In a new study reported by Farooq et al in Blood Advances, patients with relapsed or refractory lymphoma during pregnancy had a progression-free survival rate of 24% and an overall survival rate of 83%.
Background
Receiving a lymphoma diagnosis during pregnancy may be uncommon but can occur for roughly 1 in 4,000 female patients. On rare occasions, patients who achieved remission from a previous lymphoma diagnosis find out their cancer has returned during pregnancy, yet scarce data exist to guide treatment under these circumstances.
“To our knowledge, no previous data has been published for patients with [relapsed and refractory] lymphoma presenting during pregnancy,” explained lead study author Andrew Evens, DO, MBA, MSc, Associate Director of Clinical Services at Rutgers Cancer Institute of New Jersey, System Director of Medical Oncology and Oncology Lead for the Combined Medical Group at RWJBarnabas Health, and Associate Vice Chancellor of Clinical Innovation and Data Analytics at Rutgers Biomedical and Health Sciences at Rutgers University. “Yet the treatment options and prognosis are often very different for lymphoma that is newly diagnosed, vs when the cancer returns,” he added.
Study Methods and Results
In the new retrospective study, the investigators analyzed the outcomes of 23 pregnant patients who were diagnosed with relapsed and refractory lymphoma at a median of 20 weeks of gestation—and also collected data on patient demographics, disease characteristics, and obstetric and neonatal outcomes. Roughly 80% of the patients had Hodgkin lymphoma. Most of them elected to delay chemotherapy until after giving birth, though five of the patients chose to begin treatment during pregnancy as a result of personal preferences and the potentially life-threatening nature of their cancer diagnoses. This included one patient who received immune checkpoint inhibitor therapy during the majority of their second and third trimesters.
Initiating chemotherapy treatment during pregnancy can put the fetus at risk of harm, but delaying treatment may allow the cancer to progress and harm the patient as well as the fetus. Therefore, patients may elect to delay treatment until postpartum for a variety of reasons—including their age, the status of their lymphoma, and the treatment regimen they may require.
“These decisions are incredibly individualized and consider patient age, comorbidities, tumor volume, and the status of the lymphoma,” emphasized Dr. Evens. “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.”
The investigators discovered overwhelmingly positive overall survival rates at 83%, though the progression-free survival rates were lower at 24%. They also reported that 83% (n = 19/23) of the patients delivered live births—most of which were induced and over half of which were preterm. However, 17% (n = 4) of them terminated their pregnancies or experienced spontaneous abortions. The investigators performed a full follow-up on 15 of the patients and found that 10 of them had their lymphoma relapse and 2 had died.
Conclusions
The investigators noted that while it was not known precisely why the progression-free survival rates for the patients involved in the study were so low, they suggested that most patients postponed cancer treatment until after their pregnancy and may not have begun treatment until after these markers were collected. They also revealed that, when possible, fetal outcomes are most positive when the pregnancy is carried to term and emphasized the importance of close collaboration across multiple medical disciplines—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. There are previously published data from patients [with cancer] showing that preterm delivery can significantly adversely affect the child’s cognitive scores later in life,” Dr. Evens underscored.
While the sample size for their study was relatively small, the investigators reiterated that this disease profile is relatively uncommon during pregnancy and that it is often difficult to recruit pregnant patients into clinical trials.
“The goal of this study is to provide data that can inform patients and providers. While a [relapsed and refractory] lymphoma diagnosis during pregnancy is rare, we hope to ensure that oncologists and [patients] have some form of guidance on how to approach this complex clinical scenario,” concluded Dr. Evens.
Disclosure: For full disclosures of the study authors, visit ashpublications.org.
