Rutgers Cancer Institute Reviews Guidelines for Managing Blood Cancers During Pregnancy

Pregnancy-associated cancers are generally defined as those occurring during pregnancy or within one year after delivery. Cancers affect about one in 1,000 pregnancies in the U.S., with blood malignancies being the fourth most common.

About 6% of pregnancy-related cancers are Hodgkin lymphoma, and 5% are non-Hodgkin lymphoma. Leukemias in pregnancy are rarer, accounting for 1 in 10,000 pregnancies. The most common pregnancy-related leukemias are acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), and chronic myeloid leukemia (CML).

Pregnant mother

In a review published in the March 2025 issue of Seminars in Perinatology, Adam S. Zayac, M.D., and researchers at Rutgers Cancer Institute Department of Blood Disorders in New Brunswick, NJ, discuss recommendations for the diagnosis and management of lymphoma and leukemia during pregnancy.

Diagnosing lymphoma typically involves positron emission tomography-computer tomography (PET-CT), which is contraindicated during pregnancy due to potential teratogenic effects. Instead, the review recommends using magnetic resonance imaging (MRI) as a diagnostic tool during pregnancy.

The review emphasizes the importance of a multidisciplinary approach to treating lymphoma and leukemia during pregnancy. The team should include hematologists, oncologists, obstetricians, neonatologists, and experts in maternal-fetal medicine. Any treatment decisions should be made weighing the benefits of treatment to the patient against the potential risks to the fetus.

When treating pregnancy-associated lymphoma, chemotherapy and targeted agents are generally used. However, chemotherapy is contraindicated during the first trimester of pregnancy, during which organogenesis occurs and the risk for congenital abnormalities is greatest. For clinically stable patients, the recommendation is to delay chemotherapy until after the first trimester. For patients who require early treatment, Rituxan (rituximab), a chimeric anti-CD20 monoclonal antibody, is generally considered safe to use during pregnancy, although its use is associated with an increase in preterm deliveries.

Zayac and his team also discuss treatment strategies specifically for pregnancy-associated Hodgkin lymphoma and non-Hodgkin lymphoma. The review found ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) safe during and beyond the first trimester of pregnancy for treating Hodgkin lymphoma. On the other hand, the antibody-drug conjugate Adcetris (brentuximab vedotin) is contraindicated during pregnancy.

The review recommends a watchful waiting approach for asymptomatic patients diagnosed with non-Hodgkin lymphoma during pregnancy. In more aggressive cases, the CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) regimen may be used along with Rituxan.

Treatment of leukemia during pregnancy varies based on the type of malignancy being treated.

Although many people diagnosed with AML are, on average, in their 70s, 10% to 15% of AML cases are diagnosed during reproductive years. To induce remission, the standard of care for patients in the second or third trimester of pregnancy includes an anthracycline, such as daunorubicin or idarubicin, and cytarabine. The authors note, however, that anthracyclines have been associated with an increased risk of fetal cardiotoxicity.

ALL is associated with a rapid onset and serious complications. As such, the goal of treatment in pregnancy is to achieve prompt remission and a potential cure while minimizing harm to the patient and fetus. In their review, Zayac and his colleagues discuss the role of chemotherapy in ALL treatment, dissuading its use during the first trimester of pregnancy but noting it may be safe to administer during the second and third trimesters. For patients requiring treatment early in their pregnancy, targeted agents, such as Rituxan and Gleevec (imatinib), have been used with caution.

Tyrosine kinase inhibitors (TKIs), including Gleevec, Phyrago or Sprycel (dasatinib), Tasigna or Danziten (nilotinib), and Iclusig (ponatinib), are now the gold standard for managing CML. However, these small molecules cross the placenta and have been associated with congenital abnormalities. TKI treatment is generally discouraged during the first trimester of pregnancy. Gleevec and nilotinib, which both have lower rates of placental transfer, have been safely used during the second and third trimesters. The authors list peg-interferon-alpha as a safe alternative to TKIs.