Colorectal Cancer Diagnosed During Pregnancy With Delayed Treatment

Colorectal cancer during pregnancy is rare. Because of a pattern of delay in childbearing and because colorectal cancer is now diagnosed more often in young adults, the incidence is expected to rise. Diagnosis during pregnancy is challenging as many of the symptoms mimic common pregnancy symptoms. Colonoscopy is the gold standard for diagnosis, but pregnancy is a relative contraindication to colonoscopy. Once diagnosed, pregnant women often have more advanced disease. Due to its rarity, treatment is often based on case reports and limited studies. A multidisciplinary team is important in the optimization of treatment. We present a case of a 29-year-old African-American primigravid with chronic gastrointestinal symptoms diagnosed with colorectal adenocarcinoma at 17 weeks of gestation. She delayed surgical intervention for several weeks due to fear of miscarriage, and ultimately underwent exploratory laparotomy with hemicolectomy and colostomy placement at 20 weeks. Abdominal ultrasound and magnetic resonance imaging revealed non-specific hepatic lesions concerning for metastatic disease, but the patient refused biopsy due to concern for radiation harm to the fetus. Chemotherapy was considered, but postponed until the postpartum period, for fear of fetal harm. Computed tomography imaging after delivery noted an increased number of hepatic lesions, representing progression of her disease. She received two rounds of chemotherapy in the postpartum period, but remained non-compliant with treatment recommendations and ultimately was lost to follow-up.  This case presents a delayed diagnosis of colorectal cancer in pregnancy, as well as delayed treatment due to concerns for fetal harm with current therapies. It emphasizes the diagnostic challenges and the complexity and ethical issues involved when a pregnant patient faces a life-threatening terminal illness. This case adds to the growing body of literature on colorectal cancer in pregnancy and highlights the importance of clinical suspicion, informed patient centered decision making, and tailored treatment goals.