Frequency of Surveillance and Impact of Surveillance Colonoscopies in Patients With Ulcerative Colitis Who Developed Colorectal Cancer

British Society of Gastroenterology guidelines on colorectal surveillance in inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) remain at increased risk for colorectal cancer and death from colorectal cancer compared with the general population despite improvements in inflammation control with advanced therapies, colonoscopic surveillance and reductions in environmental risk factors. This guideline update from 2010 for colorectal surveillance of patients over 16 years with colonic inflammatory bowel disease was developed by stakeholders representing UK physicians, endoscopists, surgeons, specialist nurses and patients with GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodological support.An a priori protocol was published describing the approach to three levels of statement: GRADE recommendations, good practice statements or expert opinion statements. A systematic review of 7599 publications, with appraisal and GRADE analysis of trials and network meta-analysis, where appropriate, was performed. Risk thresholding guided GRADE judgements.We made 73 statements for the delivery of an IBD colorectal surveillance service, including outcome standards for service and endoscopist audit, and the importance of shared decision-making with patients.Core areas include: risk of colorectal cancer, IBD-related post-colonoscopy colorectal cancer; service organisation and supporting patient concordance; starting and stopping surveillance, who should or should not receive surveillance; risk stratification, including web-based multivariate risk calculation of surveillance intervals; colonoscopic modalities, bowel preparation, biomarkers and artificial intelligence aided detection; chemoprevention; the role of non-conventional dysplasia, serrated lesions and non-targeted biopsies; management of dysplasia, both endoscopic and surgical, and the structure and role of the multidisciplinary team in IBD dysplasia management; training in IBD colonoscopic surveillance, sustainability (green endoscopy), cost-effectiveness and patient experience. Sixteen research priorities are suggested.

Clinical features and oncological outcomes of intestinal cancers associated with ulcerative colitis and Crohn's disease

BACKGROUND

Patients with longstanding inflammatory bowel disease are at high risk of developing intestinal cancers. In this study, we aimed to elucidate the differences between intestinal cancers associated with ulcerative colitis and Crohn's disease.

METHODS

Intestinal cancers in ulcerative colitis and Crohn's disease patients treated between 1983 and 2020 at 43 Japanese institutions were retrospectively analyzed..

RESULTS

A total of 1505 intestinal cancers in 1189 ulcerative colitis and 316 Crohn's disease patients were studied. Almost all of ulcerative colitis-associated cancers (99%) were in the colon and rectum, whereas half of Crohn's disease-associated cancers (44%) were in the anus, with 11% in the small intestine. Ulcerative colitis-associated cancers were diagnosed more frequently by surveillance (67% vs. 25%, P < 0.0001) and at earlier stages (stages 0-1, 71% vs. 27%, P < 0.0001) compared with Crohn's disease-associated cancers. Colorectal cancers associated with Crohn's disease showed a significantly worse 5-year overall survival rate than those associated with ulcerative colitis (stage 2, 76% vs. 89%, P = 0.01, stage 3, 18% vs. 68%, P = 0.0009, and stage 4, 0% vs. 13%, P = 0.04). Surveillance correlated with earlier diagnoses for ulcerative colitis- and Crohn's disease-associated intestinal cancers, whereas shorter intervals between endoscopic examinations correlated with an earlier cancer diagnosis in ulcerative colitis patients but not in Crohn's disease patients.

CONCLUSIONS

The clinical and oncological features of ulcerative colitis- and Crohn's disease-associated cancers were very different. Crohn's disease-associated cancers were diagnosed at more advanced stages and were detected less frequently by surveillance. Additionally, they showed a significantly poorer prognosis.

Degenerative Ulcerative Colitis After One Year of Evolution in a 20-Year-Old Patient

Ulcerative colitis (UC) is an inflammatory bowel disease. Patients with this condition are considered to belong to a high-risk group for developing colorectal cancer (CRC). These are patients who are often not subjected to regular endoscopic monitoring and in whom the diagnosis of CRC degeneration is often a pathological discovery. The purpose of this work is to report the characteristics of a case of degenerate UC.

This is a case of a 20-year-old patient, followed for UC, who was diagnosed with CRC during a flare-up of his disease, revealed by endoscopic exploration. This patient underwent a coloproctectomy with ileoanal J-pouch reconstruction by laparotomy. The operative specimen came back in favor of a moderately differentiated Lieberkunian adenocarcinoma after an anatomopathological study. The risk of developing CRC in patients followed for UC is rare at a young age, but it becomes higher after 10 years of evolution. This risk is incriminated by several factors: duration of evolution, the extent and severity of inflammatory lesions and the notion of CRC in the family. The discovery is often made by endoscopic exploration during disease surveillance.

Risk factors for locally advanced cancer associated with ulcerative colitis: Results of a retrospective multicentric study in the era of biologics

BACKGROUND

Patients affected by ulcerative colitis (UC) are more likely to develop colorectal cancer, and are often diagnosed with lymph node involvement (N+) at surgery.

AIM

To identify the risk factors for N+ cancer in UC patients.

METHODS

Patients undergoing surgery from 2001 to 2018 in six European tertiary centres were included. N+ patients were compared to the control group (N-) for clinical variables. The evaluation of risk factors for N+ was assessed using univariate and multivariable logistic regression analyses.

RESULTS

A total of 130 patients were included. Median duration of disease was 21 years (1-52). Forty patients (30.8%) were N+ at surgery. Eighteen (13.8%) developed cancer within 10 years from the onset of UC. Younger age at surgery (Odds ratio -OR- 0.96, p = 0.042), left colon location (OR 2.44, p = 0.045) and the presence of stricture (OR 5.07, p = 0.002) were associated with N+.

CONCLUSION

Location in the left colon, presence of strictures and younger age strongly correlated with a higher risk of N+ cancer, which could develop before the starting point of surveillance. Duration, extension and severity of disease were not associated with N+. These results should be considered in the evaluation of risk of advanced cancer in UC patients.

Systematic review and meta-analysis of the incidence and prevalence and 30-year trend of inflammatory bowel diseases in Asia: a study protocol

INTRODUCTION

Inflammatory bowel diseases, including ulcerative colitis (UC), Crohn's disease (CD) and inflammatory bowel disease type unclassified (IBDU), are debilitating conditions that are rapidly growing in developing countries. Given the absence of a comprehensive systematic review and meta-analysis containing a rigorous pooled estimate of incidence and prevalence of UC, CD and IBDU, this study was conducted to determine the incidence and prevalence of these conditions in Asia and their 30-year trend.

METHODS AND ANALYSIS

Based on predefined criteria, electronic databases, including PubMed/MEDLINE, Scopus, WoS (Clarivate Analytics), Embase and Google Scholar, and some databases pertaining to Asian countries will be searched for population-based cross-sectional studies and the baseline data and final reports of population-based cohort studies involving paediatric and adult patients, with no language restrictions, from 1 January 1988 to 30 December 2018. Any disagreement in the stages of screening, selecting, quality assessment and data extraction between the two independent reviewers will be resolved by consensus, and if the disagreement is not resolved, a third expert opinion will be sought. The combination method will be used based on methodological similarities in the included studies by the Fixed Effect Model or the Random Effect Model. Forest plots will be plotted for all the studies to show the separated and pooled incidence and prevalence and their corresponding 95% CIs. The Q-statistic test and I2 statistic will be used to assess statistical heterogeneity. Funnel plots will be used to assess potential reporting bias and nonsignificant study effect. Begg's and Egger's tests will also be performed, and significant results (p>0.1) shall suggest a publication bias, in which case the 'trim and fill' method will be used. The time trends for UC, CD and IBDU will be calculated using a cumulative meta-analysis.

ETHICS AND DISSEMINATION

Since this review will use previously published studies, it will not require the consent of an Ethics Committee. The results will be prepared and disseminated through a peer-reviewed journal and will be presented in relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42019131477.

Surveillance for colorectal cancer and chemoprevention in ulcerative and Crohn's colitis: The need for clinical strategies to increase effectiveness

This review considers why current strategies for surveillance and the prevention of colorectal cancer as a long‐term complication are ineffective. The role of endoscopists, pathologists, and patients are investigated. Colorectal cancer is linked to poor compliance with therapy, and attention may be better directed at improving adherence to treatment than strengthening current surveillance programs. Clearly, 5‐ASA compounds, particularly mesalazine, are the most appropriate agents to choose, but there may also be a place for the daily intake of folic acid. Currently, the evidence in support of ursodeoxycholic acid is mixed, and it cannot be recommended, in general, to patients for the prophylaxis of colorectal cancer risk. An alternative approach through better concordance with medications is considered. The situation in Crohn's colitis is less clear. Although the risk of colorectal cancer mirrors that in ulcerative colitis, there are no published community‐based studies that exclusively assess the effects of surveillance on the early detection of cancer, and the benefits of 5‐ASA compounds in treatment seem less certain than in ulcerative colitis. In addition, there have been no assessments of the effects of any medications on cancer risk in Crohn's disease.

Surveillance Colonoscopy for Ulcerative Colitis-Associated Colorectal Cancer Offers Better Overall Survival in Real-World Surgically Resected Cases

OBJECTIVES

To determine the effectiveness of surveillance colonoscopy (SC) and optimize its use by assessing real-world surgically resected cases of ulcerative colitis (UC)-associated colorectal cancer (CRC) and dysplasia.

METHODS

Clinicopathological data of 406 (238 CRC and 168 dysplasia) patients who underwent surgical resection in 10 UC specialized institutions were retrospectively reviewed. The overall survival (OS) rates were compared between the SC and non-SC groups. The incidence of and risk factors for early-onset CRC (<8 years after UC onset) were identified. The distribution of CRC lesions was also assessed.

RESULTS

Cancer stages were significantly more advanced in the non-SC group than in the SC group (P < 0.001). The patients in the SC group showed significantly better OS than those in the non-SC group (5-year OS: 89% vs 70%; log-rank test: P = 0.001). Seventeen percent of patients developed CRC within 8 years after UC onset. The age at UC onset was a risk factor and a good predictor of early-onset CRC (<8 years) (P < 0.01; AUC: 0.85). The most common sites of CRC were the rectum (51%) and sigmoid colon (20%). Multiple CRC was identified in 16% of patients.

CONCLUSIONS

Surveillance colonoscopy was effective and improved the OS in patients with UC. We recommend that patients with late-onset UC (>40 years) undergo SCs earlier because of the high incidence of CRC within 8 years of UC onset. Moreover, the rectum and sigmoid colon should be more thoroughly examined.