How is Hodgkin's Disease Managed During Pregancy?

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What happens if you develop Hodgkin's disease when you are pregnant?  How often does this happen?

Hodgkin Lymphoma in Pregnancy

Hodgkin’s lymphoma mainly affects young individuals in their teens and twenties - the same age when women often become pregnant.  So developing Hodgkin's disease during pregnancy is not that unusual.  It's estimated that between 1 in 1,000 and 1 in 6,000 women have the face the question of how to manage Hodgkin's lymphoma during pregnancy.

Symptoms of Hodgkin Lymphoma vs Symptoms of Pregnancy

The symptoms of Hodgkin's lymphoma can overlap with symptoms we associate with pregnancy.  Some of these symptoms include feeling tired, having night sweats, and experiencing itchy skin.  Thankfully Hodgkin's disease is very curable, and people who are diagnosed don't have to worry that they delayed their diagnosis, thinking the symptoms were due to pregnancy alone.

Does Hodgkin's Lymphoma Behave Differently in Women Who are Pregnant?

Hodgkin's lymphoma behaves the same for women who are pregnant or those who are not.  You may have heard rumors that pregnancy can "fuel" cancer.  While that may be the case with, for example, an estrogen dependent breast cancer, it is not the case for women with Hodgkin's disease.  The cancer grows and spreads the same way whether you are pregnant or not.

Are Tests for Lymphoma Any Different in Pregnant Women?

If you are pregnant, your doctor will likely order different tests to diagnose and stage your disease than if you weren't pregnant.

 X-rays, CT scans, and PET scans are generally avoided during pregnancy to prevent radiation exposure to the fetus. MRI scans are used instead; they are equally good while being harmless during pregnancy. The other tests are similar and so are the stages of Hodgkin’s lymphoma.

Is an Abortion Necessary if This Cancer is Detected During Pregnancy?

It is rarely necessary to terminate a pregnancy when someone is diagnosed with Hodgkin's lymphoma.

  Most often treatment can be delayed or modified until the baby is mature enough to be delivered relatively safely.  Only if the disease is so advanced that it threatens the life of the mother, or makes a viable delivery impossible, is abortion considered.

How is Hodgkin's Lymphoma Treated During Pregnancy?

There are no fixed rules on treatment of lymphoma during pregnancy. The stage of lymphoma, the time of pregnancy and the wishes of the mother are all considered when making the treatment decision. Treatment is often delayed or modified so that the best balance can be obtained between disease control and the safety of the unborn child.

The first trimester of pregnancy

If Hodgkin’s is diagnosed during the first trimester of pregnancy, the intention is to delay the treatment if possible to prevent any damage to the fetus. The baby is most prone to harm from cancer treatments during the first three months when its organs are being formed - especially during the time span from 2 weeks to 8 weeks after conception.

 Chemotherapy is harmful at this stage, and must be avoided. Radiation is harmful too if it reaches the womb. But it may be delivered to areas far away from the womb (like the neck or the upper chest) with careful shielding of the abdomen from the rays, if it becomes necessary to start treatment. In most young women diagnosed in an early stage, it is possible to delay treatment until you reach your second trimester, or even until your baby is delivered.

The second and third trimester of pregnancy

Managing lymphoma in the latter half of pregnancy is easier because more choices are available. Waiting until the baby’s lungs mature (and it becomes suitable for delivery) is easier and steroids given to hurry this process work quite well. If starting treatment becomes necessary, some chemotherapy drugs may be started without a high risk of damage to the fetus. In fact, a few studies show that the standard combination of chemo drugs like ABVD may be given safely during the last few months of pregnancy. Radiation may also be delivered to some select areas of the body if the abdomen can be carefully shielded.

What are the Outcomes of Treating Hodgkin's Lymphoma in Pregnancy?

Results from a study that followed patients up for 20 years after treatment showed that the results of treating pregnant women with Hodgkin’s were no different from those who did not have the disease.  Survival rates are the same. Hodgkin’s lymphoma is one of few cancers where the chances of cure are high in all stages. A few months of treatment delay during pregnancy does not alter treatment results too much. Keeping your baby is a definite option and few expectant mothers will let that pass.

Sources:

Brenner, B., Avivi, I., and M. Lishner. Haematological cancers in pregnancy. Lancet. 2012. 379(9815):580-7.

Eyre, T., Lau, I., Mackillop, L., and G. Collins. Management and controversies of classical Hodgkin lymphoma in pregnancy. British Journal of Haematology. 2015. 169(5):613-30.

Yahalom, J., and S. Horwitz. Management of classical Hodgkin lymphoma during pregnancy. UpToDate. Updated 01/10/15. http://www.uptodate.com/contents/management-of-classical-hodgkin-lymphoma-during-pregnancy

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