[show abstract][hide abstract] ABSTRACT: BACKGROUND:: Recently reported risks of colorectal cancer (CRC) in inflammatory bowel disease (IBD) have been lower than those reported before 2000. The aim of this meta-analysis was to update the CRC risk of ulcerative and Crohn's colitis, investigate time trends, and identify high-risk modifiers. METHODS:: The MEDLINE search engine was used to identify all published cohort studies on CRC risk in IBD. Publications were critically appraised for study population, Crohn's disease localization, censoring for colectomy, and patient inclusion methods. The following data were extracted: total and stratified person-years at risk, number of observed CRC, number of expected CRC in background population, time period of inclusion, and geographical location. Pooled standardized incidence ratios and cumulative risks for 10-year disease intervals were calculated. Results were corrected for colectomy and isolated small bowel Crohn's disease. RESULTS:: The pooled standardized incidence ratio of CRC in all patients with IBD in population-based studies was 1.7 (95% confidence interval [CI], 1.2-2.2 ). High-risk groups were patients with extensive colitis and an IBD diagnosis before age 30 with standardized incidence ratios of 6.4 (95% confidence interval, 2.4-17.5) and 7.2 (95% confidence interval, 2.9-17.8), respectively. Cumulative risks of CRC were 1%, 2%, and 5% after 10, 20, and >20 years of disease duration, respectively. CONCLUSIONS:: The risk of CRC is increased in patients with IBD but not as high as previously reported and not in all patients. This decline could be the result of aged cohorts. The risk of CRC is significantly higher in patients with longer disease duration, extensive disease, and IBD diagnosis at young age.
[show abstract][hide abstract] ABSTRACT: Patients with long-standing colitis carry an increased risk of colorectal cancer and are therefore enrolled in colonoscopic surveillance programs. It is presently not known if endoscopic surveillance of patients with colitis with a closed rectal stump after a subtotal colectomy is justified. Neither is it clear which of these patients might be at increased risk for rectal stump cancer.
The aim of this study is to identify the risk factors for rectal stump cancer.
This investigation is a retrospective descriptive case-control study.
This study was conducted at tertiary referral centers in the Netherlands.
Colorectal cancer cases associated with inflammatory bowel disease diagnosed between 1990 and 2006 were selected in a nationwide pathology archive. Patients with rectal stump cancer were selected from this group. The pathology archive was also used to identify inflammatory bowel disease controls matched for referral center with a closed rectal stump after subtotal colectomy, but without neoplasia. Follow-up started at the date of subtotal colectomy with the formation of a rectal stump. Demographic and disease characteristics were collected at baseline.
Hazard ratios with 95% confidence intervals were calculated for factors associated with the development of rectal stump cancer with the use of univariate Cox regression analysis. End points were rectal stump cancer, end of follow-up, or death.
A total of 12 patients with rectal stump cancer and 18 matching controls without neoplasia were identified. Univariate analysis showed an association between rectal stump cancer and primary sclerosing cholangitis, and disease duration until subtotal colectomy.
This study is limited by its retrospective design, and, despite being the largest series to date, it still has a limited number of cases.
Risk factors for rectal stump cancer in a closed rectal stump after subtotal colectomy were primary sclerosing cholangitis and disease duration until subtotal colectomy.
Diseases of the Colon & Rectum 02/2012; 55(2):191-6. · 3.34 Impact Factor
[show abstract][hide abstract] ABSTRACT: The increased risk of colorectal cancer (CRC) in patients with inflammatory bowel disease (IBD) is well established. The incidence of IBD-related CRC however, differs markedly between cohorts from referral centers and population-based studies. In the present study we aimed to identify characteristics potentially explaining these differences in two cohorts of patients with IBD-related CRC.
PALGA, a nationwide pathology network and registry in The Netherlands, was used to search for patients with IBD-associated CRC between 1990 and 2006. Patients from 7 referral hospitals and 78 general hospitals were included. Demographic and disease specific parameters were collected retrospectively using patient charts.
A total of 281 patients with IBD-associated CRC were identified. Patients from referral hospitals had a lower median age at IBD diagnosis (26 years vs. 28 years (p=0.02)), while having more IBD-relapses before CRC diagnosis than patients from general hospitals (3.8 vs. 1.5 (p<0.01)). In patients from referral hospitals, CRC was diagnosed at a younger age (47 years vs. 51 years (p=0.01)). However, the median interval between IBD diagnosis and diagnosis of CRC was similar in both cohorts (19 years in referral hospitals vs. 17 years in general hospitals (p=0.13)).
IBD patients diagnosed with CRC treated in referral hospitals in The Netherlands are younger at both the diagnosis of IBD and CRC than IBD patients with CRC treated in general hospitals. Although patients from referral centers appeared to have a more severe course of IBD, the interval between IBD and CRC diagnosis was similar.
Journal of Crohn s and Colitis 11/2011; 6(4):435-40. · 3.39 Impact Factor
[show abstract][hide abstract] ABSTRACT: Colonoscopic surveillance provides the best practical means for preventing colorectal cancer (CRC) in inflammatory bowel disease (IBD) patients. Strong evidence for improved survival from surveillance programmes is sparse.
The aim of this study was to compare tumour stage and survival of IBD patients with CRC who were a part of a surveillance programme with those who were not. A nationwide pathology database (PALGA (pathologisch anatomisch landelijk geautomatiseerd archief)) was consulted to identify IBD patients with CRC treated in all eight university hospitals in The Netherlands over a period of 15 years. Patients were assigned to the surveillance group when they had undergone one or more surveillance colonoscopies before a diagnosis of CRC. Patients who had not undergone surveillance served as controls. Tumour stage and survival were compared between the two groups.
A total of 149 patients with IBD-associated CRC were identified. Twenty-three had had colonoscopic surveillance before CRC was discovered. The 5-year CRC-related survival rate of patients in the surveillance group was 100% compared with 74% in the non-surveillance group (P=0.042). In the surveillance group, only one patient died as a consequence of CRC compared with 29 patients in the control group (P=0.047). In addition, more early tumour stages were found in the surveillance group (P=0.004).
These results provide evidence for improved survival from colonoscopic surveillance in IBD patients by detecting CRC at a more favourable tumour stage.
British Journal of Cancer 10/2009; 101(10):1671-5. · 5.08 Impact Factor
[show abstract][hide abstract] ABSTRACT: Patients with inflammatory bowel disease (IBD) and concurrent primary sclerosing cholangitis (PSC) have a higher risk of developing colorectal cancer (CRC) than IBD patients without PSC. The aim of this study was to investigate potential clinical differences between patients with CRC in IBD and those with CRC in IBD and PSC, as this may lead to improved knowledge of underlying pathophysiological mechanisms of CRC development.
The retrospective study from 1980-2006 involved 7 Dutch university medical centers. Clinical data were retrieved from cases identified using the national pathology database (PALGA).
In total, 27 IBD-CRC patients with PSC (70% male) and 127 IBD-CRC patients without PSC (59% male) were included. CRC-related mortality was not different between groups (30% versus 19%, P = 0.32); however, survival for cases with PSC after diagnosing CRC was lower (5-year survival: 40% versus 75% P = 0.001). Right-sided tumors were more prevalent in the PSC group (67% versus 36%, P = 0.006); adjusted for age, sex, and extent of IBD, this difference remained significant (odds ratio: 4.8, 95% confidence interval [CI] 2.0-11.8). In addition, tumors in individuals with PSC were significantly more advanced.
The right colon is the predilection site for development of colonic malignancies in patients with PSC and IBD. When such patients are diagnosed with cancer they tend to have more advanced tumors than patients with IBD without concurrent PSC, and the overall prognosis is worse. Furthermore, the higher frequency of right-sided tumors in patients with PSC suggests a different pathogenesis between patients with PSC and IBD and those with IBD alone.
[show abstract][hide abstract] ABSTRACT: OBJECTIVE: To assess the time interval between the diagnosis of inflammatory bowel disease (IBD) and that of colorectal carcinoma (CRC), and to subsequently evaluate how many patients developed CRC before their surveillance should have commenced according to formal guidelines. DESIGN: Retrospective, descriptive. METHOD: A nationwide automated pathology database (PALGA) was used to identify patients with IBD-associated colorectal carcinoma in 7 academic medical centres in the Netherlands between January 1990 and June 2006. Data were collected retrospectively from patient records. Time intervals between onset of disease and cancer diagnosis were calculated in months. These were compared to the time intervals recommended by formal guidelines for the initiation of surveillance, namely after 8-10 years of extensive colitis, or after 15-20 years of left-sided disease. RESULTS: 149 patients were identified with confirmed diagnoses of IBD and CRC (ulcerative colitis: n = 89; Crohn's disease: n = 59; indeterminate colitis: n = 1). If the date of IBD diagnosis was taken as the onset of disease, 22% of patients were found to have developed cancer before the recommended 8 or 15-year surveillance starting points. This rate was 28% if surveillance were to start 10 or 20 years after diagnosis. If the first appearance of symptoms is taken as the onset of disease, 17-22% of patients would present with CRC prior to the start of surveillance. CONCLUSION: These results show that the diagnosis of colorectal cancer is delayed or missed in a substantial number of patients (17-28%) when coloscopic surveillance is conducted strictly according to formal guidelines.
Nederlands tijdschrift voor geneeskunde 01/2009; 153.
[show abstract][hide abstract] ABSTRACT: Latent autoimmune diabetes in adults (LADA) represents a subgroup of diabetes mellitus. LADA is characterised by adult-onset diabetes and circulating autoimmune antibodies. LADA patients may need a different therapeutic approach than the usual type 2 diabetes mellitus. When LADA is inadequately diagnosed as type 2 diabetes mellitus, LADA patients will mistakenly be exposed to a high dose of oral glucose lowering drugs and their possible side effects.
To assess which clinical features predict the presence or absence of LADA in patients older than 25 years presenting with hyperglycemia.
A structured Medline and Embase search was conducted. Titles and abstracts were screened using predetermined selection criteria. Critical appraisal was based on standardized validity criteria for diagnostic research.
One-hundred and eighty-four papers were retrieved of which after assessment of relevance and validity 2 studies remained for further analysis. One study reported a probability of LADA of 0.99 with one or two out of the following five clinical features: age at onset <50 years; acute symptoms; BMI<25 kg/m(2); a history of autoimmune disease; a family history positive for diabetes mellitus. The other study reported a probability of LADA of zero with none of the following clinical features and of 0.32 with one out of three: fasting blood glucose> or =15 mmol/l and/or HbA(1c)> or =10%; 10% reduction in body weight in the previous 3 months; BMI<25 kg/m(2).
Further testing for LADA by measurement of autoimmune antibodies appears to be unnecessary in the absence of a specific set of clinical features. Before initiating therapy applying the above criteria may help to separate LADA from usual type 2 diabetes.
Primary Care Diabetes 09/2008; 2(4):207-11. · 1.61 Impact Factor
[show abstract][hide abstract] ABSTRACT: To detect precancerous dysplasia or asymptomatic cancer, patients suffering from inflammatory bowel disease often undergo colonoscopic surveillance based on American or British guidelines. It is recommended that surveillance is initiated after 8-10 years of extensive colitis, or after 15-20 years for left-sided disease. These starting points, however, are not based on solid scientific evidence. Our aim was to assess the time interval between onset of inflammatory bowel disease (IBD) and colorectal carcinoma (CRC), and subsequently evaluate how many patients developed cancer before their surveillance was recommended to commence.
A nationwide automated pathology database (PALGA) was consulted to identify patients with IBD-associated colorectal carcinoma in seven university medical centres in The Netherlands between January 1990 and June 2006. Data were collected retrospectively from patient charts. Time intervals between onset of disease and cancer diagnosis were calculated in months.
149 patients were identified with confirmed diagnoses of IBD and CRC (ulcerative colitis n = 89/Crohn's disease n = 59/indeterminate colitis n = 1). Taking date of diagnosis as the entry point, 22% of patients developed cancer before the 8 or 15 year starting points of surveillance, and 28% if surveillance was commenced 10 or 20 years after diagnosis for extensive or left-sided disease, respectively. Using onset of symptoms to calculate the time interval, 17-22% of patients would present with cancer prior to the surveillance starting points.
These results show that the diagnosis of colorectal cancer is delayed or missed in a substantial number of patients (17-28%) when conducting surveillance strictly according to formal guidelines.
[show abstract][hide abstract] ABSTRACT: To determine how many cases of inflammatory bowel disease (IBD)-related colorectal cancer (CRC) occur before recommended colonoscopy screening commences.
A nationwide automated histological and cytopathological archive (PALGA) was used to identify patients with IBD and CRC in the period January 1990-June 2006 at the University Medical Center Utrecht, The Netherlands. The interval between the diagnosis of IBD or IBD-related symptoms and the diagnosis of CRC was calculated. The observed interval was compared with the recommended starting point for surveillance according to the British Society of Gastroenterology (BSG) and the American Gastroenterological Association (AGA), i.e. after 8-10 years for pancolitis or after 15-20 years for left-sided colitis.
33 colorectal cancers were found in 29 patients with IBD. The median age at the time of diagnosis was 29 years (range: 11-82) for IBD and 47 years (range: 23-82) for CRC. 7 of the 29 patients (24%) developed CRC before the minimum recommended time to initiate screening (8 years for pancolitis, 15 years for left-sided colitis), and 9 patients (31%) developed CRC within the maximum recommended time to initiate screening (10 years for pancolitis, 20 years for left-sided colitis). If the onset of IBD-related symptoms was considered the starting point of the disease (rather than the diagnosis of IBD), 17-24% of patients developed a CRC before surveillance would have commenced.
These results suggest that, by following the British and American guidelines for screening for IBD-related CRC, a substantial portion of cases (17-31%) would not be diagnosed in a timely manner.
Nederlands tijdschrift voor geneeskunde 01/2008; 151(50):2787-91.
[show abstract][hide abstract] ABSTRACT: Development of colitis-associated colorectal cancer is an important clinical problem in patients with colonic inflammatory bowel disease (IBD). British and American guidelines recommend to start surveillance after a disease duration of 8-10 or 15-20 years for patients with extensive or left-sided colitis, respectively.
To assess the evidence level of current surveillance strategies.
A PubMed-based literature search using the search terms inflammatory bowel disease, ulcerative colitis, Crohn's disease, dysplasia, colorectal cancer and surveillance was performed.
Low-grade and high-grade dysplastic lesions progress to cancer in a high percentage of patients. Furthermore, concurrent cancer is found in approximately one-third of the patients with colonic dysplasia. Low-level evidence showing reduced colorectal cancer-related mortality in patients who were undergoing surveillance is available. Patients with concomitant primary sclerosing cholangitis form a subgroup of IBD patients with an even higher risk of colorectal neoplasia.
Colonic surveillance prolongs life expectancy of patients with long-lasting IBD.