Impact of limiting reproductive rights of pregnant individuals with cancer in the United States

Graphical Abstract

Cancer in pregnancy affects an estimated 1 in 1000 pregnancies [1]. However, after Roe v. Wade was overturned, the numerous new state laws across the United States (US) restricting abortion, may lead to increased patient deaths from cancers while waiting for an abortion or delivery [2]. Cancer in pregnancy has been shown to be associated with not only increased maternal morbidity and mortality, but also increased obstetrical complications [3]. Every month of delay in cancer treatment has been associated with up to a 13% increase in mortality, as seen in a meta-analysis from 2020 with a total over 1.2 million patients with various cancers [4].

Prior literature has discussed that restricting abortion care may affect patients with cancer, but no studies have specifically shown how patients with gynecologic cancers are affected [5]. In using data from the United States Cancer Statistics (USCS) between 2001 and 2019 and the National Center for Health Statistics, we evaluated the demographics of reproductive-aged women to estimate the number of pregnant individuals with cancer who may be affected by these restrictions [11]. We found that from 2001 to 2019, 14,603,928 women were diagnosed with cancer in the United States and 10% (1,463,600) were of reproductive age (15–44 years). States with abortion bans were identified based on data from the Guttmacher Institute as of March 18, 2023.

In 2021, 26% of births were in the 13 states that now have complete abortion bans. The number of pregnant women with cancer was estimated by combining age-specific fertility rates and the cancer incidence of reproductive-age individuals with cancer from 2001 to 2019. An estimated 3672 pregnant women were diagnosed with cancer annually, of which 762 lived in states without access to abortion as of March 18, 2023 (Table 1). According to cancer types, 45.6% of the cancers were breast (30.9%) and gynecologic cancers (14.7%). Among gynecologic cancers, cervical cancer (43.5%) was the most common, followed by uterine (29%) and ovarian cancer (21%). The highest incidences of cervical, uterine and ovarian cancer were seen in the South, with a 2–3-fold higher incidence compared to other regions. This discrepancy was greatest in cervical cancer. Of the top ten states with the highest incidence of cervical cancer, six have complete abortion bans: Alabama, Texas, Oklahoma, Kentucky, Missouri, and Louisiana. Intersectional analysis of the age group with the highest fertility rate (25–29 years), showed the highest incidence of cervical cancer in Hispanic patients residing in Texas, double that of White patients in California (8.29 vs 4.17 per 100,000). Limitations of this analysis include inability to account for desire to terminate, unknown gestational age at time of diagnosis, teratogenicity of treatment, exclusion of individuals over 45 years, and survival data.

Table 1.

Estimated annual number of pregnant individuals with cancer by characteristic.

Characteristic		Estimated Number of Pregnant Individuals with Cancera (%)
Age	15–19	64 (1.7)
	20–24	332 (9)
	25–29	757 (20.6)
	30–34	1217 (33.2)
	35–39	961 (26.2)
	40–44	341 (9.3)
Raceb	Non-Hispanic White	2427 (66.1)
	Non-Hispanic Black	525 (14.3)
	Hispanic	448 (12.2)
	Non-Hispanic Asian	191 (5.2)
	None of the Above	84 (2.3)
Cancer Type	Breast	1135 (30.9)
	Female Genital Tract	540 (14.7)
	Cervical	235 (6.4)
	Uterine	158 (4.3)
	Ovarian	114 (3.1)
	Other female	33 (0.9)
	Hematologic	319 (8.7)
	All Other Cancers	1678 (45.7)
Stage	Localized	1931 (52.6)
	Regional	1002 (27.3)
	Distant	521 (14.2)
	Unknown	213 (5.8)
Region	Northeast	727 (19.8)
	Midwest	782 (21.3)
	South	1359 (37)
	West	804 (21.9)
Ban Statusc	Residing in States with Complete Abortion Bans	762 (20.8)

^aEstimates based on combination of age-specific fertility rates and average number of reproductive-age individuals with cancer from 2001 to 2019.

^bRace was categorized per SEER. Non-Hispanic American Indian/Alaskan and unknown races were not included due to low numbers.

^cStates with complete abortion bans were identified based on data from the Guttmacher Institute as of March 18, 2023.

With the overturning of Roe v. Wade, many states across the US enacted laws restricting abortion over the last year and these new laws likely will most affect those patients in states with stricter regulations and restrictions to abortion care. We predict that minorities and those with a lower socioeconomic status will be disproportionately disadvantaged for a myriad of reasons, as seen already in prior studies [7–10]. Hispanic and Black women are two and five times more likely to have an abortion compared to white women, respectively. Additionally, 75% of people who have abortions are of low socioeconomic status [6]. Based on our analysis; this is likely the same population that will be most affected by cervical cancer in pregnancy. American Indian or Alaska Native, Black, and Hispanic populations experienced large absolute increases in travel time to these facilities [7]. After House Bill 2 passed in Texas in 2013, there was a disproportionate burden on Hispanic patients seeking abortions, and similar trends will likely occur now with the new restrictions on abortion care [8].

The healthcare disparity gap affecting patients with cancer has only widened since the overturning of Roe v. Wade. This is evident with the increasing travel time and expense to access abortion services, with a higher impact on people residing in Southern states, those with lower incomes, and those lacking health insurance. In a prior analysis, an estimated 39% women of reproductive age would experience a 250-mile increase in travel distance to the nearest abortion facility, preventing access for over 100,000 women [9]. This is especially seen in certain geographic locations where there are more abortion regulations, such as the Southern US. A study by Rader, et al., showed that estimated travel time to the nearest abortion facility in Texas increased by almost 8 h [7]. Now since Dobbs v. Jackson, two of every five American women lack access to an abortion facility within a 30 min drive, and one in four lack access within a 90 min drive [10]. This emphasizes the growing disparities in abortion care, as accessing facilities that provide these essential services may be impossible for those without the resources to travel.

Furthermore, prior studies demonstrated that states with the most restrictive abortion access have higher cancer-related mortality [7]. Breast and gynecologic cancers constitute nearly half of cancers among reproductive age women in the US. Cervical cancer is the most common gynecologic malignancy, with the highest incidence in Hispanic patients, in states with complete abortion bans. Restrictions to abortions may disproportionately affect Hispanic women with cervical cancer who reside in Southern states who do not have access to this care - states that have already been shown to have higher cancer-related mortalities. In states with complete abortion bans, there were over 750 pregnant individuals with cancer annually who would be without access to abortions. Given the increased burden to access essential reproductive rights, the impact of these abortion restrictions may exacerbate disparities in cancer care, and subsequent oncologic outcomes. Further efforts to develop collaborative relationships with gynecologic oncologists in states without abortion restrictions, as well as expanding virtual care options are warranted to facilitate optimal patient care for this population.

HIGHLIGHTS.

• Over 750 pregnant women with cancer annually would be without access to abortions in states with complete abortion bans.

• Hispanic reproductive age women residing in states with complete abortion bans have higher incidences of cervical cancer.

• Restricting reproductive rights may lead to increased adverse outcomes in those with gynecologic cancer in pregnancy.