Even before the Dobbs ruling overturned country-wide reproductive rights, the oncology field was already facing a dearth of maternal care access challenges.
The ability to offer tailored or adapted therapy is a source of great relief to many patients diagnosed with cancer while pregnant or who become pregnant while being treated for cancer, explained Virginia F. Borges, MD, MMSc, a physician, associate professor, and director of the Young Women's Breast Cancer Translational Program at the University of Colorado Denver, during a presentation at the American Association for Cancer Research Annual Meeting 2023. Borges explained further that when data are collected and assessed on this topic, it is the minority of women who terminate a pregnancy, either by requirement or choice.
“We are facing an increasing incidence of cancer during pregnancy,” Borges said. “Interestingly, in the wake of novel [circulating tumor] technology, there have come forward reports where non-dyad haplotype was detected on fetal screening, meaning the cancer’s DNA was detected as separate from the fetus, and potentially leading to a cancer diagnosis that may have otherwise remained occult until the pregnancy was completed.”
Borges noted that there are times when the clinical presentation precludes the option to treat the cancer through the pregnancy. She cited several examples from immediate colleagues in Colorado, the first being the patient case of a young woman in the very early stages of her first trimester who was diagnosed with stage 3B cervical cancer.
“There was significant pelvic sidewall involvement from the tumor, and the treatment of concurrent chemoradiation is not possible to be given during pregnancy,” Borges said. “There were also serious viability concerns for the growth of the fetus given the size of the tumor in the pelvic cavity.”
The second patient case was that of a patient with stage 4 melanoma who showed up as very progressed and metastatic, Borges explained. The ideal treatment would be a tyrosine kinase inhibitor based on the BRAF mutation of the tumor.
“But that is not feasible in pregnancy,” Borges said. “One could consider immunotherapy, but at the time, there was no safety data on this option yet.”
However, there are more tools in the treatment toolbox for breast cancer oncologists in these situations than compared to colleagues seeing other cancers, Borges noted. It is also less common but still a real occurrence when the cancer would have a high risk of compromising the maternal health prior to the pregnancy reaching a viable time point, according to Borges. Conversely, some patients may have the opposite experience, where treatment options remain to provide disease control and the mother prioritizes minimizing the risk of her pregnancy over her own health or longevity.
Borges provided an example of the latter occurring in the patient case of a young woman with known metastatic breast cancer under Borges’s treatment for some years with no evidence of active disease state. This patient intentionally took herself off treatment and became pregnant.
“I had options to offer her for keeping her disease from progressing while she was pregnant. She had lost her first child at the age of 5 [years] to a genetic disease, and the protection of this [new] pregnancy was of paramount importance [to her]. She declined all therapy until after childbirth,” Borges said. “When we began treating her again, she survived 2 years into the life of her younger child.”
Borges noted that a more complex topic for oncologists and their patients is the increasing divide between what is possible to offer during pregnancy and the improvement in standard of care through the incorporation of novel drugs. Borges cited the example of high risk locally advanced triple negative breast cancer (TNBC), which for decades had combination chemotherapy that can be administered in the second and third trimesters as the backbone of treatment. With the advent of the Keynote 522 (NCT03036488) clinical trial data, we see improvement in progression free survival with the incorporation of pembrolizumab (Keytruda, Merck) to the chemotherapy.
“At present, there are potentially still ways to manipulate this regimen and give what we can during the pregnancy and continue the rest afterwards in ways that we hope will not diminish the outcome and results for the woman. However, [TNBC] can be very aggressive and there are times where this is not a realistic option to pursue from the beginning, or if we do choose this option from the beginning, the outcomes can go sideways, the situation can become grave, [with] the certainty of salvaging the mother or the pregnancy reaching viability unclear,” Borges said. “This is just one example from young women's breast cancer and there are many to be found across the cancers young women face during pregnancy.”
Switching to the landscape of reproductive rights, Borges explained that the US Supreme Court decision that reversed the country-wide protection of reproductive rights under Roe v Wade occurred on June 24, 2022, and it is called the Dobbs decision. On the heels of this decision, medical leaders across a multidisciplinary scope, as well as advocate partners and at least 2 leading medical journals, denounced this ruling for its impact on women's health.
“There are many pending changes being sought nationwide, and as such, there is the specter that more of the country will have deeper restrictions in the coming years,” Borges said. “For now, I focus our attention on only those states that have a full ban on abortion. Using the [American Cancer Society] Cancer Statistics Center, I tabulated the number of cases expected in 2023 by 5 of the more common cancers affecting pregnant women. These numbers are all cancers not separated by age or gender. If we apply our knowledge that cancers diagnosed during pregnancy affect 0.1% of all cancers … we anticipate 100 women are facing cancer during pregnancy in states with full abortion bans now and in the immediate future.”
Borges explained that an overview of this topic was published in JAMA Oncology, and it estimated that, at the time of the Dobbs decision, this nationwide number would approach 1500 cases per year, especially if the anticipated legal changes by states come to pass.
“If you look at when cancers are diagnosed during pregnancy, the majority arise during weeks of gestation at or beyond legal access to termination across most of the United States [following this decision],” Borges said. “If we look at it from the perspective of treatment options, 24% to 66% arise within many weeks of gestation remaining that might place the mother's life at immediate risk or diminish her likelihood of survival.”
Additionally, although many states with abortion bans have a clause related to an emergency health situation, the details of those allowable situations under these clauses remain tricky to navigate for pregnant patients. This challenge is due to how, depending on the patient’s exact cancer scenario, the threat to the mother’s health or life might not be seen as immediate.
“Whether they fall into this category in the truest of senses may not unfold until treatment is tried and the cancer proves refractory. There are many significant problems to the situation pregnant patients currently face,” Borges said. “Even a couple of weeks delay could impact the mother's health in some cancer situations. If approval is given [under the requirements of the state’s emergency health clause], how then is this accomplished? Conversely, if approval is not given, or the mother decides to pursue the pregnancy in a high-risk situation, do we have the [OB/GYN] expertise available in her community to manage the complications that may ensue?”
Borges noted that even before the Dobbs decision, the oncology field was already facing a dearth of maternal care access challenges. Now, with a large number of states banning abortion, access to that aspect of maternal care is becoming increasingly difficult as well as access to the type of care needed for high-risk pregnant cancer patients who are maintaining their pregnancy.
“I emphasize that our women facing pregnancy and cancer must make agonizing decisions. When one considers the possibility of limitations to the options of their decisions, I bring to your attention the more nuanced aspect of their care. They must make a decision now that could affect their cure rate and survival not today, but in the 5 or more years to follow,” Borges said.
Borges explained that questions regarding how these factors play into the emergency rules within the abortion bans in states across the country continue to arise. Additionally, questions regarding what degree of difference there is between what choices a woman can make if she is pregnant versus if she is not may be a difference between life and death for that patient.
“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,” Borges said. “My colleague Nicole T. Christian, MD, and I wrote our perspective on this topic about Dobbs, and it has been published in the New England Journal of Medicine. I'll leave you with the conclusions we drew then, as they still stand, in my opinion.”
Borges noted that, since she lives in a blue state in the country, she can go home and return to her usual practice of care for her pregnant patients. For this reason, she explained that she hopes she can represent and articulate well on behalf of her many colleagues who do not have this luxury and face potential risks to themselves and their livelihood.
“We were already an embattled workforce with a shortage of MDs, APPs, and RNs. Now, we add the increasing challenge of a legal-medical disconnect to a job we know how to do,” Borges said. “We face a time when we could potentially be legally bound to not discuss abortion as an aspect of medical care for our pregnant cancer patients, even when it would be the appropriate recommendation. There is high potential for emotional and moral harm to us in this time. The resources to help us care for our pregnant cancer patients are not prepared for this current situation. Where can we turn? Hopefully to each other.”
Borges explained that the need for national cooperation on this topic appears obvious, even if the laws are state specific.
“All of us who are MDs swore some version of an oath or promise when we graduated, [and] we can turn to that ethos for guidance. One example, the updated AMA ethics code, has 2 of its 9 statements that I believe pertain to today's topic. As physicians, we respect the law, and we have responsibility to seek to change the law when it goes against the best interests of our patients,” Borges said. “I believe that situation is now for our pregnant cancer patients. As always, when in doubt, do what is right for the patient.”
Borges VF. The importance of reproductive rights for pregnant women facing cancer: Difficult choices at a difficult time. Presented at AACR Annual Meeting 2023; April 17, 2023. Accessed April 17, 2023. https://www.abstractsonline.com/pp8/#!/10828/session/60