Screening differences and risk of cervical cancer in inflammatory bowel disease

Exploring genetic associations of Crohn's disease and ulcerative colitis with extraintestinal cancers in European and East Asian populations

Background

Previous studies have reported associations of Crohn's disease (CD) and ulcerative colitis (UC) with the risks of extraintestinal cancers, but the causality remains unclear.

Methods

Using genetic variations robustly associated with CD and UC extracted from genome-wide association studies (GWAS) as instrumental variables. Nine types of extraintestinal cancers of European and Asian populations were selected as outcomes. We used the inverse variance weighted method as the primary approach for two-sample Mendelian randomization analysis. Sensitivity analyses were carried out to evaluate the reliability of our findings.

Results

In the European population, we found that CD showed a potential causal relationship with pancreatic cancer (OR: 1.1042; 95% CI: 1.0087-1.2088; P=0.0318). Meanwhile, both CD (outliers excluded: OR: 1.0208; 95% CI: 1.0079-1.0339; P=0.0015) and UC (outliers excluded: OR: 1.0220; 95% CI: 1.0051-1.0393; P=0.0108) were associated with a slight increase in breast cancer risk. Additionally, UC exhibited a potential causal effect on cervical cancer (outliers excluded: OR: 1.1091; 95% CI: 1.0286-1.1960; P=0.0071). In the East Asian population, CD had significant causal effects on pancreatic cancer (OR: 1.1876; 95% CI: 1.0741-1.3132; P=0.0008) and breast cancer (outliers excluded: OR: 0.9452; 95% CI: 0.9096-0.9822; P=0.0040). For UC, it exhibited significant causal associations with gastric cancer (OR: 1.1240; 95% CI: 1.0624-1.1891; P=4.7359×10-5), bile duct cancer (OR: 1.3107; 95% CI: 1.0983-1.5641; P=0.0027), hepatocellular carcinoma (OR: 1.2365; 95% CI: 1.1235-1.3608; P=1.4007×10-5) and cervical cancer (OR: 1.3941; 95% CI: 1.1708-1.6599; P=0.0002), as well as a potential causal effect on lung cancer (outliers excluded: OR: 1.1313; 95% CI: 1.0280-1.2449; P=0.0116).

Conclusions

Our study provided evidence that genetically predicted CD may be a risk factor for pancreatic and breast cancers in the European population, and for pancreatic cancer in the East Asian population. Regarding UC, it may be a risk factor for cervical and breast cancers in Europeans, and for gastric, bile duct, hepatocellular, lung, and cervical cancers in East Asians. Therefore, patients with CD and UC need to emphasize screening and prevention of site-specific extraintestinal cancers.

[Risk factors for high-grade squamous intraepithelial lesions or cervical cancer in chronic inflammatory bowel disease]

INTRODUCTION

Chronic inflammatory bowel disease (IBD) is thought to increase the risk of high-grade histological intraepithelial lesions (HGIL) and cervical cancer. The risk factors for developing these lesions are poorly understood.

MATERIALS AND METHODS

This is a single-center retrospective case-control study including IBD patients followed at our University Hospital Center from 2011 to 2021 who presented with HGIL or cervical cancer. Four controls were case-matched according to IBD type, age, active smoking and multiparity.

RESULTS

Eighteen cases and 72 controls were included. We found no significant differences between the 2 groups with regard to mean age at IBD diagnosis, mean duration of IBD, IBD location, history of IBD-related surgery or even association with another chronic inflammatory disease. In our study, the use of immunosuppressants/biotherapies in these patients [50% (9/18) for cases vs. 56% (40/72) for controls; P=0.9] was not a risk factor for IGRA or cervical cancer. Similarly, neither the total duration of exposure to immunosuppressants/biotherapies (9.9±8years for cases vs. 6.6±5.3years for controls; P=0.1), nor combined therapies [11% (2/18) for cases vs. 6% (4/72) for controls; P=0.3], nor azathioprine or methotrexate use [22% (4/18) for cases vs. 11% (8/72) for controls; P=0.3] were found to be risk factors.

CONCLUSION

In our study, we found no risk factors for patients with IBD to develop IGRA or cervical cancer.

Treat-to-Target and Regular Surveillance of Inflammatory Bowel Disease Are Associated with Low Incidence and Early-Stage Detection of Malignancies: A Retrospective Cohort Study

Inflammatory bowel diseases (IBD), including ulcerative colitis (UC) and Crohn's disease (CD), increase the risk of malignancies, particularly colorectal cancer (CRC). We aimed to assess the incidence of malignancies in IBD patients managed using a treat-to-target approach and recommended surveillance. We retrospectively searched the electronic databases of two tertiary IBD centers in Milan from 2010 to 2019 for new diagnoses of malignancy in patients with pre-existing IBD. A total of 5239 patients with a follow-up of 19,820 years were included. In total, 71 malignancies were diagnosed in 70 patients (38 CD, 32 UC) with a mean age of 52.9 years, of whom 64% were former or active smokers. The annual incidence of all malignancies was 358 per 100,000 patient years (95% CI 275-444), and the standardized incidence rate (SIR) was 0.93 (95% CI 0.73-1.16). Gastrointestinal cancers were the most frequent (n = 17, 23.9%), in particular, CRC (n = 9), with an incidence of 45 per 100,000 (95% CI 15-74) and an SIR of 1.18 (95% CI 0.54-2.09). CRC occurred mainly in UC patients (6/8), while small bowel cancer was seen in CD patients (5/9). Melanoma and breast cancer (n = 8 each) were the most common non-GI cancers. No significant difference in incidence was found between CD or UC. Death occurred in nine patients (11%) and was due to cancer in eight of these cases, two of which were IBD-related. Most malignancies included in the surveillance were diagnosed at early (I-II) stages (20 vs. 4, p < 0.05). In patients with IBD, treat-to-target and strict surveillance were associated with a low incidence of cancer, similar to that of the general population, and the detection of malignancies at an early stage.

Identification of Potential Genes and Critical Pathways in Postoperative Recurrence of Crohn's Disease by Machine Learning And WGCNA Network Analysis

Background

Crohn's disease (CD) is a chronic idiopathic inflammatory bowel disease affecting the entire gastrointestinal tract from the mouth to the anus. These patients often experience a period of symptomatic relapse and remission. A 20 - 30% symptomatic recurrence rate is reported in the first year after surgery, with a 10% increase each subsequent year. Thus, surgery is done only to relieve symptoms and not for the complete cure of the disease. The determinants and the genetic factors of this disease recurrence are also not well-defined. Therefore, enhanced diagnostic efficiency and prognostic outcome are critical for confronting CD recurrence.

Methods

We analysed ileal mucosa samples collected from neo-terminal ileum six months after surgery (M6=121 samples) from Crohn's disease dataset (GSE186582). The primary aim of this study is to identify the potential genes and critical pathways in post-operative recurrence of Crohn's disease. We combined the differential gene expression analysis with Recursive feature elimination (RFE), a machine learning approach to get five critical genes for the postoperative recurrence of Crohn's disease. The features (genes) selected by different methods were validated using five binary classifiers for recurrence and remission samples: Logistic Regression (LR), Decision tree classifier (DT), Support Vector Machine (SVM), Random Forest classifier (RF), and K-nearest neighbor (KNN) with 10-fold cross-validation. We also performed weighted gene co-expression network analysis (WGCNA) to select specific modules and feature genes associated with Crohn's disease postoperative recurrence, smoking, and biological sex. Combined with other biological interpretations, including Gene Ontology (GO) analysis, pathway enrichment, and protein-protein interaction (PPI) network analysis, our current study sheds light on the in-depth research of CD diagnosis and prognosis in postoperative recurrence.

Results

PLOD2, ZNF165, BOK, CX3CR1, and ARMCX4, are the important genes identified from the machine learning approach. These genes are reported to be involved in the viral protein interaction with cytokine and cytokine receptors, lysine degradation, and apoptosis. They are also linked with various cellular and molecular functions such as Peptidyl-lysine hydroxylation, Central nervous system maturation, G protein-coupled chemoattractant receptor activity, BCL-2 homology (BH) domain binding, Gliogenesis and negative regulation of mitochondrial depolarization. WGCNA identified a gene co-expression module that was primarily involved in mitochondrial translational elongation, mitochondrial translational termination, mitochondrial translation, mitochondrial respiratory chain complex, mRNA splicing via spliceosome pathways, etc.; Both the analysis result emphasizes that the mitochondrial depolarization pathway is linked with CD recurrence leading to oxidative stress in promoting inflammation in CD patients.

Conclusion

These key genes serve as the novel diagnostic biomarker for the postoperative recurrence of Crohn's disease. Thus, among other treatment options present until now, these biomarkers would provide success in both diagnosis and prognosis, aiming for a long-lasting remission to prevent further complications in CD.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Cancer and IBD

Cancer is a major cause of morbidity and mortality among people with inflammatory bowel disease (IBD). Intestinal cancers may arise as a complication of IBD itself, while extra-intestinal cancers may arise due to some of the immunosuppressive therapies used to treat IBD. Colorectal cancer (CRC) and small bowel cancer risks remain elevated among persons with IBD as compared to age-and sex-matched members of the general population, and the lifetime risk of these cancers is strongly correlated to cumulative intestinal inflammatory burden. However, the cumulative risk of cancer, even among those with IBD is still low. Some studies suggest that IBD-CRC incidence has declined over the years, possibly owing to improved treatment standards and improved detection and management of early neoplastic lesions. Across studies of extra-intestinal cancers, there are generally higher incidences of melanoma, hepatobiliary cancer, and lung cancer and no higher incidences of breast cancer or prostate cancer, with equivocal risk of cervical cancer, among persons with IBD. While the relative risks of some extra-intestinal cancers are increased with treatment, the absolute risks of these cancers remain low and the decision to forego treatment in light of these risks should be carefully weighed against the increased risks of intestinal cancers and other disease-related complications with undertreated inflammatory disease. Quality improvement efforts should focus on optimized surveillance of cancers for which surveillance strategies exist (colorectal cancer, hepatobiliary cancer, cervical cancers, and skin cancers) and the development of cost-effective surveillance strategies for less common cancers associated with IBD.

Risk of uterine cervical cancer in inflammatory bowel disease: a systematic review and meta-analysis

BACKGROUND AND AIMS

There are limited data on the association between uterine cervical cancer (UCC) and inflammatory bowel disease (IBD), which includes Crohn's disease (CD) and ulcerative colitis (UC).

METHODS

This systematic review and meta-analysis assessed the risk of UCC in patients with IBD. We searched MEDLINE, Embase, Cochrane Library, Scopus, Web of Science, ClinicalTrials.gov, gray literature and conference proceedings for studies published before 21 January 2022. Two reviewers independently screened studies, extracted data and assessed quality using the Newcastle-Ottawa Scale. Subgroup analyses were based on IBD type, biologic era, immunosuppression status, study location and design, and publication status. Fifteen studies were included.

RESULTS

The pooled relative risk (RR) of UCC in IBD was 1.34 (95% confidence interval [CI], 1.07-1.69; I2 = 53.4%). In subgroup analyses, the pooled RRs of UCC in CD and UC were 1.18 (95% CI, 0.97-1.42) and 1.50 (95% CI, 1.01-12.21), respectively. The pooled RRs of UCC in pre-biologic and biologic eras were 1.36 (95% CI, 0.83-2.23) and 1.99 (95% CI, 1.03-3.86), respectively. The pooled RR of UCC in immunomodulator users was 2.18 (95% CI, 0.81-5.87). The pooled RRs of UCC in Asia, Europe and North America were 5.65 (95% CI, 2.65-12.07), 1.13 (95% CI, 0.96-1.34) and 1.38 (95% CI, 1.10-1.73), respectively.

CONCLUSIONS

The risk of UCC was significantly increased in IBD, particularly in UC but not in CD, suggesting that women with IBD should undergo regular UCC screening and consider vaccination.

Elevated risk of cervical cancer in elderly women with incident ulcerative colitis in South Korea

The association between ulcerative colitis (UC) and uterine cervical cancer is still unclear. To investigate cervical cancer risk in South Korean women with UC, we analyzed the Korean National Health Insurance claims data. UC was defined using both ICD-10 codes and UC-specific prescriptions. We analyzed incident cases of UC diagnosed between 2006 and 2015. Age-matched women without UC (control group) were randomly selected from the general population (1:3 ratio). Hazard ratios were calculated using multivariate Cox proportional hazard regression, and the event was defined as occurrence of cervical cancer. A total of 12,632 women with UC and 36,797 women without UC were enrolled. The incidence of cervical cancer was 38.8 per 100,000 women per year in UC patients and 25.7 per 100,000 women per year in controls, respectively. The adjusted HR for cervical cancer was 1.56 (95% CI 0.97-2.50) in the UC group with reference to the control group. When stratified by age, the adjusted HR for cervical cancer was 3.65 (95% CI 1.54-8.66) in elderly UC patients (≥ 60 years) compared to elderly control group (≥ 60 years). Within UC patients, increased age (≥ 40 years) and low socioeconomic status were associated with an increased risk of cervical cancer. The incidence of cervical cancer was found to be higher among elderly patients (≥ 60 years) with newly diagnosed UC in South Korea, compared to age-matched controls. Therefore, regular cervical cancer screening is recommended for elderly patients who have recently been diagnosed with UC.

Therapy patterns and surveillance measures of Inflammatory Bowel Disease patients beyond disease-related hospitalization: a claims-based cohort study

Introduction

Medical care and surveillance of inflammatory bowel disease (IBD) patients have been shown to be far from satisfactory. Data on therapy patterns and surveillance measures in IBD patients are scarce. We, therefore, aimed to compare the therapy patterns and surveillance management of IBD patients in the year before and after IBD-related hospitalization.

Methods

We examined medical therapy, surveillance management (influenza vaccination, dermatologist visits, Pap smear screening, creatinine measurements, iron measurements, and ophthalmologist visits) and healthcare utilization in 214 ulcerative colitis (UC) and 259 Crohn's disease (CD) patients who underwent IBD-related hospitalization from 2012 to 2014.

Results

IBD-related drug classes changed in 64.5% of IBD patients following hospitalization. During the 1-year follow-up period, biological treatment increased in UC and CD patients, while steroid use decreased. Following hospitalization, 63.1% of UC and 27.0% of CD patients received 5-ASA. Only 21.6% of all IBD patients had a flu shot, and 19.6% of immunosuppressed IBD patients were seen by a dermatologist in the follow-up; other surveillance measures were more frequent. Surveillance before hospital admission and consultations by gastroenterologists were strongly correlated with surveillance during the postoperative follow-up, while gender and diagnosis (UC vs. CD) were not. During the 1-year follow-up, 20.5% of all IBD patients had no diagnostic or disease-monitoring procedure.

Discussion/Conclusion

Surveillance measures for IBD patients are underused in Switzerland. Further research is needed to examine the impact of annual screenings and surveillance on patient outcomes.

Immunomodulators: still having a role?

Immunomodulators, particularly the thiopurines and to a lesser extent methotrexate, were standard of care for inflammatory bowel diseases, including Crohn’s disease and ulcerative colitis, for >40 years. While there has been a renaissance in available therapies with the advent of biologics and small molecules, an impetus remains for the ongoing use of thiopurines and methotrexate. This is particularly true for the maintenance of remission and when used in combination therapy with infliximab to suppress anti-biologic antibodies. This article summarizes the data behind immunomodulator use in Crohn’s disease, focusing on the beneficial role these drugs still have while acknowledging their clinical limitations.

Solid extraintestinal malignancies in patients with inflammatory bowel disease

Malignancies constitute the second cause of death in patients with inflammatory bowel diseases (IBD), after cardiovascular diseases. Although it has been postulated that IBD patients are at greater risk of colorectal cancer compared to the general population, lately there has been evidence supporting that this risk is diminishing over time as a result of better surveillance, while the incidence of extraintestinal cancers (EICs) is increasing. This could be attributed either to systemic inflammation caused by IBD or to long-lasting immunosuppression due to IBD treatments. It seems that the overall risk of EICs is higher for Crohn’s disease patients and it is mainly driven by skin cancers, and liver-biliary cancers in patients with IBD and primary sclerosing cholangitis. The aims of this review were first to evaluate the prevalence, characteristics, and risk factors of EICs in patients with IBD and second to raise awareness regarding a proper surveillance program resulting in early diagnosis, better prognosis and survival, especially in the era of new IBD treatments that are on the way.

Prevalence and Distribution of HPV Genotypes in Immunosuppressed Patients in Lorraine Region

Background: The primary objective of this work was to assess the prevalence and distribution of HPV genotypes in immunosuppressed patients, and to compare them with the French Monsonego cohort. Secondary objectives were to evaluate whether the risk of HPV infection was correlated with HIV viral load, CD4 cell count in HIV-infected patients and the type, number of immunosuppressive therapies or type of pathology (transplant vs. autoimmune diseases) in patients undergoing long-term immunosuppressive therapy. Methods: An observational, monocentric and historical study was conducted including all immunosuppressed patients having received an HPV testing, in the Laboratory of Virology, Nancy Regional Teaching Hospital Center, between 2014 and 2020. Immunosuppressed patients were either HIV-infected or received long-term immunosuppressive therapy. Results: In our cohort, the prevalence of HPV infection (75.6% vs. 16.1% p < 0.05), the proportion of patients with high-risk HPV infection (48.9% vs. 15.1% p < 0.05) and with multiple HPV infection (41.1% vs. 5.7% p < 0.05) were significantly higher than in the Monsonego cohort. HPV 52 (13%), 53 (13%) and 16 (10%) were the most common in the immunosuppressed population, while it was HPV 16, 42 and 51 in the Monsonego cohort. Conclusions: This study supports that a particular attention must be given to all the immunosuppressed patients for the screening and care of HPV-related diseases because of major modifications of HPV epidemiology compared with the overall population.

Association between inflammatory bowel disease and risk of abnormalities of uterine cervix

BACKGROUND

Previous studies provided inconsistent results regarding the association between inflammatory bowel disease (IBD) and risk of abnormalities of uterine cervix. The study aimed to make a meta-analysis to evaluate the association between IBD and risk of abnormalities of uterine cervix.

METHODS

Articles published until April 2021 and regarding the association between IBD and risk of abnormalities of uterine cervix were searched in the following databases: PubMed, Web of Science, EMBASE, Medline, and Google Scholar. Odds ratios (ORs) from case-control studies and relative risks (RRs) from cohort studies with their 95% confidence intervals (CIs) were computed to generate a pooled effect size and 95% CI using STATA 12.0 software.

RESULTS

The present study finally included seven cohort studies (including 94 144 IBD patients and 53 661 004 HC) and four case-control studies (including 20 267 cases and 60 034 matched controls). The meta-analysis indicated a positive association between IBD and risk of abnormalities of uterine cervix with a random-effects model (OR/RR = 2.46, 95% CI 1.55-3.91, I²  = 91.8%, p < 0.001). However, no significant association between IBD and risk of cervical cancer was showed in the study with a random-effects model (OR/RR = 1.54, 95% CI 0.83-2.85, I²  = 82.2%, p < 0.001).

CONCLUSION

In conclusion, IBD is associated with a 146% higher risk of abnormalities of uterine cervix. However, the study demonstrated no significant association between IBD and risk of cervical cancer. Thus, a conventional screening for abnormalities of uterine cervix is essential for IBD patients.

Effect of comorbid mood and anxiety disorders on breast and cervical cancer screening in immune-mediated inflammatory disease

We aimed to examine rates of breast and cervical cancer screening in women with immune-mediated inflammatory diseases (IMID), including inflammatory bowel disease (IBD), multiple sclerosis (MS) and rheumatoid arthritis (RA) versus a matched cohort with IMID; and examine the association of psychiatric comorbidity with screening in these populations. We conducted a retrospective cohort study in Manitoba, Canada using administrative data. We identified women with IBD, MS and RA, and controls without these IMID matched on age and region. Annually, we identified individuals with any active mood/anxiety disorder. Using physician claims, we determined the proportion of each cohort who had cervical cancer screening within three-year intervals, and mammography screening within two-year intervals. We modeled the difference in the proportion of the IMID and matched cohorts who underwent mammography; and pap tests using log-binomial regression with generalized estimating equations, adjusting for sociodemographics, comorbidity and immune therapy use. We tested for additive interactions between cohort and mood/anxiety disorder status. During 2006–2016, we identified 17,230 women with IMID (4,623 with IBD, 3,399 with MS, and 9,458 with RA) and 85,349 matched controls. Having an IMID was associated with lower (-1%) use of mammography; however, this reflected a mixture of more mammography in the IBD cohort (+2.9%) and less mammography in the MS (-4.8 to -5.2%) and RA (-1.5%) cohorts. Within the IBD, MS and RA cohorts, having an active mood/anxiety disorder was associated with more mammography use than having an inactive mood/anxiety disorder. The MS and RA cohorts were less likely to undergo Pap testing than their matched cohorts. In the absence of an active mood/anxiety disorder, the IBD cohort was more likely to undergo Pap testing than its matched cohort; the opposite was true when an active mood/anxiety disorder was present. Among women with an IMID, mood/anxiety disorder influence participation in cancer screening.

CANCER PREVENTION IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Inflammatory bowel disease (IBD) is associated with increased rates of malignancies; some are disease-related (like colorectal cancer) and some are primarily associated with therapy exposures. Although there may be an overlap between disease- and therapy-related cancers, the general strategy for prevention of cancer in patients with IBD lies in understanding the risk factors for these malignancies, educating patients about the recommended screening and surveillance practices, and incorporating general screening recommendations into routine IBD care. An important limitation to our understanding of the effectiveness of our intervention and prevention strategies is the lack of studies assessing mortality benefit, but in part also a reflection of the low mortality in our IBD population. In practice, it is imperative to weigh the risks of cancer or other treatment-related complications in the context of disease progression as a result of lack of or ineffective treatment for IBD when tailoring a management plan for each patient.

Use of thiopurines in inflammatory bowel disease: an update

Inflammatory bowel disease (IBD), once considered a disease of the Western hemisphere, has emerged as a global disease. As the disease prevalence is on a steady rise, management of IBD has come under the spotlight. 5-Aminosalicylates, corticosteroids, immunosuppressive agents and biologics are the backbone of treatment of IBD. With the advent of biologics and small molecules, the need for surgery and hospitalization has decreased. However, economic viability and acceptability is an important determinant of local prescription patterns. Nearly one-third of the patients in West receive biologics as the first/initial therapy. The scenario is different in developing countries where biologics are used only in a small proportion of patients with IBD. Increased risk of reactivation of tuberculosis and high cost of the therapy are limitations to their use. Thiopurines hence become critical for optimal management of patients with IBD in these regions. However, approximately one-third of patients are intolerant or develop adverse effects with their use. This has led to suboptimal use of thiopurines in clinical practice. This review article discusses the clinical aspects of thiopurine use in patients with IBD with the aim of optimizing their use to full therapeutic potential.

Increased Risk of High-grade Cervical Neoplasia in Women with Inflammatory Bowel Disease: A Case-controlled Cohort Study

BACKGROUND AND AIMS

Women with inflammatory bowel disease [IBD] may be at higher risk for cervical intraepithelial neoplasia [CIN]. However, data are conflicting. The aim of this study was to assess the risk of high-grade dysplasia and cancer [CIN2+] in IBD women and identify risk factors.

METHODS

Clinical data from adult IBD women in a multicentre Dutch IBD prospective cohort [PSI] from 2007 onwards were linked to cervical cytology and histology records from the Dutch nationwide cytology and pathology database [PALGA], from 2000 to 2016. Patients were frequency-matched 1:4 to a general population cohort. Standardised detection rates [SDR] were calculated for CIN2+. Longitudinal data were assessed to calculate CIN2+ risk during follow-up using incidence rate ratios [IRR] and risk factors were identified in multivariable analysis.

RESULTS

Cervical records were available from 2098 IBD women [77%] and 8379 in the matched cohort; median follow-up was 13 years. CIN2+ detection rate was higher in the IBD cohort than in the matched cohort (SDR 1.27, 95% confidence interval [CI] 1.05-1.52). Women with IBD had an increased risk of CIN2+ [IRR 1.66, 95% CI 1.21-2.25] and persistent or recurrent CIN during follow-up (odds ratio [OR] 1.89, 95% CI 1.06-3.38). Risk factors for CIN2+ in IBD women were smoking and disease location (ileocolonic [L3] or upper gastrointestinal [GI] [L4]). CIN2+ risk was not associated with exposure to immunosuppressants.

CONCLUSIONS

Women with IBD are at increased risk for CIN2+ lesions. These results underline the importance of human papillomavirus [HPV] vaccination and adherence to cervical cancer screening guidelines in IBD women, regardless of exposure to immunosuppressants.

Crohn's Disease and the Risk of Cancer

Crohn's disease is associated with various intestinal and extraintestinal malignancies. This article reviews the current literature regarding Crohn's disease and subsequent risk of cancer formation. Recognition of risk factors (both modifiable and unmodifiable) is essential for prevention and appropriate screening. Future investigations into the molecular mechanisms associated with Crohn-related malignancy will provide additional insight into carcinogenesis, potential for early intervention, and identification of at-risk patients.

Ulcerative Colitis

Ulcerative colitis (UC) is a chronic inflammatory bowel disease that can involve any aspect of the colon starting with mucosal inflammation in the rectum and extending proximally in a continuous fashion. Typical symptoms on presentation are bloody diarrhea, abdominal pain, fecal urgency, and tenesmus. In some patients, extraintestinal manifestations may predate the onset of gastrointestinal symptoms. A diagnosis of UC is made on the basis of presenting symptoms consistent with UC as well as endoscopic evidence showing continuous and diffuse colonic inflammation that starts in the rectum. Biopsies of the colon documenting chronic inflammation confirm the diagnosis of UC. Most cases are treated with pharmacological therapy to first induce remission and then to maintain a corticosteroid-free remission. There are multiple classes of drugs used to treat the disease. For mild to moderate UC, oral and rectal 5-aminosalycilates are typically used. In moderate to severe colitis, medication classes include thiopurines, biological agents targeting tumor necrosis factor and integrins, and the small-molecule Janus kinase inhibitors. However, in up to 15% of cases, patients in whom medical therapy fails or who have development of dysplasia secondary to their long-standing colitis will require surgical treatment. Finally, to minimize the complications of UC and adverse events from medications, a working collaboration between primary care physicians and gastroenterologists is necessary to make sure that vaccinations are optimized and that patients are screened for colon cancer, skin cancer, bone loss, depression, and other treatable and preventable complications.

Beyond pregnancy, women's health in inflammatory bowel disease

PURPOSE OF REVIEW

Women's health includes comprehensive physical, mental and preventive care. This section will provide an overview of some of the most common disorders that can impact the health and quality of life (QOL) of women with inflammatory bowel diseases (IBDs).

RECENT FINDINGS

Women with IBD are at higher risk for cervical dysplasia compared to healthy controls with most cases preventable with vaccination. Current rates of cervical cancer screening and human papilloma virus vaccination remain low. Irritable bowel syndrome is highly prevalent among women with IBD and may present with similar symptoms. In addition, gastrointestinal symptoms may worsen during the menstrual cycle. Evaluation for active inflammation and infection should be undertaken prior to changing IBD medications. Fecal incontinence is prevalent but highly underreported in women with IBD. Further, sexual dysfunction is ubiquitous in women with IBD. Many aspects of IBD impact sexual function, including side-effects of medications, changes in body image and surgical interventions.

SUMMARY

Understanding other disorders that may cause symptoms in women with IBD is important for providers to obtain a clear history, provide the appropriate treatment and improve QOL. Caring for women with IBD involves more comprehensive care beyond the treatment of active luminal inflammation.

The Treatment of Inflammatory Bowel Disease in Patients With a History of Malignancy

As patients with inflammatory bowel disease (IBD) are living longer and our medical armamentarium expands, gastroenterologists are more frequently faced with treatment decisions about patients with IBD who also have a history of malignancy. This review aims to summarize the current literature on IBD, the inherent risk of developing gastrointestinal and extra-intestinal malignancies, and the risk of malignancies associated with available biologic and immunomodulatory therapies and to discuss the overall treatment strategy for a patient with a history of malignancy.

High-risk human papilloma virus infection and cervical neoplasm in female inflammatory bowel disease patients: a cross-sectional study

Background and aim

This cross-sectional study investigated the prevalence and risk factors of high-risk human papilloma virus (HPV) infection, especially types 16 and 18, and cervical neoplasia in female Inflammatory bowel disease (IBD) patients.

Methods

From July 2014 to January 2017, sexually active, female, Chinese IBD patients (21–60 years) and age-matched controls underwent cervical ThinPrep cytology testing (TCT) and high-risk HPV-DNA detection, and completed questionnaires about awareness of cervical cancer and HPV. Cervical dysplasia was categorized as cervical intraepithelial neoplasia (CIN) 1, 2 and 3.

Results

Of 124 IBD patients (30 ulcerative colitis and 94 Crohn’s disease), 17 (13.7%) had high-risk HPV among whom 9 (7.3%) had HPV 16/18 infection and 4 (3.2%) had cervical CIN (3 CIN 3, 1 CIN 1) by pathology. Among 372 controls, 33 (8.9%) had high-risk HPV and only 1 (0.3%) had HPV 16 infection. Cervical TCT detected atypical squamous cells of unknown significance in one control; no control had CIN. The HPV 16/18 infection rate and CIN prevalence were significantly higher in IBD patients than controls (both P < 0.001). The HPV-infection rate was higher in patients administered methotrexate [P = 0.005, odds ratio (95% confidence interval) 4.76 (1.471–15.402)] or more than two immunosuppressants [P = 0.013, odds ratio (95% confidence interval) 3.64 (1.255–10.562)]. Thiopurine, steroid, infliximab and disease behavior/location were not associated with HPV infection. Only 29.3% of patients had undergone cervical-cancer screening. Awareness of HPV infection and HPV-related cervical cancer was poor (28.2%).

Conclusions

Female IBD patients are at increased risk of high-risk HPV infection and cervical neoplasia, which may be associated with immunosuppressants. Education and routine follow-up with HPV-DNA testing and TCT are recommended, especially in female Chinese IBD patients.

Identifying Patients With Inflammatory Bowel Diseases in an Administrative Health Claims Database: Do Algorithms Generate Similar Findings?

Application of selective algorithms to administrative health claims databases allows detection of specific patients and disease or treatment outcomes. This study identified and applied different algorithms to a single data set to compare the numbers of patients with different inflammatory bowel disease classifications identified by each algorithm. A literature review was performed to identify algorithms developed to define inflammatory bowel disease patients, including ulcerative colitis, Crohn's disease, and inflammatory bowel disease unspecified in routinely collected administrative claims databases. Based on the study population, validation methods, and results, selected algorithms were applied to the Optum Clinformatics® Data Mart database from June 2000 to March 2017. The patient cohorts identified by each algorithm were compared. Three different algorithms were identified from literature review and selected for comparison (A, B, and C). Each identified different numbers of patients with any form of inflammatory bowel disease (323 833; 246 953, and 171 537 patients, respectively). The proportions of patients with ulcerative colitis, Crohn's disease, and inflammatory bowel disease unspecified were 32.0% to 47.5%, 38.6% to 43.8%, and 8.7% to 26.6% of the total population with inflammatory bowel disease, respectively, depending on the algorithm applied. Only 5.1% of patients with inflammatory bowel disease unspecified were identified by all 3 algorithms. Algorithm C identified the smallest cohort for each disease category except inflammatory bowel disease unspecified. This study is the first to compare numbers of inflammatory bowel disease patients identified by different algorithms from a single database. The differences between results highlight the need for validation of algorithms to accurately identify inflammatory bowel disease patients.

Neoplasia and Precursor Lesions of the Female Genital Tract in IBD: Epidemiology, Role of Immunosuppressants, and Clinical Implications

In this review the risk of breast, ovarian, and endometrial cancer and cervical and vulvovaginal (pre)malignant abnormalities in patients with inflammatory bowel disease (IBD) with or without immune suppressive treatment will be discussed. So far, this has not been studied thoroughly and large studies taking into account diverse potential confounding factors are lacking. IBD per se has not been associated with development of cervical cancer, yet patients with Crohn's disease who smoke, have a younger age at diagnosis or who use(d) thiopurines might be more at risk. Other immunosuppressive medication seems not to increase this risk, however, as evidence at this point is incomplete, physician awareness and prevention by lifestyle counseling, HPV vaccination and (intensified) screening are warranted. The risk for breast, endometrial, ovarian, and vulvovaginal cancer in IBD patients appears to be comparable to the background population, although for breast cancer this may even be decreasedin Crohn's disease specifically. Immunosuppressive medication in general does not seem to alter this risk. Earlier and more frequent screening for breast cancer than currently conducted in general nationwide screening programs is not recommended at this moment. Current literature suggests a much lower overall malignancy recurrence rate in IBD patients than has been observed previously. More importantly, immune suppressive medication does not appear to increase the recurrence risk. Robust epidemiologic data on female genital tract cancer are needed.

Anal Neoplasia in Inflammatory Bowel Disease: Classification Proposal, Epidemiology, Carcinogenesis, and Risk Management Perspectives

Patients with inflammatory bowel disease [IBD] may develop, similarly to individuals from general population, rare cases of human papilloma virus [HPV]-related anal canal squamous cell carcinoma [SCC] and intra-epithelial precursor lesions, as well as very rare cases of anal canal adenocarcinoma. Patients with chronic perianal Crohn's disease [CD] are at substantial risk of developing SCC or adenocarcinoma from the fistula-lining epithelium, as well as SCC or adenocarcinoma arising from chronic anorectal ulcerations or strictures. Based on this lesion stratification, we provide in this review tailored incidence estimates and we propose an IBD-specific classification of all types of anal neoplasia that may occur in patients with IBD. After reviewing putative carcinogenesis of all types of neoplasia, we conclude that HPV vaccination could reduce the incidence of HPV-related lesions, although an anal screening programme related to these lesions is not mandatory on the sole basis of IBD. By contrast, we point out that all patients with chronic perianal CD should be explored in depth, including biopsies under anaesthesia and fistula curettage when necessary, in case of any change in anal symptoms ─in particular new, increasing, unexplained pain. Finally, we conclude that there is an urgent need for elaborating and evaluating surveillance algorithms in patients with chronic perianal CD, in order to avoid cancers with late diagnosis and poor prognosis.

Crohn's Disease Is Associated with the Risk for Thyroid Cancer

BACKGROUND

It is known that inflammatory bowel disease (IBD) is associated with a high risk for some of extraintestinal cancers. The aim of this study was to identify whether IBD is associated with thyroid cancer using a large national database.

METHODS

We performed a case-control study using the 2012 National Inpatient Sample (NIS) database. The study group included all patients with Crohn's disease (CD) (ICD-9 Code: 555) and ulcerative colitis (UC) (ICD-9 Code: 556), and the control group included all patients with diverticulitis (ICD-9 Code: 562.11, 562.13). Both univariable and multivariable analyses were performed to assess the risk factors associated with thyroid cancer.

RESULTS

We analyzed more than 28 million hospitalizations in 2012, with 289,935 being IBD-related admissions and 315,145 being diverticulitis-related admissions. Subjects who had IBD were found to be significantly more likely to have thyroid cancer than those with diverticulitis (odds ratio = 1.97 [1.5-2.6], P = 0.033). There was no difference between men and women in the prevalence of thyroid cancer in IBD (P = 0.6). There was no difference between CD and UC (P = 0.14) and between UC and diverticulitis (P = 0.93). In multivariate analysis, CD was found to be associated with thyroid cancer (odds ratio = 2.3 [1.06-5.1], P = 0.034). Age was shown to be a protective factor in the presence of thyroid cancer (P < 0.005), and a higher Charlson comorbidity index was associated with the presence of thyroid cancer (odds ratio, 1.5 [1.3-1.7]; P < 0.001).

CONCLUSIONS

Our study showed that CD, not UC, is associated with a higher risk for thyroid cancer. It is recommended that patients with CD may need a close monitoring of thyroid diseases.

Monitoring for Extra-Intestinal Cancers in IBD

Multiple studies have demonstrated an increased risk for extra-intestinal cancers in inflammatory bowel disease (IBD) patients, mainly from treatment modalities. Prominent cancers that are related to IBD treatment include the following: lymphoproliferative disorders associated with thiopurine use, hepatosplenic T cell lymphoma primarily in younger male patients on thiopurines and anti-tumor necrosis factor (TNF) agents, non-melanoma skin cancers in patients treated with thiopurines and anti-TNF agents, and melanomas in patients who are on monotherapy with anti-TNF agents. In addition, women with IBD may have higher rates of cervical dysplasia and cervical cancer. The focus of this review is to provide a comprehensive overview on extra-intestinal cancers in IBD patients and how to monitor for these malignancies.

Who and how to screen for cancer in at-risk inflammatory bowel disease patients

Inflammatory bowel diseases (IBDs) include both Crohn's disease and ulcerative colitis and both diseases are marked by inflammation within the gastrointestinal tract. Due to long-standing inflammation, IBD patients are at increased risk of colorectal cancer, especially patients with chronic inflammation, pancolitis, co-diagnosis of primary sclerosing cholangitis and a longer duration of disease. Small bowel inflammation places Crohn's patients at an increased risk of small bowel cancer. A higher risk of skin cancers, lymphomas and cervical abnormalities is also seen in IBD patients; this is likely related to both disease factors and the presence of immunosuppressive medication. This article reviews which patients are at an increased risk of IBD-associated or IBD treatment-associated cancers, when to begin screening and which screening methods are recommended.

Are patients with inflammatory bowel disease on chronic immunosuppressive therapy at increased risk of cervical high-grade dysplasia/cancer? A meta-analysis

BACKGROUND

Immunosuppression is a mainstay of therapy for both induction and maintenance of remission for inflammatory bowel disease (IBD). Women who are chronically immunosuppressed have been shown to be at higher risk of developing cervical high-grade dysplasia and/or carcinoma. There is contradictory data whether immunosuppressed patients with IBD have the same risk profile for cervical cancer as patients with solid organ transplant or HIV infection.

OBJECTIVE

To determine whether the risk of cervical high-grade dysplasia and/or cancer is higher in patients with IBD on immunosuppressive therapy compared with the rates in the general population.

METHODS

The studies were restricted to full-text retrospective cohort studies and case controls that had a high (6-9) Newcastle-Ottawa Score.

RESULTS

All pooled analyses were based on a random-effects model. Five cohort studies and 3 case-control studies of patients with IBD on any immunosuppression with cervical high-grade dysplasia/cancer (n = 995) were included in the meta-analysis. The total IBD population in these studies was 77,116. Patients with IBD had an increased risk of cervical high-grade dysplasia/cancer compared with healthy controls (odds ratio = 1.34, 95% confidence interval: 1.23-1.46). Heterogeneity was detected (I = 34.23, Q = 10.64, df = 7; P = 0.15). The source was found to be the type of study, as well as the odds ratio presented (crude versus adjusted).

CONCLUSIONS

There is sufficient evidence to suggest an increased risk of cervical high-grade dysplasia/cancer in patients with IBD on immunosuppressive medications compared with the general population. Given this increased risk, increased screening intervals are indicated.

Inflammatory bowel disease and cervical neoplasia: a population-based nationwide cohort study

BACKGROUND & AIMS

We examined the risk of cervical neoplasia (dysplasia or cancer) in women with ulcerative colitis (UC) or Crohn's disease (CD). We also calculated the reverse, the risk for diagnosis with cervical neoplasia before development of inflammatory bowel disease (IBD).

METHODS

We established a national cohort of women diagnosed with UC (n = 18,691) or CD (n = 8717) between 1979 and 2011 and a control cohort of individually matched women from the general population (controls, n = 1,508,334). Incidence rate ratios (IRRs) of screening activity and diagnosis of cervical neoplasia in women with IBD were assessed by Cox proportional hazards regression analysis. Odds ratios (ORs) of cervical neoplasia before diagnosis of IBD were calculated by using conditional logistic regression.

RESULTS

Women with CD underwent cervical cancer screening as often as women in the general population (IRR, 0.99; 95% confidence interval [CI], 0.96-1.02), whereas screening frequency was slightly increased in women with UC (IRR, 1.06; 95% CI, 1.04-1.08). A total of 561 patients with UC were diagnosed with dysplasia during a median follow-up time of 7.8 years, and 28 patients with UC developed cervical cancer, compared with 1918 controls. A total of 407 patients with CD were diagnosed with dysplasia during a median follow-up time of 8.3 years, and 26 patients with CD developed cervical cancer, compared with 940 controls. Patients with UC had increased risk of low-grade (IRR, 1.15; 95% CI, 1.00-1.32) and high-grade (IRR, 1.12; 95% CI, 1.01-1.25) squamous intraepithelial lesions (SILs), whereas patients with CD had increased risks of low-grade SIL (IRR, 1.26; 95% CI, 1.07-1.48), high-grade SIL (IRR, 1.28; 95% CI, 1.13-1.45), and cervical cancer compared with controls (IRR, 1.53; 95% CI, 1.04-2.27). ORs for cervical cancer were also increased 1-9 years before diagnosis of UC, compared with women without UC (OR, 2.78; 95% CI, 2.12-3.64) or CD (OR, 1.85; 95% CI, 1.08-3.15).

CONCLUSIONS

In a population-based nationwide cohort study, we found a 2-way association between IBD, notably CD, and neoplastic lesions of the uterine cervix. This observation is not explained by differences in screening activity.

Risk of cervical cancer in women with autoimmune diseases, in relation with their use of immunosuppressants and screening: population-based cohort study

Severely immunosuppressed individuals have a strongly increased risk of cervical cancer. In patients with autoimmune diseases (AID), who have defects in their immune system and receive immunosuppressants, the risk of cervical cancer is less clear. We conducted a cohort study, using Danish nationwide population-based registers including information on AID diagnoses, immunosuppressant intake, cervical screening participation, and cervical cancer incidence. Standardized incidence ratios (SIR) were computed to compare the risk of cervical cancer in AID patients to that of the general population. Hazard ratios (HR) from time-dependent Cox models stratified by AID were used to explore the effect of the most frequently used immunosuppressants, taking into account potential dose-response relationships and lag times between drug exposure and cervical cancer development. Cervical screening coverage of patients with AIDs was compared to the general population. Among 341,758 patients with AIDs, the risk of cervical cancer was not higher than in the general population (SIR = 1.0, 95% CI: 0.9-1.1, based on 720 cases). The intake of immunosuppressants was generally not associated with the risk, apart from azathioprine. The crude HR comparing the period of exposure versus non-exposure to azathioprine was 1.4 (95% CI: 0.9-2.1). Furthermore, the risk was substantially increased in patients who received a high cumulative dose of azathioprine (HR = 2.2, 95% CI = 1.2-3.9), and appeared to be highest when considering that the immunosuppressant exposure would take 5 years to trigger cervical cancer. Patients with AIDs had similarly high screening rates as the general population. Although most patients with AIDs do not have an increased risk of cervical cancer, those taking substantial amounts of azathioprine might need more stringent cervical screening measures.

Assessing patient preferences for treatment options and process of care in inflammatory bowel disease: a critical review of quantitative data

Inflammatory bowel disease (IBD), consisting of both Crohn's disease (CD) and ulcerative colitis (UC), are chronic inflammatory conditions of the intestinal tract. As there is no cure for either CD or UC, patients with these conditions face numerous treatment decisions regarding their disease. The aim of this review is to evaluate literature regarding quantitative studies of patient preferences in therapy for IBD with a focus on the emerging technique of stated preference and its application in IBD. Numerous simple survey-based studies have been performed evaluating IBD patients' preferences for medication frequency, mode of delivery, potential adverse events, etc., as well as variations in these preferences. These studies are limited, however, as they are purely descriptive in nature with limited quantitative information on the relative value of treatment alternatives. Time trade-off and standard-gamble studies have also been utilized to quantify patient utility for various treatment options or outcomes. However, these types of studies suffer from inaccurate assumptions regarding patient choice behavior. Stated preference is an emerging robust methodology increasingly utilized in health care that can determine the relative utility for a therapy option as well as its specific attributes (such as efficacy or adverse side effects). Stated preference techniques have begun to be applied in IBD and offer an innovative way of examining the numerous therapy options these patients and their providers face.

Increased risk of malignancy with adalimumab combination therapy, compared with monotherapy, for Crohn's disease

BACKGROUND & AIMS

Few studies have assessed the risk of malignancy from anti-tumor necrosis factor monotherapy or combination therapy for Crohn's disease (CD). We determined the relative risk of malignancy in patients with CD who received adalimumab monotherapy, compared with the general population. We also compared the risk of malignancy associated with combination adalimumab and immunomodulator therapy with that of adalimumab monotherapy.

METHODS

We performed a pooled analysis of data from 1594 patients with CD who participated in clinical trials of adalimumab (CLASSIC I and II, CHARM, GAIN, EXTEND, and ADHERE studies; 3050 patient-years of exposure). We calculated rates of malignancy among patients; the expected rates of malignancy, based on the general population, were derived from the Surveillance, Epidemiology, and End Results registry and National Cancer Institute survey.

RESULTS

Compared with the general population, patients receiving adalimumab monotherapy did not have a greater than expected incidence of nonmelanoma skin cancer (NMSC) or other cancers, whereas those receiving combination therapy had a greater than expected incidence of malignancies other than NMSC (standardized incidence ratio, 3.04; 95% confidence interval [CI], 1.66-5.10) and of NMSC (standardized incidence ratio, 4.59; 95% CI, 2.51-7.70). Compared with patients receiving adalimumab monotherapy, those patients receiving combination therapy had an increased risk of malignancy other than NMSC (relative risk, 2.82; 95% CI, 1.07-7.44) and of NMSC (relative risk, 3.46; 95% CI, 1.08-11.06).

CONCLUSIONS

In patients with CD, the incidence of malignancy with adalimumab monotherapy was not greater than that of the general population. Co-administration of immunomodulator therapy and adalimumab was associated with an increased risk of NMSC and other cancers.

Risk of high-grade cervical dysplasia and cervical cancer in women with systemic inflammatory diseases: a population-based cohort study

BACKGROUND

Previous studies have suggested a potential risk of cervical cancer in patients with systemic inflammatory diseases (SID) such as inflammatory bowel disease (IBD) and systemic lupus erythematosus (SLE).

OBJECTIVES

To assess the risk of high-grade cervical dysplasia, a surrogate endpoint for cervical cancer and cervical cancer, in women with SID, including IBD, psoriasis, rheumatoid arthritis (RA) or SLE, compared with the risk in women without SID.

METHODS

Using US insurance data (2001-2012), we conducted a cohort study of 133,333 women with SID, based on two or more diagnoses and one or more dispensed prescription for disease-specific treatment, and 533,332 women without SID. High-grade cervical dysplasia and cervical cancer was defined by a validated algorithm with a positive predictive value of ≥81%.

RESULTS

Over the mean follow-up of 2.1 years, the crude incidence rate of high-grade cervical dysplasia and cervical cancer per 100,000 person-years was the highest at 141.1 in SLE and the lowest at 82.2 in psoriasis among women with SID, and 73.4 in women without SID. The multivariable HR adjusted for potential confounders was 1.07 (95% CI 0.79 to 1.45) in IBD, 0.96 (95% CI 0.73 to 1.27) in psoriasis, 1.49 (95% CI 1.11 to 2.00) in RA and 1.53 (95% CI 1.07 to 2.19) in SLE. Multivariable HRs were increased, but not statistically significant, in IBD, RA and SLE with baseline use of systemic immunosuppressive drugs or steroids.

CONCLUSIONS

The risk of high-grade cervical dysplasia and cervical cancer was 1.5 times higher in women with RA and SLE than in those without SID. The risk may be increased in IBD with use of systemic immunosuppressive drugs or steroids.

Extra-intestinal malignancies in inflammatory bowel disease: results of the 3rd ECCO Pathogenesis Scientific Workshop (III)

The incidence of lymphoproliferative disorders (LD) is increasing in developed countries. Patients with inflammatory bowel disease (IBD) exposed to thiopurines are at additional risk of three specific forms of LD: Epstein-Barr-Virus-related post-transplant like LD, hepato-splenic T-cell lymphoma and post-mononucleosis lymphoproliferation. The risk of the two latter forms of LD can be reduced when considering specific immunosuppressive strategies in young males. It is still unclear whether the risk of uterine cervix abnormalities is increased in IBD women, irrespective of the use of immunosuppressants. Given the excess risk demonstrated in various other contexts of immunosuppression, it is currently recommended that all women with IBD, particularly those receiving immunosuppressants, strictly adhere to a screening program of cervical surveillance and undergo vaccination against HPV, when appropriate. Patients with IBD receiving immunosuppressants are at increased risk of skin cancers. The risk of non-melanoma skin cancer is notably increased in patients receiving thiopurines. Recent data suggest that the risk of melanoma is mildly increased in patients exposed to anti-TNF therapy. All IBD patients should adhere to a program of sun protection and dermatological surveillance, whose details should take into account the other non-IBD-related risk factors.

Dermatological adverse reactions during anti-TNF treatments: focus on inflammatory bowel disease

The clinical introduction of tumour necrosis factor (TNF) inhibitors has deeply changed the treatment of inflammatory bowel diseases (IBD). It has demonstrated impressive efficacy as compared to alternative treatments, allowing for the chance to achieve near-remission and long-term improvement in function and quality of life and to alter the natural history of Crohn's disease (CD) and ulcerative colitis (UC). As a consequence of longer follow-up periods the number of side effects which may be attributed to treatment with biologics is growing significantly. Cutaneous reactions are among the most common adverse reactions. These complications include injection site reactions, cutaneous infections, immune-mediated complications such as psoriasis and lupus-like syndrome and rarely skin cancers. We review the recent literature and draw attention to dermatological side effects of anti-TNF therapy of inflammatory bowel disease.

Thiopurines related malignancies in inflammatory bowel disease: Local experience in Granada, Spain

AIM: To investigate the incidence of neoplasms in inflammatory bowel disease (IBD) patients and the potential causative role of thiopurines.

METHODS: We performed an observational descriptive study comparing the incidence of malignancies in IBD patients treated with thiopurines and patients not treated with these drugs. We included 812 patients which were divided in two groups depending on whether they have received thiopurines or not. We have studied basal characteristics of both groups (age when the disease was diagnosed, sex, type of IBD, etc.) and treatments received (Azathioprine, mercaptopurine, infliximab, adalimumab or other immunomodulators), as well as neoplasms incidence. Univariate analysis was performed with the student t test, χ² test or Wilcoxon exact test as appropriate. A logistic regression analysis was performed as multivariate analysis. Statistical significance was establish at P values of less than 0.05, and 95%CI were used for the odds ratios.

RESULTS: Among 812 patients included, 429 (52.83%) have received thiopurines: 79.5% azathioprine, 14% mercaptopurine and 6.5% both drugs. 44.76% of patients treated with thiopurines and 46, 48% of patients who did not receive this treatment were women (P > 0.05). The proportion of ulcerative colitis patients treated with thiopurines was 30.3% compare to 66. 67% of patients not treated (P < 0.001). Mean azathioprine dose was 123.79 ± 36.5 mg/d (range: 50-250 mg/d), mean usage time was 72.16 ± 55.7 mo (range: 1-300 mo) and the accumulated dose along this time was 274.32 ± 233.5 g (1.5-1350 g). With respect to mercaptopurine, mean dose was 74.7 ± 23.9 mg/d (range: 25-150 mg/d), mean usage time of 23.37 ± 27.6 mo (range: 1-118 mo), and the accumulated dose along this time was 52.2 ± 63.5 g (range: 1.5-243 g). Thiopurine S-methyltransferase activity was tested in 66% of patients treated with thiopurines, among which 98.2% had an intermediate or high activity. Among the patients treated with thiopurines, 27.27% (112 patients) and 11.66% (50 patients) received treatment with Infliximab and Adalimumab respectively, but only 1.83% (7 patients) and 0.78% (3 patients) received these drugs in the group of patients who did not received thiopurines (P < 0.001 and P < 0.001 respectively). Finally, 6.8% (29 patients) among those treated with thiopurines have received other immunesupresants (Methotrexate, Tacrolimus, Cyclosporin), compare to 1% (4 patients) of patients not treated with thiopurines (P < 0.001). Among patients treated with thiopurines, 3.97% developed a malignancy, and among those not treated neoplasms presented in 8.1% (P = 0.013). The most frequent neoplasms were colorectal ones (12 cases in patients not treated with thiopurines but none in treated, P < 0.001) followed by non-melanoma skin cancer (8 patients in treated with thiopurines and 6 in not treated, P > 0.05).

CONCLUSION: In our experience, thiopurine therapy did not increase malignancies development in IBD patients, and was an efective and safe treatment for these diseases.

Crohn disease and the gynecologic patient

Although Crohn disease (CD) is considered an inflammatory bowel disease, extraintestinal gynecologic manifestations are varied, frequent, and oftentimes difficult to manage. Its predilection for young and reproductive-age women makes it an important disease process for the gynecologist to understand, as its complications can have long-term repercussions on the developmental, sexual, reproductive, and psychological health of affected women. Patients may present with a variety of vulvovaginal, perineal, perianal, and urologic complaints. Perianal involvement from an intestinal fistula is the most common skin manifestation seen in CD. Other gynecologic manifestations include metastatic CD and rectovaginal and urovaginal fistulas. Recognition and accurate diagnosis of extraintestinal gynecologic manifestations, as well as a good understanding of the gynecologic effects of chronic disease, are necessary for optimal management. The article provides an overview of CD and highlights the gynecologic considerations in caring for women affected by this disease.

Immunosuppression and risk of cervical cancer

A markedly increased risk of cervical cancer is known in women immunosuppressed due to AIDS or therapy following organ transplantation. The aim of this review is to determine the association between other conditions affecting the immune system and the risk of cervical cancer. Patients with end-stage renal disease seem to be at an increased risk of cervical cancer. A higher risk of cervical precancerous lesions was found in patients with some autoimmune diseases; particularly if treated with immunosuppressants. Among behavioral factors weakening the immune system, smoking appeared to strongly increase the risk of cervical cancer, while poor diet only moderately increased the risk. It is difficult to determine whether sexually transmitted infections other than human papillomavirus infection are independent risk factors. Identifying those groups of women likely to fail in clearing persistent human papillomavirus infections would help individualize screening guidelines and target immune-associated factors in the cervical cancer etiology.

Tumor necrosis factor α inhibitor therapy and cancer risk in chronic immune-mediated diseases

OBJECTIVE

To compare the incidence of cancer following tumor necrosis factor α (TNFα) inhibitor therapy to that with commonly used alternative therapies across multiple immune-mediated diseases.

METHODS

The Safety Assessment of Biological Therapeutics study used data from 4 sources: national Medicaid and Medicare databases, Tennessee Medicaid, pharmacy benefits plans for Medicare beneficiaries in New Jersey and Pennsylvania, and Kaiser Permanente Northern California. Propensity score-adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) were computed to estimate the relative rates of cancer, comparing those treated with TNFα inhibitors to those treated with alternative disease-modifying therapies. The cancer-finding algorithm had a positive predictive value ranging from 31% for any leukemia to 89% for female breast cancer.

RESULTS

We included 29,555 patients with rheumatoid arthritis (RA) (13,102 person-years), 6,357 patients with inflammatory bowel disease (1,508 person-years), 1,298 patients with psoriasis (371 person-years), and 2,498 patients with psoriatic arthritis (618 person-years). The incidence of any solid cancer was not elevated in RA (HR 0.80 [95% CI 0.59-1.08]), inflammatory bowel disease (HR 1.42 [95% CI 0.47-4.26]), psoriasis (HR 0.58 [95% CI 0.10-3.31]), or psoriatic arthritis (HR 0.74 [95% CI 0.20-2.76]) during TNFα inhibitor therapy compared to disease-specific alternative therapy. Among RA patients, the incidence of any of the 10 most common cancers in the US and of nonmelanoma skin cancer was not increased with TNFα inhibitor therapy compared to treatment with comparator drugs.

CONCLUSION

Short-term cancer risk was not elevated among patients treated with TNFα inhibitor therapy relative to commonly used therapies for immune- mediated chronic inflammatory diseases in this study.

Managing risks of neoplasia in inflammatory bowel disease

Inflammatory bowel disease (IBD) has been linked with a variety of intestinal and extraintestinal cancers. This review summarizes the latest literature with regard to which cancers are truly linked with IBD and which are not, the absolute and relative risks of these cancers, how medications commonly prescribed for IBD affect this risk, and finally strategies for managing these risks. Physicians and health professionals may find this information useful for counseling and educating patients as well as for improving patient care.

When to use biological agents in inflammatory bowel disease

The use of biological agents in inflammatory bowel diseases across the Asia-Pacific region is increasing. As new molecules and targets are identified, knowledge regarding the indications, utility, optimization and adverse effects of biological agents grows. Careful patient selection, attention to communication and patient education will maximize the benefit of these drugs. Tertiary referral centers with specific interest in inflammatory bowel diseases and experience play an important role in their use. There is enormous opportunity for patients to benefit from biological agents in the therapy of Crohn's disease and ulcerative colitis. Use of these agents has been studied across a variety of indications and populations, and at different stages in the disease course. Failure to respond or loss of response can result from different causes, and can be medically managed in many cases. More research on the pleiotropic effects, safety of biological agents and biomarkers in the prediction of response will provide a sounder basis for individually directing therapy. Adverse events such as opportunistic infection and malignancy can occur, and screening prior to therapy and discussion on risk-benefit of the various management options are important. Cost of these medications especially with maintenance therapy remains an important issue in many Asia-Pacific countries. New and more specific agents will better target therapy and minimize adverse events.

Special considerations for women with IBD

Inflammatory bowel diseases (IBD), namely Crohn disease (CD) and ulcerative colitis (UC), are common in Western society. Because at least half of the patients suffering from these diseases are women, it is important that physicians are aware of their gender-specific needs. There are multiple important concerns for women with UC and CD including issues of body image and sexuality, menstruation, contraception, screening for cervical cancer, matters related to menopause and hormone replacement therapy, osteoporosis, and the overlap seen between IBS and IBD. In this article, we have addressed these important, non-pregnancy-related issues faced by women with IBD.

Long-term complications, extraintestinal manifestations, and mortality in adult Crohn's disease in population-based cohorts

BACKGROUND

Crohn's disease (CD) is a chronic, progressive, destructive disease. Numerous intestinal and extraintestinal complications and manifestations can occur during its clinical course. This literature review summarizes our current knowledge of the long-term complications, extraintestinal complications, and mortality in CD in adults as reported in population-based studies that include long-term follow-up results.

METHODS

A literature search of English and non-English language publications listed in the electronic databases of Medline (source PubMed, 1935 to July, 2009).

RESULTS

The relative risk of incident fractures is increased in CD patients by ≈30%-40%. These patients have also have a 3-fold increased risk of deep venous thrombosis and pulmonary embolism. A variety of extraintestinal manifestations (primary sclerosing cholangitis, ankylosing spondylitis, iritis/uveitis, pyoderma gangrenosum, erythema nodosum) and diseases (asthma, bronchitis, pericarditis, psoriasis, rheumatoid arthritis, and multiple sclerosis) are associated with CD. The risks of colorectal and small bowel cancers relative to the general population are 1.4-1.9 and 21.1-27.1, respectively. A slightly increased risk of lymphoma, irrespective of medication use, has been reported in a recent meta-analysis of population-based studies. Overall mortality is slightly increased in CD, with a standardized mortality ratio of 1.4.

CONCLUSIONS

CD is frequently associated with disease complications and extraintestinal conditions. Whether the impact of changing treatment paradigms with increased use of immunosuppressives and biologic agents can reduce disease complications and associated conditions is unknown.

Review article: malignancy on thiopurine treatment with special reference to inflammatory bowel disease

BACKGROUND

Immunosuppression is a risk factor for carcinogenesis. Thiopurines specifically contribute to this. As thiopurines are used more aggressively in the treatment of IBD, it is likely that we will see more thiopurine-related malignancy.

AIM

To review the literature, exploring how immunosuppression, thiopurines specifically, might cause cancer and which malignancies occur in practice, placing specific emphasis on IBD cohorts.

METHODS

Search terms included 'malignancy' 'cancer' 'azathioprine' 'mercaptopurine' 'tioguanine (thioguanine)' 'thiopurine' and 'inflammatory bowel disease' 'Crohn's disease' 'ulcerative colitis'. We also searched for specific cancers (lymphoma, colorectal cancer, skin cancer, cervical cancer) and reviewed the reference lists of the articles detected.

RESULTS

Immunosuppression is associated with an increased risk of cancer. Thiopurines are associated with specific additional risks. In IBD cohorts, very few thiopurine-related malignancies have been reported. However, studies suggest a relative risk of 4-5 for lymphoma. This still translates into a low actual risk, (one extra lymphoma in every 300-1400 years of thiopurine treatment).

CONCLUSIONS

Whilst we must be aware of this risk and counsel our patients appropriately, thiopurines remain a mainstay of IBD therapy. We present practical advice aimed at minimizing our patients' risk of developing malignancy, whilst optimizing the benefits that thiopurines can provide.

Review article: chronic viral infection in the anti-tumour necrosis factor therapy era in inflammatory bowel disease

BACKGROUND

Anti-tumour necrosis factor (TNF) therapy is now well established in the treatment of inflammatory bowel disease and the risk of opportunistic infection is recognized. However, specific considerations regarding screening, detection, prevention and treatment of chronic viral infections in the context of anti-TNF therapy in inflammatory bowel disease are not widely adopted in practice.

AIM

To provide a detailed and comprehensive review of the relevance of chronic viral infections in the context of anti-TNF therapy in inflammatory bowel disease.

METHODS

Literature search was conducted using Medline, Pubmed and Embase using the terms viral infection, hepatitis, herpes, CMV, EBV, HPV, anti-TNF, infliximab, adalimumab, certolizumab pegol and etanercept. Hepatitis B and C and HIV had the largest literature associated and these have been summarized in Tables.

RESULTS

Particular risks are associated with the use of anti-TNF drugs in patients with hepatitis B infection, in whom reactivation is common unless anti-viral prophylaxis is used. Reactivation of herpes zoster is the most common viral problem associated with anti-TNF treatment, and may be particularly severe. Primary varicella infection may present with atypical features in patients on anti-TNF.

CONCLUSION

Appreciation of risks of chronic viral disease associated with anti-TNF therapy may permit early recognition, prophylaxis and treatment.