Childbirth rates among Hodgkin lymphoma survivors match the general population

For female survivors of cancer, childbearing potential is an important consideration. This is particularly salient in Hodgkin lymphoma, where the disease primarily affects younger people and cure is expected for the high majority of patients. 

In the past, therapeutic treatments for Hodgkin lymphoma were known to induce untoward risk for infertility. This included alkylator-based regimens such as MOPP and infra-diaphragmatic radiation, which are gonadotoxic.

Therapeutic advances over the past 20 to 30 years have included a prominent shift to doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD), which is less gonadotoxic. However, comprehensive clinical study of this has been lacking in part as analyses have relied primarily on self-reported questionnaires that are prone to selection and recall biases. Additional information is desired so providers may appropriately counsel patients on the impact that contemporary treatments have on the life-altering consequence of infertility and how to optimally guide patients on family planning.

A multinational effort examined all female patients diagnosed with Hodgkin lymphoma in the nationwide Swedish Cancer Registry between 1992 and 2009. Researchers analyzed patients by time period and examined multiple important variables that may have affected fertility (eg, age at diagnosis, disease stage, treatment, parity status, etc). The use of population-based registry data enriched with clinical data from patient medical records represented a major strength of the study.

The investigators found that the childbearing potential of female survivors improved significantly over time and that childbirth rates 3 years after diagnosis among patients treated in the contemporary era (ie, 2004-2009) were similar to those of the general population, regardless of stage or treatment. For patients treated with ABVD, there were no differences observed in childbirth rates between patients and comparators beyond 9 months from diagnosis. There were several factors that likely influenced these results, including the significant shift to use of less gonadal-toxic treatments — especially ABVD — as well as enhanced fertility counseling and improved supportive care measures. 

In addition, investigators found that six to eight cycles of the intensive contemporary regimen BEACOPP was associated with a decreased likelihood of childbearing potential within the first 3 years of diagnosis, as was use of radiation, although with a lower impact. However, after 3 years, childbirth rates appeared to approach those of the comparators.  

Collectively, these data are reassuring to providers and patients with Hodgkin lymphoma. Discussion of fertility should still be conducted, especially in patients who may receive BEACOPP and/or pelvic radiation. Further, patients who experience progressive disease usually receive intensive therapy with high-dose chemotherapy and autologous stem cell transplantation, which is associated with a high risk for infertility. Indeed, in the current series, no children were born after disease relapse. It is challenging to project newly diagnosed patients who will ultimately warrant stem cell transplantation, and fertility preservation is often difficult prior to initiation of salvage therapy.

Continued research on fertility preservation is needed, especially for older women, patients who experience disease relapse, and also toward the impact that targeted therapeutics such as brentuximab vedotin (Adcetris; Seattle Genetics, Takeda) and checkpoint inhibitors have on childbearing potential as these agents rapidly become integrated into frontline therapy.