Roe v. Wade is about more than just abortion.
In this past week following the Supreme Court’s overturning of Roe v. Wade on June 24, we apprehensively discussed the coming ripple effects we anticipate as gynecologic oncologists, as obstetrician-gynecologists, and as women.
We can relate to the desire to protect innocent human life on a deep and personal level. However, our education and experience has informed our strong stance that the “pro-life” position is not pro-life at all.
Reversing the protections offered by Roe v. Wade will have farreaching second- and third-order effects in women’s health, including cancer care delivery and cancer-specific mortality.
Aligned with this concern, several of our professional societies issued statements this past week reaffirming that abortion is medical care, plain and simple.
[Editor’s note: A compilation of statements from professional societies, advocacy groups, and cancer centers appears here.]
The difficult decision to terminate a pregnancy is nuanced and best made by that individual, and those they choose to include, in consultation with a trained physician.
Removal of this autonomy is—ironically—an injustice, and a violation of medical ethics.
Specifically for gynecologic cancer, the criminalization of pregnancy termination limits options and choices relative to fertility preservation, cancer diagnosed during pregnancy, and the management of gestational trophoblasticy—the malignant transformation of a conception.
Likely more far-reaching, however, is that the loss of the right to choose creates a social construct where women are devalued or even stigmatized, dissatisfied with their reproductive medical care, and less likely to participate in cancer screening and prevention programs or present at symptom onset for early cancer diagnosis.
If you think this is catastrophizing—keep reading.
First, let’s address onco-fertility. Many patients are diagnosed with cancer during their reproductive years and treatment of their cancer can impact fertility. Women have two options, either to freeze their eggs or to freeze embryos, a fertilized egg.
Freezing embryos has some advantages over freezing eggs alone, such as improved survival rate and a better understanding of which eggs were healthy which can lead to less procedures.
With recent anti-abortion legislation, the role of embryos in the personhood debate becomes complicated. For cancer patients who have embryos saved, many will plan for a couple of children but they can have tens of embryos.
Many choose to donate unused embryos and others chose to discard them.
Some states use language such as ‘developing humans’ or ‘conception’ in legislation that may restrict how cancer patients want to safely use their embryos to complete their families.
This leaves women with hard decisions about whether to pursue fertility preservation at all and far fewer options during an unthinkably challenging time of their life.
Additionally, many families with genetic predisposition to cancer, such as the BRCA gene mutation, will utilize IVF and pre-implantation genetic diagnosis to select embryos without the mutation.
Those embryos that carry the gene mutation might be discarded, while those that don’t would be implanted. Many couples would explicitly not want to be forced to implant embryos with a genetic predisposition to cancer and may lose the option to provide a life without a dramatically increased risk of cancer to their children.
Next is when cancer is diagnosed during pregnancy. This is thankfully not common, and we have developed many ways for pregnancy and cancer care to co-exist. These treatment modifications, however, can increase a mother’s risk for poor cancer outcomes. Some patients, however, do not have these options.
The loss of the right to choose creates a social construct where women are devalued or even stigmatized, dissatisfied with their reproductive medical care, and less likely to participate in cancer screening and prevention programs or present at symptom onset for early cancer diagnosis.
Therefore, not only must termination remain an option for these patients, but it also needs to be free of distress and stigmatization. You will be hard-pressed to find another situation in medicine so distressing as this.
An angle that didn’t immediately occur to us was in the management of gestational trophoblastic neoplasia, or GTN. GTN is also not a common event, but it occurs at the time of an abnormal chromosomal sorting at conception.
The result is a spectrum of malignancies, many of which are curable if appropriately diagnosed and managed, and nearly all of which are initially diagnosed as pregnancy.
In the context of criminalization of pregnancy termination, we are hopeful that malignant and abnormal pregnancy would be a clear indication for a medically necessary termination, but a hostile legal environment raises concerns.
Finally, our greatest concern is the social construct that lack of choice and autonomy creates for women at a very basic level.
The anti-abortion movement disregards CDC and DOJ statistics—as cited by ACOG—that more than one in three women in the U.S. have experienced rape, physical violence, or stalking by an intimate partner in their lifetime, and 4.8 million incidents of physical or sexual assault are reported annually.
These estimates do not count the incidents that went unreported due to fear or cultural acceptance as norm, and they don’t reflect the disproportionate effect on women of color, in the LGBTQIA+ community, and the economically disadvantaged.
The evidence that these populations carry a disproportionate burden of gynecologic cancer is indisputable, and there is no better concrete example than cervical cancer.
Cervical cancer incidence in the United States has significantly declined over the past several decades due to the availability of screening, the treatment of preinvasive disease, and the early detection of curable cancer.
With the advent of a preventative vaccine that was first FDA-approved in 2006 and universally endorsed by ACIP in 2011, cervical cancer is now nearly 100% preventable.
Despite this, the U.S. still sees a consistent incidence of approximately 14,000 new cases per year, with a disproportionate number in the exact same cultural groups that are adversely impacted by intimate partner violence.
In fact, these are not only the women that develop cervical cancer, but also the women that die from it, (Figure 1. Cervical Cancer Mortality in the U.S). This is no coincidence.
In 2012, a paper was published by investigators in Africa who associated the incidence and mortality of cervical cancer in women living in poor conditions and with low social status (Singh GK, Azuine RE, Siahpush M. Global Inequalities in Cervical Cancer Incidence and Mortality are Linked to Deprivation, Low Socioeconomic Status, and Human Development. Int J MCH AIDS. 2012;1(1):17-30.).
We read this with initial relief that we lived in a country that was not like this—however, we were forced to face the sobering reality that these conditions are a reality for many women in this country.
Since access to and acceptance of cervical cancer screening and prevention behaviors are so strongly linked to decreased incidence of cervical cancer, and women who lack access to just reproductive care will be more prone to avoid this care, we expect an exacerbation of cervical cancer incidence and mortality in the coming years.
Hauntingly, if you superimpose the geographic distribution of immediate, upcoming and likely abortion bans in the U.S. on the maps of cervical cancer mortality and delayed HPV vaccination uptake—also driven by misguided political forces—you can see significant correlations between attitudes toward abortion and cervical cancer burden (Figures 1 and 2).
We are curious if the gun violence pattern discussed by Robert A. Winn in the May 27 issue of TCL is similar (The Cancer Letter, May 27, 2022).
Avoidance of care will affect more than cervical cancer. The next tier involves women who have symptoms of gynecologic cancer.
They will be less likely to seek care early, and that can lead to delays in diagnosis, a more advanced stage of disease at diagnosis and less curable cancers at diagnosis.
We see this in our current practice. It is not well-documented, but it is there. Now it will be there more.
Repercussions from Roe v. Wade will trickle down also to a patient’s willingness to receive treatments and enroll in clinical trials. We already have male-female disparities in almost every aspect of care, including clinical trials.
The cancer war is far from over, and clinical trials are the only way to improve survival from cancer. Exacerbating the apprehension of women to seek health care and enroll in clinical trials will undoubtedly widen the gap.
While this overturning is seemingly based on religious, ethical, or legal arguments, we cannot ignore the fact that it precludes discussions between patients and their physicians, women and their health care providers.
The recent Supreme Court decision is distressing on a personal level, and it is about much more than abortion.
Randall, Miller, and Sullivan are all practicing gynecologic oncologists in Richmond, VA.
