Behind the Knife_ Pregnancy
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Speaker: [00:00:00] Hello, and welcome to all the Behind the Knife listeners. My name is Betelhem Yohannes. I'm currently a third-year general surgery resident at the University of Washington. Today, our team will be discussing one of the most important and evolving topics in rectal cancer care, fertility preservation and pregnancy considerations for patients undergoing treatment of rectal cancer.

We're excited to share the latest evidence and practical considerations surrounding this topic. To start, I'll let my colleague, Dr. Allen, introduce himself

Speaker 2: Thank you so much. I'm Griffin Allen. I am a second-year research fellow and rising fourth-year, uh, general surgery resident at the University of Washington, and thrilled to be here to talk about this important topic.

Speaker: Welcome, Dr. Allen. We're also very fortunate to be joined by two outstanding guest faculty members, and I'll invite them both to introduce themselves as well.

Speaker 3: Sounds good. Thank you guys for having us. I'm Dr. Siddharthan. I'm an assistant professor at the University of Washington in the, uh, section of colorectal surgery.

Speaker 4: Hi, I'm Stacey Cohen. I am a [00:01:00] professor of medicine in division of hematology oncology, so I'm a medical oncologist with a focus on GI cancers, especially colorectal cancer. Thanks for letting me join your surgical podcast today.

Speaker: Thank you all so much for joining us today. We're very excited for this discussion, so let's dive right in.

Why is this conversation important? So colorectal cancer is increasingly being diagnosed in younger patients, and in fact, it's now the leading cause of cancer-related deaths for individuals less than fifty years of age. At the same time, more people are also delaying childbearing. As a result, surgeons are more frequently caring for patients with rectal cancer who are pregnant or hoping to preserve future fertility.

This creates a new set of challenges. How do we effectively treat rectal cancer while also considering fertility, pregnancy, and maternal fetal safety? Standard therapies like pelvic radiation and surgery can significantly impact reproductive potential and future family planning. We also know that these discussions may not be happening often enough.

A [00:02:00] twenty twenty-two study found that only about half of eligible rectal cancer patients reported discussing fertility implications with their surgeon. So our goal today is to help change that. Through a case-based discussion, we'll explore how multidisciplinary teams balance cancer treatment with fertility and pregnancy considerations in real-world practice.

I'll now pass it up to my colleague, Dr. Allen, to walk us through the first case.

Speaker 2: Thank you so much. For our first case, we're gonna be talking about a patient with rectal cancer who's potentially interested in fertility preservation. And so to frame this part of our discussion, we'd like to start with a paradigmatic case.

This is patient Y, a thirty-five-year-old with no previous pregnancies who presented to her PCP with tenesmus and hematochezia, and she is ultimately diagnosed with rectal cancer. Her staging workup reveals a T3 N1 M0 tumor located five centimeters from the anal verge. Based on this, she's recommended to undergo total neoadjuvant chemo- chemoradiotherapy followed by potential low anterior resection.

Importantly, she is very interested in future fertility and wants to understand how her [00:03:00] oncologic treatment plan, including chemotherapy, radiation, and pelvic surgery, may affect her ability to become pregnant or carry a pregnancy in the future. So using this case as our foundation, let's explore some of the consideration.

To start us off, I'd like to ask a broader question about fertility after rectal cancer surgery, even outside of chemotherapy and radiation. Dr. Siddharthan, when you're counseling a patient with rectal cancer, particularly a younger patient who may want children in the future- How do you discuss the potential impact of low pelvic surgery on fertility and sexual function for both men and women?

Speaker 3: Fantastic question, Griffin, and I think it's something that's really evolved in my practice over the years. It's something that I was not very good at discussing with patients because I think we all get really tunnel vision whenever we're dealing with oncologic cases, and we're really focused on the cancer, and we really don't think about some of the long-term outcomes that we can see from doing any kind of rectal cancer surgery.

So in particular for fertility, a lot of our data is extrapolated from the inflammatory bowel disease and pouch formations in patients with ulcerative [00:04:00] colitis. What we've seen is that basically any type of pelvic surgery can often cause scarring in the pelvis. The scarring in the pelvis will decrease fertility.

On top of the scarring that occurs, there can also be difficulties with nerve function, in particular the sympathetic and parasympathetic nerves. These affect men and women very differently. There's a lot of good research for men and the effects of hypogastric nerve injury or nerve branch injury and the resulting, uh, effects on ejaculation.

For women, some of that data is not as well pronounced, but there clearly is a significant decrease in fertility with any type of pelvic surgery from any kind of injuries to the nerves. In particular, for the scarring that can happen in the pelvis, that can often impact, uh, the ability for the fallopian tubes to work adequately and for fertilization of the eggs.

And so those are really important discussions that you have with patients, especially ones who are thirty-five and potentially thinking about having children because this one intervention can radically affect their [00:05:00] ability to have children in the future. And so when it comes to those considerations, it's often really important that you have a frank discussion with the patient.

Tell them that this will decrease their fertility, and if they're interested in having future fertility, that there's options that are available to them, whether that be the reproductive endocrinology route with, you know, frozen eggs or frozen embryos, or potentially delaying surgery in some cases in situations where it can be delayed

Speaker 2: Thank you.

So even beyond pelvic surgery, I think another major consideration that is often on the top of everyone's mind is the impact of chemotherapy and radiation, which of course is a cornerstone of rectal cancer treatment. And of course, there's a growing body of literature examining how these therapies affect both fertility and reproductive health.

Dr. Cohen, could you please help us understand what patients should know regarding the fertility implications of both chemotherapy and while I know this isn't your specialty, radiation?

Speaker 4: Yeah, I think it's a great thing to bring up because, you know, we really think about rectal cancer as being trimodality care.

And [00:06:00] so we really need to break down all of the components because when we're advising a patient about what type of treatment they might receive, we are thinking about what are those long-term goals and how do we maximize the efficacy and minimize the toxicity. So with the chemotherapy and radiation components, uh, we can break those down and think about how radiation of the doses that we need to give to someone with rectal cancer really do have pretty significant impacts on fertility.

Uh, very low-dose radiation that you might get like for total body irradiation is not really going to impact fertility. But the radiation that we typically would use, twenty-five to fifty gray to a pelvic area is going to cause scarring of the uterus such that someone would be unable to carry a child afterwards.

And then there's also, even if you do an oophorectomy trying to remove the ovaries out of the field, that's not always successful. So there can be direct impact to the ovaries as well as to the uterus. And then on top of that, we have the chemotherapy component, and chemotherapy being [00:07:00] toxic, cell-killing chemicals, we don't want someone ideally to get pregnant while they've been on chemotherapy.

Or really, we advise waiting one year after chemotherapy. And we don't know if-- really we're kind of extrapolating from some of the breast cancer data, but we really don't know like when the magical right time that someone would be safe to try to start having a kid naturally. But we usually advise one year.

So in your young rectal cancer patient, like the patient that you're discussing now, we typically advise fertility preservation prior, and then counseling patients about whether or not we anticipate they would be able to carry a child, uh, or would need a surrogate depending on whether they would receive radiation or not

Speaker 2: So with those risks in mind, just to kind of sum everything up and talk about what potential fertility options are, and we've kind of already hit on a few, including oocyte or embryo-cryopreservation, as well as ovarian transpo-transposition.

Dr. Satharkun, how do you approach this discussion of fertility preservation when counseling patients before treatment even [00:08:00] begins?

Speaker 3: Great question. So again, I think it really depends on the treatment, and this is really a discussion that we have at tumor board, oftentimes deciding what is kind of the pathway we're gonna do, whether it be consolidation chemotherapy or cure radiation first.

In terms of the different procedures and different things, if they're interested in oocyte preservation, we'll do an early referral to reproductive endocrinology. And oftentimes there can be, whether it be sperm banking for men or embryo-cryopreservation for women, and this can be done before we begin therapy.

And that probably has the most long-term, uh, success, 'cause obviously it's pretty similar to what it would be for somebody who was doing this outside of their rectal cancer therapy. The biggest issue is it requires a procedure and the timing and coordination of that is often the most difficult part, 'cause you obviously wanna start therapy for rectal cancer as soon as you can.

Sperm banking is a great option for men and has excellent results. In terms of the procedures that are available, there are ovarian transpositions [00:09:00] and ovary-uterine transpositions that have been described, and this is something that we've recommended for a few of our patients who end up getting radiation.

Um, this is where we basically pu- rem- pexy the ovaries out of the pelvis. Um, this is done by our gynecology colleagues, and there is kind of mixed results. It's a little bit hard to study because it's hard to know sometimes what someone's fertility was before the transposition compared to after. What we have seen is that it is helpful, especially in a situation of where radiation's gonna be performed for con- local control of the rectal cancer.

There are some discussions about doing uterine transposition. I've never seen this in my practice, but it is definitely something that has been described in the literature. I will say critics of both of these procedures, it's potentially an operation that comes with risks with maybe unclear success rates.

And so I think just a formal discussion with your reproductive endocrinology colleagues very early on is probably the most important thing that can be done

Speaker 2: Thank you so much, Dr. Siddarthan and Dr. Georgoff for [00:10:00] sharing your insights. So to summarize for our listeners, despite the growing number of patients who may desire future fertility, many are not receiving counseling.

And it's important because both men and women can face fertility loss and sexual dysfunction even from just surgery alone. And it's-- and on top of that, chemotherapy and radiation will add, of course, clear and dose-related risks to future fertility. Early referral to reproductive endocrinology specialist is pivotal and should be the default for all patients of potential childbearing age with, of course, typical options including egg, sperm, or embryo brain-- banking.

Even with these strategies fertility may be challenging, and these pregnancies, of course, even afterwards, may be more complex, may require additional assistance from maternal-fetal medicine specialists. But overall, this highlights the need for early multidisciplinary and, of course, patient-centered counseling.

Speaker: Let's move into our second case. To ground this discussion in a real-world scenario, we have a thirty-five-year-old woman in her second pregnancy who presented with several months of hematochezia. [00:11:00] Notably, she had experienced rectal bleeding during her first pregnancy as well, but after a first-trimester miscarriage, her symptoms improved, and no further workup was pursued at that time.

During her second pregnancy, however, the bleeding persisted, prompting further evaluation, and she underwent flexible sigmoidoscopy, which revealed a five-centimeter mass located approximately ten centimeters from the anal verge. Biopsy confirmed a microsatellite stable rectal adenocarcinoma. Staging workup demonstrated a non-metastatic, clinically stage T3N1M0 mid-rectal cancer.

So with that clinical picture in mind, a locally advanced rectal cancer diagnosed during ongoing pregnancy, let's walk through some of the considerations for managing this patient. Let's start with one of the biggest challenges in this case, which is diagnosis. Colorectal cancer is less common in young patients to begin with, and now we're layering pregnancy on top of that.

Dr. Siddarthan, from your perspective, what makes [00:12:00] colorectal cancer particularly difficult to diagnose during pregnancy?

Speaker 3: So I think the first thing is that it is obviously extremely rare. You know, it has an estimated incidence of point zero zero two percent. And so it's extremely uncommon, and it wouldn't be in someone's differential, especially someone who doesn't treat rectal or colon cancer very frequently.

Unfortunately, often these patients are also not part of staging or screening, excuse, guidelines because they're obviously too young to be even within the screening guidelines of about forty-five years old That being said, the hallmarks that we always see with, you know, suspicion of an rectal cancer would be rectal bleeding, constipation, anemia, change in bowel habits, abdominal discomfort, and even fatigue.

The hard part with pregnancy is oftentimes these symptoms overlap, and I think one of the most common things that gets diagnosed in pregnancy is hemorrhoids. And obviously that makes sense because the increased blood flow into the pelvis during pregnancy will cause the hemorrhoids to engorge. And so sometimes it's hard to [00:13:00] know if this is just hemorrhoids and nothing to worry about, or potentially could this be a malignancy.

I think there's also a really big psychological burden and barrier when we deal with pregnant patients. We often want to avoid doing anything because we're always very worried about the fetus and preterm labor and different issues. And so I think we sometimes ignore some of the symptoms that the pregnant women express, even if it could be something that'd be much more worrisome in someone who was not pregnant

Speaker: Yeah, I think you hinted on my next question, which is-

is there is sometimes hesitation around imaging or endoscopy in pregnancy. So can you walk me through what actually is considered safe and appropriate workup when colorectal cancer is suspected?

Speaker 3: Yeah, absolutely. So I think the most im- first step, important first step is in someone with rectal bleeding is to do a thorough anorectal exam.

So that would be an external look, a digital rectal exam, and anoscopy. This is extremely safe and can be done in any patient. I think the hard part is many people who would be seen as patient, gynecologists and primary care doctors do not feel comfortable [00:14:00] doing this. If you see suspect rectal bleeding and you see a large hemorrhoid, you can kind of attribute the bleeding potentially to that hemorrhoid in that situation.

If you don't see anything, then that should probably indicate further workup, likely with a flexible sigmoidoscopy. The benefit of flexible sigmoidoscopy is these can often be done without any sedation and can be done in an office with an experienced provider. This obviously prevents any kind of potential impact on the fetus from medications associated with sedation, but also could give you the answer.

The other big thing to keep in mind is most early onset colorectal malignancies are rectal cancers, and these would be diagnosed with a flexible sigmoidoscopy. In terms of imaging and staging, MRI is safe for staging of rectal cancers in the situ- in pregnancy, but you must avoid gadolinium because this can be teratogenic.

The other big thing is we often will do CT scans in select situations with shielding of the fetus, especially for a CT of the chest. But like all of these decisions, it's very [00:15:00] complicated and requires a formal discussion with the patient as well as a multidisciplinary approach, which I think is the most important thing when you're confronting a patient in this situation.

Speaker: Yeah, and I think the same goes with when we think about treatment. So before we dive into the pregnancy-specific nuances of treatment, I think it would be helpful to ground our listeners in the standard approach. So Dr. Siddharthan, can you start by walking us through the typical management of non-metastatic, locally advanced rectal cancer in a non-pregnant patient?

Speaker 3: Sure. Absolutely. So, you know, we have three modalities of treatment for rectal cancer. We have chemotherapy, radiation, and surgery. Over a long time with various studies, we've really kind of ironed it out into, for mid to low rectal cancers, the use of total neoadjuvant therapy, or TNT for short. TNT incorporates both chemotherapy and chemoradiation.

There is still some debate about whether chemoradiation should be done first before-- aft-- or second after chemotherapy This is kind of our standard [00:16:00] approach for most stage II or stage III rectal cancers. For very early stage T1 cancers, we can think about a local excision or a, a formal resection depending on the location.

For anything much more than that or if tumors with concerning features, T&T is almost always recommended. And so for our kind of in general, often patients will get T&T. We'll reassess to see their response and then determine whether or not we'll move forward with a full radical resection versus a watch and wait protocol.

Watch and wait is a newer kind of approach to these complicated rectal cancers, and it's when we've seen a complete clinical response from T&T, and we expect this to happen in between twenty-five to thirty percent of patients. The key with watch and wait is that the patients need to be watched and wait.

I think the biggest issue that we run into or we see is often patients are told they have a complete clinical response, and they don't have the follow-up necessary to make sure that a recurrence doesn't occur

Speaker: So building from that foundation, how [00:17:00] does pregnancy change the patient? What specific considerations come into play when you're thinking a-about timing of surgery, the role of neoadjuvant therapy, radiation exposure, and overall treatment sequencing in pregnancy?

And I'll invite both Dr. Siddhartha and Dr. Cohen to weigh in on this.

Speaker 3: Sure. Absolutely. So I can start from the surgical side of things. So just from the anatomy of the uterus as well as having a pregnant, uh, uterus, this can obviously obstruct your view of potentially trying to do a surgery. Nowadays, many of us are able to do these surgeries robotically, but obviously if there's a pregnant uterus in the way, it needs to be manipulated out of the way, pushed out of the way, or potentially ma-manipulated, and this can induce labor.

And so from just a technical feasible point of view, sometimes these rectal cancers are not resectable when patients are pregnant.

Speaker 4: So adding to that you know, I think there's obviously a lot of hesitancy in treating a pregnant patient, and we are certainly seeing this happen more and more as we see the rising [00:18:00] epidemic of younger people getting rectal cancer.

But I think we have to try and still give the best outcomes to both mom and baby. And so I've seen some cases where patients got diverting colostomies, uh, early on out of a, out of a concern that they were going to have an obstructive issue during the pregnancy. But actually, we can treat patients fairly successfully with chemotherapy in the second and third trimester.

So I have treated several pregnant women for colorectal cancer where they've been able to deliver healthy pregnancies with babies that don't really show any sign of having been exposed to chemotherapy. And so, I think, you know, when someone is found in the first trimester, it's actually a little bit trickier, but often these cases present in the second trimester or later.

And so what we can do is actually just support that patient with chemotherapy through the time of the delivery in conjunction with MFM and surgery and everybody and [00:19:00] hold off on any radiation, hold off on that full staging MRI that we wanna get with contrast. But, uh, keep them on chemotherapy, deliver that healthy pregnancy, and then actually assess the status of the disease, likely giving them then chemoradiation and surgery, but really making those considerations depending on how everything looks after they've received some neoadjuvant therapy.

And this would be a little bit different than our standard patient because often we'll start with chemoradiation, but again, we would not wanna give radiation to a pregnant woman.

Speaker 3: Yeah, and I, I think the other big thing that sometimes gets missed in these conversations is if it is a early first trimester pregnancy, a discussion with the patient about potential termination of the pregnancy is really important.

Uh, I think it's really important that you have that conversation with the patient so they understand that that is an option, um, because I think oftentimes it kinda gets skipped. And it's really dependent on what the patient wants for themselves as well as for their potential fetus

Speaker: I do want to [00:20:00] acknowledge the ethical complexity in a case like this.

And while we won't dive deeply into the ethics today, I think when treating a patient, a pregnant patient with rectal cancer there are ethical considerations that need to be at the forefront of o- our minds. And I was wondering, Dr. Siddharth and Dr. Cohen, if you have some sort of way of discussing with patients about these kinds of, you know, considerations.

Speaker 3: I think the most important thing is just being honest with the patient and having a very frank discussion about what their goals are, whether it be for their pregnancy, for, and for their rectal cancer treatment, and kind of talking through with them the various options. It's obviously a horrible situation to be in, to be diagnosed with a rectal cancer at the time of being pregnant.

But I think kind of leveling with the patient and making sure that they understand that there are options and that it isn't... there isn't guidelines or clear this is how what we have to do in this situation. It's really just having a really frank [00:21:00] discussion with a multidisciplinary team and trying to come up with what's the best treatment plan for that specific patient.

And so I think coming into it, you have patients who maybe have had children before, and they, you know, they're okay with some decrease in fertility. Or the reverse is this is their first child ever, and that it's really important that they deliver this child. And so I think it really is important that you have a frank conversation with them so they understand the risks and benefits of each approach.

Speaker 4: I would echo that, that in, you know, oncology, unfortunately, we are often counseling patients about situations where they don't wanna be in that situation. Maybe they have a metastatic incurable cancer or a poor prognosis. And here it's certainly complex because you're taking care of, uh, both mom and baby at that time.

But I think that, um, just as Dr. Siddharthan said, you know, we just need to be open to really having that conversation and thinking through the options. And I think when we're most successful is when we acknowledge that elephant in the room and, and really [00:22:00] say, "Here's what's going on, here's what we can do, and here's what we can't do," and help that patient make the most informed decision in a hard situation.

Speaker 3: The patient that we're talking about today, this is a real, real patient that we had. It was her third time trying to have a pregnancy, and she finally got pregnant and was very excited to have the baby. So her goal was to have the baby. And we kind of modified and changed our treatment approach based off of that being her main goal.

Um, so she ended up getting chemotherapy during her second and third trimester. She delivered. We restaged her. She got radiation after getting transposition of her ovaries for future fertility improvements. And then she eventually went-- underwent an LAR about six months after delivery So we kind of realized what her goals are, what our goals were for the treatment, and kind of tailored it specifically to what worked best for her.

Speaker: I think you both have highlighted how, uh, much of a layered complexity there is in taking care of patients like these and how rare these presentations are. [00:23:00] And I'm just wondering, to wrap up our discussion, what your advice is for junior faculty or residents, uh, as far as building the comfort that comes with having these complex discussions and the knowledge base, uh, around these rare presentations?

Speaker 3: What I would say is it never gets easier. This is always a very difficult situation, no matter how many times you see it. And I think that knowing that going into it, that this is gonna be complicated, it's gonna be hard, it's gonna be a difficult conversation, is the first step. And then I think again, just I, I'm so happy that I have a doctor like Dr.

Cohen here to help me because it is the multidisciplinary coordination is the key for taking care of these patients.

Speaker 4: And I would echo that. I mean, I think that we are so lucky to have such a well-formed multidisciplinary team, and this is just one example of how complicated cancer care is in twenty twenty fix and beyond.

But I think that when we are thoughtful about it and, uh, really try [00:24:00] to think through all of the different issues and opportunities, we can really provide excellent care to our patients, which is fundamentally what we're all trying to do. I

Speaker: really want to say thank you so much for both of you for sharing your expertise on a complex case like this.

Um, I do want to summarize for our listeners. The first is that we don't want to incur on pregnancy and kind of ignore these persistent GI symptoms that deserve further evaluation. Second is appropriate staging and endoscopy can be safely pursued, as Dr. Sidarthan, you mentioned, uh, with multidisciplinary coordination.

And lastly, uh, treatment sequencing is highly individualized, and patient buy-in, patient input is highly important in these complex decision points. And also patient's values and goals need to take priority as well. Overall, I just want to say thank you so much, Dr. Sidarthan, Dr. Cohen, my colleague, Dr. Allen, for joining us in this episode.

And thank you to all listeners who tuned in. And of course, thank you to Behind the Knife for hosting us. Be sure to dominate the [00:25:00] day.