The American Cancer Society’s key stakeholders are people with cancer and their families.
As described in our public statement, and as a non-partisan organization, we hold a steadfast commitment to health equity. We believe that everyone should have a fair and just opportunity to prevent, find, treat, and survive cancer, and not be disadvantaged because of how much money they make, the color of their skin, their age; their sex, sexual orientation, or gender identity; their physical or mental ability; or where they live.
In overturning the 50-year-old landmark 1973 Roe v. Wade decision on June 24, the Supreme Court determined that the U.S. Constitution does not confer a right to abortion and therefore granted the authority to determine abortion rights to individual states.
The result is the potential for immediate and profound impact for certain cancer patients and their families because of where they live.
Cancer during pregnancy is a reality on the rise
Annually, up to one in 1,000 pregnant women in the U.S. receive a cancer diagnosis.1-3 This number is expected to increase as a function of the increase in maternal childbearing age in the United States.4
Moreover, it is notable that cancer is the second most common cause of death for women during childbearing age,5 and further, that cancer diagnoses during pregnancy are often delayed due to overlapping symptoms such as fatigue, anemia, and nausea.6
Given the strong link between early detection and treatment with increased cancer survivorship, we are concerned about the implications for the ruling to impede timely, life-saving care for cancer patients.
Challenges to cancer care during pregnancy
The proposal in some states to define personhood at fertilization (e.g., as exemplified in under Arkansas law, which immediately went into effect after the Supreme Court ruling and defines in statute an “unborn child mean(ing)an individual organism of the species Homo sapiens from fertilization until live birth”) creates a likely barrier for a subset of pregnant women to receive immediate, effective cancer care.
Notably, while surgical procedures are generally considered safe during pregnancy, other common cancer interventions which ensure a better outcome for the mother are not recommended if the goal is continuation of pregnancy6,7 due to the impact of treatment on a fetus.
For example, any type of radiation therapy is avoided during pregnancy, regardless of the location of the cancer. Further, most cytotoxic chemotherapies must also be avoided during the first trimester if the clinical goal is to prevent harm to the fetus, thus in some cases placing the health of the mother at risk by delaying treatment.
This is particularly important in fast-growing, aggressive cancers where delays in treatment measured in days or weeks can be lethal to the mother.
Such decisions regarding how to move forward using a patient-centered approach require thoughtful discussion between the pregnant patient and the oncology team, which historically have not been interfered with by government.
It is also notable that many uncertainties remain with regard to use of chemotherapy and targeted therapies during pregnancy, since pregnant women are excluded from almost all clinical trials. There is therefore a concern that sufficient lack of understanding of therapeutic intervention on a developing embryo or fetus will lead to hesitancy to treat the patient.
In the modern era of oncology, additional cancer therapies with the potential to save or extend life of the mother are not recommended during any stage of pregnancy.6,7 Amongst these are hormonal therapies for breast cancer (e.g., tamoxifen, anastrozole), which is the most common cancer diagnosed in pregnant women.
As for newer generation targeted agents, limited understanding of drug safety during pregnancy creates clinical challenges for oncologists and their worry about potential legal or criminal implications of their decisions.
For example, after a thoughtful conversation of risk, benefits, and alternatives between an oncologist and a pregnant patient with chronic myeloid leukemia, they may together choose to move forward with imatinib as a proven treatment to prolong disease-free survival.
As imatinib can be associated with spontaneous abortion, we worry that the threat of state law-based criminal or civil penalties may preclude this shared decision-making conversation, thus reducing patient autonomy in managing their own cancer and putting the oncologist at risk.
Immunotherapy, which has yielded significant promise in a subset of cancer types occurring in pregnant women, has yet to be assessed for the impact on the fetus and maintenance of a successful pregnancy.
Some immunomodulatory agents are known to cross the placenta and have the potential to cause direct toxicity to the fetus. Given these concerns, a subset of immunotherapies is not currently recommended during pregnancy.
Given the more narrow range of options for some pregnant patients to receive cancer care without the potential danger of fetal harm, questions arise regarding the implications of new or proposed state legislation for timely access to cancer care.
As such, the American Cancer Society’s Cancer Action Network is actively monitoring the implications of the Dobbs vs. Jackson ruling, and will continue to advocate for evidence-based, unimpeded access to cancer care.
Learning by precedent: potential impact of abortion restrictions on cancer care
Given the challenges described above, the importance of addressing the issue of barriers to cancer care for pregnant patients is critical. In the aftermath of the Dobbs vs. Jackson ruling, families in some states will face an unprecedented and potentially life-threatening dilemma for the pregnant patient, especially in states where the exceptions are statutorily defined as the life of the mother and medical emergencies rather than the health of the mother.
Put simply, in such scenarios there is a significant concern that timely cancer care to the pregnant patient would be impeded due to potential harm to the developing fetus, and physician hesitancy to treat due to fear of unintended pregnancy termination and legal prosecution.
While to some it may seem inconceivable that such critical barriers to care may manifest itself within the United States, precedent in other countries serves as a cautionary tale.
For example, in Nicaragua where there is a total ban on abortion, it has been reported that pregnant women have been unable to receive potentially life-saving cancer care due to the potential of harm to the fetus or inducing a spontaneous abortion.
Indeed, women and girls who terminate pregnancy in Nicaragua face two years in prison, and medical professionals can be sentenced to up to six years for providing care that even unintentionally leads to an abortion.8
Similar themes have been observed in the Dominican Republic, including a horrifying and highly publicized story of a 16-year-old girl who was nine weeks pregnant and diagnosed with leukemia. This young woman was initially denied chemotherapy due to concern that the treatment which could have saved her life may inadvertently terminate the pregnancy.
She ultimately died of her cancer at 13 weeks pregnancy due to delayed treatment.
This case is notable given the similarity to some proposed legislation within a subset of U.S. states, wherein according to the Dominican Republic constitution, the right to life is inviolable from the moment of conception until death.9
Even more recent and alarming reports have emerged from Poland, in which the ban on abortion has had consequence on cancer care. As reported by The New York Times, pregnant women diagnosed with aggressive cancer have even resorted to leaving the country to receive care.10
Importantly, all these cases violate the well-accepted ethical principal in medicine of “dual effect”, where after thoughtful discussions between patients and their clinicians, sometimes it is permissible to experience a negative outcome if the primary intention is for a good outcome (e.g., saving the mother’s life) and risks of the negative outcome are minimized to the extent possible.
This principle, widely applied across medicine during times of patient extremus and complex clinical situations, prioritizes the intentionality of the patient and their clinical team (e.g., saving the mother’s life).
Further concerns arise as related to the potential for a disproportionate impact on persons of color. Research has shown that Black men and women have the highest death rate and shortest survival of any racial or ethnic group in the nation for most cancers.
Strikingly, Black women have a 41% higher death rate from breast cancer as compared to whites, which is the most frequent cancer type diagnosed in the pregnant population. Inflammatory breast cancer, which is an aggressive subtype for which rapid treatment is imperative, is more common in Black women.
In parallel to the increased cancer burden for Black women, Black women in the United States have reduced access to highly effective contraception as compared to whites, and as such a higher rate of unintended pregnancies.11
Given these data, there is reason to predict that barriers of cancer care to pregnant individuals have the potential to impact communities of color even more deeply.
Implications for fertility preservation
Finally, proposed new legislation has the potential to impact all cancer patients who seek fertility preservation. Current guidelines recommend that all cancer patients of childbearing age should receive the option for fertility preservation. Studies demonstrate that lack of such preservation is a common regret, which affects downstream quality of life during cancer survivorship.12
More than 80,000 young adults aged 20-39 are diagnosed with cancer each year in the U.S., many of whom opt to preserve for fertility preservation to start or grow their families after their cancer therapy is complete. Further, approximately 5%-6% of the population in childbearing age are cancer survivors.13
The most recommended approach to fertility preservation for cancer patients is through the creation and freezing of fertilized embryos for post-treatment implantation. Oftentimes, to ensure success of this process, multiple such embryos are created.
It remains unclear after the recent Dobbs ruling how embryos that are not considered viable (due to non-life sustaining malformations) or that are beyond the family’s needs will be treated by varying state laws.
This creates significant uncertainty for patients, their families, and oncology teams related to potential new financial, civil, and criminal penalties that have not for five decades interfered in this critical patient/clinician discussion.
In sum, the Dobbs vs. Jackson ruling has significant implications for the cancer patients and families we represent.
This is not a partisan issue. Through the American Cancer Society Cancer Action Network, we are committed to working with states to provide needed information about the consequences of reproductive legislation on access to care for pregnant cancer patients, access to fertility preservation for all cancer patients of childbearing age, and any other implication with the potential to influence cancer survivorship.
As aligned to our mission to improve the lives of cancer patients and their families, we will continue to advocate for policies that maximize all person’s ability to survive and thrive after a cancer diagnosis.
Citation:
- Donegan WL. Cancer and pregnancy. CA Cancer J Clin. 1983;33(4): 194–214.
- Nieminen U, Remes N: Malignancy during pregnancy. Acta Obstet Gynecol Scand 49:315-319, 1970
- 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
- US Census report.
- Siegel RL, Miller KD, Jemal A: Cancer statistics, 2019. CA Cancer J Clin 69:7-34, 2019
- Silverstein J, Post AL, Chien AJ, Olin R, Tsai KK, Ngo Z, Van Loon K. Multidisciplinary Management of Cancer During Pregnancy. JCO Oncol Pract. 2020 Sep;16(9):545-557. doi: 10.1200/OP.20.00077. PMID: 32910882.
- Hepner A, Negrini D, Hase EA, Exman P, Testa L, Trinconi AF, Filassi JR, Francisco RPV, Zugaib M, O’Connor TL, Martin MG. Cancer During Pregnancy: The Oncologist Overview. World J Oncol. 2019 Feb;10(1):28-34. doi: 10.14740/wjon1177. Epub 2019 Feb 26. PMID: 30834049; PMCID: PMC6396773.
- Hutchison C. Nicaragua’s anti-abortion policy endangers women, criminalizes doctors, experts say. ABC News. 2010 Feb 10. Nicaragua’s Anti-Abortion Policy Endangers Women, Criminalizes Doctors, Experts Say – ABC News (go.com)
- Romo R. Dominican Republic abortion ban stops treatment for pregnant teen with cancer. CNN. 2012 July 25. Dominican Republic abortion ban stops treatment for pregnant teen with cancer | CNN
- Bennhold K, Pronczuk M. Poland Shows the Risks for Women When Abortion Is Banned. The New York Times. 2022 June 26. https://www.nytimes.com/2022/06/12/world/europe/poland-abortion-ban.html
- American Cancer Society. Cancer Facts & Figures for African American/Black People 2022-2024.
- Benedict C, Thom B, Kelvin JF. Young Adult Female Cancer Survivors’ Decision Regret About Fertility Preservation. J Adolesc Young Adult Oncol. 2015 Dec;4(4):213-8.
- Pinelli S, Basile S. Fertility Preservation: Current and Future Perspectives for Oncologic Patients at Risk for Iatrogenic Premature Ovarian Insufficiency. BioMed research international, 2018, 6465903.
