When Jill Hawkins realized that she was six weeks pregnant this March, her oncologist gave her two options.
One was to continue with the pregnancy and switch to interferon, a treatment that would be safer for the fetus, but more toxic to her. Alternatively, she could get an abortion.
Hawkins was diagnosed with chronic myeloid leukemia in August 2021 and was taking the drug Bosulif (bosutinib), a tyrosine kinase inhibitor not recommended for use during any part of pregnancy.
“At the end of the day, for me, I can handle the risk to me, or the birth defect. I don’t think I can handle both. I don’t think I can handle the uncertainty and the fear around all of it. I need to feel good about one thing. In this situation, I didn’t feel good about any of it,” Hawkins, a clinical social worker and therapist based in New York City, said to The Cancer Letter. “It’s not a good idea for my health. Do I want to let go of this pregnancy and be sad and grieve, or do I want to keep it and feel anxious and fearful of losing my life?”
As she was making the decision, Hawkins took one week off the tyrosine kinase inhibitor, and after speaking with her fertility doctor and her oncologist about the risks involved, chose to terminate the pregnancy.
“It could have been a very difficult pregnancy. I could have lost my life. I could have had to make a really hard decision at 24 weeks,” Hawkins said, referring to potential birth defects caused by Bosulif that would become apparent by that point. “There were so many potential negatives attached to both choices. I just had to make the preferable of the two shitty choices I had.”
Hawkins said the direct, non-judgmental approach of her New York doctors made all the difference as she weighed her options.
“Having had an abortion seven years ago in Houston, I had a very different, very horrific, judgmental experience. This felt just like night and day. I felt so supported,” Hawkins said.
Hawkins, 37, was given a choice that pregnant cancer patients have lost in states where abortion has become illegal following the Supreme Court’s June 24 ruling on Dobbs v. Jackson Women’s Health.
Decisions like the one made by Hawkins belong in the doctor-patient relationship, said Eric Winer, director of Yale Cancer Center, physician-in-chief of Smilow Cancer Network, and Alfred Gilman Professor of Medicine and Pharmacology at Yale. Winer, who is also president of the American Society of Clinical Oncology, was not speaking on behalf of the professional society.
“Limiting the option of terminating a pregnancy severely curtails the ability of clinicians when caring for a pregnant patient with cancer to be able to provide the kind of guidance that we typically provide,” Winer said to The Cancer Letter. “A decision that’s made in the examining room has been made in the courts.”
The Supreme Court’s ruling has activated “trigger bans” on abortion in 13 states, with more states expected to impose bans or severe restrictions. At least three states have temporarily blocked trigger bans.
Abortion restrictions will have immediate implications for cancer patients. Approximately one in 1,000 patients—about 6,400 American women—are diagnosed with cancer during pregnancy each year. For perspective, here are the overall cancer incidence rates among women: 55 in 100,000 women ages 20-29 and 161 in 100,000 women ages 30-39 are diagnosed with cancer each year.
“Reversing the protections offered by Roe v. Wade will have far-reaching second- and third-order effects in women’s health, including cancer care delivery and cancer-specific mortality,” wrote Devin T. Miller, Leslie M. Randall, and Stephanie A. Sullivan, all practicing gynecologic oncologists in Richmond, VA, in a guest editorial for The Cancer Letter. “Our education and experience has informed our strong stance that the ‘pro-life’ position is not pro-life at all.”
The guest editorial appears here.
There is little data on the safety of next-generation targeted agents during pregnancy. Therefore, drugs like Bosulif come with concerns about risk to the fetus—and, now, legal liability.
“I do think there are going to be physicians in some states who are going to be called upon to give patients good care, where that good care now will run afoul of the criminal law as it might be interpreted by some of those states,” I. Glenn Cohen, deputy dean and and James A. Attwood and Leslie Williams Professor of Law at Harvard Law School, said to The Cancer Letter.
A conversation with Cohen appears here.
Patients must be able to trust their doctors, Julie R. Gralow, chief medical officer and executive vice president of the American Society of Clinical Oncology, said in a guest editorial published in this issue of The Cancer Letter.
We are therefore concerned about the potential impact of the decision that inserts the government and even lay-people into the most private and personal decisions patients face.
The Dobbs ruling creates uncertainty and confusion that can undermine the sacred doctor-patient relationship.
Already, the prevailing confusion and fear has caused many physicians, including those where access to abortion is protected, to question whether delivering standard evidence-based cancer care could result in harassment, prosecution, prison sentence, or revocation of their medical license.
These concerns are a threat to high quality, equitable cancer care.
Gralow’s guest editorial appears here.
In an analysis of the impact of the Dobbs decision, Karen E. Knudsen, CEO of American Cancer Society and the American Cancer Society Cancer Action Network, touches on a clinical scenario analogous to Hawkins’s.
Writes Knudsen:
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.
Knudsen’s guest editorial appears here.
In addition to harming cancer patients, the bans fundamentally endanger their doctors. Physicians face higher rates of infertility and other pregnancy complications, including miscarriage.
“Let’s say I come out of residency. I come to practice in a state that has these strict laws. I get pregnant, I’m having a miscarriage. I’m sitting in the exam room, and my doctor says, ‘Well, I can’t do anything until that heart stops—even though I know that as you’re bleeding out or as you’re becoming septic, your life will be in danger, but it’s not a danger enough yet for me to do that procedure,” Theresa Rohr-Kirchgraber, president of the American Medical Women’s Association, said to The Cancer Letter. “I don’t want to be in a position where that could ever happen. So, therefore, I’m not going to even consider a job in a state like that.”
A study showed that 24.1% of American female physicians are diagnosed with infertility, and 42% of female surgeons included in a survey had experienced pregnancy loss; meanwhile, 11% of women of reproductive age in the US have experienced fertility problems, and it is estimated that up to 26% of all pregnancies end in miscarriage.
Retaining a workforce—and recruiting into institutions in states with restrictive abortion laws, has just become more difficult—oncologists say.
Lives at stake
“The goal in any case is, ideally, to preserve both the mother’s health and viability of the embryo/fetus. But in some cases, this just isn’t possible,” Katherine Van Loon, a gastrointestinal oncologist at UCSF, said to The Cancer Letter. “Taking away a woman’s bodily autonomy to pursue a termination of the pregnancy and prioritize her own health will create a scenario in which oncologists can’t provide necessary care. We will lose these lives unnecessarily—at a profound cost to the women and their families.”
With the Roe v. Wade protections stripped away, fear has infected America’s patient examining rooms.
“What I don’t want to see is us compromise the care of the pregnant patient with cancer based solely on the overturning of Roe v. Wade. There are people whose lives are at stake, and we have the responsibility to treat that person with cancer as our first and foremost objective,” Don Dizon, professor of medicine and surgery at Brown University, and director of Community Outreach and Engagement at Legoretta Cancer center at Brown University, said to The Cancer Letter.
The Roe v. Wade reversal may cost patients their lives, said Maitri Kalra, a hematologist/oncologist and clinical assistant professor of medicine at Indiana University Health Ball Memorial Cancer Center.
In Indiana, where Kalra practices, abortion is still legal, but Republican lawmakers are expected to push for further restrictions or an outright ban.
“The conversation is very difficult, but the choice is that we either treat [our patients] suboptimally for their cancer, meaning we give them chemotherapy which may not be effective for their cancer, and they can retain their pregnancy,” Kalra said to The Cancer Letter. “Or they can medically terminate the pregnancy and get the optimal treatment, which would be best from the cancer standpoint.”
Most pregnant patients Kalra treats in the first trimester opt for medical termination of their pregnancy—“They need to survive first.”
Poor outcomes are a major concern. Unsafe abortions are another.
“My other concern is that they might resort to some other means of abortion, which would be highly unsafe, because—this is putting them in a very desperate situation,” Kalra said. “They might desperately try to do things to get rid of their pregnancy by some home remedies, which can get really unsafe for the patient’s life.”
At a time when the oncology profession is focused on health disparities, the Supreme Court’s decision has likely worsened outcomes for the underserved, Van Loon said.
“In circumstances in which a woman has to travel to another state to terminate a pregnancy in order to prioritize her own health, it’s going to result in additional delays to cancer care, and it’s going to galvanize inequities between those who have the resources to be able to travel versus those who do not,” said Van Loon, associate professor of clinical medicine at UCSF and director of the Global Cancer Program at UCSF Helen Diller Family Comprehensive Cancer Center.
Overturning Roe v. Wade limits access not only to voluntary abortions, but also to treatment for miscarriages—and, possibly, contraceptives and reproductive technologies. This could place doctors, who are more likely to experience pregnancy complications, miscarriages, and infertility, at higher risk.
“A lot of my colleagues that I know of are undergoing infertility treatment, because they’re unable to get pregnant by the time they finish their training,” Kalra said. “It puts that into question, and it puts that into an area of concern. You never know when that right would be taken away from you.”
Abortion bans are likely to affect patients and physicians across the country, even in states that protect abortion rights, said Ariela L. Marshall, director of the Women’s Thrombosis and Hemostasis Program at Penn Medicine.
“If abortion is now outlawed in at least half of the states, and you have to travel to another state, that’s going to double or triple the waiting list in all those states,” Marshall said to The Cancer Letter. “We know that the further you get along in a pregnancy, the more complex it can become to have an abortion. So, if it’s waitlist, that’s pretty much a guarantee that people are going to be having later-term abortion in places where it’s still legal.”
Cancer centers and medical societies have a responsibility to take action, said Shikha Jain, assistant professor of medicine in the Division of Hematology and Oncology, director of communication strategies in medicine at the University of Illinois Chicago, and associate director of oncology communication and digital innovation at the University of Illinois Cancer Center.
“I’m terrified for our next generation of people coming up and what this means. I’m scared for my children. I’m scared for my patients. I’m mad and disappointed and frustrated,” said Jain, also the CEO and co-founder of IMPACT, president, CEO, and founder of Women in Medicine NFP, and founder and chair of the Women in Medicine Summit. “This is a ruling that is not supported by the majority of the country, and its impacts are going to be devastating for years to come, and we need to do something now to change it.”
One in a thousand
A 2019 study published in the World Journal of Oncology found that one in 1,000 pregnancies annually are affected by a concurrent cancer diagnosis—and this risk estimate doesn’t include patients like Hawkins, who became pregnant after cancer diagnosis.
As the nationwide trend to postpone childbirth to a later age continues, the incidence of cancer during pregnancy is expected to increase.
“When cancer is diagnosed during pregnancy, a huge multidisciplinary effort is typically required to try to figure out how to manage it. On one hand, we need to take care of the mother, and there’s also an embryo or fetus at stake,” Van Loon said. “In many of those cases, the fetus can remain viable without compromising the mother’s care, but in a portion of cases, preservation of the pregnancy to viability could compromise the mom’s prognosis and potential outcomes.”
The most common cancers associated with pregnancy are, in order of decreasing frequency, melanoma and breast cancer, cervical cancer, and lymphomas and leukemias.
The number of cancer diagnoses during pregnancy is further expected to increase as the use of cell-free DNA screening in early pregnancy expands, Van Loon said. This technology can sometimes detect cancer.
“We’re going to see an increase in early-term diagnosis of cancer in pregnancy,” Van Loon said. “I just took care of a recent case where it was picked up through somewhat routine blood work for a woman. She ended up with a diagnosis of metastatic rectal cancer. Those are really complex situations—we could be seeing this more and more, and earlier in pregnancy.”
Consider a scenario where a pregnant person is diagnosed with cervical cancer.
“If it’s very early, in the first 12 weeks of a pregnancy, and we know it’s a cervical lesion—this is something we discuss at multidisciplinary tumor conferences,” said Dizon, also director of the Pelvic Malignancies Program, founder of The Oncology Sexual Health First Responders Clinic, director of the Hematology-Oncology Outpatient Clinics at Lifespan Cancer Institute, and director of medical oncology at Rhode Island Hospital.
The gold standard for treating locally advanced cervical cancer is chemotherapy plus radiation. But radiation causes pregnancy loss, and chemotherapy early on in a pregnancy is dangerous to the fetus.
“If this pregnancy is something you truly, truly want—then the two options would be to just observe until you get into the second trimester, in which case we can give primary chemotherapy until the point of delivery, knowing that there is no comparative data in a pregnant patient that says cure rates are as good as chemo-radiation,” Dizon said. “And in fact, in non-pregnant patients, the data suggests chemotherapy is not as good as chemo-radiation.”
Waiting to treat a patient until the second trimester is risky, he said.
“That whole thing of surveillance—it’s a scary time. Can we guarantee there will be no progression while we wait? No, we cannot,” he said. The worst case is to see someone progress from locally advanced or just a cervical lesion to all of a sudden being a very bulky tumor that is no longer amenable to definitive treatments.”
How are we going to protect these patients who are going for—life-saving, in some cases—care, and then they’re going to be prosecuted when they come home?
Shikha Jain
Early in his career, Dizon treated a patient with cervical cancer who was in the second trimester of pregnancy. The cancer was growing exponentially, and without treatment she was not expected to survive through the pregnancy.
The best treatment in this case was hysterectomy, which includes an abortion. That was what the patient chose.
“To do a hysterectomy in the second trimester—no one escaped without trauma. The nurses, the OR team, the surgeon who had to perform it, the woman who really wanted this baby,” Dizon said. “This is not a neutral decision for anybody.”
The Supreme Court’s June 24 decision to reverse Roe v. Wade doesn’t take cases like this into account, Dizon said.
“It just boggles the mind that that kind of nuance is just not taken into consideration for this theoretical argument of life beginning at conception,” he said. “To just minimize that this experience can be very traumatic within the context of cancer—that it is traumatic.”
What happens to patients who require that same treatment as Dizon’s patient, in states where abortion is illegal?
Dizon has seen this play out before, back when he was an attending physician at a Catholic hospital.
“The ultimate conclusion was if you don’t offer the services at this Catholic hospital, we need to transfer this patient, and that’s what happened,” he said. “If you are in a red state, and a colleague, and a cancer center provider, we always have to think of the person in front of us who is dealing with that cancer, and we need to get her the best care possible.”
Pregnant patients with Hodgkin lymphoma in states where abortion is illegal will receive suboptimal treatment, IU’s Kalra said.
“This is a very fast-growing tumor, and at the same time very curable. It has more than a 90% cure rate with the current chemotherapy treatment,” Kalra said. “However, if they cannot get that treatment in a timely manner, this can be life-threatening.”
How should a doctor in Kalra’s situation respond if the patient is unable to obtain an abortion?
“I would have to treat them with a chemotherapy that is probably less effective from their lymphoma standpoint,” she said. “It would be compromising care, essentially. We would be able to give them some treatment that would be a compromise of care, which none of us would want.
“If you give a man a chance for a cure, versus a suboptimal treatment, if you have a choice, which one would you choose? That’s a no-brainer.”
Now, pregnant patients will be offered a different menu of therapeutic options.
“Right now, these patients will not be getting that choice very soon,” Kalra said.
Patients who receive chemotherapy and become pregnant are at higher risk for bad outcomes, Jain said.
Banu Symington, a hematologist/oncologist and medical director based in rural Wyoming, said conversations she used to have with pregnant patients—whether to continue with the pregnancy and delay care, or terminate the pregnancy—are now off the table.
“I’m going to tell them that their ability to make a choice about abortion is taken out of their hands,” she said to The Cancer Letter. “I could, I suppose, make a case that waiting is an extreme hazard to their lives, but most of the time waiting means that their treatment will not be as successful.”
This is not about protecting life. This is about power, and controlling people’s bodies, and making sex into something that’s only supposed to happen for procreation, and otherwise you’re punished.
Jill Hawkins
Even before this ruling, an abortion in Wyoming was never easy to obtain. The only clinic was based in Jackson, near the Idaho border, and that clinic would only offer medical abortions up to 10 weeks.
In May, someone set fire to a newly built abortion clinic in Casper, WY. It was initially supposed to open in mid-June and is now not expected to open at all.
To Symington’s knowledge, the hospital affiliated with her center has not performed an abortion in 40 years. In the past, the hospital informed patients about abortion clinics in Utah.
“Once Utah makes abortion illegal in that state, a patient who would normally only have to drive two-and-a-half hours to get a medical abortion is going to have to drive across the state to Colorado to get an abortion,” she said.
Taking away the ability to choose is the entire problem, Hawkins said.
“It’s horrifying to me that we would value the future potential life of a tiny little ball of cells that we already know is at super high risk of not being a successful pregnancy, of not being a healthy baby,” Hawkins said.
The effects of abortion bans reach deep into family planning of people with cancer and their family members.
“It goes beyond the woman who’s pregnant with cancer, and includes the woman who may be taking care of her husband, who is dying of cancer, and who finds out that she’s pregnant,” Yale’s Winer said. “I think it’s both the patient with cancer, but also the family with cancer.
“I just feel very strongly that this is a setting where a woman needs to be able to make her own decision,” Winer said.
Because of the toxicity of chemotherapy, Symington advises her male chemo patients to avoid causing pregnancies.
“The other woman may have no knowledge that she’s been exposed to sperm that may be damaged,” Symington said. “She won’t know that she’s carrying a potentially mutated fetus, and her health will not be endangered by that mutation. So, she’ll carry it to term. There will be no excuse for her to get an abortion.”
Not a decision for the courts
In a state with an abortion ban, pregnant patients with cancer may need to convince the courts that cancer presents a medical emergency.
Even if the courts ultimately concur, the Kafkaesque proceedings would take time, leading to treatment delays.
“Let’s say it’s unclear as to whether it’s considered an emergency situation or not,” Jain said to The Cancer Letter. “While we are waiting for the courts to decide during that entire time—time does not stop. Cancer will progress. A pregnancy will continue. And by the time a decision comes down from the courts, it may be too late to safely terminate the pregnancy.”
It’s preposterous to suggest that the courts have a role to play in limiting access to care in this clinical setting, Winer said.
“This is really a very fundamental decision that should be made between the people taking care of a woman who has cancer and is pregnant, and the woman,” Winer said. “The fact that treatment would be delayed because a judge is making a ruling or reviewing a situation just horrifies me.”
Patients with financial means will travel to states where abortion is legal.
“Patients with all sorts of different problems and challenges are going to be flooding these states, if they have the resources,” the University of Illinois’s Jain said. “And those who don’t have the resources are going to end up bleeding out in their homes or in their home states.”
In states that preserve abortion rights, patients who need immediate care may run into long wait lists.
“There are going to be challenges of timing, because, again, the further you go along in the pregnancy, the more complicated it can be to actually do a safe abortion,” Jain said. “In some situations, the abortion may be a medical emergency, and the patient may not be able to get to a site in time.”
All of this will widen disparities in care and, likely, an increase in the maternal death rate.
“We’re going to see an increase in our already bad maternal mortality numbers, especially in populations like the African American population,” Jain said.
The peril of criminal prosecution
The risk of criminal charges for providing abortion care now looms as a new reality for physicians.
Many find themselves reflecting on past clinical scenarios that, should they recur in post-Roe America, would spell out peril.
UPenn’s Marshall tells the story of a young woman with immune thrombocytopenia whose platelet counts were dangerously low—a condition exacerbated by pregnancy.
“She managed to survive through [two prior] pregnancies, but became pregnant a third time,” Marshall said. “She wanted to have an abortion, and she was told, ‘Your platelets are not at a safe enough level for this procedure.’”
The patient came to Marshall for a treatment that would allow her to have a safe abortion.
“I’m just thinking, for her sake, and for my sake as a physician, if I was in a state where to aid and abet an abortion is illegal, is my treating her blood condition so she can have an abortion illegal? Is treating my patient in a way that she needs to be treated now illegal, even if I’m not the one physically doing the abortion?”
After Roe was overturned, a physician Jain knows was treating a patient who was in the middle of a miscarriage.
“The physician did not know if they could legally take care of this patient, or would they be prosecuted for helping a patient who was miscarrying, because the treatment would’ve been to do a D&C, or dilation and curettage, or dilation and evacuation,” she said. “But is that considered illegal? Because it’s the same procedure as what’s done for an abortion. Miscarriages are also abortions. They’re just abortions that happen naturally.
“We really are at a point where physicians are going to be practicing medicine, scared that they’re going to be arrested for homicide or manslaughter, because they’ve done something to save their patient’s life,” she said.
Symington’s patients who are able to become pregnant receive a pregnancy test before each cycle of chemo.
“With laws being enacted in many states that anyone who aids or abets a termination of a pregnancy could be held liable, we are concerned about our records being subpoenaed to show that a patient was pregnant at one visit and isn’t pregnant at the next visit,” Symington said.
Doctors who do try to make the case to terminate a pregnancy because of cancer may face consequences more severe than legal battles. Some also fear for their lives and their families.
“If we think that we’re going to be personally attacked, we may be a little more reticent about sticking our necks out to help our patients get medical abortions,” Symington said.
Patients who seek to terminate pregnancy in another state may run afoul of the law.
“Women who do leave the state to get this done may come back and face legal battles, because they have technically violated the law of their state,” Jain said. “How are we going to protect these patients who are going for—life-saving, in some cases—care, and then they’re going to be prosecuted when they come home?”
Harvard Law’s Cohen said this scenario is plausible.
“If your state prohibits abortion, can they also prohibit you to travel out of the state? No state, as far as I know, has passed a law to that effect yet, but that doesn’t mean that they won’t,” said Cohen, faculty director of the Petrie-Flom Center for Health Law Policy, Biotechnology & Bioethics.
“One of the biggest issues for people in the medical community—beyond what the rules actually are—will be the uncertainty around the rules,” Cohen said. “How do you practice and how do you make decisions about whether to relocate your clinic or to offer something, if you just don’t know what’s going to happen?”
When physicians become patients
“When physicians become pregnant, they are the patient,” UPenn’s Marshall said. “Knowing that female physicians often start to build families at an older age, and that as we age, the risks of complications both to mom and baby are a lot higher—so, for mom, things like preeclampsia and preterm birth, and for baby, things like severe chromosomal abnormalities—[pregnancy] could even be lethal, or have a very high risk of being nonviable.”
“If we knew one of those conditions was present, a lot of us would choose, I think, to have an abortion,” Marshall said. “But [the Dobbs v. Jackson Women’s Health decision] means that this whole population of female physicians is going to not be able to have access to that care, even when it may be right for them and their families.”
Doctors tend to start building families later due to the length of their training. The median age at first childbirth was 32 years in physicians and 27 years in nonphysicians, according to another 2021 study. This can lead to pregnancy complications.
“There’s also the stress of the job—the shift work, the overnight and unpredictable schedules, and emotional stress,” Marshall said. “These, not incidentally, are all risk factors for bad pregnancy outcomes.”
Bans on abortion could limit access to treatment for miscarriages and ectopic pregnancies, which often require the same procedure as an abortion. A 2021 survey found that, out of 692 female surgeons, 29 (42.0%) had experienced a pregnancy loss, more than twice the rate of the general population.
“Providers would be scared of this, and even when they’re actually providing the normal, warranted care, could somebody who is very anti-abortion or anti-choice, and looking for a way to scare or punish doctors, say, ‘How do you know that wasn’t an abortion that you’re treating,’ when it was actually a miscarriage?” Marshall said.
A 2016 study found that, out of 600 female physicians who graduated medical school between 1995 and 2000, 24.1% of respondents who had attempted to become pregnant were diagnosed with infertility. The average age at diagnosis was 33.7 years.
The Roe v. Wade decision may complicate the use of assisted reproductive technologies, Marshall said.
“A lot of us out there have frozen embryos,” said Marshall, who helped found an infertility task force with the American Medical Women’s Association. “If they’re created and stored in a state where, technically, it might be illegal to stop paying those hundreds of dollars per year for storage fees—would that count as abortion? We have seven frozen embryos; would we be guilty of killing seven?”
Limits or outright bans on abortion threaten the empathy and trust upon which the physician-patient relationship rests, Marshall said.
“We’re always saying that the physician-patient relationship is sacred. If physicians can’t get the care we need and patients can’t get the care they need, it’s impacting us, it’s impacting our patients, and it’s impacting what’s supposed to be a sacred relationship,” Marshall said. “If we can’t have the power to deliver appropriate care and the support to remain empathetic while doing it, then I think the whole idea of being a physician is just shattered.”
The Dobbs decision will have an outsized impact on doctors, in turn compromising the quality of care for patients, Marshall said.
“If you’re suffering yourself, if you are burnt out, if you are not able to provide empathetic care because of the mental anguish of not being able to access abortion care, that’s taking out of commission a whole group of physicians who now won’t be able to provide care for their own patients,” Marshall said. “I also think we don’t talk enough about implications for male physicians.
“Data show that many male physicians, if they’re married, are married to another physician. So, it may not impact them physically, but what if it’s their wife or partner that’s going through a pregnancy that they don’t want? They are also forced to be a bystander in this process,” Marshall said.
Some doctors will be factoring abortion rights into their choice of jobs and training programs.
Kalra has a colleague who is—right now—weighing her options.
“She’s thinking of putting this as a decision maker in terms of where she would be choosing a fellowship program, because we are physicians, but we are also women in reproductive age,” Kalra said. “With this rule being passed, and being in such a state, my concern is not just having an unwanted pregnancy, but also, what if I’m pregnant with a chromosomal abnormality? I now won’t have rights, in some states, to decide whether I want to have a child with a chromosomal abnormality, or not.
“With the long course of training, a lot of physicians, by the time they have their first pregnancy, they are more than 35. It’s not uncommon. Which puts them at high risk of chromosomal abnormalities.”
Implications for recruitment and retention are obvious at this early stage, doctors say.
“They may not leave the state—they may leave medicine altogether because they’re just tired of being told what to do from non-medical individuals who are negatively impacting patient care,” Jain said. “For all of the advances in and research that we’ve been able to advance medical care in this nation over the last several decades, it is being put so far backwards.”
On a larger scale, Symington is concerned about doctors losing the skills needed to perform abortions.
“A lot of people who are trained and leave residency with the ability to perform abortions, if they join a practice where the senior partner doesn’t want to do abortions, they’re not going to be doing abortions,” she said. “That’s going to be a skill set that they lose. How can you train residents in how to do an abortion if you are in a state where abortions are illegal?”
Medical students may choose to avoid states where they will not be trained to perform abortions and treat miscarriages, said AMWA’s Rohr-Kirchgraber, who is based in Georgia, where abortion rights are under fire.
“We know that where you do your residency, you’re most likely to stay there to see patients and establish care,” Rohr-Kirchgraber said. “So, if we put all these students through our medical school system, and then we make them leave to go elsewhere to get the training that they require, they’re not coming back.”
“We’re talking about real people”
Cross-state coalitions—formal or informal—may help mitigate the harm caused by abortion bans.
To help patients receive proper treatment, health systems in states where abortion is illegal may end up partnering with counterparts in states where abortion is legal, Dizon said.
“Alliances, probably, is what this might look like, where there’s going to be alliances between two health systems across state lines that say, this is a hospital you go to,” he said. “Not only will it take more time, but it’s going to take that person out of their center of support. I mean, it’s not an easy thing to uproot for cancer care.”
Cancer centers in states that ban or limit abortion rights still have a responsibility to provide life-saving care, said Leonidas C. Platanias, director of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University and the Jesse, Sara, Andrew, Abigail, Benjamin and Elizabeth Lurie Professor of Oncology in the Departments of Medicine and Biochemistry and Molecular Genetics.
“There may be variations [of laws] from state to state,” Platanias said to The Cancer Letter. “There should be some advocacy on behalf of the cancer centers in these states to make sure high-risk situations for the patients are prevented.”
Winer, who lives and works in a state that protects abortion rights, said Yale Cancer Center’s doors are open.
“We would be happy to take care of people from anywhere who are in need of our services,” he said. “I think that’s a very practical thing that we can do in places like Connecticut. On the other hand, I think probably, the more important thing that we can do is to raise awareness about this whole issue.”
We’re always saying that the physician-patient relationship is sacred. If physicians can’t get the care we need and patients can’t get the care they need, it’s impacting us, it’s impacting our patients, and it’s impacting what’s supposed to be a sacred relationship.
Ariela L. Marshall
Symington hopes oncology leaders speak loud and clear against this ruling.
“I’m hoping for leadership to come out strongly against interference of government in the physician-patient relationship,” she said. “I hope they come out strongly against these proposed laws about crossing state lines to prosecute people in other states for helping people get an abortion.
“I really am in favor of—if abortions are legal in federal lands, let’s have an abortion clinic in every post office. It might help business,” Symington said. “I’m being facetious, but we need to preserve the ability of patients in every state to get abortions if they need them, because people can’t always travel.”
Jain said medical societies have power on a national level to fight against the Supreme Court decision.
“They need to be using that power to advocate for this to be reversed,” she said. “We need all medical societies to not just be putting out statements. They need to be doing more.”
Medical societies should not hold conferences in states where abortion is banned, Jain said.
“The concern is, as medical experts, as physicians, as healthcare workers, I don’t think we should be supporting having large conferences in these locations, because it’s not safe, medically, for women to attend these conferences and those locations,” she said.
“I would be concerned attending a conference in any of these states, because if, God forbid, something were to happen to me or to one of the attendees, I would be concerned as to what type of medical care they would be able to get if they needed emergency care or otherwise.”
Dizon said oncologists should help people understand that abortion is a nuanced issue, and that not every pregnancy is viable.
“We’re talking about real people and various situations, all of which are different, all of which are complicated, and all of which require a doctor and a patient to have a very meaningful conversation,” Dizon said. “At the end of the day, there’s a decision. In the oncology world, it’s never a decision that people approach lightly. It’s always a decision that has consequences.
“People experience pregnancy loss, and it can happen naturally—but to subject women to risk to their lives for something that is not viable goes against everything that we stand for in this country,” Dizon said. “It’s essentially committing half of our population to, essentially, indentured servitude, because we are not giving them the choice of whether or not to carry. We’re just saying you need to carry your pregnancy.”
Hawkins said the view of motherhood as the be-all, end-all for women seemed to influence the way her doctors framed her options.
“I think it’s telling that even these very pro-choice providers, their first thought was, how do we help this woman keep this baby?” Hawkins said. “Part of me is just still really surprised that my high-risk pregnancy doctor, two different oncologists, and my IVF specialist—everyone just really, really wanted to do everything they could to help me figure out how to have this baby, if that’s what I wanted. And while I respect and understand and appreciate that, I also feel like we’re all conditioned to think that way, that the end goal for any woman in her thirties is to have kids.”
In August, Hawkins plans to work with a fertility specialist to freeze embryos so she and her partner could have the option of having a child at a time that works for them.
No one should be denied the right to choose, Hawkins said.
“I was hesitant to share my story, because you don’t need to have cancer, or be raped, or be a victim of incest to make a decision to not want to have a baby. I feel very strongly about that,” Hawkins said. “This is not about protecting life. This is about power, and controlling people’s bodies, and making sex into something that’s only supposed to happen for procreation, and otherwise you’re punished.”
Matthew Bin Han Ong contributed to this story.
