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Teaching Resources

Planning and Guiding In-Class Peer Review

Resource overview.

How to plan and guide in-class peer review.

Incorporating peer review into your course can help your students become better writers, readers, and collaborators. However, peer review must be planned and guided carefully.

The following suggestions for planning and guiding peer review are based on our approach to peer review. This approach implements four key strategies:

  • Identify and teach the skills required for peer review.
  • Teach peer review as an essential part of the writing process.
  • Present peer review as an opportunity for students to learn how to write for an audience.
  • Define the role of the peer-reviewer as that of a reader, not an evaluator.

These tips are are organized in four areas:

Before the Semester Starts

During the semester and before the first peer-review session, during and after peer-review sessions, peer review is challenging work.

The Center for Teaching and Learning provides sample worksheets (Peer Review Worksheet for Thesis-Driven Essay) that may be adapted to suit various types of courses and genres of writing.

1. Determine how peer review will fit into the course.

A. Decide which writing assignments will include a peer-review session. Given the time that is required to conduct peer-review sessions successfully (see below), in undergraduate courses, peer review will work best with papers of 5 pages or less. Instructors who want to incorporate peer-review sessions for longer papers will have to ask students to complete part of the work outside of class (e.g. reading peers’ papers and preparing written comments); such an approach is likely to be more successful if students first practice peer review during class, with the guidance of the instructor.

B. Decide when peer-review sessions will occur.  The ideal time for peer review is after students have written a complete draft of a paper, but while there is still time for substantial revision.

Each peer-review session will require at least one class period. While it is possible to complete a session in one hour, a one-and-one-half hour class period is preferable (see below for a detailed discussion of how to structure peer-review sessions).

As you look over your course schedule, make time for a “mock” peer-review session before you ask students to review one another’s writing, so that they can learn to identify and begin practicing the skills necessary for peer review. Before the semester begins, furthermore, you should find a short sample paper that will serve as the focus of the “mock” peer review. You can also write this short paper yourself (for more detailed suggestions on how to set up a mock peer-review session, see below).

Instructors should schedule the first peer-review session early in the semester to give students time to get to know one another and to develop peer-review skills. The atmosphere of trust and mutual respect that is necessary for the success of peer-review sessions does not develop instantaneously. Ideally, the first peer-review session should focus on a short piece of writing, such as a paragraph or two, so that students develop comfort with giving and receiving feedback before taking on the task of reading longer papers.

2. Design peer-review worksheets that students will complete during each peer-review session.

These worksheets  should include specific tasks that reviewers should complete during the session. The guidance you provide on the worksheets should help students stay “on task” during the session and should help them discern the amount of commenting that is desirable.

The role of the peer-reviewer should be that of a reader, not an evaluator or grader. Do not replicate the grading criteria when designing these worksheets. Your students will not necessarily be qualified to apply these criteria effectively, and they may feel uncomfortable if they are given the responsibility to pronounce an overall judgment on their peers’ work.

Peer-review worksheets should ask the reviewer to begin by offering a positive comment about the paper. After that point, the peer-reviewer role in commenting should be descriptive: each reviewer should describe his response to the paper. For example, a peer-reviewer might write: “I found this description very clear” or “I do not understand how this point relates to your thesis.” The worksheet should give students specific tasks to complete when recording their response to a paper (Nilson 2003). Where evaluation is required, it should be based on the reviewer’s impressions as a reader. Examples of specific tasks include:

  • Indicate which parts of the paper the reader finds most or least effective, and why
  • Identify or rephrase the thesis
  • List the major points of support or evidence
  • Indicate sentences or paragraphs that seem out of order, incompletely explained, or otherwise in need of revision

Performing these tasks should enable each peer-reviewer to provide the writer with a written response that will help the writer determine which parts of the paper are effective as is, and which are unclear, incomplete, or unconvincing.

Do not require students to tell the writer how to revise the paper. Advanced undergraduates, students who have been meeting in peer-review groups for an extended time, and graduate students may be able to handle adding more directive responses (e.g. suggesting that the writer make specific changes).

3. During the course-planning process, think carefully about the kind of comments that you will provide students when you review drafts and grade papers.

With your comments, you can model for your students the qualities you would like to see reflected in their comments as peer-reviewers. For example, you can give them examples of comments that are descriptive and specific.

4. Decide whether and how you will grade students’ contributions to peer-review sessions.

One way to communicate to students the importance of peer review and the skills it requires is to grade their contributions to the peer-review process. If you do grade students’ performances in peer review, you will need to decide ahead of time what exactly you will be grading and what criteria you will use to judge their achievement. Furthermore, you might decide to use a straightforward -√/ √/ √+ system, or you might assign a point-value to different aspects of the work required for peer review. You should then decide how to incorporate each peer-review score into the course grade or into the grade earned for each paper.

The following example illustrates a point-system approach to grading student performance in peer review:

Brought 2 copies of paper to class: 5 pts Provided peers with specific, constructive written feedback: 0-5 pts Participated actively in discussion of each paper: 0-5 pts Wrote specific response to peers’ feedback: 0-5 pts Total score for each peer-review session: 0-20 pts.

This example makes it clear that those students who do not bring a draft to be peer-reviewed would nevertheless earn points by acting as reviewers of their peers’ work. Of course, if you use such a point-system, you will need to explain to the students the criteria by which you judge their performance in each category. Providing students with graded examples will help to clarify these criteria.

Whatever you decide regarding whether and how you will grade each student’s performance in peer review, you should observe and evaluate what students are doing during peer review so that you can give them some feedback and suggestions for improvement throughout the semester (see below for further suggestions on how to observe and evaluate peer review).

1. Hold a “mock” peer-review session.

First, copy and distribute a brief sample paper. You can either use a paper submitted by a student in an earlier semester (block-out the name and ask the student’s permission to distribute the paper) or write a sample paper yourself, approximating a draft that would be typical of students in your course. Next, ask students to take 5 minutes to read the paper and 10 minutes to write some comments, using a peer-review worksheet. If time allows, you can ask students to work in groups of 3-4 to produce written comments; if you do so, give them an additional 5-10 minutes for group discussion.

After students have produced written comments individually or as a group, use a document camera or overhead projector to display a blank peer-review worksheet. Then, ask students to present their reviewing comments to the class and use these to write comments on the displayed worksheet. When necessary, follow-up with questions that help the students phrase their comments in more specific and constructive ways. For example, if a student comments, “I like the first paragraph,” you might ask, “can you tell the writer what you find effective or appealing about that paragraph? And why?” Your aim should be to help students understand that the point of their comments should be to describe their experience as readers with specific language, not to praise or condemn their peers or to tell the peer how they would write the paper. Note that while students often hesitate to give specific feedback to a writer face-to-face, they may actually be overly critical when critiquing something written by a writer who is not present. Therefore, it might be helpful to direct students to construct their comments as if the writer were indeed in the room, listening.

2. Teach students how to think about, respond to, and use comments by peer-reviewers.

Just as your students will need to learn and practice the skills involved in providing constructive feedback on their peers’ writing, they will also need to learn how to respond, as writers, to the feedback they receive. Therefore, you might consider including in the “mock” peer-review session, described above, an exercise in which you ask your students to put themselves in the position of the writer and come up with a plan for revision based on the comments that they and their classmates have formulated in response to the sample paper.

Students must learn how to approach a peer-review session with an open mind (and a thick skin, perhaps). Often, undergraduate students go into a peer-review session thinking that their papers are essentially “done” and need to be edited or changed only slightly. Thus they “hear” only those responses that confirm this view and they end up making very few changes to their papers after the peer-review session and before submitting the final draft to the instructor. Alternatively, they can become so discouraged by what they view as a negative response from a peer that they are not able to discern what is useful about those responses.

To help students resist the understandable temptation to become either discouraged or defensive during the peer-review session and to help them focus on listening carefully to their peers’ comments, it is useful to institute a rule that prohibits writers from speaking when peer-reviewers are offering feedback. An exception might be made in a case in which the writer does not understand a reviewer’s comments and needs to ask for more information.

In addition, instructors should require each writer to respond in writing to their peers’ comments. This written response can be recorded directly on the peer-review worksheet, or it can take the form of an informal letter (addressed to the peer-reviewers). Alternatively, instructors might require each writer to sketch out a plan for revision that 1) indicates any changes she will make in response to the reviewers’ comments and 2) explains any decisions she has made to disregard a specific comment or suggestion.The point of such writing exercises is to ask students to take their peers’ comments seriously and to think carefully about how readers respond to the choices they have made in their writing–even if that means determining that they will decide not to make changes based on those comments.

3. Assign three students to each peer-review group: maintain the same groups throughout the semester.

With groups of three, each student will be reviewing the papers of two peers during each peer-review session, but each group will discuss three papers (for detailed instructions on how to structure each session, see below).

It is best to assign students to groups, rather than to have them define the groups themselves. Students often want to form groups with friends, which may actually create difficulties. As you may want to explain to your students, it can be more difficult to provide honest feedback to a writer when that writer is a friend. Moreover, assigning students to the groups will allow the instructor to ensure that the groups are heterogeneous in terms of, for example, student ability, gender, race, and academic major. Such heterogeneity can enhance student learning in groups (Millis 2002).

Maintaining the groups throughout the semester will help your students build the trust that is necessary for peer review to be successful (Millis 2002). You should only reassign students to another group in the rare case when one or two group members drop the course. You should encourage your students to speak with you if they find that their peer-review groups are not functioning as well as desired, but you should also make it clear that you are interested in helping them find ways to work together to solve whatever problems have surfaced.

4. Ask each student to bring 2 copies of his or her paper to class on the designated day.

You can tell students that these copies are required, but if they do not bring copies of their own paper to class, they should come to class anyway, so that they can act as reviewers of other students’ papers.

1. Structure each peer-review session: give students clear instructions and time limits.

To start each session, distribute peer-review worksheets (see above), explain how students should complete the worksheets, set time limits, and ask each group to designate one person as a time-keeper to make sure that the group stays on schedule.

Peer-review sessions can be accomplished during one-hour classes, but instructors may find that a 90-minute class is preferable. If you teaching a one-hour or 50 minute class, consider asking students to read their peers’ papers before coming to class, then spending the first 10 minutes reviewing the paper and writing comments.

The following is a peer-review schedule that can work in a 90-minute class.

I.  When papers are around three pages long, peer-reviewers should spend about 20-25 minutes reading and reviewing each paper: 15 minutes reading the paper (tell students to read each paper twice) and 5-10 minutes writing comments. You should lengthen the time limit when necessary, for instance when papers are longer or when they are written in a foreign language. This schedule will mean that during the first 45-50 minutes of class, each student will be reading and writing comments on papers written by two peers.

II.  After all 3 students have finished commenting on the two papers submitted by their peers, the group should then devote 5-10 minutes to a “discussion” of each paper (spending a total of 15-30 minutes discussing three papers). During this discussion, the 2 reviewers should present spoken feedback to the writer. If reviewers feel uncomfortable with providing spoken feedback, they might start by reading their written comments out loud to the writer. Doing so can produce the added benefit of helping the reviewers clarify their written comments. As noted above, the writer of the paper should not speak during this discussion, except perhaps to ask a clarifying question.

2. Take an active role in observing the progress of each group and offering guidance when appropriate.

Even with clear instructions, peer-review sessions can go awry. Circulate throughout the session to make sure that the groups stay focused. Listen carefully to the spoken feedback, and use questions to help students make their comments as specific and descriptive as possible. For example, if you hear a student saying, “I was confused by the third paragraph,” you might prompt them to say more by asking, “Can you tell the writer where you got lost?” or “What word or phrase confused you? Why?” Students will soon learn to supply such details themselves.

Paying attention to how the groups are functioning overall can help you determine whether you need to give additional guidance to the class as a whole. For example, you might tell students that you noticed that many groups seem to be rushing through the spoken feedback period for each paper, and that even reviewers who wrote detailed and constructive comments on the worksheet are giving only cursory responses when speaking to the writer (e.g. “I thought you did a good job,” or “Your paper was interesting”). You might then remind them that they do not need to present an overall judgment of the paper, but they should try to say something specific that can help the writer revise the paper.

3. Have each student submit the completed peer-review worksheets when they turn-in the final drafts of their papers.

Whether or not you are grading the responses that reviewers and writers write on the peer-review worksheets, you should read the completed worksheets to get a sense of what students are actually doing during the peer-review sessions and how they are responding to one another’s comments. Having the students turn in the worksheets also helps you communicate to them that you are taking the peer-review process seriously. Instructors should also give students feedback on their performance during peer review so that they know what they are doing well and what they should try to improve upon.

4. Regularly assess how the peer-review sessions are going; seek and incorporate student input.

You should review completed peer-review worksheets when you grade papers not only to evaluate individual student performance, but also to gauge the success of the peer-review sessions and to determine what you might do to improve them.

Are students writing thoughtful comments that provide an adequate amount of detail? If not, spend some time in class before the next peer-review session giving students suggestions for how to phrase comments in a specific, constructive way.

Are students using the peer-review worksheets to develop thoughtful responses to peer comments? Are they coming up with plans for revision that take into account at least some of their peers’ comments? Again, if needed, give your students additional guidance and in-class activities that will lead them through the process of identifying potential aspects needing revision and coming up with a plan for revision that takes into account peer comments.

Around midterm, ask students to complete anonymous evaluation forms that include questions such as, “What is the most important insight that I have learned as a result of the peer-review process?” and “What can be done (by the instructor or by students, or both) to make the peer-review sessions run more smoothly?”

Be prepared to hear that the peer-review sessions are not functioning as well as you believe they are, and be open to making changes that incorporate your students’ observations and ideas. In other words, model the same open-mindedness to revision that you want them to display as writers during peer review.

Instructors who ask their students to review their peers’ writing should recall how difficult it is–even after years of experience–to accomplish with efficiency the tasks involved in responding to student writing: reading drafts of papers (usually multiple papers at one sitting), quickly discerning each draft’s strengths and most pressing problems, then formulating specific and well written comments that will help the writer improve the paper. It can also be difficult, even for experienced writers, to respond effectively to the comments they receive from reviewers of their work. It is essential, then, that you plan carefully the guidance you will give your students on how to conduct and utilize peer review, and that you give them a chance to reflect on the process.

Bean, John C. (2001).  Engaging Ideas: The Professor’s Guide to Integrating Writing, Critical Thinking, and Active Learning in the Classroom . San Francisco: Jossey-Bass.

Gottschalk, Katherine and Keith Hjortshoj (2004). “What Can You Do with Student Writing?” In  The Elements of Teaching Writing: A Resource for Instructors in All Disciplines . Boston: Bedford/St. Martin’s.

Millis, Barbara J. (2002). “ Enhancing Learning-and More! Through Collaborative Learning. IDEA Paper 38 . The IDEA Center.

Nilson, Linda. (2003). “Improving Student Peer Feedback.” College Teaching, 51 (1 ), p. 34-38.

Have suggestions?

If you have suggestions of resources we might add to these pages, please contact us:

[email protected] (314) 935-6810 Mon - Fri, 8:30 a.m. - 5:00 p.m.

Canvas at Penn

Canvas at Penn

Penn's Source for Courseware Innovation & News

Peer Review Assignment Best Practices for Instructors

Canvas has a built-in Peer Review tool that allows instructors to assign student submissions to each other for feedback. This feature can be enabled for groups and can be set up to be anonymous. 

If the built-in tool in Canvas doesn’t meet your needs, there may be other options . 

Before You Start

We strongly recommend working with your LSP if you want to create a peer review assignment in Canvas to create the best experience for you and your students.

  • Consider providing clear instructions or a rubric in your assignment for students on what a peer review is in Canvas , how they will grade, and how they can view their feedback .
  • We recommend reiterating to students that it is important that they submit on time so they don’t hold the assignment up for others in the course.
  • Students who haven’t submitted an assignment can no longer be invited to review others’ work. If students don’t submit, they can’t participate. 

How to Create a Peer Review Assignment in Canvas

  • If this will be a group assignment, you will see an additional option to “Allow intra-group peer reviews”. Select this if you would like Canvas to select a member of the same group for that student to review.

Note – Canvas assigns peer reviews to individuals, EVEN if it’s a Group Project assignment. The only project member who will see feedback is the one the peer reviewer was assigned to. It will not be visible to other project members.

  • If you select assign reviews manually , instructors will need to go in and pair up the students after students have finished submitting their assignments.
  • Instructors should provide a buffer for students to allow for late submissions and not use the same time as the due date of the assignment.
  • Once all additional settings have been configured, save and publish the assignment.
  • Students will receive an email and a to do list item once they have been assigned a peer to review. Students will not receive a peer to review until they submit the assignment.

Keep in Mind

  • We recommend using the Manually Assign Peer Reviews option (see screenshot below) to assign peer reviews later if they need to be done at a specific time. 

peer review assignment grade

  • “ If a student has not submitted the assignment or submits the assignment after the due date, the student will not automatically be assigned a peer review and you must manually assign one. ”
  • For assignments with Turnitin enabled, only the original student can see the originality score, not the assigned reviewer. Reviewers won’t be able to assess this information, since it isn’t visible to them.

Known Issues 

The manual drag and drop option to assign peer reviews has not been reliable . For the best experience, we recommend using the “assign peer reviews now” option for this need instead.

  • Automatic (randomly assigned) peer reviews may take up to an hour to be assigned to students. We recommend letting your students know that there may be a delay before submissions are available to them to review.
  • Clear your cache on a PC  
  • Clear your cache on a Mac  

Please try the instructions linked above for your preferred browser and then open a new window and try logging in again. 

Clearing the browser cache can also sometimes solve issues students are having with peer reviews, and the above instructions may be helpful to share with them as well.

Other Peer Review Options

  • Wharton instructors – contact the Wharton Courseware team ( [email protected] ) for a full list of your options for peer review assignments. 
  • If you’re already using Perusall in your course, consider using Perusall’s peer review functions . 
  • For group assignments: consider creating a Canvas discussion board or using Ed Discussion to allow students to share feedback with the entire group.

Please contact [email protected] or your Local Service Provider for assistance. 

Last Updated: 31 Oct 2023

Center for Teaching Innovation

Resource library, teaching students to evaluate each other, why use peer review.

Peer assessment, or review, can improve overall learning by helping students become better readers, writers, and collaborators. A well-designed peer review program also develops students’ evaluation and assessment skills. The following are a few techniques that instructors have used to implement peer review.

Planning for peer review

  • Identify where you can incorporate peer review exercises into your course.
  • For peer review on written assignments, design guidelines that specify clearly defined tasks for the reviewer. Consider what feedback students can competently provide.
  • Determine whether peer review activities will be conducted as in-class or out-of-class assignments (or as a combination of both).
  • Plan for in-class peer reviews to last at least one class session. More time will be needed for longer papers and papers written in foreign languages.
  • Model appropriate constructive criticism and descriptive feedback through the comments you provide on papers and in class.
  • Explain the reasons for peer review, the benefits it provides, and how it supports course learning outcomes.
  • Set clear expectations: determine whether students will receive grades on their contributions to peer review sessions. If grades are given, be clear about what you are assessing, what criteria will be used for grading, and how the peer review score will be incorporated into their overall course grade.

Before the first peer review session

  • Give students a sample paper to review and comment on in class using the peer review guidelines. Ask students to share feedback and help them rephrase their comments to make them more specific and constructive, as needed.
  • Consider using the sample paper exercise to teach students how to think about, respond to, and use comments by peer reviewers to improve their writing.
  • Ask for input from students on the peer review worksheet or co-create a rubric in class.
  • Prevent overly harsh peer criticism by instructing students to provide feedback as if they were speaking to the writer or presenter directly.
  • Consider how you will assign students to groups. Do you want them to work together for the entire semester, or change for different assignments? Do you want peer reviewers to remain anonymous? How many reviews will each assignment receive?

During and after peer review sessions

  • Give clear directions and time limits for in-class peer review sessions and set defined deadlines for out-of-class peer review assignments.
  • Listen to group discussions and provide guidance and input when necessary.
  • Consider requiring students to write a plan for revision indicating the changes they intend to make on the paper and explaining why they have chosen to acknowledge or disregard specific comments and suggestions. For exams and presentations, have students write about how they would approach the task next time based on the peer comments.
  • Ask students to submit the peer feedback they received with their final papers. Make clear whether or not you will be taking this feedback into account when grading the paper, or when assigning a participation grade to the student reviewer.
  • Consider having students assess the quality of the feedback they received.
  • Discuss the process in class, addressing problems that were encountered and what was learned.

Examples of peer review activities

  • After collection, redistribute papers randomly along with a grading rubric. After students have evaluated the papers ask them to exchange with a neighbor, evaluate the new paper, and then compare notes.
  • After completing an exam, have students compare and discuss answers with a partner. You may offer them the opportunity to submit a new answer, dividing points between the two.
  • In a small class, ask students to bring one copy of their paper with their name on it and one or two copies without a name. Collect the “name” copy and redistribute the others for peer review. Provide feedback on all student papers. Collect the peer reviews and return papers to their authors.
  • For group presentations, require the class to evaluate the group’s performance using a predetermined marking scheme.
  • When working on group projects, have students evaluate each group member’s contribution to the project on a scale of 1-10. Require students to provide rationale for how and why they awarded points.

Peer review technologies

Best used for providing feedback (formative assessment), PeerMark is a peer review program that encourages students to evaluate each other’s work. Students comment on assigned papers and answer scaled and free-form questions designed by the instructor. PeerMark does not allow you to assign point values or assign and export grades.

Contact the Center for a consultation on using these peer assessment tools.

Cho, K., & MacArthur, C. (2010). Student revision with peer and expert reviewing.  Learning and Instruction , 20 (4), 328-338.

Kollar, I., & Fischer, F. (2010). Peer assessment as collaborative learning: A cognitive perspective.  Learning and Instruction , 20 (4), 344-348.

The Teaching Center. (2009). Planning and guiding in-class peer review.  Washington University in St. Louis.  Retrieved from  http://teachingcenter.wustl.edu/resources/writing-assignments-feedback/planning-and-guiding-in-class-peer-review/ .

Wasson, B., & Vold, V. (2012). Leveraging new media skills in a peer feedback tool.  Internet and Higher Education , 15 (4), 1-10.

Xie, Y., Ke, F., & Sharma, P. (2008). The effect of peer feedback for blogging on college students’ reflective learning processes.  Internet and Higher Education , 11 (1), 18-25.

van Zundert, M., Sluijsmans, D., & van Merriënboer, J. (2010). Effective peer assessment processes: Research findings and future directions.  Learning and Instruction , 20 (4), 270-279.

Instruct­ional Resources

Resources for instructors to use when planning, creating, teaching, and assessing

  • High Stakes and Low Stakes Assessment
  • Promoting Integrity through Assessment Design
  • Open Book Assessments
  • Assessment Strategies: Considerations for Remote Instruction
  • End-of-Course Assessment Options
  • Bulletproofing Online Assessments
  • Considerations for Constructing an Exam
  • Question Types in Brightspace
  • Addressing Informal Accommodation Requests
  • Making Feedback Learner-Centered
  • Providing Feedback Electronically
  • Types of Feedback
  • Feedback Technologies
  • Soliciting Feedback from Students on Their Learning Experience (Alternatives to CEQs)
  • Types of Rubrics
  • Steps for Creating a Rubric
  • Resources to help create or use rubrics

Creating a Peer Review Assignment

From abstract to concrete: creating a peer review assignment.

If your course analysis and planning revealed the need for an assignment that includes peer review, now it is time to design that assignment. This resource will guide you in creating the peer review components of an assignment. It includes guidance for describing the assignment, clarifying expectations related to peer review, and how to provide feedback. Examples from a course that used peer review are included.

Any assignment design should include:

  • A clear description of the assignment
  • Learning outcomes
  • Evaluation breakdown and criteria
  • An outline of what is expected of students
  • A rubric or questions and criteria to consider when reviewing a peer’s work
  • Procedural or technical information needed to complete the assignment

The example content on this page under the Show/Hide links is from a first year Folklore course.

Information That Goes in the Course Syllabus

Below are items to consider including in your course syllabus. This information may be dispersed among pages such as the “Course Evaluation” page and the “Course Format and Expectations” page.

Short Essays

There are three (3) short essays that will go through the peer review process—each essay will be worth 20%.

Part of your grade will be based on your work within the peer review process. Learning to offer great peer feedback is a skill that requires practice, and can be very rewarding for all involved. Learning to receive peer feedback and use it effectively can help you improve your work in this course and future courses. To get the most out of this peer review process, you need to make each draft a complete, full-length essay with a controlling idea, organization, and conclusion.

For each short essay you will:

  • Submit a draft, by the due date, for your peers to review (1%)
  • Review the work of two of your peers and provide feedback that they can use to improve their essay (2%)
  • Reflect on your peers’ feedback of your work and revise your draft using feedback from your peers and your own reflections (1%)
  • Revise your draft using feedback from your peers and your own reflections and submit a final version of your essay for your instructor (16%)

How to Provide Feedback

Think about how to share written feedback in a constructive way. Read the papers of each of your group members and provide feedback that they can use to improve their paper. An effective peer review includes the following:

  • general comments about the paper;
  • specific descriptions of what you liked / didn’t like or what was effective / ineffective; and
  • specific advice about what can be improved.

The following statements stems will help you respond to your peers:

  • “I’d like to hear more about…”
  • “This is what I find interesting…”

And, as always, think about the questions:

  • “What surprised me?”
  • “What intrigued me?”
  • “What disturbed me?”

Additional Tips

  • Don’t withhold constructive feedback about areas of improvement.
  • Pay attention to the language used – positive and constructive versus judgemental.
  • Focus on the strengths and weakness of the individual’s work, not the individual themselves or their personality.
  • Be specific.
  • If possible, begin and end with positive comments, include areas for improvement in the middle.
  • Be realistic — are the suggested changes doable within the content of the assignment?
  • Present your own thoughts on your peer’s work versus stating your suggested changes as facts.

When providing feedback via comments, be sure that it has the right level of detail and that it is clear and states your objective opinion. If feedback is excessively brief or vague, excessively detailed, or subjective rather than objective, it becomes about personal taste and preference and may be confusing, off-putting or difficult to use.

Peer Review Using peerScholar

When your assignment draft is complete you will use peerScholar to complete the peer review process.

Peer review has three phases in peerScholar:

  • Create — submit your work for your peers to review
  • Assess — review your peer’s assignment and provide feedback to your to them
  • review feedback that your peers provided to you
  • carefully consider how you would like to incorporate the feedback
  • revise your essay and resubmit it for your instructor

Submit your assignment via peerScholar by the due date provided in the course schedule. Your assignment will be available to your peers for review when the Create phase is closed and the Assess phase begins.

Submission Steps:

  • On the page “Short Essay: Peer Review Phase 1” click the link “peerScholar”.
  • Once peerScholar opens, select the “Create” link.
  • Copy and paste your essay into the compose window, or attach a file.
  • Save your work.
  • Select “Preview” to see what your saved essay will look like when you submit it.

Now it is time to review essays from two of your peers and provide feedback to them. Your peers will do the same for you! Feedback will be available when the Assess phase is closed and the Reflect phase begins.

Steps to provide feedback to your peers:

  • On the page “Short Essay: Peer Review Phase 2” click the link “peerScholar”.
  • Once peerScholar opens, select the “Assess” link.
  • Carefully read the work of each or your peers and provide them with feedback using the inline comments tool and by answering the questions provided.

Review the feedback you received from your peers on your work and think critically about it to decide how you want to incorporate their feedback. Then, revise your essay and resubmit for your instructor.

Steps to reflect on your peers’ feedback and to resubmit your essay:

  • Once peerScholar opens, select the “Reflect” link.
  • Carefully read the feedback that each peer provided. Decide on how you want to incorporate the feedback.
  • Toggle to the Revision screen to see you a copy of your original composition. Revise your essay and resubmit it to peerScholar for your instructor to grade. You may also upload a revised document.

Where possible, include a rubric in a peer review assignment. The rubric will benefit instructors when they configure the assignment and create assessments to use during the peer review, it will benefit students when they complete the assignment, and it will benefit all of those involved in evaluating and providing feedback.

Educational Benefits of Using a Rubric

  • Students can score their peer’s work using the rubric
  • A rubric can act as a guide in a student’s exploration of their peer’s work
  • Using a rubric encourages a discovery mind set
  • Students can identify examples of what good work looks like and what poor work looks like
  • If you average five or more peer-assessments that took place based on a rubric, the average score tends to be a very good estimate of the student’s skill

Making the Rubric Available to Students

Make sure a copy of the rubric is available in Brightspace and peerScholar:

  • Attach a rubric as part of the assignment details in the course syllabus
  • In the Create phase of peerScholar, attach a rubric and refer to the attached rubric in the instructions

Information That Goes in a Module

You can add specific information about an assignment, phase, or deliverable directly in your module or weekly content. Information can include:

  • Descriptions and details about a specific topic or deliverable
  • Required readings and resources
  • Value for the deliverable
  • Link to launch the application, if applicable

Note: The title of the short essay has been changed and links are inactive.

Week 3: Overview

Short essay: “title tbd” (20%).

If you haven’t started already, it’s time to start your Short Essay: “Title TBD”.

Instructions

Read the story “Title TBD”, and watch the two videos of the stories being told. After carefully reading the tale, and watching the videos, please consider the following questions:

  • What “life lessons” are emphasized in the tale?
  • How might these tales reflect the values and beliefs of members of Newfoundland outport communities in the first half of the 20th century?
  • What “real world” lessons are highlighted through this tale?
  • Have you heard/seen/read alternate versions of this tale?
  • What does each version of the story emphasize? (Compare and contrast)

When your draft version of your essay is complete, submit it via peerScholar for your peers to review.

See the course evaluation page for general information about Short Essays and about peer review. See the course schedule for dues dates.

peer review assignment grade

Peer review templates, expert examples and free training courses

peer review assignment grade

Joanna Wilkinson

Learning how to write a constructive peer review is an essential step in helping to safeguard the quality and integrity of published literature. Read on for resources that will get you on the right track, including peer review templates, example reports and the Web of Science™ Academy: our free, online course that teaches you the core competencies of peer review through practical experience ( try it today ).

How to write a peer review

Understanding the principles, forms and functions of peer review will enable you to write solid, actionable review reports. It will form the basis for a comprehensive and well-structured review, and help you comment on the quality, rigor and significance of the research paper. It will also help you identify potential breaches of normal ethical practice.

This may sound daunting but it doesn’t need to be. There are plenty of peer review templates, resources and experts out there to help you, including:

Peer review training courses and in-person workshops

  • Peer review templates ( found in our Web of Science Academy )
  • Expert examples of peer review reports
  • Co-reviewing (sharing the task of peer reviewing with a senior researcher)

Other peer review resources, blogs, and guidelines

We’ll go through each one of these in turn below, but first: a quick word on why learning peer review is so important.

Why learn to peer review?

Peer reviewers and editors are gatekeepers of the research literature used to document and communicate human discovery. Reviewers, therefore, need a sound understanding of their role and obligations to ensure the integrity of this process. This also helps them maintain quality research, and to help protect the public from flawed and misleading research findings.

Learning to peer review is also an important step in improving your own professional development.

You’ll become a better writer and a more successful published author in learning to review. It gives you a critical vantage point and you’ll begin to understand what editors are looking for. It will also help you keep abreast of new research and best-practice methods in your field.

We strongly encourage you to learn the core concepts of peer review by joining a course or workshop. You can attend in-person workshops to learn from and network with experienced reviewers and editors. As an example, Sense about Science offers peer review workshops every year. To learn more about what might be in store at one of these, researcher Laura Chatland shares her experience at one of the workshops in London.

There are also plenty of free, online courses available, including courses in the Web of Science Academy such as ‘Reviewing in the Sciences’, ‘Reviewing in the Humanities’ and ‘An introduction to peer review’

The Web of Science Academy also supports co-reviewing with a mentor to teach peer review through practical experience. You learn by writing reviews of preprints, published papers, or even ‘real’ unpublished manuscripts with guidance from your mentor. You can work with one of our community mentors or your own PhD supervisor or postdoc advisor, or even a senior colleague in your department.

Go to the Web of Science Academy

Peer review templates

Peer review templates are helpful to use as you work your way through a manuscript. As part of our free Web of Science Academy courses, you’ll gain exclusive access to comprehensive guidelines and a peer review report. It offers points to consider for all aspects of the manuscript, including the abstract, methods and results sections. It also teaches you how to structure your review and will get you thinking about the overall strengths and impact of the paper at hand.

  • Web of Science Academy template (requires joining one of the free courses)
  • PLoS’s review template
  • Wiley’s peer review guide (not a template as such, but a thorough guide with questions to consider in the first and second reading of the manuscript)

Beyond following a template, it’s worth asking your editor or checking the journal’s peer review management system. That way, you’ll learn whether you need to follow a formal or specific peer review structure for that particular journal. If no such formal approach exists, try asking the editor for examples of other reviews performed for the journal. This will give you a solid understanding of what they expect from you.

Peer review examples

Understand what a constructive peer review looks like by learning from the experts.

Here’s a sample of pre and post-publication peer reviews displayed on Web of Science publication records to help guide you through your first few reviews. Some of these are transparent peer reviews , which means the entire process is open and visible — from initial review and response through to revision and final publication decision. You may wish to scroll to the bottom of these pages so you can first read the initial reviews, and make your way up the page to read the editor and author’s responses.

  • Pre-publication peer review: Patterns and mechanisms in instances of endosymbiont-induced parthenogenesis
  • Pre-publication peer review: Can Ciprofloxacin be Used for Precision Treatment of Gonorrhea in Public STD Clinics? Assessment of Ciprofloxacin Susceptibility and an Opportunity for Point-of-Care Testing
  • Transparent peer review: Towards a standard model of musical improvisation
  • Transparent peer review: Complex mosaic of sexual dichromatism and monochromatism in Pacific robins results from both gains and losses of elaborate coloration
  • Post-publication peer review: Brain state monitoring for the future prediction of migraine attacks
  • Web of Science Academy peer review: Students’ Perception on Training in Writing Research Article for Publication

F1000 has also put together a nice list of expert reviewer comments pertaining to the various aspects of a review report.

Co-reviewing

Co-reviewing (sharing peer review assignments with senior researchers) is one of the best ways to learn peer review. It gives researchers a hands-on, practical understanding of the process.

In an article in The Scientist , the team at Future of Research argues that co-reviewing can be a valuable learning experience for peer review, as long as it’s done properly and with transparency. The reason there’s a need to call out how co-reviewing works is because it does have its downsides. The practice can leave early-career researchers unaware of the core concepts of peer review. This can make it hard to later join an editor’s reviewer pool if they haven’t received adequate recognition for their share of the review work. (If you are asked to write a peer review on behalf of a senior colleague or researcher, get recognition for your efforts by asking your senior colleague to verify the collaborative co-review on your Web of Science researcher profiles).

The Web of Science Academy course ‘Co-reviewing with a mentor’ is uniquely practical in this sense. You will gain experience in peer review by practicing on real papers and working with a mentor to get feedback on how their peer review can be improved. Students submit their peer review report as their course assignment and after internal evaluation receive a course certificate, an Academy graduate badge on their Web of Science researcher profile and is put in front of top editors in their field through the Reviewer Locator at Clarivate.

Here are some external peer review resources found around the web:

  • Peer Review Resources from Sense about Science
  • Peer Review: The Nuts and Bolts by Sense about Science
  • How to review journal manuscripts by R. M. Rosenfeld for Otolaryngology – Head and Neck Surgery
  • Ethical guidelines for peer review from COPE
  • An Instructional Guide for Peer Reviewers of Biomedical Manuscripts by Callaham, Schriger & Cooper for Annals of Emergency Medicine (requires Flash or Adobe)
  • EQUATOR Network’s reporting guidelines for health researchers

And finally, we’ve written a number of blogs about handy peer review tips. Check out some of our top picks:

  • How to Write a Peer Review: 12 things you need to know
  • Want To Peer Review? Top 10 Tips To Get Noticed By Editors
  • Review a manuscript like a pro: 6 tips from a Web of Science Academy supervisor
  • How to write a structured reviewer report: 5 tips from an early-career researcher

Want to learn more? Become a master of peer review and connect with top journal editors. The Web of Science Academy – your free online hub of courses designed by expert reviewers, editors and Nobel Prize winners. Find out more today.

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Peer Review

Peer Review

About this Strategy Guide

This strategy guide explains how you can employ peer review in your classroom, guiding students as they offer each other constructive feedback to improve their writing and communication skills.

Research Basis

Strategy in practice, related resources.

Peer review refers to the many ways in which students can share their creative work with peers for constructive feedback and then use this feedback to revise and improve their work. For the writing process, revision is as important as drafting, but students often feel they cannot let go of their original words. By keeping an audience in mind and participating in focused peer review interactions, students can offer productive feedback, accept constructive criticism, and master revision. This is true of other creative projects, such as class presentations, podcasts, or blogs. Online tools can also help to broaden the concept of “peers.” Real literacy happens in a community of people who can make meaningful connections. Peer review facilitates the type of social interaction and collaboration that is vital for student learning.

Peer review can be used for different class projects in a variety of ways:

  • Teach students to use these three steps to give peer feedback: Compliments, Suggestions, and Corrections (see the Peer Edit with Perfection! Handout ). Explain that starting with something positive makes the other person feel encouraged. You can also use Peer Edit With Perfection Tutorial to walk through the feedback process with your students.
  • Provide students with sentence starter templates, such as, “My favorite part was _________ because __________,” to guide students in offering different types of feedback. After they start with something positive, have students point out areas that could be improved in terms of content, style, voice, and clarity by using another sentence starter (“A suggestion I can offer for improvement is ___________.”). The peer editor can mark spelling and grammar errors directly on the piece of writing.
  • Teach students what constructive feedback means (providing feedback about areas that need improvement without criticizing the person). Feedback should be done in an analytical, kind way. Model this for students and ask them to try it. Show examples of vague feedback (“This should be more interesting.”) and clear feedback (“A description of the main character would help me to imagine him/her better.”), and have students point out which kind of feedback is most useful. The Peer Editing Guide offers general advice on how to listen to and receive feedback, as well as how to give it.
  • For younger students, explain that you need helpers, so you will show them how to be writing teachers for each other. Model peer review by reading a student’s piece aloud, then have him/her leave the room while you discuss with the rest of the class what questions you will ask to elicit more detail. Have the student return, and ask those questions. Model active listening by repeating what the student says in different words. For very young students, encourage them to share personal stories with the class through drawings before gradually writing their stories.
  • Create a chart and display it in the classroom so students can see the important steps of peer editing. For example, the steps might include: 1. Read the piece, 2. Say what you like about it, 3. Ask what the main idea is, 4. Listen, 5. Say “Add that, please” when you hear a good detail. For pre-writers, “Add that, please” might mean adding a detail to a picture. Make the chart gradually longer for subsequent sessions, and invite students to add dialogue to it based on what worked for them.
  • Incorporate ways in which students will review each other’s work when you plan projects. Take note of which students work well together during peer review sessions for future pairings. Consider having two peer review sessions for the same project to encourage more thought and several rounds of revision.
  • Have students review and comment on each other’s work online using Nicenet , a class blog, or class website.
  • Have students write a class book, then take turns bringing it home to read. Encourage them to discuss the writing process with their parents or guardians and explain how they offered constructive feedback to help their peers.

Using peer review strategies, your students can learn to reflect on their own work, self-edit, listen to their peers, and assist others with constructive feedback. By guiding peer editing, you will ensure that your students’ work reflects thoughtful revision.

  • Lesson Plans
  • Strategy Guides

Using a collaborative story written by students, the teacher leads a shared-revising activity to help students consider content when revising, with students participating in the marking of text revisions.

After analyzing Family Pictures/Cuadros de Familia by Carmen Lomas Garza, students create a class book with artwork and information about their ancestry, traditions, and recipes, followed by a potluck lunch.

Students are encouraged to understand a book that the teacher reads aloud to create a new ending for it using the writing process.

While drafting a literary analysis essay (or another type of argument) of their own, students work in pairs to investigate advice for writing conclusions and to analyze conclusions of sample essays. They then draft two conclusions for their essay, select one, and reflect on what they have learned through the process.

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Help Articles

How to edit and re-submit a peer-graded assignment, learner help center jul 31, 2023 • knowledge, article details.

If you want to make changes to a peer-graded assignment after you submit it, you can edit and resubmit your assignment. You should only resubmit a peer-graded assignment before your personalized deadline.

If you don't pass a peer-reviewed assignment:

  • You can re-submit the assignment to be graded again
  • If the deadline has passed, you might not get peer reviews
  • If you've already completed peer reviews for other people's assignments, you won't need to do them again

What happens when you resubmit a peer-graded assignment

When you resubmit a peer-graded assignment, peer reviews and grades for your first submission will be deleted.

If you resubmit after your personalized deadline, you might not get feedback from your peers, and your assignment will be marked Didn't Pass. Learn how to solve problems with peer-graded assignments

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Edit and resubmit

To edit and resubmit a peer-graded assignment:

  • Open the course you want to resubmit an assignment in.
  • Click the Grades tab.
  • Open the assignment you want to resubmit.
  • Click Edit submission at the bottom of the submission page.
  • If you have already gotten feedback, you'll need to confirm your choice to edit your project. Editing the assignment will delete any reviews you've already gotten.
  • Make your changes, then click Preview to see the changes.
  • Click Submit for review to resubmit your edited project.
  • You can confirm that your updated assignment has been resubmitted by going to the GRADES page where the assignment will be marked as Submitted.

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If you can’t submit your assignment, make sure that your answers are all over the minimum word limit. Make sure to submit responses in full sentences so your peers are able to review your assignment.

You may not be able to submit your assignment if your answers are too similar to another learner’s submission. Please keep in mind that plagiarism is against the Coursera Honor Code. 

If you see a notification letting you know that your assignment answers are similar to another learner’s submission, you’ll need to update your response before submitting. 

Once you’ve updated your answers with original work, the Submit for review button will appear.

If you need more time to work on your assignment, you can click Save draft and come back to it later.

If you think you shouldn’t be seeing this error, you can click the link below the notification to let us know. You’ll be able to submit your assignment after you edit your answers.

If you aren’t seeing any error messages, but are still not able to submit your assignment, try these troubleshooting steps.

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Some private courses (such as courses in a Degree or MasterTrack program) may have a limit on how many times you can submit a peer-graded assignment.

If there's an attempt limit for your assignment, you'll see an 'Attempts' section listed near the top of the page when you open the assignment.

If you meet the attempt limit and need help with your grade, you can reach out to your program support team. You can find your dedicated support email address in the onboarding course for your program.

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  • Effect of the HPV...

Effect of the HPV vaccination programme on incidence of cervical cancer and grade 3 cervical intraepithelial neoplasia by socioeconomic deprivation in England: population based observational study

Linked editorial.

HPV vaccine: the key to eliminating cervical cancer inequities

  • Related content
  • Peer review
  • Milena Falcaro , senior statistician 1 ,
  • Kate Soldan , scientist and epidemiologist 2 ,
  • Busani Ndlela , cancer information analyst 3 ,
  • Peter Sasieni , professor of cancer epidemiology 1
  • 1 Centre for Cancer Screening, Prevention and Early Diagnosis, Wolfson Institute of Population Health, Queen Mary University of London, London EC1M 6BQ, UK
  • 2 Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Division, UK Health Security Agency (UKHSA), London, UK
  • 3 National Disease Registration Service (NDRS), NHS England, London, UK
  • Correspondence to: P Sasieni p.sasieni{at}qmul.ac.uk (or @petersasieni on X)
  • Accepted 27 March 2024

Objectives To replicate previous analyses on the effectiveness of the English human papillomavirus (HPV) vaccination programme on incidence of cervical cancer and grade 3 cervical intraepithelial neoplasia (CIN3) using 12 additional months of follow-up, and to investigate effectiveness across levels of socioeconomic deprivation.

Design Observational study.

Setting England, UK.

Participants Women aged 20-64 years resident in England between January 2006 and June 2020 including 29 968 with a diagnosis of cervical cancer and 335 228 with a diagnosis of CIN3. In England, HPV vaccination was introduced nationally in 2008 and was offered routinely to girls aged 12-13 years, with catch-up campaigns during 2008-10 targeting older teenagers aged <19 years.

Main outcome measures Incidence of invasive cervical cancer and CIN3.

Results In England, 29 968 women aged 20-64 years received a diagnosis of cervical cancer and 335 228 a diagnosis of CIN3 between 1 January 2006 and 30 June 2020. In the birth cohort of women offered vaccination routinely at age 12-13 years, adjusted age standardised incidence rates of cervical cancer and CIN3 in the additional 12 months of follow-up (1 July 2019 to 30 June 2020) were, respectively, 83.9% (95% confidence interval (CI) 63.8% to 92.8%) and 94.3% (92.6% to 95.7%) lower than in the reference cohort of women who were never offered HPV vaccination. By mid-2020, HPV vaccination had prevented an estimated 687 (95% CI 556 to 819) cervical cancers and 23 192 (22 163 to 24 220) CIN3s. The highest rates remained among women living in the most deprived areas, but the HPV vaccination programme had a large effect in all five levels of deprivation. In women offered catch-up vaccination, CIN3 rates decreased more in those from the least deprived areas than from the most deprived areas (reductions of 40.6% v 29.6% and 72.8% v 67.7% for women offered vaccination at age 16-18 and 14-16, respectively). The strong downward gradient in cervical cancer incidence from high to low deprivation in the reference unvaccinated group was no longer present among those offered the vaccine.

Conclusions The high effectiveness of the national HPV vaccination programme previously seen in England continued during the additional 12 months of follow-up. HPV vaccination was associated with a substantially reduced incidence of cervical cancer and CIN3 across all five deprivation groups, especially in women offered routine vaccination.

Introduction

Human papillomavirus (HPV) comprises a family of viruses, a subset of which are responsible for virtually all cervical and some anogenital and oropharyngeal cancers. 1 More than 100 countries worldwide have introduced prophylactic HPV vaccination as part of routine immunisation schedules. 2 One important outcome yet to be reported is whether vaccination has reduced or increased the inequalities seen for cervical disease in the UK and elsewhere.

In England, the national HPV vaccination programme started in 2008 using the bivalent Cervarix vaccine to prevent infections due to HPV types 16 and 18, which are estimated to cause around 80% of all cervical cancers in the UK. 3 Vaccination was offered routinely to 12-13 year old (school year 8) girls and as part of a catch-up campaign to those aged <19 years. 4 In September 2012 the programme switched to the quadrivalent vaccine (Gardasil), which additionally protects against HPV types 6 and 11 (responsible for genital warts), and in 2019 the programme was extended to 12-13 year old boys. Those who are eligible but not vaccinated can receive the vaccine free of charge from their general practitioner until their 25th birthday. 5

The introduction and implementation of HPV immunisation in this way means that noticeable discontinuities exist in the proportion of women vaccinated by date of birth, enabling a rigorous evaluation of the effectiveness of the programme. 6 For example, women born in August 1990 are unlikely to have received HPV vaccination, whereas among those born in the year from 1 September 1990 nearly 70% have received at least one dose of the vaccine.

Findings on the early effect of national HPV vaccination programmes have been encouraging. A wealth of real world evidence for the effect of vaccination on HPV prevalence exists 7 8 9 10 11 and evidence is growing for its effectiveness in reducing high grade cervical intraepithelial neoplasia (CIN) 12 13 14 15 and cervical cancer in vaccinated women. 14 16 17 18 19 For instance, we found that in England rates of grade 3 CIN (CIN3) and of cervical cancer were greatly reduced among those who were offered HPV vaccination, and that the magnitude of the reduction was greatest in the cohorts with the highest uptake and younger age at vaccination. 14 We estimated that by mid-2019 the immunisation programme had prevented cervical cancer in nearly 450 women and CIN3 in around 17 000 women.

Along with preventing ill health, a key aim of the NHS is to reduce health inequalities. 20 To this end, we investigated whether the effect of immunisation against HPV has resulted in a reduction in inequalities in cervical disease or a widening. Concern has been expressed that if the uptake of HPV vaccination is lower in those at greatest risk of cervical cancer, as has been seen in the US, 21 this could accentuate health inequalities. One study found that the introduction of HPV immunisation in England might initially have increased inequities in HPV related cancer incidence among ethnic minority groups because of the differential effect of herd protection in subpopulations with dissimilar vaccination coverage. 22 Previous studies have suggested that white people have a higher awareness of HPV and acceptance of the immunisation 23 and that vaccination uptake is lower in women from ethnic minority groups and more deprived areas. 24 Using data on HPV vaccination coverage by local area, however, a study found little variation by deprivation score in women offered routine vaccination (83% v 86% for most and least deprived areas, respectively) and only a small negative correlation between deprivation and vaccine uptake in those offered catch-up vaccination (47% v 53% for most and least deprived areas, respectively). 25 A full understanding of the effect of HPV vaccination across different socioeconomic groups is complicated by the poor uptake of cervical screening observed among younger women in the most deprived areas, leading to lower rates of screen detected cervical cancer and CIN3 at age 25 years compared with women in less deprived areas. 26 27

We replicated results from an analysis of population based cancer registry data to evaluate if the high vaccination effectiveness seen previously continued during an additional year of follow-up. The combined data were also used to investigate the effect of the vaccination programme by socioeconomic deprivation.

To represent socioeconomic deprivation, we used the index of multiple deprivation, a small area measure based on several domains of deprivation, such as income, employment, and health. The index is determined by using a standard statistical geographical unit, called lower super output area, which divides England into small areas of similar sized populations (on average about 1500 residents, or 650 households). 28 The lower super output areas are then ranked from the most to the least deprived and divided into five equal groups. The first and fifth groups correspond to the 20% most deprived and 20% least deprived lower super output areas in England, respectively.

We retrieved the records of all women aged 20-64 years resident in England with a diagnosis of invasive cervical cancer (ICD-10 (international classification of diseases, 10th revision) code C53) or CIN3 (ICD-10 code D06) between 1 January 2006 and 30 June 2020. These records are stored in the database managed by NHS England’s National Disease Registration Service, 29 and for each patient included information on index of multiple deprivation derived from the patient’s home postcode at the time of diagnosis. To convert these counts into rates, we used mid-year estimates of the female population for England by single year of age, calendar year (January 2006 to June 2020), and index of multiple deprivation (five groups). These estimates were retrieved from multiple tables publicly available on the website of the UK’s Office for National Statistics (ONS). 30 The supplementary material provides more details about the index of multiple deprivation versions used by the National Disease Registration Service and ONS, along with information on how we derived the population estimates required in our statistical analysis.

Statistical analysis

We separately analysed incidence rates of cervical cancer and CIN3 by using extensions of our previously described age-period-cohort Poisson model. 14 31 32 Data on women with cancer or CIN3 were aggregated by single month of age, calendar time (period), and date of birth (cohort). We derived the corresponding population risk time by subdividing the mid-year ONS population estimates into one month intervals for age, period, and cohort. For the analysis of the effectiveness by deprivation, we further split both the data on women with cancer or CIN3 and the population estimates by deprivation group (fifths). We then used the population risk time as the denominator for calculating rates (formally, the subdivided population estimates were log transformed and included in the Poisson regression model as an offset). Confidence intervals were computed using robust standard errors. 33 34

The code for the analysis was written and tested on synthetic data (extending the Simulacrum dataset) 35 by a statistician (MF) at King’s College London and then run on the real dataset by an analyst (BN) at the National Disease Registration Service.

We started by considering a core model where we included the main effects for age, period, and birth cohort, along with selected age by cohort and age by period interactions (see supplementary table S1). The interaction terms were included to account for variations in screening policy and historical events that affected cervical cancer rates. Specifically, we defined seven birth cohorts to capture differences in the age at first invitation to screening and the school years in which HPV vaccination was offered (see table 1 ). We added terms for seasonality and for events that may have affected registrations for cervical cancer and CIN3, such as the covid-19 lockdown, the “Jade Goody effect,” 36 37 and the 2019 cervical screening awareness campaign. In our previous paper, 14 we used several similar regression models to study the sensitivity of results to the precise way in which we adjusted for potential confounding factors. Because we found that the estimates of the cohort specific incidence rate ratios changed little across the various models, here we report on only a single model adjustment for confounders.

Characteristics of the birth cohorts

  • View inline

Using the core model described, we investigated if the high effectiveness of the HPV immunisation programme reported previously 14 continued during an additional 12 months of follow-up. To do this we split the main effect of each cohort offered vaccination into two subgroup effects depending on whether the data related to the periods 1 January 2006 to 30 June 2019 or 1 July 2019 to 30 June 2020; this approach corresponded to adding three cohort by period interaction terms.

To evaluate the impact of socioeconomic deprivation on incidences of cervical cancer and CIN3, we extended the core model by adding main effects for deprivation and deprivation by cohort interactions. Specifically, we allowed the effect of each deprivation level to vary between unvaccinated women (cohorts 1-4) and those offered vaccination (cohorts 5-7), but we assumed it was otherwise constant within these two groups. We did not include further interactions between deprivation and other covariates as they were not of primary interest in this analysis. Using the fitted Poisson regression models, we made “what if” predictions by changing the value of one or more predictors and by leaving the others as observed. In this way it was possible to compare what happened (factual scenario) with what would have happened under an alternative (counterfactual) scenario.

We also carried out a sensitivity analysis where the effects of these deprivation by cohort interactions were allowed to vary across the three different groups offered vaccination (ie, we used 15 terms instead of five). For cervical cancer, owing to small numbers in cohort 7, we fitted a reduced model where the effects of these interactions were constrained to be the same for cohorts 6 and 7.

All analyses were performed in Stata, version 17. 38

Patient and public involvement

Patient and public involvement contributors were not formally involved in this research. We did, however, engage with Cancer Research UK (CRUK), Jo’s Cervical Cancer Trust, and the HPV Coalition on the importance of these analyses and the dissemination of the results. This included taking part in a video produced by ITN Business for World Cancer Day 2023, writing a piece for the 20th anniversary of the creation of CRUK, and engaging with international media about our research findings on the effect of the English HPV vaccination programme. We have also discussed the research and a draft of this paper with individual patients, journalists, and patient and public involvement representatives linked to broader research programmes.

Table 1 lists the characteristics of the birth cohorts included in the study. We defined the different cohorts so that each cohort is homogeneous in terms of the age women would have been offered HPV vaccination (if at all) and the age at which they would have first been invited for cervical screening.

Overall, there were 231.1 million women years of observation between 1 January 2006 and 30 June 2020 on women aged 20-64 years in England. During this time, 29 968 women received a diagnosis of invasive cervical cancer and 335 228 a diagnosis of CIN3 ( table 2 ). Observations between 1 July 2019 and 30 June 2020 have not been reported previously. With these additional 12 months of follow-up, there are, in the routine vaccination group (cohort 7), about twice the number of diagnoses compared with the same group in our previous study (we now have 13 v 7 previously for cervical cancer, 109 v 49 for CIN3; see supplementary table S2).

Summary statistics of study population

Our previously published findings on the effect of the national HPV vaccination were largely confirmed with the new data ( table 3 , also see supplementary table S3). The analysis showed that the previously observed low rates of disease and the estimated high effectiveness of the immunisation programme continued during the additional 12 months of follow-up (diagnoses in July 2019 to June 2020) among women born since 1 September 1990. In particular, the estimated effects of vaccination for that later period in cohort 7 (those born since 1 September 1995) imply a reduction in incidence of 83.9% (95% confidence interval (CI) 63.8% to 92.8%) for cervical cancer and 94.3% (92.6% to 95.7%) for CIN3 ( table 3 ). The relative risk reduction estimates for the earlier period are not identical to those reported previously because we also had new data for the unvaccinated cohorts that affected the baseline rates.

Estimated relative risk reductions (percentages) in incidence of invasive cervical cancer and CIN3 in the three cohorts offered HPV vaccination compared with the most recent unvaccinated cohort

Supplementary table S4 shows the full estimates from modelling the effects of vaccination in different levels of socioeconomic deprivation, with summary results reported in table 4 , table 5 , and table 6 . The highest incidence rates for invasive cervical cancer were observed among women living in the most deprived areas (first fifth) but, while in the reference unvaccinated group there was a strong downward gradient moving from women in the most deprived areas to those in the least deprived, little difference was found between the second and fifth fifths of deprivation in the groups offered vaccination. In both the reference and the vaccination cohorts the highest rates of CIN3 occurred in those from the most deprived areas, but no clear trend was observed among the other four fifths of deprivation (see supplementary tables S5 and S6).

Estimated number of invasive cervical cancers and CIN3s predicted and prevented by mid-2020 in the three cohorts of women offered HPV vaccination

Estimated cohort specific numbers of invasive cervical cancers predicted and prevented by mid-2020 among women in the least and most deprived areas

Estimated cohort specific numbers of CIN3 predicted and prevented by mid-2020 among women in the least and most deprived areas

Overall, our model estimated that 687 (95% CI 556 to 819) cervical cancers and 23 192 (22 163 to 24 220) CIN3s had been prevented by the vaccination programme up to mid-2020 among young women in England ( table 4 ). The greatest numbers for cervical cancer were prevented in women in the most deprived areas (192 and 199 for first and second fifths, respectively) and the fewest in women in the least deprived fifth (61 cancers prevented). The number of women with CIN3 prevented was high across all deprivation groups but greatest among women living in the more deprived areas: 5121 and 5773 for first and second fifths, respectively, compared with 4173 and 3309 in the fourth and fifth fifths, respectively. When we looked at the corresponding cohort specific figures ( table 5 and table 6 ), we noticed differences between the cohorts, particularly for CIN3. In all three cohorts offered vaccination the numbers and rates of prevented cervical cancers were much higher in women from the most deprived areas than least deprived areas ( table 5 ). The proportion of women with prevented cervical cancer in each cohort was, however, similar between the first and fifth fifths of deprivation. For CIN3 ( table 6 ), the results were more complicated. In women offered vaccination at age 16-18 years (cohort 5), the proportion of cervical cancers prevented was substantially less in those from the most deprived areas (29.6%) compared with those from the least deprived areas (40.6%). An inequality still existed in cohorts 6 and 7, but it was greatly reduced (67.7% v 72.8% in cohort 6 and 95.3% v 96.1% in cohort 7).

In England, the social-class gradient for cervical cancer is one of the steepest of any cancers: women in the most deprived fifth have had double the risk of those in the least deprived fifth. 39 40 Some of this results from differences in exposure to HPV and risk of an infection becoming persistent, 41 but differential uptake of cervical screening has also been an important factor. Previous research has highlighted the need for new engagement strategies to improve attendance for cervical screening among young women living in more socially deprived areas. 42 Encouragingly, the coverage of HPV vaccination has been (at least for the routine campaign and before the covid-19 pandemic) uniformly high. 43 It is, however, important to investigate whether immunisation—including the indirect effects achieved by high uptake—is helping to reduce health inequalities.

Using population based cancer registrations updated to mid-2020, which provided information on about twice the expected number of cancers in women offered HPV vaccination aged 12-13 years than in our previous analysis, we were able to show that the high vaccination effectiveness seen previously was confirmed with more recent data. The largest differences between the old and the new data were found for cohort 6 (the catch-up group offered the vaccine at age 14-16 years): for cervical cancer the estimated effectiveness increased, whereas for CIN3 it decreased. The reasons behind these differences are unclear. The results for cohorts 6 and 7 in the new data are more in keeping with what we would have expected given that the proportion of disease caused by HPV types 16 and 18 is greater for invasive cancer than for CIN3.

We also investigated the effect of the HPV immunisation programme by socioeconomic deprivation. Overall, we found that the programme was associated with a substantial reduction in the expected number of women with cervical cancers and CIN3 in all fifths of deprivation. For cervical cancer before vaccination, the downward gradient with decreasing deprivation was strong. In all cohorts offered vaccination, the highest rate was still seen among women living in the most deprived areas, but little difference was observed between women living in the second to fifth deprived areas. For CIN3, similar patterns were observed for the reference unvaccinated group and the three cohorts offered vaccination, but rates were greatly reduced in all fifths of deprivation in the latter. When we compared women in the most deprived areas with those in the least deprived areas in terms of percentage of disease averted, we observed differences across the cohorts for CIN3, with women in the least deprived areas in the older catch-up cohort (vaccine offered at age 16-18 years) having a greater proportion of averted CIN3s after HPV immunisation than women in the most deprived area (40.6% v 29.6%). The same, although to a much less extent, was observed for the younger catch-up cohort (72.8% v 67.7%). For invasive cervical cancer, we found no evidence of a less beneficial impact (in terms of percentage of cases averted) of the vaccination in women living in the most deprived areas; in fact, especially for the older catch-up cohort, the percentage was slightly higher in women in the most deprived areas compared with those in the least deprived areas.

The observed incidences of cervical cancer and CIN3 depend on three key factors: the intensity of exposure to HPV infections (including age at first exposure), the uptake of cervical screening, and HPV vaccination coverage. It is therefore difficult to disentangle the effects of these three drivers on the index of multiple deprivation specific rates with the data at hand. The health inequality in CIN3 in cohort 5 might result from the lower vaccination coverage among women in the most deprived areas since at age 16-18 years when they became eligible for vaccination more of those from the most deprived fifth may not have been in school or, for other reasons, may have missed the offer of HPV immunisation. These observations are consistent with previous understanding that higher uptake of catch-up vaccination was associated, although not as strongly as in some countries, with lower deprivation. 25 It is, however, reassuring that cohorts 6 and 7 showed little inequality in relative reductions in cancer (as in vaccination coverage).

However, since the UK has recently announced a change to a one dose schedule for routine HPV vaccination, ensuring this change achieves high coverage (including in the birth cohorts currently with lower coverage owing to covid-19 related interruption to schooling, and to immunisation services) is important to maintain the effects we have seen on cervical disease and on inequalities. Further investigations could be carried out in the future to check for any effect on cancer incidence caused by covid-19, gender neutral vaccination (since 2019), a change in the type of vaccine used, or reduced dose schedules.

Strengths and limitations of this study

Our analysis has several strengths. Our study provides direct evidence for the effect of a public health intervention (such as HPV vaccination) on cancer rates by deprivation. We used high quality data from population based cancer registries and were able to investigate the extent of socioeconomic inequalities in cohorts offered vaccination and whether the effectiveness of the HPV immunisation continued in an additional year of follow-up. The code for the analysis was written and tested using simulated data and an independent analyst later ran the code on the real dataset, guaranteeing reliable and robust results and preserving patient confidentiality.

The main limitations of our study are that it was observational and individual level data on vaccination status were not available. However, previous published research 14 provided detailed information on potential confounding factors and the best way to adjust for these in the analysis. Additionally, the discontinuities in vaccine uptake with date of birth makes this study powerful and less prone to biases from unobserved confounders than an analysis based on individual level data on HPV vaccination status.

Women born after 1 September 1999 were offered the Gardasil vaccine from 1 September 2012. As these women were at most aged 20 years and 10 months at the end of the study follow-up (30 June 2020), it is not yet possible with the data available to compare the effectiveness of the programme among those offered Cervarix and those offered Gardasil. This additional comparative analysis will become feasible with a longer follow-up on the recipients of Gardasil.

Policy implications

We found that the high effectiveness of the national HPV immunisation continued in the additional year of follow-up (July 2019 to June 2020). This is encouraging as it validates the previously published results and further supports consideration of more limited cervical screening for cohorts with high vaccination coverage aged 12-13 years. Moreover, although women living in the most deprived areas are still at higher risk of cervical cancer than those in less deprived areas, the HPV vaccination programme is associated with substantially lowered rates of disease across all fifths of socioeconomic deprivation. For cervical cancer, this has led to the levelling-up of the rates across the second to fifth fifths of deprivation so that the strong downward gradient observed in the reference unvaccinated cohort is no longer present in the cohorts offered vaccination. For CIN3, in the older catch-up cohorts women living in the least deprived areas seem to have benefited more from vaccination than those living in the most deprived areas, but the rates were still greatly reduced in all socioeconomic groups. Cervical screening strategies for women offered vaccination should carefully consider the differential effect both on rates of disease and on inequalities that are evident among women offered catch-up vaccination.

Conclusions

The HPV vaccination programme in England has not only been associated with a substantial reduction in incidence of cervical neoplasia in targeted cohorts, but also in all socioeconomic groups. This shows that well planned and executed public health interventions can both improve health and reduce health inequalities.

What is already known on this topic

In England, immunisation against human papillomavirus (HPV) has been associated with greatly reduced incidence rates of cervical cancer and grade 3 cervical intraepithelial neoplasia (CIN3) up to June 2019, especially among women offered routine vaccination at age 12-13 years

The social-class gradient for cervical cancer incidence has been one of the steepest of any cancers

Concern has been raised that HPV vaccination could least benefit those at highest risk of cervical cancer

What this study adds

The high effectiveness of vaccination against HPV seen previously continued during an additional year of follow-up, from July 2019 to June 2020

The English HPV vaccination programme was associated with substantially lower rates of cervical cancer and CIN3 in all fifths of socioeconomic deprivation, although the highest rates remained among women in the most deprived areas

For cervical cancer, the strong downward gradient from high to low deprivation observed in the reference unvaccinated cohort was no longer present among those offered vaccination

Ethics statements

Ethical approval.

Not required as the study used aggregated data from the National Disease Registration Service as well as publicly available information from the Office for National Statistics website.

Data availability statement

The cancer registry data analysed for this paper are securely held by the National Disease Registration Service (NDRS). Requests to access the data can be made through NHS England’s DARS service ( https://digital.nhs.uk/services/data-access-request-service-dars ). The Simulacrum ( https://simulacrum.healthdatainsight.org.uk/ ) is a synthetic dataset developed by Health Data Insight and derived from anonymous cancer data provided by NHS England’s NDRS. Mid-year population estimates are freely downloadable from the Office for National Statistics website ( https://www.ons.gov.uk/ ).

Acknowledgments

We thank Alejandra Castañon (LCP Health Analytics), Marta Checchi (UK Health Security Agency), and Lucy Elliss-Brookes (NHS England) for helpful comments on the study protocol, and Kwok Wong (NHS England) for contributing to the quality assurance of the data extraction code.

Contributors: PS had the original idea. He is the guarantor. MF and PS conceptualised the study and prepared the study protocol, which was subsequently reviewed by the other co-authors. MF wrote and tested the Stata code (checked by PS) for the data analysis and drafted the manuscript. BN extracted the dataset and ran the Stata code on it. All authors critically reviewed and approved the final submitted version. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

Funding: This work was supported by Cancer Research UK (grant No C8162/A27047). The funder had no role in the study design or in the collection, analysis, interpretation of data, writing of the report or decision to submit the article for publication.

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare support from Cancer Research UK for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Transparency: The lead author (the manuscript’s guarantor) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Dissemination to participants and related patient and public communities: The results of this research will be disseminated through the media, blogs and scientific meetings and will inform the design and implementation of interventions to reduce health inequalities. We will also work with others to produce information for the public to support human papillomavirus immunisation and cervical screening programmes and, if the opportunity arises, to contribute summary data for an international meta-analysis of similar studies.

Provenance and peer review: Not commissioned; externally peer reviewed.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/ .

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peer review assignment grade

  • Case Report
  • Open access
  • Published: 16 May 2024

Intestinal perforation due to colorectal cancer during pregnancy: case report and literature review

  • Yan Gao 1 &

BMC Pregnancy and Childbirth volume  24 , Article number:  374 ( 2024 ) Cite this article

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Metrics details

Colorectal cancer (CRC) in pregnancy is sporadic. We reported a case of a woman at 23 + 4 weeks of gestation who presented with abdominal pain. The patient underwent an ultrasound and MRI, during which a colonic mass was noted. Considering a probable incomplete intestinal obstruction, a colonoscopy, biopsy, and colonic stenting were performed by a multidisciplinary team. However, sudden hyperthermia and CT demonstrated intestinal perforation, and an emergency caesarean section and colostomy were conducted. The histological analysis confirmed moderately high-grade adenocarcinoma.

Peer Review reports

Case presentation

A 36-year-old Chinese woman (gravida 0 para 0) with no family history of cancer presented at the Emergency Department of Peking University First Hospital, Beijing, China, at 23  +4  weeks of pregnancy. She complained of 3-day diarrhoea and aggregating abdominal pain. The patient had iron deficiency anaemia for five years and rectal bleeding for two years, which was treated with sigmoidoscopy and haemorrhoid surgery, and she denied other diseases in her remote pathological history.

Upon admission, physical examination revealed abdominal tenderness and rebound pain, particularly in the right upper quadrant (RUQ) and below the xiphoid. There was a suspicious tenderness at McBurney's point. The laboratory examination showed as follows: white blood cell (WBC) count 10.51X10 9 /L, haemoglobin (Hb) 82 g/L, C-reactive protein (CRP) 40 mg/L, potassium 3.08 mmol/L, sodium 131.21mmo1/L; otherwise, the coagulation function, amylase, lipase, and liver and kidney function were within normal range. Abdominal ultrasound demonstrated dilated intestines at the left upper quadrant and a mass measuring 8 cm behind the uterus suggestive of intestinal origin. The abdominal and pelvic Magnetic Resonance Imaging (MRI) without contrast indicated an irregular thickening of the large bowel between the colon and sigmoid colon, with an extension of 8-10 cm (Fig.  1 ). Therefore, a rectum and sigmoid colon neoplasm accompanied by incomplete intestinal obstruction was the initial suspicion.

figure 1

MRI at admission

Considering the complexity of the patient's condition, a multidisciplinary meeting was organised, including the department of obstetrics, general surgery, haematology, endoscopy, imaging department, and other departments. During the discussion, all the participating departments agreed with the initial suspicion of colon cancer (T4aN + Mx). A colonoscopy was recommended to clarify the diagnosis further and to decide whether termination of pregnancy was appropriate based on the pathological results.

An emergency sedation-free colonoscopy was performed and revealed an exophytic circumferential mass located at the junction of the rectum and sigmoid colon, 13 cm away from the anus. The mass surface was ulcerated and covered with white moss. Additionally, there was a narrowing lumen of 3-4 cm in length, which did not allow for the endoscope to progress (Fig.  2 ). The biopsy was taken. Meantime, anti-infection therapy, iron intravenous iron supplementation therapy, and parenteral nutrition were initiated.

figure 2

Colonoscopy findings

On the second day after admission, the patient's pain was relieved. The stool was soft and yellow, with a small amount of red mucus visible on the surface. Since the haemoglobin level gradually decreased to 69 g/L, 2 Units of red blood cells were transfused to correct anaemia. After a blood transfusion, the patient developed a fever, with a maximum temperature of 38.9 ℃, accompanied by chills, shortness of breath, and wheezing (50–60 breaths/minute). Blood oxygen saturation was 91% and 94% after oxygen uptake of 3L/min, blood pressure was 102/60 mmHg. Full blood count (FBC) showed WBC 10.07 × 10 9 /L, Hb 81 g/L, platelet 204 × 10 9 /L, and CRP 146 mg/L. Blood gas analysis showed a pH of 7.46, an oxygen saturation index of 94%, and oxygen partial pressure of 65 mmHg. An emergent computed tomography (CT) suggested intestinal perforation due to colon lesions.

Consequently, at 23 +5  weeks of gestation, an emergency cesarean section and transverse colostomy were performed simultaneously with the collaboration of obstetricians and a colorectal surgeon. A transverse incision was made, and a large lesion occupying the sigmoid colon was detected during the operation, surrounded by enlarged lymph nodes. No metastatic nodules were found in the peritoneum, omentum, and pelvic wall, and no apparent signs of perforation were observed in the intestinal canal above the retroflexion of the peritoneum. A latex drainage tube behind the uterus was placed. After the surgery, the patient was transferred to the Surgical Intensive Care Unit (SICU), where she received treatment including acid suppression, anti-infection therapy and parenteral nutritional support, which gradually transitioned to a regular diet. Eventually, the patient was discharged on the 11th day post-operation.

The postoperative histopathological result demonstrated moderately to high differentiated adenocarcinoma. Immunohistochemical staining results were listed: P53 90% + , Her-20, MLH1 + , PMS2 + , MSH2 + , MSH6 + . Microsatellite stability: MSS. No tumour cells were found in the placenta. Under the guidance of general surgery, the patient took capecitabine orally 25 days after surgery and planned to undergo two courses of intravenous chemotherapy before undergoing further surgical treatment.

Colorectal cancer (CRC) in pregnancy is exceedingly rare. The incidence rate of CRC in pregnancy is 0.002% to 0.008% [ 1 ]. Typical symptoms/signs include hematochezia or melena, abdominal pain, apart from unexplained iron deficiency anaemia, or a change in bowel habits [ 2 ]. Less common presenting symptoms include abdominal distention or nausea and vomiting, which may be indicators of obstruction.

A delayed diagnosis during pregnancy may be due to overlapping symptoms with that of normal pregnancy in the context of the expected low incidence of CRC at such an early maternal age. The reluctance of medical teams to conduct diagnostic tests due to potential risks to the fetus often leads to a delayed diagnosis, thus complicating treatment and worsening the prognosis [ 3 ]. Various serum markers have been associated with CRC, particularly carcinoembryonic antigen (CEA). However, all these markers, including CEA, have a low diagnostic ability to detect primary CRC due to significant overlap with benign disease and low sensitivity for early-stage disease [ 4 ].

Nonionising radiation imaging, such as Ultrasound and MRI, is favoured during pregnancy. Despite low intrauterine doses, CT scan can be used in pregnancy if necessary.

Diagnostic imaging studies typically expose the fetus to less than 50 mGy (0.05 Gy, five rads), and there is no evidence of an increased risk of fetal anomalies, intellectual disability, growth restriction, or pregnancy loss from ionising radiation at this dose level [ 5 , 6 ].

In the United States and elsewhere, the standard practice at most institutions is that all patients with stage II, III, or IV CRC undergo chest, abdomen, and pelvic CT before or after resection, an approach endorsed by the National Comprehensive Cancer Network.

Colonoscopy is the most accurate diagnostic test for CRC since it can localise and biopsy lesions throughout the large bowel, detect synchronous neoplasms and remove polyps. Endoscopy is recommended in pregnancy when the patient has significant or continuous bleeding, severe or refractory nausea and vomiting or abdominal pain, and strong suspicion of colon mass [ 7 ].

The optimal time for advanced endoscopic procedures during the pregnancy is the second trimester; however, if the consequences of a delayed procedure can cause harm to the patient or the fetus, then one should proceed with a multidisciplinary team [ 8 ].

GI endoscopy in pregnant patients is inherently risky because the fetus is susceptible to maternal hypoxia and hypotension, either of which could lead to fetal demise. Other risks to the fetus include teratogenesis (from medications given to the mother or ionising radiation exposure) and premature birth [ 9 ].

A systematic review was conducted to identify studies regarding CRC-p and conduct a pooled analysis of the reported data. Seventy-nine papers written on 119 patients with unequivocal CRC-p were included. The calculated pooled risk is 0.002%, and age at diagnosis has decreased over time. The median age at diagnosis was 32 (range, 17–46) years. 12%, 41% and 47% of CRC-p were diagnosed during the first, second and third trimester respectively. Among the cases, bleeding occurred in 47% of patients, abdominal pain in 37.6%, constipation in 14.1%, obstruction in 9.4% and perforation in 2.4%. Regarding cancer, 53.4% of the CRC-p was in the colon, while 44% was in the rectum. Out of 82 patients whose treatment was described, 9.8% received chemotherapy during pregnancy. None of their newborns developed permanent disability, one developed hypothyroidism, and 72% of newborns were alive. Hence, treatment of CRC-p should be timely and needs to be discussed carefully by a multidisciplinary team, with close patient monitoring [ 10 ].

Treatment of CRC-p is influenced by several factors, including tumor location and stage at presentation, surgical settings (elective vs. urgent/ emergent) and gestational age. The decision-making process must involve anesthesiologists, colorectal surgeons, oncologists and gynaecologists, while the mother will make the final decision.

If the tumour is resectable, surgical excision after diagnosis should be performed as soon as possible if the diagnosis is made before 20 weeks of gestation. A total abdominal hysterectomy may be necessary to provide greater access to the rectum or if the uterus is involved. If diagnosis is made later in pregnancy (> 20 weeks), surgery can be postponed until fetal pulmonary maturity is reached (28–32 weeks) or after delivery. However, waiting until after the fetus is delivered does pose risks to the mother, and the patient should be fully informed of these risks [ 11 ].

When malignant neoplasm is diagnosed during gestation, maternal life-saving chemotherapy poses life-threatening concerns for the developing fetus [ 12 ]. Exposure to chemotherapy in the first trimester poses the most significant risk for teratogenicity, with an incidence of spontaneous abortions or malformations up to 15–25% [ 13 ]. In the second or third trimesters, chemotherapy is generally considered safer but is associated with an increased incidence of small for gestational age fetuses (SGA) [ 14 , 15 ]. Chemotherapy is often continued until 35 gestational weeks or three weeks before the expected due date. Timing is recommended to avoid the increased risk of chemotherapy-related complications, such as bone marrow suppression, bleeding, and maternal and fetal death during delivery [ 16 ].

A distance of > 30 cm from the field edges will expose the embryo/fetus to only 4–20 cGy. Therefore, many areas (e.g., head and neck, breast, and extremities) can be treated with radiation. Lead shielding over the embryo or fetus can also reduce the exposure. Because of the location of the tumour and proximity of the embryo/fetus, Radiation therapy (RT) is contraindicated during pregnancy. Radiation therapy can be used postoperatively only after delivery or elective abortion in pregnant patients. Future fertility should be considered before treatment because RT can cause permanent damage to the ovaries, which can lead to infertility [ 11 , 17 ].

Colorectal cancer is the most common cause of large bowel obstruction, comprising 60 per cent of all cases.

Patients who present with an acute malignant colorectal obstruction may require immediate surgery if they have a perforation or pending perforation, or if they are clinically unstable (tachycardic, hypotensive, acidotic), or are symptomatic. Perforation occurs more commonly at the point of obstruction, most likely due to local tumour invasion or inflammatory reaction, rather than in the proximal, dilated colon. The decision to choose a staged versus one-stage procedure depends upon several factors, including the location of the obstructing lesion, condition of the proximal colon, medical comorbidities of the patient, as well as their life expectancy, goals of care, and the presence of proximal perforation [ 18 , 19 , 20 ].

Colorectal cancer in pregnancy is rare. For patients whose symptoms include chronic anaemia that is difficult to correct with iron supplements and persistent gastrointestinal symptoms during pregnancy, it is necessary to be vigilant about the possibility of digestive tract tumours. It's essential to note that tumours should be suspected when all benign causes are excluded despite low incidence [ 21 , 22 ]. Ultrasound and magnetic resonance imaging are relatively safe examinations during pregnancy, and if necessary, pelvic CT and gastroscopy can be performed for diagnosis.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

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Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China

Yan Gao & Yu Sun

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Y. G. and Y. S. contributed to patient management. Y. G. wrote the initial draft of the manuscript. Y. S. provided substantial edits and additions to the manuscript. All authors read and approved the final manuscript.

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Gao, Y., Sun, Y. Intestinal perforation due to colorectal cancer during pregnancy: case report and literature review. BMC Pregnancy Childbirth 24 , 374 (2024). https://doi.org/10.1186/s12884-024-06533-9

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Received : 25 December 2023

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Published : 16 May 2024

DOI : https://doi.org/10.1186/s12884-024-06533-9

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  • Colorectal cancer
  • Intestinal perforation
  • Intestinal obstruction

BMC Pregnancy and Childbirth

ISSN: 1471-2393

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