By Charlotte Huff

Kaiser Health News

As abortion bans go into effect across a contiguous swath of the South, cancer physicians are wrestling with how new state laws will influence their discussions with pregnant patients about what treatment options they can offer.

Cancer coincides with roughly 1 in 1,000 pregnancies, most frequently breast cancer, melanoma, cervical cancer, lymphomas, and leukemias. But medications and other treatments can be toxic to the developing fetus or cause birth defects. In some cases, hormones that are supercharged during pregnancy fuel the cancer’s growth, putting the patient at greater risk.

Although new abortion restrictions often allow exceptions based on “medical emergency” or a “life-threatening physical condition,” cancer physicians describe the legal terms as unclear. They fear misinterpreting the laws and being left in the lurch.

For instance, brain cancer patients have traditionally been offered the option of abortion if a pregnancy might limit or delay surgery, radiation, or other treatment, said Edjah Nduom, a brain cancer surgeon at Emory University’s Winship Cancer Institute in Atlanta.

“Is that a medical emergency that necessitates the abortion? I don’t know,” Nduom asked, trying to parse the medical emergency exception in the new Georgia law. “Then you end up in a situation where you have an overzealous prosecutor who is saying, ‘Hey, this patient had a medical abortion; why did you need to do that?’” he said.

Pregnant patients with cancer should be treated similarly to non-pregnant patients when feasible, though sometimes adjustments are made in the timing of surgery and other care, according to a research overview, published in 2020 in Current Oncology Reports.

With breast cancer patients, surgery could be performed early on as part of the treatment, pushing chemotherapy to later in the pregnancy, according to the research. Cancer experts typically recommend avoiding radiation therapy throughout pregnancy, and most chemotherapy drugs during the first trimester.

But with some cancers, such as acute leukemia, the recommended drugs have known toxic risks to the fetus, and time is not on the patient’s side, said Gwen Nichols, chief medical officer of the Leukemia & Lymphoma Society.

“You need treatment urgently,” she said. “You can’t wait three months or six months to complete a pregnancy.”

Another life-threatening scenario involves a patient early in her pregnancy who has been diagnosed with breast cancer that’s spreading, and tests show that the cancer’s growth is spurred by the hormone estrogen, said Debra Patt, an oncologist in Austin, Texas, who estimated she has cared for more than two dozen pregnant patients with breast cancer.

“Pregnancy is a state where you have increased levels of estrogen. It’s actually actively at every moment causing the cancer to grow more. So I would consider that an emergency,” said Patt, who is also executive vice president over policy and strategic initiatives at Texas Oncology, a statewide practice with more than 500 physicians.

When cancer strikes individuals of child-bearing age, one challenge is that malignancies tend to be more aggressive, said Miriam Atkins, an oncologist in Augusta, Georgia. Another is that it’s unknown whether some of the newer cancer drugs will affect the fetus, she said.

While hospital ethics committees might be consulted about a particular treatment dilemma, it’s the facility’s legal interpretation of a state’s abortion law that will likely prevail, said Micah Hester, an expert on ethics committees who chairs the department of medical humanities and bioethics at the University of Arkansas for Medical Sciences College of Medicine in Little Rock.

“Let’s be honest,” he said. “The legal landscape sets pretty strong parameters in many states on what you can and cannot do.”

It’s difficult to fully assess how physicians plan to handle such dilemmas and discussions in states with near-total abortion bans. Several large medical centers contacted for this article said their physicians were not interested or not available to speak on the subject.

Other physicians, including Nduom and Atkins, said the new laws won’t alter their discussions with patients about the best treatment approach, the potential impact of pregnancy, or whether abortion is an option.

“I’m going to always be honest with patients,” Atkins said. “Oncology drugs are dangerous. There are some drugs that you can give to [pregnant] cancer patients; there are many that you cannot.”

The bottom line, maintain some, is that termination remains a critical and legal part of care when cancer threatens someone’s life.

Patients “are counseled on the best treatment options for them, and the potential impacts on their pregnancies and future fertility,” Joseph Biggio Jr., chair of maternal-fetal medicine at Ochsner Health System in New Orleans, wrote in an email. “Under state laws, pregnancy termination to save the life of the mother is legal.”

Similarly, Patt said that physicians in Texas can counsel pregnant patients with cancer about the procedure if, for instance, treatments carry documented risks of birth defects. Thus, physicians can’t recommend them, and abortion can be offered, she said.

“I don’t think it’s controversial in any way,” Patt said. “Cancer left unabated can pose serious risks to life.”

Patt has been educating physicians at Texas Oncology on the new state law, as well as sharing a JAMA Internal Medicine editorial that provides details about abortion care resources. “I feel pretty strongly about this, that knowledge is power,” she said.

Still, the Texas law’s vague terminology complicates physicians’ ability to determine what’s legally permissible care, said Joanna Grossman, a professor at SMU Dedman School of Law. She said nothing in the statute tells a doctor “how much risk there needs to be before we label this legally ‘life-threatening.’”

And if a woman can’t obtain an abortion through legal means, she has “grim options,” according to Hester, the medical ethicist. She’ll have to sort through questions like: “Is it best for her to get the cancer treatment on the time scale recommended by medicine,” he said, “or to delay that cancer treatment in order to maximize the health benefits to the fetus?”

Getting an abortion outside Georgia might not be possible for patients with limited cash or no backup child care or who share one car with an extended family, Atkins said. “I have many patients who can barely travel to get their chemotherapy.”

Charles Brown, a maternal-fetal medicine physician in Austin who retired this year, said he can speak more freely than practicing colleagues. The scenarios and related unanswered questions are almost too numerous to count, said Brown, who has cared for pregnant women with cancer.

Take as another example, he said, a potential situation in a state that incorporates “fetal personhood” in its law, such as Georgia. What if a patient with cancer can’t get an abortion, Brown asked, and the treatment has known toxic effects?

“What if she says, ‘Well, I don’t want to delay my treatment — give me the medicine anyway,’” Brown said. “And we know that medicine can harm the fetus. Am I now liable for harm to the fetus because it’s a person?”

Whenever possible, physicians have always strived to treat the patient’s cancer and preserve the pregnancy, Brown said. When those goals conflict, he said, “these are gut-wrenching trade-offs that these pregnant women have to make.” If termination is off the table, “you’ve removed one of the options to manage her disease.”

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by Kaiser Health News, North Carolina Health News
September 24, 2022

New abortion laws jeopardize cancer treatment for pregnant patients

by Kaiser Health News, North Carolina Health News
September 24, 2022

By Charlotte Huff

Kaiser Health News

As abortion bans go into effect across a contiguous swath of the South, cancer physicians are wrestling with how new state laws will influence their discussions with pregnant patients about what treatment options they can offer.

Cancer coincides with roughly 1 in 1,000 pregnancies, most frequently breast cancer, melanoma, cervical cancer, lymphomas, and leukemias. But medications and other treatments can be toxic to the developing fetus or cause birth defects. In some cases, hormones that are supercharged during pregnancy fuel the cancer’s growth, putting the patient at greater risk.

Although new abortion restrictions often allow exceptions based on “medical emergency” or a “life-threatening physical condition,” cancer physicians describe the legal terms as unclear. They fear misinterpreting the laws and being left in the lurch.

For instance, brain cancer patients have traditionally been offered the option of abortion if a pregnancy might limit or delay surgery, radiation, or other treatment, said Edjah Nduom, a brain cancer surgeon at Emory University’s Winship Cancer Institute in Atlanta.

“Is that a medical emergency that necessitates the abortion? I don’t know,” Nduom asked, trying to parse the medical emergency exception in the new Georgia law. “Then you end up in a situation where you have an overzealous prosecutor who is saying, ‘Hey, this patient had a medical abortion; why did you need to do that?’” he said.

Pregnant patients with cancer should be treated similarly to non-pregnant patients when feasible, though sometimes adjustments are made in the timing of surgery and other care, according to a research overview, published in 2020 in Current Oncology Reports.

With breast cancer patients, surgery could be performed early on as part of the treatment, pushing chemotherapy to later in the pregnancy, according to the research. Cancer experts typically recommend avoiding radiation therapy throughout pregnancy, and most chemotherapy drugs during the first trimester.

But with some cancers, such as acute leukemia, the recommended drugs have known toxic risks to the fetus, and time is not on the patient’s side, said Gwen Nichols, chief medical officer of the Leukemia & Lymphoma Society.

“You need treatment urgently,” she said. “You can’t wait three months or six months to complete a pregnancy.”

Another life-threatening scenario involves a patient early in her pregnancy who has been diagnosed with breast cancer that’s spreading, and tests show that the cancer’s growth is spurred by the hormone estrogen, said Debra Patt, an oncologist in Austin, Texas, who estimated she has cared for more than two dozen pregnant patients with breast cancer.

“Pregnancy is a state where you have increased levels of estrogen. It’s actually actively at every moment causing the cancer to grow more. So I would consider that an emergency,” said Patt, who is also executive vice president over policy and strategic initiatives at Texas Oncology, a statewide practice with more than 500 physicians.

When cancer strikes individuals of child-bearing age, one challenge is that malignancies tend to be more aggressive, said Miriam Atkins, an oncologist in Augusta, Georgia. Another is that it’s unknown whether some of the newer cancer drugs will affect the fetus, she said.

While hospital ethics committees might be consulted about a particular treatment dilemma, it’s the facility’s legal interpretation of a state’s abortion law that will likely prevail, said Micah Hester, an expert on ethics committees who chairs the department of medical humanities and bioethics at the University of Arkansas for Medical Sciences College of Medicine in Little Rock.

“Let’s be honest,” he said. “The legal landscape sets pretty strong parameters in many states on what you can and cannot do.”

It’s difficult to fully assess how physicians plan to handle such dilemmas and discussions in states with near-total abortion bans. Several large medical centers contacted for this article said their physicians were not interested or not available to speak on the subject.

Other physicians, including Nduom and Atkins, said the new laws won’t alter their discussions with patients about the best treatment approach, the potential impact of pregnancy, or whether abortion is an option.

“I’m going to always be honest with patients,” Atkins said. “Oncology drugs are dangerous. There are some drugs that you can give to [pregnant] cancer patients; there are many that you cannot.”

The bottom line, maintain some, is that termination remains a critical and legal part of care when cancer threatens someone’s life.

Patients “are counseled on the best treatment options for them, and the potential impacts on their pregnancies and future fertility,” Joseph Biggio Jr., chair of maternal-fetal medicine at Ochsner Health System in New Orleans, wrote in an email. “Under state laws, pregnancy termination to save the life of the mother is legal.”

Similarly, Patt said that physicians in Texas can counsel pregnant patients with cancer about the procedure if, for instance, treatments carry documented risks of birth defects. Thus, physicians can’t recommend them, and abortion can be offered, she said.

“I don’t think it’s controversial in any way,” Patt said. “Cancer left unabated can pose serious risks to life.”

Patt has been educating physicians at Texas Oncology on the new state law, as well as sharing a JAMA Internal Medicine editorial that provides details about abortion care resources. “I feel pretty strongly about this, that knowledge is power,” she said.

Still, the Texas law’s vague terminology complicates physicians’ ability to determine what’s legally permissible care, said Joanna Grossman, a professor at SMU Dedman School of Law. She said nothing in the statute tells a doctor “how much risk there needs to be before we label this legally ‘life-threatening.’”

And if a woman can’t obtain an abortion through legal means, she has “grim options,” according to Hester, the medical ethicist. She’ll have to sort through questions like: “Is it best for her to get the cancer treatment on the time scale recommended by medicine,” he said, “or to delay that cancer treatment in order to maximize the health benefits to the fetus?”

Getting an abortion outside Georgia might not be possible for patients with limited cash or no backup child care or who share one car with an extended family, Atkins said. “I have many patients who can barely travel to get their chemotherapy.”

Charles Brown, a maternal-fetal medicine physician in Austin who retired this year, said he can speak more freely than practicing colleagues. The scenarios and related unanswered questions are almost too numerous to count, said Brown, who has cared for pregnant women with cancer.

Take as another example, he said, a potential situation in a state that incorporates “fetal personhood” in its law, such as Georgia. What if a patient with cancer can’t get an abortion, Brown asked, and the treatment has known toxic effects?

“What if she says, ‘Well, I don’t want to delay my treatment — give me the medicine anyway,’” Brown said. “And we know that medicine can harm the fetus. Am I now liable for harm to the fetus because it’s a person?”

Whenever possible, physicians have always strived to treat the patient’s cancer and preserve the pregnancy, Brown said. When those goals conflict, he said, “these are gut-wrenching trade-offs that these pregnant women have to make.” If termination is off the table, “you’ve removed one of the options to manage her disease.”

This article first appeared on North Carolina Health News and is republished here under a Creative Commons license.

1
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During the past decade, a growing body of research has shown that air pollution harms older adults’ brains, contributing to cognitive decline and dementia. What hasn’t been clear is whether improving air quality would benefit brain health.

Two studies published this year by researchers at six universities and the National Institute on Aging provide the first evidence of such benefits in an older population.

One report, published in the Proceedings of the National Academy of Sciences, found that the risk of dementia declined significantly in women 74 and older following a decadelong reduction in two types of air pollution: nitrogen dioxide, a gaseous byproduct of emissions from motor vehicles, industrial sources, and natural events such as wildfires; and fine particulate matter, a mix of extremely small solids and liquids arising from similar sources.

A second report in PLOS Medicine, relying on the same sample of more than 2,200 older women, found that lower levels of these pollutants were associated with a slower rate of cognitive decline. In areas where air quality improvement was most notable, the rate of cognitive decline was delayed by up to 1.6 years, depending on the test.

Both studies are national in scope and account for other factors that could affect results, such as participants’ socioeconomic status, neighborhood characteristics, preexisting medical conditions, and lifestyle choices such as smoking.

What might explain their results? “We think that when air pollution levels are reduced, the brain is better able to recover” from previous environmental insults, said Xinhui Wang, an assistant professor of research neurology at the University of Southern California’s medical school. This hypothesis needs to be examined further in animal studies and through brain imaging, she suggested.

There are several theories about how air pollution affects the brain. Extremely tiny particles — a human hair is at least 30 times as large as the largest particle — may travel from the nasal cavities to the brain via the olfactory (smell) system, putting the brain’s immune system on high alert. Or, pollutants may lodge in the lungs, causing an inflammatory response that spreads and leads to the brain.

Also, pollutants can damage the cardiovascular system, which is essential to brain health. (Links between air pollution, stroke, and heart disease are well established.) Or tiny particles can cross the blood-brain barrier, wreaking direct damage. And oxidative stress may occur, releasing free radicals that damage cells and tissue.

Older adults are especially vulnerable to air pollution’s harmful effects because of reduced lung capacity and pollutants’ potential to exacerbate conditions such as respiratory illnesses and heart disease. Also, air pollution’s effects accumulate over time, and the longer people live the more risks they may encounter.

Yet recognition of the potential cognitive consequences of air pollution is relatively recent. Following several small studies, the first national study demonstrating a link between air pollution and cognition in a diverse sample of older men and women was published in 2014. It found that seniors living in areas with high levels of fine particulate matter were more likely to experience cognitive problems than people living in less polluted areas.

Another study, published a couple of years later, extended those findings by reporting that air pollution’s cognitive effects are magnified in older adults living in disadvantaged neighborhoods where pollution levels tend to be highest. The chronic stress that residents of these neighborhoods experience may “increase the rate at which neurons are damaged by toxic challenges,” the authors wrote.

Air pollution is only one of many factors that influence cognitive decline and dementia, researchers agree, and results of this kind establish associations, not causation.

Newer research suggests that older adults’ cognition is affected even when exposures are below standards set by the Environmental Protection Agency. “With older adults, there really is no level at which air pollution is safe,” said Jennifer Ailshire, an associate professor of gerontology and sociology at the University of Southern California.

“It’s important to keep on reducing the standards for these pollutants,” said Antonella Zanobetti, principal research scientist for environmental health at Harvard’s T.H. Chan School of Public Health. With colleagues, she has a National Institute on Aging grant to study how air pollution affects the risk of Alzheimer’s disease and related dementias among Medicare beneficiaries. In 2019, her work showed that higher levels of fine particulate matter are linked to more hospitalizations among older adults with dementia — a marker of disease progression.

Last year, in one of the largest U.S. studies to date, a different set of researchers examined the link between long-term exposure to fine particulate matter and nitrogen dioxide among 12 million Medicare beneficiaries with diagnoses of Alzheimer’s disease and other forms of dementia. Exposure to high levels of these pollutants appeared to accelerate cognitive decline that was already relatively advanced, leading to an increase in diagnoses, researchers concluded.

In addition to population-wide studies, nearly 20 scientific laboratories across the world are studying how air pollution contributes to dementia in animals. At USC, Caleb Finch, a professor who studies the neurobiology of aging, is co-principal investigator for a five-year, $11.5 million grant from the National Institute on Aging to study how air pollution in urban areas informs the risk of dementia and accelerated brain aging.

Among the questions that Finch said need to be addressed are: Which areas of the brain appear most vulnerable to air pollutants? When are people most at risk? How long does the damage last? Is recovery possible? And do lifestyle interventions such as diet and exercise help?

“The main point is we now realize that Alzheimer’s disease is very sensitive to environmental effects, including air pollution,” Finch said.

Recognizing this, the Lancet’s Commission on Dementia Prevention, Intervention, and Care in 2020 added air pollution to a list of modifiable risk factors for dementia and estimated that up to 40% of dementia cases worldwide might be prevented or delayed if these risk factors were addressed.

For her part, Ailshire is optimistic that public policies can make a difference. From 2000 to 2019, she noted, average annual fine particulate matter pollution decreased 43% nationally due to efforts to improve air quality. “I’m very hopeful that these efforts will continue,” she told me.

What can older adults concerned about air pollution do on their own?

On very hot days, go for a walk in the morning instead of the afternoon, when ozone levels are higher, said Dr. Anthony Gerber, a pulmonologist at National Jewish Health, a medical center in Denver specializing in respiratory diseases. Ozone, a toxic gas, is formed when various chemicals interact with sunlight and heat.

If you live in the western U.S., where wildfires disseminating fine particulate matter have become more common, “wear a KN95 mask” on days when fires are affecting air quality in your area, Gerber said. Also, if you can afford it, consider buying air purifiers for your home, he advised, noting that fine particulates can get into homes that aren’t well sealed.

To check air quality levels in your area, go to AirNow.gov, Ailshire recommended. “If it’s a high-risk day, that might not be the day to go out and do heavy yardwork,” she said.

But don’t stay inside all the time and become overly self-protective. “It’s really important for older adults to be outside and exercise,” Gerber said. “We don’t want seniors to end up sick because they’re breathing lots of particulates, but we don’t want them to become inactive and stuck at home either.”

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Originally Appeared Here

Media contact:
Erin Horn
Senior Media Relations Specialist
701-516-4903 / erin.horn@sanfordhealth.org

BISMARCK, N.D. (Sept. 22, 2022) – Sanford Health recently completed the renovation of the Sanford Family Birth Center,  located on the fifth floor of Sanford Medical Center in Bismarck. This renovation follows the opening of a new neonatal intensive care unit (NICU) on the sixth floor of Sanford Medical Center in Bismarck that opened in July 2020.

Sanford’s new NICU in Bismarck is the only NICU in the region with private rooms, allowing parents and babies to stay in the same room. It also offers NicView, a new 24/7 video streaming service that helps families stay connected and watch their baby through a webcam in the baby’s crib. The NicView service was made possible through the Sanford Health Foundation.

“Since 2017, Sanford Bismarck has welcomed more than 7,000 babies,” said Maggie Seamands, executive director of inpatient services. “Every element of the newly renovated Family Birth Center has been uniquely designed to help make the experience as comfortable as possible for our patients and their families.”

The updated Family Birth Center consists of:

• 8 labor and delivery suites
• 17 post-partum rooms
• 2 c-section operating rooms
• Nursery with procedure room
• 1 triage room
• Updated family lounge
• Updated lobby

A virtual tour of the newly renovated Sanford Family Birth Center is available on the Sanford website: sanfordhealth.org/locations/Sanford-birth-center

The Sanford Bismarck region provides health care to central and western North Dakota, eastern Montana and northern South Dakota. It includes 21 clinics in Bismarck, Mandan, Minot, Dickinson and Watford City, as well as a Level II trauma center located in Bismarck.

About Sanford Health
Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland. Headquartered in Sioux Falls, South Dakota, the organization serves more than one million patients and 220,000 health plan members across 250,000 square miles. The integrated health system has 47 medical centers, 2,800 Sanford physicians and advanced practice providers, 170 clinical investigators and research scientists, more than 200 Good Samaritan Society senior care locations and world clinics in 8 countries around the globe. Learn more about Sanford Health’s commitment to shaping the future of rural health care across the lifespan at sanfordhealth.org or Sanford Health News.

###

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A look at three of the top health-related stories in the news from the last week to keep you Health Smart.

YORK, Pa. —

Depression on the rise 

Depression is on the rise, women’s health has suffered during the second year of the pandemic, and one in five pregnancy-related deaths in the United States were found to be preventable. It’s all in this week’s Health Smart. 

Nearly one in 10 Americans are now suffering with mental health issues. A new report shows that the age group who has seen the biggest increase is teens and young adults. Researchers say the data shows the pandemic contributed to the increase, adding that it’s especially worrisome for little ones because there aren’t annual screenings to look for it.   

Pregnancy-related deaths 

One in five pregnancy-related deaths in the U.S. are preventable. A recent study looked at two years of data and found more than half of the deaths happened up to one year after delivery. The top causes were suicide, excessive bleeding, and cardiac and coronary conditions. The Centers for Disease Control and Prevention says the findings show there needs to be better initiatives to make sure pregnant women get the help they need at the right time.  

Bad dreams and dementia 

If you experience bad dreams, and lots of them, and you’re in mid-life, you could be at an increased risk of developing dementia. Researchers in England found that people who have frequent bad dreams were four times more likely to have cognitive decline over the next decade than those without bad dreams often. One possibility as to why this is, is because bad sleep leads to a build up of proteins associated with dementia.

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