Pregnancy testing uncommon among adolescents with acute leukemia

Adolescent girls with acute leukemia rarely received pregnancy screenings prior to treatment with teratogenic chemotherapy, according to the results of a cross-sectional study.

Teenaged girls with acute lymphoblastic leukemia had the lowest screening rates, results showed.

The majority of chemotherapeutic regimens used to treat childhood and adolescent leukemia can have harmful effects on a fetus. However, clinicians may not identify sexual behaviors in children and adolescents with chronic conditions, and the symptoms of pregnancy can be mistaken for other ailments.

“While sexual health discussions and education may traditionally be thought to be the responsibility of the patient’s primary care provider, adolescents with cancer will often see their oncologist frequently over the course of their cancer treatment and afterwards,” Pooja Rao, MD, MSCE, who served as a pediatric hematologist–oncologist at Children’s Hospital of Philadelphia during the conduct of this study, and is currently a faculty member at Penn State Hershey Medical Center, said in a press release. “Oncologists, therefore, are well-positioned to initiate discussions about sexual health with their patients.”

The analysis included data from 35,650 adolescent girls (range, 10-18 years) with an ED visit documented in the Pediatric Health Information System between 1999 and 2011.

This population represented three distinct cohorts, including 889 girls with newly diagnosed ALL and 127 girls with acute myeloid leukemia. These cohorts were compared with 34,634 girls who received a CT scan of the abdomen and/or pelvis. Because radiology department institution protocols require pregnancy screening, researchers considered the CT scan cohort to be the best available patient population for comparing pregnancy screening rates with the leukemia cohorts.

Billing of a pregnancy test on the same day or prior to teratogenic chemotherapy exposure within the same index admission served as the study’s primary outcome measure.

All cohorts had similar rates of private vs. public insurance coverage. However, a greater proportion of girls with ALL were aged 10 to 13 years (57%) than girls in the AML (44%) and CT scan cohorts 39%; P < .0001), and a greater proportion were of non-Hispanic white race (75% vs. 63% vs. 69%; P < .0001).

Thirty-five percent of girls in the ALL cohort received an appropriately timed pregnancy test, as did 64% of the AML cohort and 58% of the CT scan cohort.

Screening appeared to increase with age across cohorts; however, girls in the ALL cohort continued to receive fewer appropriately timed pregnancy tests than girls in the CT scan or AML cohorts.

An analysis adjusted for hospital clustering and patient age showed that girls in the ALL cohort remained significantly less likely to receive pregnancy tests than girls in the CT scan cohort (adjusted prevalence ratio, 0.71; 95% CI, 0.65-0.78). Further, girls in the AML cohort appeared more likely to receive a pregnancy test than girls in the CT scan cohort; however, this trend did not reach statistical significance (adjusted prevalence ratio, 1.12; 95% CI, 0.99-1.27).

The researchers observed an increase over time for pregnancy screening in the ALL cohort. Screening rates in the CT scan and AML cohorts remained fairly stable throughout the observed period.

Researchers also observed hospital center–level variation in pregnancy screening.

“Although earlier studies suggested regional variation in pregnancy screening and practice variation across centers has also been described for supportive-care measures such as analgesia administration in pediatric cancer patients, to our knowledge, no prior reports have demonstrated different intracenter practice variation in pregnancy screening,” the researchers wrote.

Because the study data were restricted to the period between 1999 and 2011, Rao and colleagues acknowledged that they could not capture more recent screening data.

The generalizability of the results may be limited, due to the sole inclusion of treatment centers within the Pediatric Health Information System database.

“Since nearly all chemotherapy agents used for childhood and adolescent acute leukemia can cause potential harm to a developing fetus, our findings indicate a need for standardized pregnancy screening practices for adolescent patients being treated for cancer,” Rao said. – by Cameron Kelsall

Disclosure: Rao reports no relevant financial disclosures. Other study researchers report grants and/or research funding outside the submitted work from Alex’s Lemonade Stand, American Cancer Society, Hyundai Hope on Wheels Foundation, Merck and Pfizer.