Abortion ruling may narrow options for pregnant cancer patients



My patient, a 30-year-old woman in her second trimester, was having a routine fetal ultrasound when the x-ray tech saw something unexpected – a lump coming out of her kidney, near her uterus. She underwent a biopsy, was diagnosed with acute lymphoblastic leukemia and was immediately sent to the leukemia ward of my hospital for treatment.

I can only imagine the rollercoaster of emotions she had to go through, from excitement at the sight of her soon-to-be baby to a devastating diagnosis of cancer.

Acute leukemia is considered a medical emergency — it is a rapidly growing cancer. If left untreated, patients die within weeks, and sometimes within days or even hours. When a person has acute leukemia, the bone marrow cannot produce the normal components of blood. With a low red blood cell count, people can become profoundly anemic; with fewer platelets, people are prone to excessive bleeding; and with dysfunctional white blood cells, people can suffer life-threatening infections.

By definition, people with leukemia have a weakened immune system. Pregnancy also affects the immune system, and the combination of the two can make people even more susceptible to infections.

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Shortly after he arrived, I sat on the edge of his hospital bed and had the conversation that patients and oncologists dread. Should she try to keep the fetus, knowing the risks, or should she have an abortion?

Certain chemotherapy drugs, including those needed to treat her leukemia, could cross the placenta and cause irreparable damage or death to the fetus. The drugs could also cause infection or bleeding in my patient, further lowering her blood count, which would cause similar side effects in the fetus. My patient would also be more at risk of dying herself.

When I met her, almost two decades ago, before Dobbs v. Jackson Women’s Health Organization overturned the right to abortion guaranteed by Roe vs. Wade, it was a difficult discussion. Now, in some states, we can add this complexity — opting for an abortion could be illegal.

Supreme Court ruling leaves states free to ban abortion

She was silent after I asked the question, and so poised that she replied, “It’s my first baby. I know the risks of trying to keep him. But I still want to try. »

We started chemotherapy the next day and had the obstetrics team perform daily ultrasounds on the fetus. For the first few days, my patient looked great, even teasing us and telling jokes. The fetus was also doing well. She taped the ultrasound pictures on her hospital wall, which lifted our spirits and reminded us of what was at stake.

Then she had a fever. That morning, she looked worried for the first time since we met.

“Something is wrong,” she told me. “Something is seriously wrong.”

Her blood pressure had started to drop and we suspected she had started to develop sepsis – the body’s extreme response to an infection that can lead to death.

“We’ll take care of you,” I told her, trying to reassure her as much as myself. But I was worried.

We immediately gave her antibiotics, but within two hours she had to be moved to intensive care because her blood pressure had dropped further. Within eight hours, she had been placed on a ventilator. Twelve hours after the onset of fever, the fetus is dead. At hour 18, my patient died too.

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Cancer is unusual in pregnant women, affecting approximately 1 in 1,000 pregnancies. It is estimated to result in approximately 6,000 cases each year in the United States and accounts for approximately 0.1% of all malignancies. Pregnancy itself is not considered a risk factor for developing cancer, although theories abound as to whether hormonal changes or immune system suppression during pregnancy could promote tumor growth. The co-occurrence is probably just a rotten coincidence. The most common malignancies in pregnant women are cervical cancer, breast cancer, melanoma, lymphoma and leukemia.

Every oncologist I know has at least one history of treating a pregnant patient. I have a few.

My patient chose not to have an abortion, and both she and her fetus died. Others made the same decision, and both mother and baby survived – I have snapshots of those babies with yearly updates. They had better outcomes because they had a different type of leukemia, or were treated at a different stage of fetal development, or were just lucky and didn’t have an infection or bleeding complication .

Some of my patients have chosen to have an abortion and have gone into remission from their cancers. Others, with slower growing cancers, were able to delay chemotherapy just long enough to deliver.

In all of these scenarios, my patients could make independent choices, weighing the risks and benefits of maintaining or terminating a pregnancy.

Post-Roe confusion spurs delays and denials of some vital pregnancy care

But the Supreme Court’s decision to overturn deer introduced complications for future cases.

Thirteen states have “trigger bans” on abortion that have gone into effect, with exceptions to protect the life of the mother that are too vague to know when they can be invoked. My own state of Florida prohibits abortions after 15 weeks of pregnancy, with a similar exception. (This was temporarily blocked by a Florida judge and reinstated on July 5.)

As physicians who are sworn to provide the best care to our patients, my colleagues and I need guidance on what poses an immediate threat to a pregnant person’s life. A patient who is bleeding profusely from pregnancy is certainly in grave danger. And I would say that a pregnant cancer patient who is about to receive chemotherapy also poses an immediate health threat that would be greatly increased due to the side effects.

This guidance would help us engage in a more informed consent process with particularly vulnerable patients to receive chemotherapy that understands the risks, benefits and possible legal consequences.

My patient’s story still haunts me. Would she be alive today if she had had an abortion? Maybe. But I’m reassured to know that she had the freedom to make that choice.

Mikkael A. Sekeres is chief of the division of hematology and professor of medicine at the Sylvester Comprehensive Cancer Center at the University of Miami, and author of “When the blood breaks down: life lessons from leukemia» and the forthcoming book “Drugs and the FDA: Safety, Effectiveness, and Public Trust.” Follow him on Twitter @MikkaelSekeres.

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