Colonoscopic surveillance Colonoscopic surveillance for prevention of for prevention of

colorectal cancer in colorectal cancer in people with ulcerative people with ulcerative

colitis, Crohn’s disease or colitis, Crohn’s disease or adenomasadenomas

NICE CG 118 - March 2011NICE CG 118 - March 2011

What this presentation What this presentation coverscovers

BackgroundBackground DefinitionsDefinitions EpidemiologyEpidemiology ScopeScope RecommendationsRecommendations Costs and savings Costs and savings DiscussionDiscussion Find out moreFind out more

BackgroundBackground

Adults with inflammatory bowel Adults with inflammatory bowel disease (IBD) or with adenomas have a disease (IBD) or with adenomas have a higher risk of developing colorectal higher risk of developing colorectal cancer than the general population.cancer than the general population.The recommendations are broadly The recommendations are broadly consistent with those in the 2010 British consistent with those in the 2010 British Society of Gastroenterology guidelines.Society of Gastroenterology guidelines.

DefinitionsDefinitionsAdenomaAdenoma

Baseline colonoscopyBaseline colonoscopy

Bowel preparation Bowel preparation

ChromoscopyChromoscopy

Crohn’s diseaseCrohn’s disease

ColitisColitis

ColonoscopyColonoscopy

Computed tomographic colonographyComputed tomographic colonography

(CTC)(CTC)

Inflammatory bowel diseaseInflammatory bowel disease

SigmoidoscopySigmoidoscopy

Image reproduced with kind permission of Dr. Bruce Fox, Derriford Hospital, Plymouth

EpidemiologyEpidemiology

The risk of developing colorectal cancer for people The risk of developing colorectal cancer for people with ulcerative colitis is estimated as 2% after with ulcerative colitis is estimated as 2% after 10 years, 8% after 20 years and 18% after 30 years 10 years, 8% after 20 years and 18% after 30 years of disease.of disease.

The risk of developing colorectal cancer for people The risk of developing colorectal cancer for people with Crohn's disease is considered to be similar to with Crohn's disease is considered to be similar to that for people with ulcerative colitis with the same that for people with ulcerative colitis with the same extent of colonic involvement.extent of colonic involvement.

Guideline recommendations Guideline recommendations

The recommendations The recommendations cover three key areas:cover three key areas:

Providing information Providing information and supportand supportpeople with IBDpeople with IBDpeople with people with adenomas.adenomas.

Image reproduced with kind permission of Professor Marco Novelli, University College London

Providing information and Providing information and supportsupport

What to discuss with people who are considering colonoscopic What to discuss with people who are considering colonoscopic surveillance:surveillance: potential benefits, limitations and risks particularlypotential benefits, limitations and risks particularly

- - early detection and prevention of colorectal cancer early detection and prevention of colorectal cancer - quality of life and psychological outcomes.quality of life and psychological outcomes.

Information about the procedure, including:Information about the procedure, including: bowel preparationbowel preparation

impact on everyday activitiesimpact on everyday activities

sedationsedation

potential discomfortpotential discomfort

risk of perforation and bleeding.risk of perforation and bleeding.

People with People with inflammatory inflammatory bowel diseasebowel disease

Offer surveillance using colonoscopy Offer surveillance using colonoscopy with chromoscopy to people with IBD, with chromoscopy to people with IBD, based on risk:based on risk:Low risk: offer at 5 yearsLow risk: offer at 5 yearsIntermediate risk: offer at 3 years Intermediate risk: offer at 3 years High risk: offer at 1 yearHigh risk: offer at 1 year

Image reproduced with kind permission of Professor Marco Novelli, University College London

Offer a baseline colonoscopy with chromoscopy and targeted biopsy of any abnormal areas to determine the risk of developing colorectal cancer

Low risk •Extensive but quiescent ulcerative or Crohn’s colitis or •Left-sided ulcerative colitis (but not proctitis alone) or Crohn’s colitis of a similar extent

Intermediate risk •Extensive ulcerative or Crohn’s colitis with mild active inflammation (confirmed endoscopically or histologically) or•Post-inflammatory polyps or•Family history of colorectal cancer in a first-degree relative aged 50 or over

High risk •Extensive ulcerative or Crohn’s colitis with moderate or severe active inflammation (confirmed endoscopically or histologically) or•Primary sclerosing cholangitis (including after liver transplant) or•Colonic stricture in the past 5 years or•Any grade of dysplasia in the past 5 years or•Family history of colorectal cancer in a first-degree relative aged under 50

Offer colonoscopic surveillance to people whose symptoms started 10 years ago and who have:• ulcerative colitis (but not proctitis alone) or• Crohn’s colitis involving more than one segment of colon

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Low risk • Left-sided ulcerative colitis (but not proctitis alone) or Crohn’s colitis of a similar extent or • Extensive but quiescent ulcerative or Crohn’s colitis

Follow-up •Offer colonoscopy with chromoscopy at 5 years •Offer a repeat colonoscopy with chromoscopy if incomplete. Consider whether a more experienced colonoscopist is needed

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Findings at follow-up •Offer the next colonoscopy with chromoscopy based on the person’s risk at the last complete colonoscopy: – low risk – offer at 5 years – intermediate risk – offer at 3 years– high risk – offer at 1 year

Intermediate risk • Extensive ulcerative or Crohn’s colitis with mild active inflammation (confirmed endoscopically or histologically) or• Post-inflammatory polyps or• Family history of colorectal cancer in a first-degree relative aged 50 or over

Follow-up•Offer colonoscopy with chromoscopy at 3 years •Offer a repeat colonoscopy with chromoscopy if incomplete. Consider whether a more experienced colonoscopist is needed

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Findings at follow-up •Offer the next colonoscopy with chromoscopy based on the person’s risk at the last complete colonoscopy: – low risk – offer at 5 years – intermediate risk – offer at 3 years– high risk – offer at 1 year

High risk • Extensive ulcerative or Crohn’s colitis with moderate or severe active inflammation (confirmed endoscopically or histologically) or• Primary sclerosing cholangitis (including after liver transplant) or• Colonic stricture in the past 5 years or• Any grade of dysplasia in the past 5 years or• Family history of colorectal cancer in a first-degree relative aged under 50

Follow-up•Offer colonoscopy with chromoscopy at 1 year •Offer a repeat colonoscopy with chromoscopy if incomplete. Consider whether a more experienced colonoscopist is needed

Findings at follow-up•Offer the next colonoscopy with chromoscopy based on the person’s risk at the last complete colonoscopy: – low risk – offer at 5 years – intermediate risk – offer at 3 years– high risk – offer at 1 year

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People with adenomasPeople with adenomas

Offer appropriate Offer appropriate colonoscopic surveillance colonoscopic surveillance based on individual’s risk based on individual’s risk of developing colorectal of developing colorectal cancer determined at cancer determined at initial adenoma removal.initial adenoma removal.

Image reproduced with kind permission of Professor Marco Novelli, University College London

Risk of developing colorectal Risk of developing colorectal cancer in people with cancer in people with

adenomasadenomasLow risk:Low risk: one or two adenomas smaller than 10 mm. one or two adenomas smaller than 10 mm.   Intermediate risk:Intermediate risk: three or four adenomas smaller than three or four adenomas smaller than 10 mm10 mm oror one or two adenomas if one is 10 mm or one or two adenomas if one is 10 mm or larger.larger.  High risk:High risk: five or more adenomas smaller thanfive or more adenomas smaller than 10 mm 10 mm oror three or more adenomas if one is 10 mm three or more adenomas if one is 10 mm or larger.or larger.

Table 2

For people who have had adenomas removed use the findings at removal to determine the risk of developing colorectal cancer

Low risk• One or two adenomas smaller than 10 mm

Intermediate risk• Three or four adenomas smaller than 10 mm or

• One or two adenomas if one is 10 mm or larger

High risk• Five or more adenomas smaller than 10 mm or

• Three or more adenomas if one is 10 mm or larger

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Low risk• One or two adenomas smaller than 10 mm

Follow-up•Consider colonoscopy at 5 years•Offer a repeat colonoscopy if incomplete. Consider whether a more experienced colonoscopist is needed.•If colonoscopy is not clinically appropriate, consider CTC. If CTC is not available or appropriate consider double contrast barium enema. Discuss the risks and benefits with the person and their family or carers if these techniques are being considered for ongoing surveillance

Findings at follow-up•No adenomas – stop surveillance•Low risk – consider the next colonoscopy at 5 years. Follow up as for low risk•Intermediate risk – offer the next colonoscopy at 3 years. Follow up as for intermediate risk•High risk – offer the next colonoscopy at 1 year. Follow up as for high risk

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Intermediate risk• Three or four adenomas smaller than 10 mm or• One or two adenomas if one is 10 mm or larger

Follow-up•Offer colonoscopy at 3 years•Offer a repeat colonoscopy if incomplete. Consider whether a more experienced colonoscopist is needed.•If colonoscopy is not clinically appropriate, consider CTC. If CTC is not available or appropriate consider double contrast barium enema. Discuss the risks and benefits with the person and their family or carers if these techniques are being considered for ongoing surveillance

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Findings at follow-up•No adenomas – offer the next colonoscopy at 3 years. Stop surveillance if there is a further negative result•Low or intermediate risk – offer the next colonoscopy at 3 years. Follow up as for intermediate risk•High risk – offer the next colonoscopy at 1 year. Follow up as for high risk

High risk• Five or more adenomas smaller than 10 mm or• Three or more adenomas if one is 10 mm or larger

Follow-up•Offer colonoscopy at 1 year •Offer a repeat colonoscopy if incomplete. Consider whether a more experienced colonoscopist is needed •If colonoscopy is not clinically appropriate, consider CTC. If CTC is not available or appropriate consider double contrast barium enema. Discuss the risks and benefits with the person and their family or carers if these techniques are being considered for ongoing surveillance.

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26)

Findings at follow-up•No adenomas, or low or intermediate risk – offer the next colonoscopy at 3 years. Follow up as for intermediate risk• High risk – offer colonoscopy at 1 year. Follow up as for high risk

DiscussionDiscussion How do easy is it to identify people who should How do easy is it to identify people who should

be included in a surveillance programme?be included in a surveillance programme?

How easy is it to access information needed to How easy is it to access information needed to put them in the correct risk group?put them in the correct risk group?

Are the full range of tests (e.g. CTC) available?Are the full range of tests (e.g. CTC) available?

What are the problems we face trying to discuss What are the problems we face trying to discuss potential benefits, limitations and risks with potential benefits, limitations and risks with people who are considering colonoscopic people who are considering colonoscopic surveillance? surveillance?

What are the local logistics for getting patients What are the local logistics for getting patients into a colonoscopic surveillance programme? into a colonoscopic surveillance programme?