2015-05-08 20:37:06 UTC

Colon Cancer Surveillance for IBD in 2015

May 5, 2015

In 2015, we are at a crossroads when it comes to techniques for colon cancer surveillance in IBD patients.

Fernando Velayos, MD

Fernando Velayos, MD

Associate Professor, University of California San Francisco School of Medicine

The field of colon cancer surveillance in inflammatory bowel disease (IBD) unfortunately still remains one of controversies and seeming contradictions. This perspective will highlight key questions and controversies on this topic for 2015 as well as key principles that are not in dispute.

2015 is when the real debate on chromoendoscopy for IBD surveillance begins.

Chromoendoscopy is a technique whereby dye spray (indigo carmine or methylene blue) is applied to the colonic mucosa during colonoscopy to detect subtle dysplastic lesions. The topic of surveillance and chromoendoscopy has been placed at the forefront of clinical care with publication of a consensus statement on surveillance in IBD patients. This publication was approved by the governing boards of AGA, ASGE and five other international societies.

Key question for debate is whether chromoendoscopy is the new standard of care for IBD surveillance in centers with high-definition scopes.

The consensus publication does not give a clinical recommendation per se, but rather it reports numerical agreement on clinical statements, the strength of recommendation and the grade of evidence. Statement 3, relevant to many gastroenterologists in the U.S. reads:

“When performing surveillance with highdefinition colonoscopy, chromoendoscopy is suggested rather than white light colonoscopy.” This guideline was endorsed by 84 percent of the 21 voting members (gastroenterologists, endoscopists, pathologists), but was given only a conditional recommendation and the evidence was rated as low quality. The question up for debate is whether this conditional recommendation based on low quality data is sufficient to create standards that affect the practice of every gastroenterologist and patient with IBD in the U.S. The alternative is to continue to support the measured approach endorsed in the previous 2010 AGA guidelines that considered “chromoendoscopy with targeted biopsies an acceptable alternative to white light endoscopy for endoscopists who have experience in this technique.”

Is there a chromoendoscopy paradox?

A paradox is a statement that, despite sound reasoning from acceptable premises, leads to conclusions that are not logical or selfcontradictory. For example, with regard to chromoendoscopy, reports on the superiority of dye spray chromoendoscopy over white light colonoscopy would suggest chromoendoscopy should be the standard of care, except that there is uncertainty on whether small lesions that would have not been detected otherwise are of clinical significance compared to those detected on random biopsies. In addition, optimistic reports of IBD related colon cancer rates finally nearing that of the general population would lead to the natural conclusion that our current cancer prevention strategies are effective, not that there is a need for new techniques for preventing colon cancer in IBD patients. Even so, as a community, we should encourage efforts to improve the yield of IBD surveillance colonoscopy and dye spray chromoendoscopy is one tool readily available.

Should IBD colon cancer surveillance be performed by every gastroenterologist?

This is an unaddressed question in our field. For decades, whether it is taking random biopsies or using dye spray chromoendoscopy or how dysplasia is described (flat, DALM, ALM, etc.), IBD colon cancer prevention has been treated differently and has been more complicated than in non-IBD patients. In 2015, we are at a crossroads and will need to decide if newer techniques should be considered a modification of a core activity already performed in non- IBD patients (colon cancer prevention via colonoscopy) or if it should it be its own niche and boutique procedure, left for those with sufficient time to conduct intense exams or working knowledge of these complexities. From a patient convenience and continuity of care perspective, it would clearly be best for IBD patients to receive cancer prevention exams where they receive regular care.

Dr. Velayos has no conflicts to disclose.

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