Overturning Roe v Wade: Stipulations in Cancer Care?
When the general public considers the stipulations of government regulations on access to reproductive and abortion care, and which sectors of healthcare this affects, minds are quick to associate its effects with the women’s health field of Obstetrics & Gynecology. Though this is certainly not incorrect, it is pertinent for both the general public (voters) and our country’s policymakers to recognize that these stipulations are much more far-reaching, leaving no health specialty untouched. When the right to access this care in the confidential safety of a physician-patient relationship is no longer considered inherent, leaving decisions in the hands of state lawmakers, danger can quickly ensue, muddling the definition at which such care is considered “medically indicated”. Suddenly, politicians are taking the place of board-certified MDs, sitting in their pristine offices wearing their carefully pressed suits, patient non-facing, determining the point at which a pregnant woman’s life is in enough danger to necessitate pregnancy termination efforts, and ultimately leaving physicians traumatically unable to fulfill their duties of doing no harm.
Though these situations are inarguably complicated, it only further indicates the need for these to be addressed in the confidential, safe, and private relationship between a physician and patient rather than blanketed laws drafted by medically inexperienced policymakers that falsely and unjustly simplify the matter as a firm “right” or “wrong.” In states such as Texas, where the wording of the law essentially enables anybody to sue anybody for providing any information that could lead one to an abortion, it leaves any instance of pregnancy termination, or a simple referral for such care, at risk of criminalization, greatly disabling physicians of all specialties and putting the lives of women at grave risk.
Cancer is a diagnosis unanimously deemed unjust, unfair, and frankly “wrong.” It is never a partisan matter: cancer sucks. It is a diagnosis that invokes a level of fear, even in cases that carry favorable survival outcomes; and even though there are modifiable risk factors at play in the development of some cancers, one would be cruel to suggest that a victim ever had a “choice” in the matter of developing a cancer. This much can be agreed on. Could you imagine if a day ever came where we denied someone definitive treatment for lung cancer because they were a lifetime smoker? Or where we denied someone a definitive treatment for HPV-mediated cervical cancer or oral cancer because they had sex? On the other hand, women’s reproductive rights carry such a stigma that pregnancy is assumed 100% in their control, and if a pregnancy becomes life-threatening, well… you should not have had sex. Disregard the fact that over half of women have experienced sexual violence (“sexual activity in which consent is not obtained or freely given”, Center for Disease Control and Prevention) and one in four women have survived rape – almost half of whom were minors (CDC, 2022).
Furthermore, there are dire consequences on cancer care itself that directly stem from the stipulations of the overturning of Roe v Wade. It is important to realize, again, that the medical consequences of these decisions extend so far beyond the general basics of women’s health and reproductive rights. Broadly, pregnancy is a contraindication to many surgeries, systemic therapies (chemotherapies, immunotherapies, targeted therapies), and radiation therapies required for definitive cancer care – most especially those required for explicitly female cancers such as breast and gynecologic cancers. Though the median age of breast cancer diagnosis is well over the median age of both pregnancy and menopause, it is the most common cancer found during pregnancy (ASCO, Cancer.Net). The era of the COVID-19 pandemic has fostered prolific research on the outcomes of cancer treatment delay, and this can also easily be applied in the situation of treatment delay due to pregnancy (most particularly if diagnosis occurs in early pregnancy). A meta-analysis published in the British Medical Journal in October 2020 highlighted an 8% decrease in local control for each four-week delay in breast cancer treatment (with worse breast cancer specific survival outcomes after a delay over 20 weeks) as well as a 23% increase in mortality for each four-week delay in adjuvant radiation for cervical cancer. Though breast surgery is considered safe in pregnancy, radiation and chemotherapy are often held until, at least, late term (ideally after delivery) meaning that women diagnosed with more aggressive forms or higher stages of breast cancer in early pregnancy are at a much higher risk of undergoing treatment delays – all in the setting of a more aggressive or higher stage disease, which is obviously much more likely to progress during the interim of holding definitive therapies. In the setting of cervical cancer, there are no modalities of treatment that are safe in pregnancy.
In sum, the implications of politics directing the practice of medicine, a career which requires the investment of grueling decades and hundreds of thousands of dollars, is not only a direct slap in the face to those who have dedicated their entire lives to master the science and art of shared medical decision-making with their patients. It is a direct danger to the lives of women everywhere. It has implications that extend so far beyond just a woman’s reproductive health. Reproductive care is, certainly, undeniably, an intricately complex issue. But the science of it is not a science mastered by politicians. By its complexity alone, it is a matter that needs to be entrusted to the privacy of an in-depth discussion between a woman and her trusted medical provider. There is no other way.
Disclaimer: The views and statements expressed in this piece are my own and have no relation to those of any academic, hospital, practice, or other institution with which I am affiliated.