What to Do When Tough-to-Treat Lymphoma Strikes During Pregnancy
Not a lot is known about how physicians should handle cases in which a pregnant woman is diagnosed with relapsed/refractory lymphoma.
A new study may provide some perspective.
Though uncommon, this issue is still experienced by about one in 4,000 women, according to background notes with the study published June 1 in Blood Advances.
Relapsed means the lymphoma reappears after remission, and refractory means it's staying the same or getting worse.
“To our knowledge, no previous data has been published for patients with [relapsed/refractory] lymphoma presenting during pregnancy,” explained Dr. Andrew Evens, associate director for clinical services at Rutgers Cancer Institute of New Jersey.
“Yet the treatment options and prognosis are often very different for lymphoma that is newly diagnosed, versus when the cancer returns,” Evens said in a news release from the American Society of Hematology.
For the study, Evens and his team followed 23 of these patients to shed some light on outcomes.
The study found that patients with relapsed/refractory lymphoma during pregnancy experienced a progression-free survival rate of 24% — meaning the disease had not worsened — and an overall survival rate of 83%. Nineteen live births were reported.
The 23 patients had been diagnosed at a median of 20 weeks' gestation — half before and half after — approximately the second trimester.
About 80% of the patients had Hodgkin lymphoma.
Most decided to delay their chemotherapy until after the baby was born, though five began treatment during pregnancy.
Evens said this decision was due to personal preference and the potentially life-threatening nature of their cancer diagnoses. One of the patients who underwent treatment received checkpoint inhibitor therapy during the majority of the second and third trimesters.
Four of the patients terminated their pregnancies or had miscarriages. Of the 19 live births, most of the women were induced and more than half of the babies were born early.
The researchers did a follow-up on 15 patients and found that 10 had relapsed and two had died.
While starting chemotherapy in pregnancy can put the fetus at risk, delaying treatment can allow the cancer to progress and can also harm the patient and child, the study authors noted.
“These decisions are incredibly individualized and consider patient age, comorbidities, tumor volume, and the status of the lymphoma,” Evens said. “Often the patient chooses to carry the pregnancy to term and treat the cancer afterward. Conversely, there are cases where a patient is highly symptomatic, as well as cases that are life-threatening both to the patient and the fetus. Under those circumstances, we strongly consider treating the cancer during pregnancy if beyond the first trimester.”
Evens said a possible reason why progression-free survival was so low is that most patients postponed cancer treatment until after their pregnancy.
He emphasized the importance of close collaboration among doctors, especially maternal-fetal medicine.
“While every case is unique, for patients wishing to proceed with pregnancy, we generally recommend taking the gestation to term delivery at 37 weeks or beyond,” Evens said. “There are previously published data from cancer patients showing that preterm delivery can significantly adversely affect the child's cognitive scores later in life.”
The Leukemia & Lymphoma Society has more on relapsed and refractory lymphoma.
SOURCE: American Society of Hematology, news release, June 1, 2023