Cancer Biology or Ineffective Surveillance? A multicentre retrospective analysis of colitis-associated post-colonoscopy colorectal cancers

Misha Kabir; Siwan Thomas-Gibson; Ahmir Ahmad; Rawen Kader; Lulia Al-Hillawi; Joshua Mcguire; Lewis David; Krishna Shah; Rohit Rao; Roser Vega; James E East; Omar D Faiz; Ailsa L Hart; Ana Wilson

doi:10.1093/ecco-jcc/jjad189

Cancer Biology or Ineffective Surveillance? A multicentre retrospective analysis of colitis-associated post-colonoscopy colorectal cancers

J Crohns Colitis. 2023 Nov 6:jjad189. doi: 10.1093/ecco-jcc/jjad189. Online ahead of print.

Authors

Misha Kabir^{1

2}, Siwan Thomas-Gibson^{2

3}, Ahmir Ahmad^{2

3}, Rawen Kader^{4

5}, Lulia Al-Hillawi^{6

7}, Joshua Mcguire^{8

9}, Lewis David¹⁰, Krishna Shah¹¹, Rohit Rao⁹, Roser Vega⁴, James E East^{6

12}, Omar D Faiz^{2

13}, Ailsa L Hart^{2

14}, Ana Wilson^{2

3}

Affiliations

¹ Division of GI Services, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London.
² Imperial College London, UK.
³ Wolfson Endoscopy Unit, St Mark's Hospital, UK.
⁴ Division of GI Services, University College London Hospitals NHS Foundation Trust, London, UK.
⁵ Division of Surgery and Interventional Science, University College London, UK.
⁶ Translational Gastroenterology Unit, Nuffield Department of Medicine, John Radcliffe Hospital, Oxford, UK.
⁷ University of Oxford, Oxford, UK.
⁸ Blizard Institute, Queen Mary University of London, UK.
⁹ Department of gastroenterology, Barts Health NHS Trust, London, UK.
¹⁰ Department of gastroenterology, East and North Hertfordshire, UK.
¹¹ Department of gastroenterology, Imperial College Healthcare NHS Trust, UK.
¹² Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK.
¹³ Department of Colorectal Surgery, St Mark's Hospital, UK.
¹⁴ IBD Unit, St Mark's Hospital, UK.

PMID: 37941424
DOI: 10.1093/ecco-jcc/jjad189

Abstract

Background and aims: Inflammatory bowel disease (IBD) is associated with high rates of post-colonoscopy colorectal cancer (PCCRC), but further in-depth qualitative analyses are required to determine whether they result from inadequate surveillance or aggressive IBD cancer evolution.

Methods: All IBD patients who had a colorectal cancer (CRC) diagnosed between January 2015 to July 2019 and a recent (<4 years) surveillance colonoscopy at one of four English hospital trusts underwent root cause analyses as recommended by the World Endoscopy Organisation to identify plausible PCCRC causative factors.

Results: 61% (n=22/36) of the included IBD CRCs were PCCRCs. They developed in patients with high cancer risk factors (77.8%; n=28/36) requiring annual surveillance, yet 57.1% (n=20/35) had inappropriately delayed surveillance. Most PCCRCs developed in situations where (i) an endoscopically unresectable lesion was detected (40.9%; n=9/22), (ii) there was a deviation from the planned management pathway (40.9%; n=9/22) e.g. service, clinician or patient-related delays in acting on a detected lesion, or (iii) lesions were potentially missed as they were typically located within areas of active inflammation or post-inflammatory change (36.4%; n=8/22).

Conclusions: IBD PCCRC prevention will require more proactive strategies to reduce endoscopic inflammatory burden, improve lesion optical characterisation, adherence to recommended surveillance intervals and patient acceptance of prophylactic colectomy. However, the significant proportion appearing to originate from non-adenomatous-looking mucosa which fail to yield neoplasia on biopsy yet display aggressive cancer evolution highlight the limitations of current surveillance. Emerging molecular biomarkers may play a role in enhancing cancer risk stratification in future clinical practice.

Keywords: cancer; inflammatory bowel disease; surveillance.