The U.S. Supreme Court reversal of Roe v. Wade has led to appropriate heightened concern for not only the infringement on women’s rights, but also the unprecedent removal of a lifesaving medical procedure. This has uncovered a torrent of concerning patient scenarios that, in the absence of guidance on exceptions, will undoubtfully lead to higher mortality rate among women.
Our patients and the medical community require more direction; we have so many questions and a discernable lack of answers. What we do know is that this monstrous change will affect our daily lives, our education, our practice, and most importantly, the people we took a Hippocratic oath to protect. It is difficult to summarize the medical impact this will have on women, particularly marginalized populations where the rate of abortion is higher.1 Dr. Amanda Jean Stevenson has estimated that in the first year after the ban on abortion, there will be a 7 percent increase in pregnancy-related deaths, and in subsequent years, a 21 percent increase.1 The increase in pregnancy-related death will be profound in non-Hispanic black women and in women of lower socioeconomic status.1
The Centers for Disease Control and Prevention has reported that states with the most restrictive abortion laws already have the highest maternal mortality rates.2 The lack of access to abortions will have a unique impact on women who are diagnosed with cancer during pregnancy. Of the 3.6 million births in the United States, 1.5 million (41%) were in the 26 states that are expected to ban abortions. In these states, there are an estimated 1,500 women who will be diagnosed with pregnancy-associated cancers.3 Due to the ban on abortion, it is estimated that 135 to 420 of these women will experience a compromise in their care, increasing chance of death.3
Patient Outcomes
In the United States, cancer is the second most common cause of death in women of reproductive age.4 The most common cancer diagnoses in this age group are breast cancer, lymphoma, melanoma, colorectal cancer, leukemia, breast cancer, and cervical cancer.4 The incidence of concurrent pregnancy and malignancies is one in 1,000 live births. Of these cases, 14 percent will receive a diagnosis occurring at zero to three months before delivery — a period associated with the most unfavorable perinatal and cancer outcomes.3 The incidence of hematologic malignancies during pregnancy is 0.02 percent. With women delaying pregnancies to older age, the incidence of cancer diagnosis during pregnancy is expected to continue to increase.5 A hematologic malignancy during pregnancy requires a precise and swift multidisciplinary approach to safely and sensitively maneuver the intertwined social, ethical, and treatment complexities.Chemotherapy exposure during the first trimester leads to increased risk of premature birth and neurocognitive dysfunction.6 The choice to terminate a pregnancy can be difficult to make, and unfortunately, a delay in chemotherapy initiation until the second or third trimester is not always feasible. Studies summarizing the effects of chemotherapy on maternal and fetal outcomes are limited in quantity, and the studies that are available report conflicting results. Data on newer agents such as targeted therapies, bispecific agents, and chimeric antigen receptor T cells are even more sparse or nonexistent.
A large multicenter, prospective case-control study compared 129 children exposed to chemotherapy versus 111 children in a control group. The report showed a higher incidence of preterm delivery (61.2%), but at a median age of 22 months there was no significant difference in cognitive development of the chemotherapy-exposed group compared to the control group and no difference in cardiac toxicity at 36 months of age.7 While these data are reassuring, the length of time of evaluation was short and truly does not represent long-term outcomes. The study reported a statistical difference in infant birth weight in pregnant women who had chemotherapy compared to women who did not.6 Low birth weight and very-low birth weight can be associated with increased perinatal morbidity and mortality, preterm birth, hypoglycemia, and perinatal mortality.6 One large study using the U.S. National Inpatient Sample (NSI) database examined hospital discharges from 2004 to 2014 and showed that maternal complications and outcomes were worse in women with hematologic malignancies. These included higher incidence of peripartum cardiomyopathy, acute kidney injury and arrythmia, postpartum hemorrhage, and placental abruption compared to women with no cancer during pregnancy or no history of cancer.4 A similar study performed using NSI data from 2013 to 2016 demonstrated that patients in the cancer group were more likely to experience severe morbidity and death during the hospitalization.8 Dr. Netanel Horowitz and colleagues demonstrated that overall survival in patients with pregnancy-associated acute myeloid leukemia was 30 percent lower than in the age-matched pregnant population, which may be due to differences in pharmacokinetics, undertreatment, and delay in referral to allogenic stem cell transplantation.9 What do we do when we need to start treatment urgently, which is the case in acute leukemia, when we know that delays in care lead to worse outcomes. Will we need to appeal against the order? Will it be problematic to find OB-GYN specialists with training in abortions who are willing to perform them? Will the patient have to travel out of state to have this procedure performed, further delaying care?
Education
The effect of the abortion ban in the United States will affect medical training of future OB-GYN, family medicine, and internal medicine specialists. Of all OB-GYN residency programs in the United States, 44.8 percent are in states that are likely or certain to ban abortion.10 Only time will tell how this will affect access to health care. Will medical students choose not to rank programs in states based on abortion laws, due to their own beliefs or family needs? Will this further increase access to certain specialties?
Changes to the Patient-Physician Relationship
The patient-physician relationship is sacred, and criminalizing that relationship will have a longstanding negative effect on all. It could alter the way we practice and how patients provide information to their physicians. The Hippocratic oath states, “I will respect the privacy of my patients and their data, for their problems are not disclosed to me that the world may know. Most especially, must I tread with care in matters of life and death.”
Is this pledge compromised if medical personnel face criminal charges for taking care of patients? Will insurance companies choose not to cover life-preserving procedures or medical interventions if a physician practices abortion care? Will they be permanently blocked from certain insurance networks? Currently, insurance plans may deny coverage to patients with prior medical conditions. Is there a risk that patients will now lose coverage or be denied future coverage if they undergo an abortion? If medical staff are criminalized for practicing lifesaving care, we will undoubtfully experience a decline in new physicians, nurses, physician assistants, and nurse practitioners.
An unbalanced governmental interference in medical practice is a detrimental path. This is best illustrated in the fervent opposition and polarizing views on mask mandates and COVID-19 vaccinations. As a medical community, we persevered and continued to advocate for our patients the best way we could. We need to do the same now and advocate for a reversal of this decision, and in the meantime, develop guidance and clear medical exceptions to help us navigate these times. We need the medical community to develop this guidance, since we are best geared to do so. We cannot wait for each state to make those exceptions as they are needed at a national level. This is not about opinions, political views, or beliefs; it is about patients and proper and best practices. We took an oath to protect, and the latest restrictions on abortion will continue to hinder that oath. We cannot wait until it permanently shifts medical care and future medical training. This is the obligation of our medical community, and we need to continue to fight for our patients.
Competing Interests
Dr. Isenalumhe indicated no relevant conflicts of interest.
Editor's Note: The Hematologist welcomes opinion columns on issues affecting patients with blood diseases and/or the community caring for these patients.
