Colorectal cancer in ulcerative colitis: a Scandinavian population-based cohort study

Olén, Ola; Erichsen, Rune; Sachs, Michael; Pedersen, Lars; Halfvarson, Jonas; Askling, Johan; Ekbom, Anders; Sørensen, Henrik Toft; Ludvigsson, Jonas F.

doi:10.1016/s0140-6736(19)32545-0

Cited by 281 publications

(220 citation statements)

References 31 publications

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“…The cumulative probabilities of developing cancer were reported to be 2% by 10 years, 8% by 20 years and 18% by 30 years of disease duration. However, more recent population‐based cohort studies and updated meta‐analyses suggest that the risk of cancer is lower than previously thought, although overall this rate is still significantly higher than the non‐IBD population 2‐7 . Cumulative risks of colorectal cancer in a more recent meta‐analysis were 1% by 10 years, 2% by 20 years and 5% after more than 20 years of disease duration 3 .…”

Section: Introductionmentioning

confidence: 91%

“…The ratio of early stage vs late stage cancers detected was also higher in the surveillance group compared to the nonsurveillance group 10 . Taking tumour stage into account, ulcerative colitis patients are still more likely to die of colorectal cancer than patients without ulcerative colitis, but this risk appears to be declining over time 7 …”

Section: Introductionmentioning

confidence: 92%

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Systematic review with meta‐analysis: IBD‐associated colonic dysplasia prognosis in the videoendoscopic era (1990 to present)

Kabir

Fofaria

Arebi

et al. 2020

Aliment Pharmacol Ther

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Background Introduction The prognosis of dysplasia in patients with IBD is largely determined from observational studies from the pre‐videoendoscopic era (pre‐1990s) that does not reflect recent advances in endoscopic imaging and resection. Aims To better understand the risk of synchronous colorectal cancer and metachronous advanced neoplasia (ie high‐grade dysplasia or cancer) associated with dysplasia diagnosed in the videoendoscopic era, and to stratify risk according to a lesion's morphology, endoscopic resection status or whether it was incidentally detected on biopsy of macroscopically normal colonic mucosa (ie invisible). Methods A systematic search of original articles published between 1990 and February 2020 was performed. Eligible studies reported on incidence of advanced neoplasia at follow‐up colectomy or colonoscopy for IBD‐dysplasia patients. Quantitative and qualitative analyses were performed. Results Thirty‐three studies were eligible for qualitative analysis (five for the meta‐analysis). Pooled estimated proportions of incidental synchronous cancers found at colectomy performed for a pre‐operative diagnosis of visible high‐grade dysplasia, invisible high‐grade dysplasia, visible low‐grade dysplasia and invisible low‐grade dysplasia were 13.7% (95% CI 0.0‐54.1), 11.4% (95% CI 4.6‐20.3), 2.7% (95% CI 0.0‐7.1) and 2.4% (95% CI 0.0‐8.5) respectively. The lowest incidences of metachronous advanced neoplasia, for dysplasia not managed with immediate colectomy but followed up with surveillance, tended to be reported by the studies where high definition imaging and/or chromoendoscopy was used and endoscopic resection of visible dysplasia was histologically confirmed. Conclusions The prognosis of IBD‐dysplasia diagnosed in the videoendoscopic era appears to have been improved but the quality of evidence remains low. Larger, prospective studies are needed to guide management. PROSPERO registration no: CRD42019105736.

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Section: Introductionmentioning

confidence: 91%

Section: Introductionmentioning

confidence: 92%

Systematic review with meta‐analysis: IBD‐associated colonic dysplasia prognosis in the videoendoscopic era (1990 to present)

Kabir

Fofaria

Arebi

et al. 2020

Aliment Pharmacol Ther

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“…The development of CRC in patients with inflammatory bowel disease is a significant concern for both clinicians and patients, with a meta‐analysis of 116 studies from across the world reporting an incidence of 0.3% per year in UC, 60 and a separate meta‐analysis suggesting a comparable risk in Crohn's colitis 61 . A very recent population‐based cohort study from Scandinavia has suggested that the risk of CRC for patients with UC has decreased over the last five decades, with an overall HR of 1.66 (95% CI 1.57‐1.76) compared to the general population 61 . In a separate population‐based cohort study, the same authors reported a HR of 1.74 (95% CI 1.54‐1.96) for patents with CD compared to the general population 63 …”

Section: The Role Of 5‐asa In Crc Prevention—a Key Consideration?mentioning

confidence: 99%

Review article: withdrawal of 5‐aminosalicylates in inflammatory bowel disease

Chapman

Gomes

Louis

et al. 2020

Aliment Pharmacol Ther

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Summary Background 5‐aminosalicylates (5‐ASA) are widely used in inflammatory bowel disease (IBD), but emerging evidence suggests that they may be safely withdrawn in significant subsets of patients. This is important to address: 5‐ASA therapy accounts for up to 25% of total healthcare costs in ulcerative colitis (UC), while almost a third of patients with Crohn's disease (CD) receive long‐term 5‐ASA despite no clear evidence of benefit. Further, rationalising medication burden may improve overall adherence and outcome. Aims To summarise the rationale for 5‐ASA withdrawal, review the current evidence in both UC and CD and consider the data surrounding colorectal cancer (CRC) prevention, guiding an evidence‐based withdrawal strategy. Methods PubMed was searched to identify relevant studies. Only papers published in English were reviewed, with priority given to randomised clinical trials and meta‐analyses. Results For patients with UC, consideration of 5‐ASA withdrawal should be made on a case‐by‐case basis, but it appears safest for those in deep remission without any of the following risk factors: younger age (<40 years), remission for less than 2 years, a history of multiple flares, extensive disease. 5‐ASA withdrawal should also be considered in patients with UC escalated to biologic therapy who have achieved remission and in all patients with CD. Although 5‐ASA therapy may have chemopreventive benefits for CRC, the cost‐benefit ratio appears significant, and this indication is not justified by evidence in those who have achieved remission and are continuing therapy with other agents, or in those in sustained remission without a history of extensive disease. Conclusions Although the majority of patients with IBD receive 5‐ASA during their disease course, safe withdrawal appears possible in many, with important implications for both health economics and patient experience. A number of unanswered questions, however, remain.

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“…Patients with Ulcerative Colitis (UC) have an increased lifetime risk of developing colorectal cancer (CRC) and of CRC-related death [1][2][3] . Consequently, UC patients are advised to engage in a colonoscopic surveillance programme 8-10 years after diagnosis [4][5][6][7] .…”

Section: Introductionmentioning

confidence: 99%

Multi-centre derivation and validation of a colitis-associated colorectal cancer risk prediction web-tool

Curtius

Kabir

Bakir

et al. 2020

Preprint

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Background and Aims Ulcerative colitis (UC) patients diagnosed with low-grade dysplasia (LGD) have increased risk of developing advanced neoplasia (AN; high-grade dysplasia or colorectal cancer). We aimed to develop and validate a predictor of AN risk in UC patients with LGD and create a visual web-tool to effectively communicate the risk. Methods In our retrospective multi-centre validated cohort study, adult UC patients with an index diagnosis of LGD, identified from four UK centres between 2001-2019, were followed until progression to AN. In the discovery cohort (n=248), a multivariate risk prediction model was derived from clinicopathological features using Cox regression. Validation used data from 3 external centres (n=201). The validated model was embedded in a web-based tool to calculate and illustrate patient-specific risk. Results Four endoscopic variables were significantly associated with future AN progression in the discovery cohort: endoscopically visible LGD > 1 cm (HR = 2.8; 95% CI 1.3-6.0), incomplete endoscopic resection (HR = 2.9; 95% CI 1.3-6.5), moderate/severe histological inflammation within 5 years of LGD diagnosis (HR = 3.0; 95% CI 1.3-6.7), and multifocality (HR = 2.8; 95% CI 1.3-6.1). In the validation cohort, this 4-variable model accurately predicted future AN cases with overall calibration Observed/Expected = 1 (95% CI 0.63-1.5), and achieved perfect specificity for the lowest predicted risk group over 13 years of follow-up. Conclusion Multi-cohort validation confirms that patients with large, unresected, and multifocal LGD and recent moderate/severe inflammation are at the highest risk of developing AN. Personalised risk prediction provided via the Ulcerative Colitis-Cancer Risk Estimator web-tool (www.UC-CaRE.uk) can be used to support treatment decision-making.

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Colorectal cancer in ulcerative colitis: a Scandinavian population-based cohort study

Cited by 281 publications

References 31 publications

Systematic review with meta‐analysis: IBD‐associated colonic dysplasia prognosis in the videoendoscopic era (1990 to present)

Systematic review with meta‐analysis: IBD‐associated colonic dysplasia prognosis in the videoendoscopic era (1990 to present)

Review article: withdrawal of 5‐aminosalicylates in inflammatory bowel disease

Multi-centre derivation and validation of a colitis-associated colorectal cancer risk prediction web-tool

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