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Contraception during surgical and adjuvant treatment of colon cancer — DFSRH MCQ

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HardColorectal CancerContraception during surgical and adjuvant treatment of colon cancerDFSRH

A 37-year-old woman has newly diagnosed stage III colon cancer. She is scheduled for open right hemicolectomy in 28 days, with an anticipated 7-day admission and reduced mobility during early recovery. Six months of adjuvant capecitabine is planned once she has recovered from surgery. She uses a monophasic combined oral contraceptive containing ethinylestradiol 30 micrograms and levonorgestrel. She is on day 16 of the packet, has taken every tablet correctly and had condomless intercourse 48 hours ago. There has been no other condomless intercourse, vomiting, severe diarrhoea or interacting medication. A urine pregnancy test is negative. She wishes to avoid pregnancy throughout cancer treatment, accepts an etonogestrel implant and declines intrauterine contraception. There is no contraindication to progestogen-only contraception. Which is the most appropriate management plan?

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Correct answer: B — Insert the implant today, stop the combined oral contraceptive immediately and use no emergency or additional contraception.

The combined oral contraceptive should be stopped now because FSRH recommends discontinuing combined hormonal contraception and changing to an alternative method at least 4 weeks before planned major surgery or an expected period of limited mobility. Continuing it for another 7 days would leave less than the recommended 4-week interval. The implant can be inserted immediately. She is in week 3 of correctly used combined hormonal contraception; FSRH switching guidance specifies that an etonogestrel implant may be inserted at this point without emergency contraception, additional precautions or overlap. Her intercourse 48 hours earlier was contraceptively covered, so neither levonorgestrel emergency contraception nor a follow-up pregnancy test is indicated on these facts. Capecitabine is contraindicated in pregnancy, and its UK product information requires effective contraception throughout treatment and for 6 months after the final dose. An implant inserted now provides highly effective, non-oral contraception across this period. A delays cessation of oestrogen until surgery. B incorrectly treats protected intercourse as an emergency-contraception indication. C adds unnecessary overlap and fails to stop combined hormonal contraception at least 4 weeks preoperatively. E creates avoidable reliance on condoms and there is no requirement to await postoperative menstruation before implant insertion.

Reference: FSRH Guideline: Combined Hormonal Contraception (January 2019; amended October 2023) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-guideline-combined-hormonal-contraception-october-2023.pdf FSRH Guideline: Progestogen-only Implant (February 2021; amended July 2023) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-guideline-progestogen-only-implants.pdf Capecitabine 150 mg film-coated tablets: Summary of Product Characteristics (Revised 6 June 2025) — https://www.medicines.org.uk/emc/product/14590/smpc