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Pregnancy does not increase Hodgkin’s lymphoma relapse risk
Pregnancy did not appear to increase the risk for relapse in survivors of Hodgkin’s lymphoma, according to the results of a registry study conducted in Sweden.
“We conducted this study because Hodgkin’s lymphoma survivors, as well as clinicians, have expressed worries that pregnancy may increase the risk for relapse, despite a lack of empirical evidence to support such concerns,” Ingrid Glimelius, MD, PhD, researcher in the department of immunology, genetics and pathology at Uppsala University and oncologist at Akademiska Hospital in Uppsala, Sweden, said in a press release. “This rigorous study should help put those fears to rest.”
To determine if an association existed between pregnancy and relapse risk among survivors of Hodgkin’s lymphoma, Glimelius and colleagues accessed Swedish health care registries and medical records of women of childbearing age diagnosed with the disease between 1992 and 2009.
Researchers commenced follow-up 6 months after diagnosis, when the disease could be considered in remission. They defined pregnancy-associated relapse as a relapse during pregnancy or within 5 years of giving birth.
The study included data from 449 women, 32% of whom (n = 144) became pregnant during follow-up.
Forty-seven relapses occurred during follow-up, one of which they deemed a pregnancy-associated relapse. Thus, women exposed to pregnancy had a lower relapse rate, but this association did not reach statistical significance (adjusted HR for comparison = 0.29; 95% CI, 0.04-2.18).
A greater percentage of relapses occurred in the calendar periods 1992-1997 (11.8%) and 1998-2003 (14.1%) than in the most recent calendar period (6.6%). However, after controlling for time from diagnosis and clinical characteristics, calendar period of diagnosis did not appear to significantly influence relapse risk.
The researchers calculated an expected number of relapses among women with a recent pregnancy of 3.76, given that they would experience the same relapse rate as that of women without a recent pregnancy. The study’s observed-to-expected ratio was 0.27 (95% exact CI, 0.01-1.51).
The proportion of women with advanced-stage disease was comparable among parous women with (29.3%) or without (28.4%) pregnancies during follow-up, but higher among nulliparous women (42.4%).
Women aged older than 30 years at diagnosis appeared at increased risk for relapse compared with women aged 18 to 24 years at diagnosis (30 to 34 years, HR = 2.41; 95% CI, 1.12-5.2; 35 to 40 years; HR = 2.51; 95% CI, 1.13-5.59).
Neither chemotherapy regimen nor number of cycles administered appeared to affect relapse outcomes.
The researchers identified the small patient cohort as a study limitation. Further, they reported that they did not have access to information regarding elective or spontaneous abortions among the study population.
“Based on these findings, we see no evidence that Hodgkin's lymphoma survivors who become pregnant are at higher risk for relapse,” Caroline E. Weibull, MSc, biostatistician and doctoral candidate in the department of medical epidemiology and biostatistics at Karolinska Institutet in Stockholm, said in a press release. “After accounting for differences in age and disease severity, we found that the probability of becoming pregnant did not differ markedly between patients with advanced- and early-stage disease or between patients who had different types of chemotherapy.” – by Cameron Kelsall
Disclosure: One study researcher reports honoraria from and a consultant role with Celgene, Nordic Nanovector, Roche, Takeda and Tolero Pharmaceuticals. Glimelius, Weibull and the other researchers report no relevant financial disclosures.
Perspective
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As cancer treatments improve, more and more people are surviving their cancer diagnosis. Further, modern cancer treatments are less gonadotoxic than they previously were. Increasingly, children and young adults diagnosed with cancer are able to maintain fertility and are able to contemplate family building. Infertility has been found to be the most important consequence of cancer treatment among female survivors.
As suggested in the paper by Weibull and colleagues, very limited data had suggested that pregnancy would increase the risk for recurrence of many types of cancers, including Hodgkin’s Lymphoma. The rationale for this opinion was that the immune changes associated with pregnancy would be conducive to tumor recurrence.
In the current study, the researchers use the nationwide Swedish Cancer Registry, along with other national databases, to determine the Hodgkin’s lymphoma recurrence rate of those who had become pregnant vs. those who did not. They identified 449 women of childbearing age over a 17-year period who met criteria for inclusion and defined pregnancy-related relapse as one that occurred during pregnancy or within 5 years of delivery. Of the 449 women, 144 became pregnant, and there was no difference in recurrence rate among those who became pregnant and those who did not.
Importantly, during this study, the researchers divided women by severity of disease and found recurrence was similar among those who became pregnant and those who did not in each group. This eliminates the possibility of the “healthy mother” effect, as they call it, meaning that women with less-severe disease are more likely to become pregnant and less likely to recur.
The findings of this study are of profound importance to those with cancer and contribute to a growing understanding about survivorship and future family building. Previous studies have shown that women treated with chemotherapy who maintain fertility do not subsequently have increased risk for birth defects or offspring with increased cancer risk. The current study by Weibull and colleagues provides reassurance for survivors that pregnancy will not compromise their own health, either.
References:
Green DM, et al. Am J Obstet Gynecol. 2002;doi:10.1067/mob.2002.126643.
Zeltzer LK. Cancer. 1993;doi:10.1002/cncr.1097-0142.