Consider fertility preservation when treating lymphoma in young women
Click Here to Manage Email Alerts
Ann LaCasce, MD, MMSc, medical oncologist, director of the Dana-Farber/Partners CancerCare Hematology-Medical Oncology Fellowship Program, and associate professor of medicine at Harvard Medical School, spoke with Healio about the importance of fertility preservation when treating young women with lymphoma, considerations when treating pregnant women, the link between radiation treatment and breast cancer risk, and the greatest areas of unmet needs in lymphoma.
Because lymphoma is less common among women than men, does treatment differ?
It depends on the subtype of lymphoma. There are a few specific lymphomas that may be more common in women, including one type called primary mediastinal B-cell lymphoma (PMBL). Follicular lymphoma is the second most common lymphoma we see in adults and it’s slightly more common in women.
Therapies are really similar for women and men. One consideration when you’re treating young women is to think about fertility preservation. For men, it’s very straight forward in that we can do sperm banking, but for women it may be more complicated regarding egg preservation. On occasion, we need to do that before people initiate treatment, but fortunately most of our therapies for lymphoma — at least the common lymphomas — don’t cause infertility. We will often put women on leuprolide acetate (Lupron, AbbVie) to shut off their menstrual cycles and theoretically prevent the follicles in the eggs from maturing and therefore protect them from the effects of the chemotherapy. In young women, sometimes we will add that after a discussion with the patient about the pros and cons of that.
That’s one way in which the therapy may be different, but in general it’s really quite similar.
Can pregnant women receive lymphoma treatment?
Yes, pregnant women can receive lymphoma treatment. Typically, we do not give chemotherapy during the first trimester because there may be teratogenic effects. But, during the second and third trimester, regimens for our common lymphomas that we see in younger women, including Hodgkin lymphoma and aggressive non-Hodgkin lymphoma, can be given safely to pregnant women.
For pregnant patients, how can clinicians care for the risks and benefits of treatment for the mother as well as the potential risks to the fetus of in utero exposure to treatment?
What’s important when you treat a woman who is pregnant is to work closely with the high-risk obstetrician. With the chemotherapy regimens that we’re using, we know what is safe to use in women, but working with an OB plus sometimes a pharmacist with supportive care meds, sometimes there are limitations in what we can use. For nausea, we have a lot of good options, so it’s not very often an issue, but we have to think about the timing of the delivery and what the blood counts are going to look like. All those sorts of things require very close coordination with the obstetrician who has experience in treating pregnant women with chemotherapy.
What is the association between Hodgkin lymphoma and breast cancer?
It’s really not the lymphoma itself, it’s the radiation that causes the risk. Women younger than 30 or 35 years who receive chest radiotherapy have a significantly increased risk for developing subsequent breast cancer many years down the line. Our current approach with younger women is to avoid radiation to the chest if we can. Many of these women will do well with chemotherapy alone without radiation.
If we do have to use radiation in a woman younger than 30 or 35 years, then we will typically screen that woman carefully for the subsequent development of breast cancer — there are data for using both mammography and breast MRI. There are also some ongoing prevention studies looking at low-dose tamoxifen. There’s a study here at Dana-Farber that is trying to answer the question can we protect women.
What are the greatest unmet needs related to lymphoma in women?
The greatest unmet needs in lymphoma aren’t really specific to women. There are certain diseases that still need significant improvements in our therapies, including T-cell lymphomas, which tend to be significantly less sensitive to chemotherapy than B-cell lymphomas. For aggressive lymphomas that recur following initial standard chemotherapy, despite having stem cell transplantation and CAR T cells — which have really changed the field — there’s still a population of patients who relapse after those modalities and that is a very high unmet need in lymphoma. We still need better therapies for mantle cell lymphoma. It’s a disease that’s more common in men, but we also see women who develop mantle cell lymphoma.
Fortunately, we’re lucky in lymphoma in that many of our patients do very well. We’re able to treat women who are pregnant with good outcomes, which is remarkable. Hopefully things will continue to improve as CAR-T gets better and some of these novel therapies continue to evolve.
Collapse
Click Here to Manage Email Alerts