Colorectal cancer in pregnancy

Abstract

1Department of Colorectal Surgery, University College Hospital Galway, Galway, Ireland *Author for correspondence: Tel.: +353 91 544544; Fax: +353 91 526588; myles.joyce@hse.ie Cancer in pregnancy represents a rare entity with potentially deleterious sequelae [1]. Fortunately, the peak age of diagnosis of malignancy does not overlap with the peak age of childbirth. Therefore, although colorectal cancer is an increasingly common disease, it’s incidence in pregnancy has remained low since it was first reported by Cruveilhier in the early 1800s [2]. Currently, incidence is reported to be 0.002% [3]. Among pregnant women, gynecological, hematological and endocrine malignancies are more common than colorectal cancer. However, as maternal age increases, the incidence of cancer in pregnancy may begin to rise [1,4]. Despite the rarity of this pathology, consequences may be potentially catastrophic and considerable clinical and ethical dilemmas arise in almost all areas of management [5]. Significant uncertainty regarding prognosis exists in the literature. In a review of 42 pregnant patients with colorectal cancer above the peritoneal reflection, Chan et al. reported that 56% of these patients had died by the time the cases were reported in the literature [6]. However, Dahling et al. report that stagefor-stage, survival is similar between pregnancy-associated and nonpregnancyassociated cases of colorectal cancer [7]. Maternal–fetal conflict frequently exists since optimum management for the mother may be harmful to the fetus and vice versa. Therefore, management should only be undertaken where a multidisciplinary team is available, including surgeon, medical oncologist, radiologist, obstetrician and neonatologist. Furthermore, significant psychological support and counselling are often necessary. Although pregnancy is a time of extensive medical observation, paradoxically, diagnosis of colorectal cancer in this period may be delayed due to a number of factors. First, symptoms and signs of colorectal malignancy may be considered physiological in pregnancy. For example, rectal bleeding, change in bowel habit, bloating, anemia or development of a pelvic mass [8]. Chene et al. have proposed a useful algorithm to aid doctors to differentiate between the ‘normal’ symptomatology EDITORIAL