagining it’s really hard to make that call in a state where there are these black-and-white rules about who can have an abortion.
AM: Yeah, absolutely. As physicians, the majority of us go into this field because we want to help people. It’s hard when you feel that there are laws in place that don’t allow you to give the best care possible for your patients.
Do you think this will affect where physicians choose to practice, or is this going to have an impact on physician burnout?
AM: Yes. Healthcare providers, in general, are so burnt out from the pandemic to begin with. Then, when you pile these rules and regulations on top of that, I absolutely do think it will impact where providers choose to practice.
If you’re worried about litigation for trying to care for your patients—I think people will move. I also think people will move to places that align with their core beliefs. People may not want to raise families in places where they don’t feel that it represents their background.
This all seems to stem from certain religious backgrounds. When you’re trying to care for all of your patients, and there may be patients who don’t agree with this, or you yourself maybe don’t, that’s not your core background—it’s hard to be in a place where you can’t practice medicine, or raise a family, and feel safe.
I understand also that women physicians have higher rates of miscarriage and pregnancy complications, for a number of reasons—so, I guess there are situations where doctors will be equally impacted by these restrictions.
AM: Oh yeah, absolutely. There’s also concern that—as physicians, it can be harder to have pregnancies, like you mentioned—but also for cancer patients, where there’s thoughts of legislation to regulate life at conception.
You need to document all the rationale behind it, but who’s going to make the determination that your rationale is good enough?
When you think about IVF, embryos, things like that—where, at least for patients who have chemotherapy, that can affect their fertility, and then they’re trying to get pregnant later by different means than the norm—they may get in situations where their life is in danger again.
I think it’s just all very complicated and, like you said, I think it’s hard when there are these black-and-white laws from people who don’t understand the nuances of medicine and how it impacts patients.
The people who are trying to put all these regulations in place, unless they personally go through this as human beings or know people who do, they don’t understand it to that level.
So, what has been the reaction among the doctors at your cancer center? Have you been talking about this with colleagues, or are people reacting silently?
AM: I think there’s both. Definitely, there are a lot of reactions—we have different groups, for hematology/oncology physicians—and as far as on social media, people discuss it.
I think people are very blown away and taken aback by this. Within my own institution, I think, people are very concerned.
That’s why we’re trying to preemptively understand, how does this apply to us? When these scenarios come up, can we be proactive in knowing what we can or cannot do? And how do we counsel our patients in regard to this?
There are a lot of conversations, but I also think people get concerned about talking about this more publicly, because of the repercussions. It can be a little bit unnerving to talk about things where people can have such strong reactions, and how it can impact your career—even just speaking out.
Is there anything that we have missed that you would like to share about the impacts of these abortion restrictions?
AM: I think the biggest thing that I’d like to share is that you have to remember that you have to have a mom in order to have a healthy baby.
This needs to be better thought of: How do we best take care of moms, people who are pregnant, providing them with the best care?
Not having such restrictive laws in place that don’t allow physicians or healthcare providers to do their jobs.
Sometimes, things happen very quickly with cancer patients, and we don’t have time to call a lawyer, necessarily, and talk to the attorney general in the state to decide about care for our patients.
I think we’re going to run into problems because of that.
Yes. You don’t have time to have a court decide if it’s a medical emergency or not, when somebody’s life is at stake.
AM: Exactly. Well, thank you.
Thank you for sharing. Lovely to meet another Alice.
