Reply to Letter to the Editor

We thank Sahu et al. for their comments on our paper ‘Pregnancy: part of life in chronic myelogenous leukemia.’[1] The issues highlighted in their submission are highly relevant and important to a setting where resources are constrained and optimal standards of care may be difficult to achieve. This situation is commonly encountered in developing countries where access to drugs and the ability to closely monitor disease by advanced molecular diagnostics is limited. Management of chronic myelogenous leukemia (CML) in unusual clinical situations such as pregnancy requires an individualized approach directed toward optimizing care to ensure favorable outcomes for both the parent and the fetus wherever possible. As shown in our paper, close monitoring of disease status by quantitative polymerase chain reaction (PCR)based testing and judicious use of available therapies can be used effectively to manage such patients. Although both the hydroxyurea and leukocyte apheresis are useful adjuncts to therapy in some conditions, there is little evidence to recommend these as the mainstay of management in all cases. Despite emerging data describing favorable outcomes in the fetuses of patients exposed to Imatinib and some other tyrosine kinase inhibitors (TKIs) in the early stages of pregnancy, it is important to consider that these agents were immediately withdrawn at the time pregnancy was detected thereby minimizing exposure where possible.[2–4] Adverse fetal outcomes were documented in cases where Imatinib was not discontinued early.[5] In this respect, interferon-based therapy appears to be the least likely to result in adverse maternal or fetal outcomes and can also provide some measure of disease control beyond cytoreduction alone. We recognize that there are likely to be differences in practice in resource-constrained settings and appreciate the difficulties that may be associated in managing complex issues such as pregnancy in CML, particularly in a younger patient population. This scenario effectively demonstrates the premise of our article that with the life expectancy of CML patients now being nearly the same as that of normal individuals. Efforts are necessary to ensure that pregnancy and childbirth can also be an achievable milestone without compromising disease control.