Each year, about 27,000 women age 45 or younger are diagnosed with breast cancer in the United States. Of those, about 4% are pregnant at the time of their diagnosis.
This diagnosis during what is already a worrying and thrilling time can require a woman to make agonizing decisions about her own health and the health of the fetus. In some cases, the most appropriate but difficult decision may be to terminate the pregnancy – an option that a recent U.S. Supreme Court decision has significantly limited or taken away from women in many states.
In a perspective published Saturday in The New England Journal of Medicine, University of Colorado Cancer Center members Nicole Christian, MD, an assistant professor of surgical oncology in the CU School of Medicine, and Virginia Borges, MD, a professor of medical oncology, detail how the Supreme Court decision in Dobbs V. Jackson Women’s Health Organization will harm some patients.
The decision, which holds that the U.S. Constitution does not confer a right to obtain an abortion and overturned the landmark Roe v. Wade decision from 1973, has led to new restrictions on reproductive choice, including limiting or denying abortion access in many states.
“Our job as doctors is to provide patient-centered, evidence-based care, and making moral judgments about a patient’s decisions is not how we accomplish that goal,” Christian says. “Reproductive care is health care, and the most important thing I can do in navigating these choices with patients is to give them unbiased information and support them in decision making.”
Potential to harm
Christian and Borges emphasize in the perspective that while they are oncologists rather than clinicians who provide abortion services, the Dobbs decision has the potential to harm some of their patients. “Indeed, the harmful effects will become a reality for all clinicians who care for women of childbearing age,” they write.
“When the Dobbs ruling came out, I had a lot of thoughts about how it impacted me personally as a woman in America,” Christian says. “Then I thought about how lucky I am that I take care of patients in Colorado, where the state legislature has protected reproductive health choices. But as a regional health care center, we see patients from states with much more restrictive options. I have patients from Oklahoma, Nebraska, occasionally Texas, and their options are a lot more limited now.”
For women who are diagnosed with breast cancer during pregnancy, the weight of decisions they must make to help ensure the health of the fetus are compounded by decisions they must make regarding their own health.
“For most of our patients who are pregnant with breast cancer, it’s a highly desired pregnancy,” Christian says. “Some of our patients have come through fertility treatments, some have had secondary infertility and been trying to have another child for a long time. They may already have children, and suddenly have to face balancing the decisions associated with a wanted pregnancy and medical interventions that may not be compatible with a healthy pregnancy.”
Making informed decisions
Even when breast cancer patients receive innovative, multidisciplinary care from CU Cancer Center teams, “there remain situations, however, in which we cannot offer complete or safe treatment to a pregnant person with a breast cancer diagnosis,” Christian and Borges write. “And even when we can, it may be overwhelming or impossible for the patient to manage breast cancer treatment in addition to pregnancy — and then care for a newborn.”
For some patients balancing pregnancy and a breast cancer diagnosis, abortion is the necessary and correct option. “Under Dobbs, some U.S. patients will be forced to carry a high-risk pregnancy and will have limited choices for treating their cancer. Making this compromise could result in worse oncologic outcomes and a greater risk of death for these patients — risks that apply to pregnant patients with any type of cancer,” Christian and Borges write.
Women who receive a breast cancer diagnosis during pregnancy must make a series of difficult decisions about the health of the fetus and their own health, as well as assess the risk to both if they decide to continue the pregnancy during cancer treatment.
“In situations where women decide to continue with the pregnancy, which is a decision we will support, it’s not at no risk to the fetus,” Christian says. “We may be exposing the fetus to toxic chemicals that are necessary to effectively treat the breast cancer, but that’s a risk that women are having to make decisions about.”
Deciding to terminate a pregnancy following a breast cancer diagnosis “is an extremely difficult choice and one that women do not make lightly,” Christian says. “Denying women this essential reproductive health care only makes what is already an excruciating time that much harder.”
Christian and Borges emphasize that “these difficult decisions should be informed by physicians’ extensive training and understanding of the scientific literature, and made as part of the meaningful dialogue of a patient–physician relationship. They are not decisions that should be made by the state. Though our team is multidisciplinary, there is no role in it for the government.”