Long-held protocols for managing patients with inflammatory bowel disease (IBD) are being challenged by new data and advances in technology. During an ASGE Clinical Symposium on Monday titled Advances in Detection and Management of Dysplasia in IBD, four experts will review the latest data in this area and the implications for patient care.
Symposium moderator James F. Marion, MD, professor of medicine at the Icahn School of Medicine at Mount Sinai and a gastroenterologist at the Feinstein IBD Center at Mount Sinai Hospital, New York, NY, said endoscopists are at a crossroads when it comes to assessing and surveying patients with IBD. Old literature sets off significant alarms in terms of cancer risk, he said.
“The traditional teaching about risk was the hockey stick,” Dr. Marion explained. The “hockey stick” graph, which originally comes from climate science, is one that shows a long period with no change and then a sudden upswing, mirroring a hockey stick. “After you’d had colitis for 10 years, the percentage risk of colorectal cancer steadily increased over your lifetime. So by the time you’d had the disease for 25 years, you were looking at a risk of 15 to 20 percent of having colon cancer. But a lot of this comes from a different era of IBD treatment and management. Patients weren’t well controlled and we didn’t have the management tools we have today.”
Adam Cheifetz, MD, director of the Center for Inflammatory Bowel Disease at Beth Israel Deaconess Medical Center, Boston, MA, will review the old literature and more recent data during a lecture titled “Dysplasia and Cancer in IBD: Epidemiology, Etiology, Risk Factors, and Natural History.”
“One of the nice things about having higher resolution scopes is we now have good, prospective, controlled trials that hadn’t been done before,” Dr. Marion said. “They’ve helped us understand the natural history of dysplasia in these patients better.”
Considering the new data available, Dr. Marion said there’s good news and better news.
“First, our ability to detect dysplastic changes has vastly improved,” he said. “It’s not just that we’re using higher resolution colonoscopes. We’re also using adjunct techniques such as chromoendoscopy, which allows you to better delineate dysplasia when it’s small and relatively harmless. So that’s one piece of good news.”
The better news is that cancer risk in IBD may be much lower than previously thought.
“It is not a hockey stick. Patients don’t need to walk around as if there is this ‘sword of Damocles’ over their heads thinking they will get colon cancer,” Dr. Marion said.
Even though IBD patients show less cancer and less dysplasia, when something is found, it’s often smaller, flatter and harder to see, he added. That makes having better tools for early detection even more important. But as is often the case when advances in technology come about, there’s controversy.
“With chromoendoscopy, I think there’s general agreement about its sensitivity for picking up dysplasia early, but there’s disagreement about how often it should be used and which patients should be considered for this type of adjunct technique,” Dr. Marion said.
The other issue is whether random biopsy should still be used. Roy Soetikno, MD, FASGE, assistant professor of medicine at the VA Palo Alto Health Care System, CA, will examine the pros and cons of random biopsy and chromoendoscopy during the session.
“Random biopsy has been the foundation of surveying patients, but we now have a good evidence base showing that this technique is not only expensive and imprecise, it really has the worst record for picking up dysplasia in any meaningful way of all the techniques available. And yet it remains in the guidelines,” Dr. Marion said. “It’s hard to convince people to let go of a technique they’ve been using, even when the evidence so far shows it doesn’t work as well as using your eyes.”
Dr. Marion said endoscopists need to be more precise and targeted in risk-stratifying these patients to improve surveillance.
“Colon cancer is a devastating diagnosis, so we need to protect patients,” he said. “Risk stratification is something that is missing from our current guidelines in the U.S. The data that we’re seeing is going to allow us to move away from a one-size-fits-all surveillance protocol for patients with colitis.”
Monday’s symposium will also include lectures by Helmut Neumann, MD, PhD, professor of medicine and head of endoscopic research in the department of medicine at the University of Erlangen-Nuremberg, Germany, and Ralf Kiesslich, MD, PhD, from the division of gastroenterology at Johannes Gutenberg University of Mainz, Germany. Dr. Neumann will present a lecture titled “Beyond HighDefinition Imaging: Magnifying and Confocal Microscopy” and Dr. Kiesslich will present “Endoscopic Management of NonPolypoid Neoplasia in IBD.”
Please refer to the DDW Mobile App or the schedule-at-a-glance in Monday’s issue for the time and location of this and other DDW® events.