A CANCER DIAGNOSIS always brings hard decisions, but women who are diagnosed with cancer during a pregnancy face especially complicated and difficult choices. The known effects of some cancer treatments on pregnancy, the lack of data around interactions with newer treatments, the competing timelines of the disease and fetal development, and the values of the person getting treatment all must be considered when making treatment decisions.
But decisions made in statehouses, not clinics, imbued a Presidential Select Symposium on pregnancy and cancer held April 17 at the American Association for Cancer Research (AACR) Annual Meeting 2023 in Orlando, Florida, with particular relevance. (The AACR publishes Cancer Today.) The Supreme Court decision that ended nationwide abortion rights in 2022 and the subsequent abortion bans passed in many states have numerous implications—from emergency care to fertility preservation options—for people diagnosed with cancer during a pregnancy and for providers who care for them.
“We’re obviously speaking about something that is both timely and timeless,” said medical oncologist Ann Partridge, the vice-chair for medical oncology at the Dana-Farber Cancer Institute in Boston. “Cancer diagnosed during pregnancy is something that’s happened … ever since people were getting pregnant and getting cancer.”
One out of every 1,000 pregnancies will be complicated by a cancer diagnosis, most commonly breast, thyroid and cervical cancers, said Partridge, who presented on the prevalence of cancer during a pregnancy. She noted that the number of women who receive a cancer diagnosis during pregnancy has risen since 2002, a trend influenced by women having children at later ages when cancer risk generally is higher.
When treating cancer in someone who is pregnant, providers face complex challenges in deciding the best course for care, Partridge explained. A mother’s treatment could harm a developing fetus, but the fetus also depends on the mother’s well-being in the short-term.
“When we are trying to maintain a pregnancy, we need to know that it can be difficult to avoid some element of compromise when it comes to both maternal and fetal well-being,” Partridge said. Patient autonomy and shared decision-making between doctor and patient, a goal in all care, takes on special importance in this context, she said, even when patient preferences are in tension with conventional medical values.
Partridge shared a framework for approaching care that starts by determining the optimal treatment, regardless of the pregnancy, then considering the risks to the fetus if the mother chooses to continue the pregnancy. In some cases, there may be very little risk in proceeding with care as usual, but in other cases it may be necessary to discuss other measures, such as adjustments to cancer treatment, inducing early delivery or terminating the pregnancy if that is the person’s choice and is feasible. In high-risk cases where abortion is prohibited and safely continuing the pregnancy requires changes to cancer treatment that could compromise its effectiveness, it may be necessary to bring together a team from multiple disciplines, including ethics and legal experts.
The changing legal landscape was brought home through the signing, just days before the symposium, of a law banning abortions after six weeks of pregnancy in Florida, where the conference was taking place, a point that came up throughout the program.
“As I discuss the increasingly boxed-in situation that our pregnant patients are facing, I feel as though the walls are becoming increasingly higher around them, placing them in a dangerous and untenable situation when the baseline situation was bad enough,” said Virginia Borges, a medical oncologist at the University of Colorado Cancer Center in Aurora who gave a presentation on the importance of reproductive rights for pregnant women facing cancer.
Though many of the laws in states that have banned abortion include language ostensibly allowing abortion care in medical emergencies, Borges outlined questions about how those situations are determined and what happens next, including who decides whether a particular case qualifies as a medical emergency.
“I emphasize that our women facing pregnancy and cancer must make agonizing decisions,” Borges said. “They must make a decision now that could affect their cure rate and survival not today but in the five or more years to follow.” She asked what difference in survival a doctor would have to demonstrate before a woman has “the right to say it is an emergency for her life.”
Borges discussed how the U.S. has faced a lack of quality maternity care for years, a challenge that is particularly acute in some of the same states that have passed laws restricting abortions. Additionally, women who do qualify for an abortion as emergency care in states where abortion is otherwise illegal could have difficulty finding a provider to do the procedure.
The restrictions are having an impact on care now, Borges noted. Based on the number of cancer cases diagnosed in each state, she estimated that there will be 100 cases this year just in states that have a full abortion ban in place. She also cited a JAMA Oncology report from 2022 that estimated the number of women facing cancer and pregnancy in 26 states that were planning some restrictions on abortion would reach 1,500 per year.
Lisa Coussens, AACR’s immediate past president who organized the symposium and the associate director for basic research at Oregon Health & Science University’s Knight Cancer Institute in Portland, acknowledged that the conference itself faced some controversy for being held in a state that has restricted abortion options for women. She said that after considering the practical challenges of moving a conference that had been contracted years earlier, the AACR decided to make a stand around its mission.
“Our mission is education and outreach. And that doesn’t just extend to our membership, it extends to communities that vote and legislators that have the power to enact or eradicate bad legislation,” Coussens said. “We have put out statements denouncing this legislation based upon the impact that it has on reproductive freedoms in general.” She added that the organization’s voice could be more impactful because it stayed to share the data and perspectives from the researchers and clinicians who speak at the Annual Meeting.
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