Newly Diagnosed Hodgkin Lymphoma Can Be Safely Managed During Pregnancy

By Will Boggs MD

October 21, 2019

NEW YORK (Reuters Health) - Hodgkin lymphoma diagnosed during pregnancy can be safely managed without interruption of pregnancy in most cases, according to new findings.

"Maternal outcome is not worse when compared to nonpregnant patients," Dr. Frederick Amant of University Hospitals Leuven, KU Leuven, in Belgium, told Reuters Health by email. "This is important since gestational changes result in chemodilution and hence the hypothesis that chemo may be less effective. This is not the case, so that is an argument not to interrupt pregnancy but preserve the pregnancy and treat the mother."

Previous studies have documented reassuring birth outcomes in mothers with Hodgkin lymphoma, and increased awareness of the feasibility of antenatal chemotherapy has led to more pregnant women receiving anticancer drugs.

For their study, online September 26 in The Lancet Haematology, Dr. Amant and his colleagues used data from the International Network on Cancer, Infertility and Pregnancy (INCIP) obtained from 17 academic centers in 11 countries.

They evaluated the management and obstetric outcomes of 134 pregnant women diagnosed with Hodgkin lymphoma during pregnancy, compared with 211 nonpregnant women with Hodgkin lymphoma matched for stage and prognostic score at diagnosis.

During pregnancy, 56 women (42%) received no therapy, 72 women (54%) received chemotherapy and six women (4%) received radiation therapy.

The most common chemotherapy regimen, administered to 66 women, was ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) at standard doses.

Most pregnancies (120, 90%) resulted in a live birth. There were two stillbirths and two miscarriages, and 10 women (7%) diagnosed in the first half of pregnancy opted for termination of pregnancy.

Significantly more women receiving antenatal therapy had preterm complications, mainly contractions (12% vs. 7%) and preterm rupture of membranes (5% vs. 0).

The incidence of neonates who were small for gestational age did not differ significantly between chemotherapy-exposed and non-exposed neonates.

Four of 123 children (3%) had a major congenital anomaly at birth, and four children had minor physical abnormalities. About a third of children were admitted to the neonatal intensive-care unit, mainly due to prematurity.

Survival with early- and advanced-stage Hodgkin lymphoma did not differ significantly between pregnant patients and matched controls. Moreover, survival did not differ significantly between 21 patients with early-stage disease with a pregnancy-related delay in initiation of treatment and their controls.

"Issues of maternal prognosis are no longer an argument to interrupt the pregnancy," Dr. Amant said. "This is especially important, since patients are frequently older and with a history of infertility."

"We need to investigate this in other cancer types, too," he said. "Therefore, INCIP continues to collect data, including new cases and long-term follow-up."

Dr. Giovanni Codacci-Pisanelli from Sapienza University of Rome, who co-authored a linked editorial, told Reuters Health by email, "It is very important that everyone involved in the assistance to a pregnant woman (hematologists/oncologists, obstetricians/gynecologists, general practitioners) is aware of the fact that cancer during pregnancy (and specifically Hodgkin lymphoma) does not (certainly not always) require the termination of pregnancy! There are other possibilities that certainly must be discussed in detail with the woman (and hopefully with her partner), which undoubtedly imply some risks, but may give important results."

"I want to add that many hematologists/oncologists are well aware of this progress, and that no one has any right to instill unjustified fear in women, particularly in this especially sensitive phase of their life," he said. "Unfortunately, this does happen: and a scary word said by the least competent of bystanders will destroy every speech made by the most competent specialist."

"Until some years ago, pregnancy after cancer was considered something inconceivable," Dr. Codacci-Pisanelli said. "We now know that it may be possible with no consequences for the woman or for her children."

Dr. Caroline E. Weibull from Karolinska Institutet, in Stockholm, who recently reported similar childbearing potential for women with and without Huntington lymphoma, told Reuters Health by email, "The trend has gone towards administering ABVD during pregnancy, or inducing delivery for women diagnosed in late pregnancy. This is already considered safe, despite limited empirical data on how to manage women diagnosed with Hodgkin lymphoma during pregnancy. Therefore, this paper further confirms the safety of these treatment guidelines."

"The multicenter setting is impressive and reassuring in terms of generalizing the results," she said. "It would have been interesting to compare pregnancy outcomes not just within women diagnosed with Hodgkin lymphoma (ABVD-exposed and not), but also by including a healthy-pregnancies control group. It also remains unknown whether initiation of more intense treatment regimens (e.g., novel drugs and BEACOPP chemotherapy) during pregnancy is safe in relation to pregnancy outcomes and prognosis for the woman."


Lancet Haematol 2019.