Forty-Year Analysis of Colonoscopic Surveillance Program for Neoplasia in Ulcerative Colitis: An Updated Overview

Abstract

Objectives:This study provides an overview of the largest and longest-running colonoscopic surveillance program for colorectal cancer (CRC) in patients with long-standing ulcerative colitis (UC).Methods:Data were obtained from medical records, endoscopy, and histology reports. Primary end points were defined as death, colectomy, withdrawal from surveillance, or censor date (1 January 2013).Results:A total of 1,375 UC patients were followed up for 15,234 patient-years (median, 11 years per patient). CRC was detected in 72 patients (incidence rate (IR), 4.7 per 1,000 patient-years). Time-trend analysis revealed that although there was significant decrease in incidence of colectomy performed for dysplasia (linear regression, R=−0.43; P=0.007), IR of advanced CRC and interval CRC have steadily decreased over past four decades (Pearson's correlation, −0.99; P=0.01 for both trends). The IR of early CRC has increased 2.5-fold in the current decade compared with past decade (χ2, P=0.045); however, its 10-year survival rate was high (79.6%). The IR of dysplasia has similarly increased (χ2, P=0.01), potentially attributable to the recent use of chromoendoscopy that was twice more effective at detecting dysplasia compared with white-light endoscopy (χ2, P<0.001). CRCs were frequently accompanied by synchronous CRC or spatially distinct dysplasia (37.5%). Finally, the risk of CRC was not significantly different between “indefinite” or low-grade dysplasia (log-rank, P=0.78).Conclusions:Colonoscopic surveillance may have a significant role in reducing the risk of advanced and interval CRC while allowing more patients to retain their colon for longer. Given the ongoing risk of early CRC, patients with any grade of dysplasia who are managed endoscopically should be monitored closely with advanced techniques.

DNA Methylation and Mutation of Small Colonic Neoplasms in Ulcerative Colitis and Crohnʼs Colitis

“…CRC detected at surveillance may be at earlier stage, and therefore have a better prognosis than when presenting symptomatically(10–12), and evidence suggests that regular colonoscopic surveillance reduces CRC mortality in patients with IBD. (11, 13) Despite these encouraging data, patient compliance with surveillance colonoscopy is poor, even among those at highest risk.…”

Advanced imaging in colonoscopy: contemporary approach to dysplasia surveillance in inflammatory bowel disease

“…Data from a recent published study analysing 40 years of IBD surveillance at St Mark's Hospital (London, UK) show that high definition and chromoendoscopy have led to an increase in dysplasia rates from 3.7% to 5%, reaching 8.6% when HD and CE are combined. Cancers tended to be diagnosed at an earlier stage and incidence ratios of interval cancers (ie, those diagnosed between two scheduled screening procedures) also declined 4. However, there was no decrease in all-stages CRC rates over time in the St Mark's series,4 while recent data on surveillance from three Dutch referral centres disputed the advantage of targeted CE biopsies over the random sampling approach 37.…”

“…Cancers tended to be diagnosed at an earlier stage and incidence ratios of interval cancers (ie, those diagnosed between two scheduled screening procedures) also declined 4. However, there was no decrease in all-stages CRC rates over time in the St Mark's series,4 while recent data on surveillance from three Dutch referral centres disputed the advantage of targeted CE biopsies over the random sampling approach 37. As data on the aggressiveness of early dysplastic lesions are also equivocal,8 one may argue that patients are subjected to frequent unnecessary procedures, due to overdiagnosis.…”

“…Population-based meta-analyses showed that the overall CRC incidence ratio in all patients with inflammatory bowel disease (IBD) is 1.7,1 with patients with CD having a 1.9-fold2 and patients with UC having a 2.4-fold3 increase in lifetime CRC risk, compared with the general population. These rates are lower than previously thought, perhaps reflecting the positive impact of colonoscopy in detecting and managing neoplasia in early stages, or better disease management 4 5. Also, initial studies often involved patients from tertiary referral centres, where the risk many be higher as these patients tend to have more severe disease 6…”

Getting a Low Grade for Missing High-Grade Dysplasia and Colorectal Cancer in IBD

“…Accordingly, surveillance at 2-year intervals is recommended starting 8-10 years after diagnosis, with colectomy recommended for colonoscopic identification of high-risk lesions such as multifocal or polyploid LGD, HGD, and CRC [2]. Over the last decade, as newer endoscopic techniques such as chromo-, narrow-band, and highdefinition endoscopy have matured, the management of IBD-associated mucosal abnormalities, particularly LGD, has shifted toward decreasing rates of colectomy in favor of endoscopic management [3]. This trend was generally endorsed in the Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients: International Consensus Recommendation (SCENIC) guidelines for the management of dysplasia and carcinoma in IBD [4].…”