Ethical Considerations of Suspected Colorectal Cancer in Pregnant Persons

Jane Smith is 34 years old and 19 weeks pregnant with her first child. She presented to the emergency department, because over the past 48 hours, she began noticing significant blood in her stools, a symptom she has not previously experienced. She denies vaginal bleeding but describes the rectal blood as “bright red.” Earlier that morning, Jane also experienced rectal bleeding in the absence of a bowel movement and grew increasingly concerned. Jane was diagnosed with irritable bowel syndrome with constipation (IBS-C) several years ago, but she has never been examined more closely by a gastroenterologist to rule out potentially more serious causes of her symptoms. Jane has also expressed several times throughout her pregnancy that she is very excited to “finally be pregnant,” after trying unsuccessfully for 3 years, and that she “would do anything” to keep her baby safe and carry the pregnancy to term. Jane was in a monogamous relationship with the baby’s father for several years, but they are no longer together. She does not currently have health insurance because she was laid off from her job over a year ago, has been removed from her previous partner’s health insurance, and has not found another job with health benefits. Both of Jane’s parents passed away recently and she is not close with her 2 brothers, who live in different states.Jane is admitted to the intensive care unit due to heavy rectal bleeding and assigned to Julia, an acute care nurse practitioner. Julia is concerned because she would typically refer a patient with these symptoms to a gastroenterologist (GI specialist), who would likely order a colonoscopy. She knows that colonoscopies are not usually recommended during the first trimester of pregnancy because of possible fetal complications and are only recommended if necessary in the second trimester.1 She is unsure if Jane’s case warrants a colonoscopy. She does not want to assume the worst-case scenario, but Jane’s symptoms may suggest colorectal cancer (CRC). In reviewing Jane’s medical record, Julia sees that Jane had an uncle who passed away at age 41 from an “unknown stomach cancer.” Given Jane’s symptoms and family history, further follow-up is warranted.Julia decides to place an urgent referral to the Division of Gastroenterology, and the GI specialist meets with Jane in the intensive care unit (ICU) later that afternoon. The GI specialist has worked with other patients who had cancer during pregnancy, along with their oncologists, and he tells Julia during their initial conversation that he strongly encourages screening procedures once cancer is suspected, and that he typically recommends terminating pregnancies prior to 20 weeks if cancer is diagnosed, particularly if the cancer has metastasized, due to concern for the pregnant person’s health. Julia is unsure what Jane would say to these recommendations, and she understands that it will be important to have a conversation with Jane about her personal values and beliefs surrounding the pregnancy, parenthood, and the health and welfare of herself and her fetus. Together, the GI specialist, Julia, a maternal fetal medicine specialist, an oncologist, a neonatologist, and Jane will determine the next steps to take.Colorectal cancer during pregnancy is rare, occurring in approximately 1 in 13 000 deliveries. Less than a quarter of these cases are diagnosed prior to delivery.1 But the incidence of CRC for women in their reproductive years is increasing, with one estimate predicting CRC incidence for women ages 20 to 34 years will increase by over 90% by 2030.1 Although guidelines for CRC screening were recently revised—with both the American Cancer Society and US Preventive Services Task Force now recommending screening for all average risk individuals beginning at age 45—these changes benefit those who delay childbearing but not those under 45 at risk for developing CRC.2,3 The US Centers for Disease Control and Prevention recommend that people who have an increased risk of CRC talk to their doctor about when to begin screening, as they may need to begin screening before age 45. This includes people with a strong family history of CRC or certain types of polyps, a personal history of inflammatory bowel disease (IBD), a genetic syndrome such as familial adenomatous polyposis, or hereditary non-polyposis colorectal cancer, also known as Lynch syndrome.3 The US Multi-Society Task Force on Colorectal Cancer recommends that people with a family history of CRC, or a documented advanced adenoma in a first-degree relative aged younger than 60 years or 2 first-degree relatives with these findings at any age, receive a colonoscopy beginning at age 40, or 10 years before the age of diagnosis of their youngest affected relative, whichever is earlier.4 These guidelines can aid in earlier diagnosis of those with known risk factors, but individuals must be aware of their personal and family history. Even when this is known, only about 20% to 30% of CRC cases have an identifiable predisposing factor.5,6It is also imperative to recognize that CRC disproportionately affects Black individuals in the United States.7 Black individuals have a 20% greater likelihood of getting CRC and a 40% greater chance of dying from CRC compared with other racial or ethnic groups.7 Apart from their increased CRC risk, Black women are also 3 times more likely than White women to die from a pregnancy-related cause. Factors contributing to this disparity include structural racism, implicit bias, variation in access to quality health care, and underlying chronic conditions.8 Taking this into consideration when evaluating a pregnant person with suspected CRC is essential.Diagnosis of CRC during pregnancy is complicated for several reasons. First, CRC symptoms are similar to symptoms associated with uncomplicated, healthy pregnancies, such as abdominal cramping, constipation, iron deficiency, nausea, vomiting, anemia, and even rectal bleeding. This complicating factor can lead to delayed diagnosis.2 According to existing literature, pregnant persons often have advanced disease by the time they present with CRC. Therefore, studies encourage clinicians to fully evaluate pregnant patients who present with gastrointestinal symptoms, balancing safety risks, to rule out CRC.2Another complicating factor is that CRC screening in pregnant persons can be risky, depending on the trimester, or even the week, when symptoms present. Although colonoscopies are typically the criterion standard for treatment in nonpregnant persons and also allow for biopsy and removal of a tumor if it is detected, the bowel preparation medications, drugs used for sedation, and the procedure itself are relatively contraindicated during pregnancy because of potential damage to the placenta and fetus and potential hypoxia and hypotension for the pregnant person.9 Therefore, there is currently no consensus about how or when to screen for CRC during pregnancy.2,10Other diagnostic options besides colonoscopy are available, and although some are less conclusive, they may be helpful in determining next steps in a pregnant person with suspected CRC because they pose less risk to the developing fetus. These include a detailed physical examination, carcinoembryonic antigen (CEA) level testing, ultrasonography, abdominal magnetic resonance imaging (MRI), computed tomography (CT) imaging, upper gastrointestinal system (GIS) endoscopy, and/or a sigmoidoscopy. Carcinoembryonic antigen testing and abdominal imaging via non-contrast MRI or hepatic ultrasound can be performed as an initial assessment for CRC, as CEA is typically not increased in a normal pregnancy, and the abdominal imaging techniques could give insight into whether the suspected cancer may have metastasized to common sites such as the liver and lung.2 Ultrasound and MRI are preferred in pregnant patients, as they do not have ionizing radiation. In addition to these imaging techniques, CT scans may be considered if it is determined that benefits of accurate and early diagnosis of potential complications outweigh the risk of radiation to the fetus.11 An upper GIS endoscopy and a sigmoidoscopy are considered safer endoscopic procedures than a colonoscopy, with sigmoidoscopies arguably being the safest.9 A recently published case report of a 30-year-old patient who presented at 9 weeks of pregnancy with fresh rectal bleeding in the absence of hemorrhoids and constipation whose provider performed a sigmoidoscopy procedure showed that the cancerous mass was identified and completely removed, resulting in an uneventful pregnancy and the delivery of a healthy baby.5 However, according to a 2021 systematic review in the Journal of Digestive Endoscopy, endoscopies should be performed in pregnancy only if strongly indicated and should be postponed until the second trimester or after birth unless an emergency, such as a significant GI bleed or suspected malignancy, is present. By the second trimester, organogenesis of the fetus has already occurred and the uterus is not yet as large as it will be in the third trimester, when there is a higher risk of uterine trauma.9 Therefore, in cases of ambiguity about CRC in the first trimester, risks of this screening procedure must be weighed against benefits.There is currently no consensus about the standard treatment for CRC in pregnancy,2,9 so a multidisciplinary approach that involves consideration of the gestational age, tumor stage, and the need for emergency surgery or adjuvant chemotherapy is used to determine appropriate treatment in each case.9 If the pregnancy is within the first 20 weeks, the recommendation is to perform a surgical procedure to resect the cancerous tumor because, as pregnancy advances, the risk of tumor progression increases.9,12 If it is possible to resect the tumor and the cancer has not spread, the pregnancy may be continued. However, if cancer has spread to other areas, such as the uterus and ovaries, or if it blocks access to the colon and rectum such that the ability to remove the tumor via surgery is compromised, it is usually recommended that the pregnancy be terminated, as this indicates a higher-stage disease and a need for immediate, aggressive treatment.9,13 If a CRC diagnosis is made after 20 weeks, it may be safe to delay surgery until after delivery, as delivery can be performed after the fetus has achieved lung maturation.9 Glucocorticoids may be administered antenatally to help promote lung maturity.14 Neonatology consultation can be helpful in these cases.In addition to surgery, adjuvant chemotherapy may be an option, although there is conflicting evidence regarding its use during pregnancy.15 Some literature reports that certain drugs such as irinotecan and oxaliplatin may be safe for pregnant persons with CRC who are in the second or third trimester. However, other studies have found that there are risks of intrauterine growth restriction and premature birth with chemotherapy during these trimesters, so the decision must be made carefully. Chemotherapy is not typically recommended during the first trimester, when organogenesis is occurring.9,15 Although adjuvant chemotherapy is recommended for patients with stage III CRC, it is unclear whether it is beneficial for those diagnosed with stage I or II cancer.16Establishing clear recommendations for safe, early detection and treatment options will likely improve the physical outcomes for pregnant persons with CRC. Even still, ethical questions may remain, in terms of how to determine an appropriate course of action for such patients. We will use Jane’s case to highlight the ethical issues that can arise when CRC is suspected in a pregnant person.A primary ethical issue that Jane’s case highlights is how to ensure proper informed consent, given the varying levels of risk and uncertainty associated with screening, diagnosis, and treatment options for pregnant persons with suspected CRC. The ethical principle of autonomy recognizes Jane’s right as a patient to make decisions and act throughout her course of care. The practice of informed consent is intended to support this right.17 In order to promote Jane’s autonomy, Jane’s providers have an ethical duty to be knowledgeable about and inform her of all her screening and treatment options, within the medical standard of care. This information should be provided using evidence-based research that outlines the benefits and risks for both Jane and her fetus, so that she can make informed decisions.18 For example, if Jane is diagnosed with CRC and her oncologist recommends surgery followed by adjuvant chemotherapy, which the oncologist believes to be safe based on recent studies, Jane must be told that even if chemotherapy is used after the first trimester, there may be a risk of intrauterine growth restriction and/or premature birth.9 Jane should also be encouraged to ask questions about risks, benefits, and alternative options during symptom evaluation, diagnostic work-up, and treatment, should this be necessary.19 Clinicians should acknowledge any limitations of safety data for pregnant persons and their fetuses, such as those we described for endoscopies.20While Jane’s providers may fully intend to adhere to the requirements and implications of informed consent, they may have personal views that conflict with their ability to present Jane with all available diagnostic and treatment options. For example, if Julia believes that Jane should not have a colonoscopy because this may harm Jane’s fetus, Julia may be hesitant to disclose information about this option. In such a case, conscientious objection could play a role. Conscientious objection refers to the refusal of a health care professional to participate in a certain procedure, or to refuse treatment, based on conscience.21 If Julia has an objection to a colonoscopy for Jane based on deeply held ethical or religious views, rather than personal preferences, prejudice, bias, or arbitrariness, and communicates this to leadership in a timely manner, Jane’s care can be transferred to an alternative clinician so that all medically appropriate and available options are presented.22 Recent legal changes in certain states following the Dobbs v Jackson Supreme Court decision,23 which granted states increased rights to limit or outlaw abortion, could limit the number of clinicians willing to disclose and/or perform certain screening, diagnostic, or treatment options that have traditionally incorporated pregnancy termination, regardless of clinician beliefs about the appropriateness of these options. These potential legal influences are important to keep in mind, as clinicians consider what informed consent entails for this patient population.If conscientious objection does not apply to Julia, she can help informed consent by Jane’s health care and This would Julia to on available diagnostic and treatment options, their benefits and risks to both Jane and her fetus. if Jane is not information to her care, Julia could with the on Jane’s the advanced practice nurse in cases Jane’s can with the that the patient understands the risks and benefits associated with each of the recommendations they are and that they as they are to their should they or have further second important ethical issue that Jane’s case highlights is the of the pregnant and into their of care when CRC is In the case Jane that she “would do anything” to keep her baby safe and carry her pregnancy to term. Therefore, it is possible that Jane may to her health over her If Jane with such a one potential is that Jane could but her fetus could be likely This may questions for Jane’s about whether it is to a baby who will have no and potentially no family to care for is that one of Jane’s such as her GI specialist, may recommend of the pregnancy if a more CRC and a recommendation is likely to be with Jane’s values and and could a These potential case highlight that a is important as options are and advanced practice can the case of Julia can act as an the of Jane’s preferences, and beliefs into her care. Julia could begin this by Jane’s and values with and in her medical so that all are Julia could an with Jane’s providers to what they to be recommendations for Jane’s care, and Julia could help to ensure that these recommendations with Jane’s preferences, prior to to conflicting values of care can lead to ethical Julia can help these by for Jane’s if significant arise and an consultation if the is to their conflict and with a of care that with Jane’s issues of are important to consider in the case of a pregnant person with suspected CRC. diagnostic and treatment for cancer have medical have resulting in significant for cancer patients and their In is a that is now used to the or that the of cancer treatment can have on the quality of of a patient or The of cancer treatment includes not only the but also to time at or or as as to and from can the to which a patient or family personal insurance and the of CRC such as age, of chemotherapy, and support are associated with In this case, Jane does not currently have insurance does not to have close family who may be to is and is these that Jane may be at a risk of Therefore, it is important to this into consideration when determining Jane’s access to treatment, as she may If Jane is compromised, Julia be of for or support for her diagnosis and/or the very Julia could any from Jane to the of care that treatment a more advanced practice or can help existing and for their patient to receive available In this case, Julia could Jane with a which could help her such as or she could refer Jane to who could Jane with in a health insurance of these could help the risk of a patient treatment due to or a screening or treatment fully has several options to consider to the ethical First, they could determine that Jane’s symptoms, her rectal bleeding and family history of cancer, the recommendation of a over a less option, in the of and and her suspected CRC. Although Jane’s diagnosis does not increase her risk of CRC, a personal history of so Jane’s would want to ensure that she has not been A of this option, from an is that it the issue of informed consent, as Jane’s providers would be all risks and benefits of the colonoscopy and their this informed consent based on research Jane’s autonomy by her to determine her course of care. This also as a colonoscopy performed during the second trimester of pregnancy is and would likely Jane’s However, this is not with Jane’s known and values because it has a higher likelihood of her fetus. this is more than alternative and could place Jane at increased risk for which is an important second is that the could to recommend less initial screening options such as a more detailed physical examination, CEA testing, abdominal imaging via a and a hepatic along with evaluating more common such as a blood for the of anemia, or a for liver The of this is that it Jane’s values and her fetus. However, although these are considered safe during pregnancy and may helpful they could findings or lead to detection of earlier more of CRC. are not as as a colonoscopy and do not allow for tumor treatment or a providers may as this the principle of However, as as her providers disclose all risks and benefits associated with this this would the requirements of informed consent and would Jane’s autonomy, should she to this if these were performed and it was later determined that a colonoscopy was Jane would be for the of testing, which once increase Jane’s risk of third could the risks of the options described The could recommend a in addition to some of the less imaging and testing procedures in This approach would for sigmoidoscopies are considered safer than colonoscopies during given that the sigmoidoscopy procedure is and is not this Jane’s values and by to her to with diagnostic procedures and treatment, as as these options do not pose a significant risk to her is less than a although it would be important for clinicians to during informed consent, that there would be some risk to Jane’s fetus. However, this risk is less than that of a colonoscopy. depending on which insurance Jane decides to this would also likely be a less than a colonoscopy, which the issue of potential this may be the appropriate for Jane’s case, Julia determined with Jane that she was unsure if she would be to treatment on her but that she want to with screening and treatment options, if She want to consider any options that had a likelihood of her fetus, and she would not consider of her pregnancy, regardless of whether this increased her risk of Jane was diagnosed with early stage rectal cancer via sigmoidoscopy after following the recommendation for 3 described with no of at the time of diagnosis, but Jane a colonoscopy and a CT 2 options that may have diagnostic She to surgical removal of the mass that had been as the had been to remove it via the and she so with the that they may during the procedure, but she that she not want to the pregnancy, even if a that complicated the She also the of adjuvant chemotherapy, should a more advanced stage be determined via the surgery, and that she would this Jane with a that could her and was to Jane with in a health insurance Julia also several with the to evaluate next steps based on Jane’s Julia the associated with her when the with Jane’s decision to of the pregnancy, even if that could not be were The with the and which identified a different willing to the case and perform surgery according to Jane’s The mass was removed during surgery via a and no were Jane was diagnosed with stage II CRC. Jane a healthy baby at weeks and she not need adjuvant chemotherapy based on a follow-up colonoscopy and CT that the cancer had not This case how the diagnosis of CRC and determining a treatment during pregnancy can be but advanced practice and can be to evaluate any ethical issues that may In can ensure that cases Jane’s are in a that proper informed consent, with the pregnant preferences, and to