Seismic Change Occurs in Small Bites

Jill Gilbert, MD

If you are not already aware, the Dobbs v Jackson Women’s Health Organization decision is a landmark decision of the US Supreme Court in which the court held that the Constitution of the United States does not confer a right to abortion. Several states have passed trigger laws that make abortion a felony and hold patients and providers liable for these charges.

Regardless of your personal stand on abortion, this will most likely affect your practice. A recent article published in JAMA Network Open demonstrated that chemotherapy exposure prior to 12 weeks gestational age was associated with a 21.7% rate of major congenital malformations (95% CI, 7.5%-43.7%; odds ratio, 9.24; 95% CI, 3.13-27.30).¹

It should also be noted that certain chemotherapy agents such as immunotherapy and newer agents were not included in this cohort analysis and the absolute risk is not known. It is virtually certain that if you are a treating oncologist, you will be faced with a patient of childbearing age. You will need to be aware of the risks of chemotherapy in pregnancy and may need to counsel patients about contraception. But what if the patient is already pregnant?

When I think about this scenario, I remember that my North Star as a physician is safe and equitable patient care. Thus, I must advocate for the patient and a full treatment approach that includes considerations for a woman who finds herself in this situation. Multiple professional societies have addressed this Dobbs decision. The American Society of Clinical Oncology (ASCO) provided an official statement:

ASCO is committed to the delivery of medically appropriate, equitable, evidence-based cancer care. For patients of childbearing age, a cancer diagnosis raises medical considerations around pregnancy and fertility preservation. Every patient should have the ability to pursue, in partnership with their oncologist, all treatment options that offer the best chance of a successful outcome for their cancer.

Unfortunately, the implementation of laws based on the Dobbs decision could limit these options.²

The American Society of Hematology (ASH) has taken a stronger stance, even demonstrating the willingness to pull out of New Orleans, Louisiana, as a potential location for future meetings due to the draconian trigger ban on abortion that went into immediate effect in the state following the Dobbs decision.

ASH president Jane N. Winter, MD, and other local and national ASH leaders met with Louisiana Governor John Bel Edwards and his staff to educate them about the impact of this law on hematology patients and to ensure that members who suffer an obstetric emergency while attending the 2022 ASH Annual Meeting & Exposition in New Orleans this month will be treated according to standard of care and not politics. The future possibility of holding ASH annual meetings in New Orleans is presently unclear.³

ASH further notes that:

Having the right to choose to terminate a pregnancy is critical for the patients our members serve. Blood disorders, including sickle cell disease and blood cancers like leukemia and lymphoma, can pose a profound risk to maternal health. In some cases, denying women their right to terminate a pregnancy puts them at risk of serious illness or death.

Further, limiting access to reproductive health resources damages the relationship between patients and providers, which is paramount to providing the highest quality of care. ASH strongly opposes any federal action that interferes with this relationship and harms patients’ abilities to seek necessary medical treatment.

ASH supports the right to maternal health care that addresses hematologic disorders and advocates for access to reproductive health services for all people. We remain committed to combating inequities in hematology and supporting clinicians who serve vulnerable populations, including those at risk of maternal health conditions.⁴

It is likely that you will face these situations, and it is time to think about how you will respond. Ask your program director. Ask your hospital legal counsel. Ask your state oncology society for guidance. Have a plan. You will be asked to provide the facts to the patient, and you will need to understand the laws and how to best provide safe cancer and hematological care.

We have already seen the seismic effects of government involvement in medical decisions. Let’s look at the legislative push to regulate opioid prescribing. In many states, providers are fearful of providing opioids. As a result, patients are often underdosed or sent to a pain clinic that is not experienced in managing cancer-related pain. Controlling cancer-related pain is our wheelhouse and, moreover, it is our duty. Thankfully, many states have exemptions for patients with cancer.⁵

The glimmer of hope for our patients concerning the restrictive abortion legislation can actually be found in those exemptions from opioid prescribing restrictions for patients with cancer. This did not happen by chance. The providers in your state, along with your state societies, were critical in the lobbying efforts and allyship that amended the legislation and allowed our cancer patients to be treated equitably and successfully for their cancer-related pain. This can happen again, and in fact, providers and professional societies are coming together in states with trigger bans to do just that. You can be a part of the effort by contacting your state society (either ASH or ASCO or the American Medical Association).

Change can happen again if patient care, and not politics, is the goal.

I have tried to give a concrete example of how involvement of the boots on the ground, the providers, can impact important legislative advances in health care, even in these political times. You are not just a chemotherapy provider. You are training to provide care for the entire patient and, unfortunately, this may clash with a political climate that at times seems at odds with practicing best care.

Jill Gilbert, MD, is a professor and the Associate Director for Research, Education, and Professional Development at Vanderbilt University Medical Center in Nashville, Tennessee.

References

1. van Gerwen M, Maggen C, Cardonick E, et al. Association of chemo-therapy timing in pregnancy with congenital malformation. JAMA Netw Open. 2021;4(6):e2113180. doi:10.1001/jamanetworkopen.2021.13180
2. ASCO statement on Supreme Court decision in Dobbs v. Jackson Women’s Health. June 27, 2022. Accessed November 18, 2022. https://bit.ly/3tEzxMP
3. Winter JN. No room for ambiguity: ASH’s advocacy for maternal health after the Dobbs decision, part 2. October 20, 2022. Accessed November 18, 2022. https://bit.ly/3VaawF2
4. ASH advocates for the right to maternal health care. News release. American Society of Hematology. June 24, 2022. Accessed November 21, 2022. https://bit.ly/3VidlDI
5. Bulls HW, Bell LF, Orris SR, et al. Exemptions to state laws regulating opioid prescribing for patients with cancer-related pain: a summary. Cancer. 2021;127(17):3137-3144. doi:10.1002/cncr.33639