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Surveillance for Dysplasia in Patients With Inflammatory Bowel Disease: A National Survey of Colonoscopic Practice in New Zealand

  • Original Contribution
  • Published:
Diseases of the Colon & Rectum

BACKGROUND

Patients with chronic ulcerative colitis and Crohn’s colitis have an increased risk of colorectal cancer. Because of this, surveillance colonoscopy is practiced.

AIMS

We aimed to describe the practice of surveillance colonoscopy in New Zealand, with comparison among specialties, and with practice internationally.

SUBJECTS

New Zealand colonoscopists (both physicians and surgeons) looking after patients with inflammatory bowel disease were surveyed to evaluate attitudes about surveillance colonoscopy and ways in which colonoscopy results are interpreted.

METHODS

A postal survey assessed the colonoscopist’s understanding of how and why surveillance colonoscopy is undertaken and their interpretation of the results from such evaluations.

RESULTS

Of the196 physicians and surgeons surveyed, 180 responded (92 percent). Sixty responses were excluded. Only 24 of 120 respondents (20 percent) correctly defined dysplasia. The median number of biopsies taken at colonoscopy was 17. Eighty of 120 (67 percent) and 77 of 120 (64 percent) doctors underestimate the risk of invasive malignancy if low-grade or high-grade dysplasia, respectively, is identified. The colectomy referral rate for dysplasia-associated lesion or mass was 115/120 (96 percent); that for high-grade dysplasia was 110/120 (92 percent); and that for low-grade dysplasia was 26/120 (22 percent). Thirty of 120 (25 percent) doctors offer patients the option of colectomy after 20 years of colitis. Seventy of 120 (58 percent) doctors sought the opinion of a second pathologist if dysplasia was found. There were differences in responses between specialist groups, with colorectal surgeons most likely to correctly define dysplasia and appreciate the significance of low-grade dysplasia.

CONCLUSIONS

Many New Zealand colonoscopists have a poor understanding of the definition and importance of dysplasia associated with colitis. Although colectomy referral rates are higher in this study than in similar studies, low-grade dysplasia is often not referred for colectomy. Improved education may improve surveillance practice.

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REFERENCES

  1. JA Eaden KR Abrams JF Mayberry (2001) ArticleTitleThe risk of colorectal cancer in ulcerative colitis: a meta-analysis Gut 48 526–35

    Google Scholar 

  2. B Lindberg B Persson B Veress H Ingelman-Sundberg H Grankvist (1996) ArticleTitleTwenty years colonoscopic surveillance of patients with ulcerative colitis. Detection of dysplastic and malignant transformation Scand J Gastroenterol 31 1195–204

    Google Scholar 

  3. A Ekbom C Helmick M Zack HO Adami (1990) ArticleTitleUlcerative colitis and colorectal cancer: a population-based study N Engl J Med 323 1228–33

    Google Scholar 

  4. SN Gyde P Prior RN Allen et al. (1988) ArticleTitleColorectal cancer in ulcerative colitis: a cohort study of primary referrals from three centres Gut 29 206–17

    Google Scholar 

  5. TA Ullman (2002) ArticleTitleCancer in inflammatory bowel disease Curr Treat Options Gastroenterol 5 163–71

    Google Scholar 

  6. BI Korelitz (1989) Inflammatory bowel disease and cancer JE Berk WE Haubrich MH Kalser (Eds) Bockus gastroenterology. Volume 4 EditionNumber4th ed W.B. Saunders Philadelphia 1435–77

    Google Scholar 

  7. PM Choi FW Nugent DJ Schoetz ML Silverman RC Haggitt (1993) ArticleTitleColonoscopic surveillance reduces mortality from colorectal cancer in ulcerative colitis Gastroenterology 105 418–24

    Google Scholar 

  8. JA Eaden BA Ward JF Mayberry (2000) ArticleTitleHow gastroenterologists screen for colonic cancer in ulcerative colitis: an analysis of performance Gastrointest Endosc 51 123–8

    Google Scholar 

  9. DB Sachar (1993) ArticleTitleClinical and colonoscopic surveillance in ulcerative colitis: are we saving colons or saving lives Gastroenterology 105 588–9

    Google Scholar 

  10. P Karlen D Kornfeld O Brostrom P-G Persson A Ekbom (1998) ArticleTitleIs colonoscopic surveillance reducing colorectal cancer mortality in ulcerative colitis? A population based case control study Gut 42 711–4

    Google Scholar 

  11. A Kornbluth DB Sachar (1997) ArticleTitleUlcerative colitis practice guidelines in adults Am J Gastroenterology 92 204–11

    Google Scholar 

  12. Anonymous. Guidelines for colorectal cancer screening and surveillance. Gastrointest Endosc 2000;51:777–82.

  13. JA Eaden JF Mayberry (2002) ArticleTitleBritish Society for Gastroenterology. The Association of Coloproctology for Great Britain and Scotland. Guidelines for screening and surveillance of asymptomatic colorectal cancer in patients with inflammatory bowel disease Gut 51 V10–2

    Google Scholar 

  14. CN Bernstein WM Weinstein DS Levine F Shananan (1995) ArticleTitlePhysician’s perceptions of dysplasia and approaches to surveillance colonoscopy in ulcerative colitis Am J Gastroenterol 90 2109–14

    Google Scholar 

  15. SB Hannauer (2000) ArticleTitleSurveying surveillance: are gastroenterologists consistently inconsistent, inconsistently consistent, or poorly educated Gastrointest Endosc 51 240–2

    Google Scholar 

  16. BJ McKenna HD Appelman (2002) ArticleTitleDysplasia can be a pain in the gut Pathology (Phila) 34 518–28

    Google Scholar 

  17. CN Berstein F Shanahan WM Weinstein (1994) ArticleTitleAre we telling patients the truth about surveillance colonoscopy in ulcerative colitis? Lancet 343 71–4

    Google Scholar 

  18. J Eaden K Abrams H McKay H Denley J Mayberry (2001) ArticleTitleInter-observer variation between general and specialist gastrointestinal pathologists when grading dysplasia in ulcerative colitis J Pathol 194 152–7

    Google Scholar 

  19. The New Zealand Medical Register. 2001. Medical Council of New Zealand, Wellington, New Zealand.

  20. RH Riddell H Goldman DF Ransohoff et al. (1983) ArticleTitleDysplasia in inflammatory bowel disease: standardized classification with provisional clinical applications Hum Pathol 14 931–68

    Google Scholar 

  21. DF Ransohoff (1988) ArticleTitleColon cancer in ulcerative colitis Gastroenterology 94 1089–91

    Google Scholar 

  22. DM Foxworthy JA Wilson (1985) ArticleTitleCrohn’s disease in the elderly. Prolonged delay in diagnosis J Am Geriatr Soc 33 492–5

    Google Scholar 

  23. D Wengrower E Goldin A Fich E Granot (1997) ArticleTitleCrohn’s disease in late adolescence: acute onset or long-standing disease? J Clin Gastroenterol 24 224–6

    Google Scholar 

  24. RH Riddell (1990) ArticleTitleScreening strategies in gastrointestinal cancer Scand J Gastroenterol Suppl 175 177–84

    Google Scholar 

  25. BA Lashner SB Hanauer MD Silverstein (1988) ArticleTitleOptimal timing of colonoscopy to screen for cancer in ulcerative colitis Ann Intern Med 108 274–8

    Google Scholar 

  26. S Warren SC Sommers (1948) ArticleTitleCicatrizing enteritis (regional enteritis) as a pathological entity: analysis of one hundred and twenty cases Am J Pathol 24 475–501

    Google Scholar 

  27. S Friedman PH Rubin C Bodian E Goldstein N Harpaz DH Present (2001) ArticleTitleScreening and surveillance colonoscopy in chronic Crohn’s colitis Gastroenterology 120 820–6

    Google Scholar 

  28. CE Rubin RC Haggitt GC Burmer TA Brentnall AC Stevens (1992) ArticleTitleDNA aneuploidy in colonic biopsies predicts future development of dysplasia in ulcerative colitis Gastroenterology 103 1611–20

    Google Scholar 

  29. BA Taylor JH Pemberton HA Carpenter et al. (1992) ArticleTitleDysplasia in chronic ulcerative colitis: implications for colonoscopic surveillance Dis Colon Rectum 35 950–6

    Google Scholar 

  30. RD Cohen SB Hanauer (1995) ArticleTitleSurveillance colonoscopy in ulcerative colitis: is the message loud and clear Am J Gastroenterol 90 2090–2

    Google Scholar 

  31. AJ Woolrich MD DaSilva BI Korelitz (1992) ArticleTitleSurveillance in the routine management of ulcerative colitis: the predictive value of low grade dysplasia Gastroenterology 103 431–8

    Google Scholar 

  32. JK Greenson (2002) ArticleTitleDysplasia in inflammatory bowel disease Semin Diagn Pathol 19 31–7

    Google Scholar 

  33. BA Lashner (1992) ArticleTitleRecommendations for colorectal cancer screening in ulcerative colitis: a review of research from a single university-based surveillance program Am J Gastroenterol 87 168–75

    Google Scholar 

  34. JE Lennard-Jones DM Melville BC Morson JK Ritchie CB Williams (1990) ArticleTitlePrecancer and cancer in extensive ulcerative colitis; findings among 401 patients over 22 years Gut 31 800–6

    Google Scholar 

  35. TA Ullman EV Loftus S Kakar LJ Burgart WJ Sandborn WJ Tremaine (2002) ArticleTitleThe fate of low grade dysplasia in ulcerative colitis Am J Gastroenterol 97 922–7

    Google Scholar 

  36. MW Thompson-Fawcett CS Richard BI O’Connor Z Cohen RS McLeod (2000) ArticleTitleQuality of life is excellent after a pelvic pouch for colitis associated neoplasia Dis Colon Rectum 43 1497–502

    Google Scholar 

  37. LW Kohler JH Pemberton AR Zinsmeister KA Kelly (1991) ArticleTitleQuality of life after proctocolectomy. A comparison of Brooke ileostomy, Kock pouch and ileal pouch–anal anastomosis Gastroenterology 102 679–84

    Google Scholar 

  38. CA Rubio R Befrits T Ljung E Jaramillo P Slezak (2001) ArticleTitleColorectal carcinoma in ulcerative colitis is decreasing in Scandinavian countries Anticancer Res 21 2921–4

    Google Scholar 

  39. CA Rubio R Befrits (1997) ArticleTitleColorectal adenocarcinoma in Crohn’s disease: a retrospective histologic study Dis Colon Rectum 40 1072–8

    Google Scholar 

  40. J Askling PW Dickman P Karlen et al. (2001) ArticleTitleFamily history as a risk factor for colorectal cancer in inflammatory bowel disease Gastroenterology 120 1356–62

    Google Scholar 

  41. KW Nuako DA Ahlquist DW Mahoney DJ Schaid DM Siems NM Lindor (1998) ArticleTitleFamilial predisposition for colorectal cancer in chronic ulcerative colitis: a case-control study Gastroenterology 115 1079–83

    Google Scholar 

  42. D Kornfeld A Ekbom T Ihre (1997) ArticleTitleIs there an increased risk for colorectal cancer in patients with ulcerative colitis and concomitant primary sclerosing cholangitis? A population based study Gut 41 522–55

    Google Scholar 

  43. EV Loftus WJ Sandborn WJ Tremaine et al. (1996) ArticleTitleRisk of colorectal neoplasia in patients with primary sclerosing cholangitis Gastroenterology 110 628–30

    Google Scholar 

  44. EV Loftus HI Aguilar WJ Sandborn et al. (1998) ArticleTitleRisk of colorectal neoplasia in patients with primary sclerosing cholangitis and ulcerative colitis following orthotopic liver transplantation Hepatology 27 685–90

    Google Scholar 

  45. A Ekbom D Kornfeld (1996) ArticleTitleSulphasalazine use as a preventative factor for colorectal cancer in ulcerative colitis patients: a review Inflamm Bowel Dis 2 276–8

    Google Scholar 

  46. H Allgayer W Kruis (2002) ArticleTitleAminosalicylates: potential antineoplastic actions in colon cancer prevention Scand J Gastroenterol 37 125–31

    Google Scholar 

  47. CN Bernstein J Eaden AH Steinhart P Munkholm PH Gordon (2002) ArticleTitleCancer prevention in inflammatory bowel disease and the chemoprophylactic potential of 5-aminosalicylic acid Inflamm Bowel Dis 8 356–61

    Google Scholar 

Download references

ACKNOWLEDGMENTS

The authors thank Associate Professor Christopher Frampton (Christchurch School of Medicine and Health Sciences, University of Otago, New Zealand) for advice with statistical analysis, Mrs. Sue Shanks for assistance, and New Zealand gastroenterologists, general surgeons, and colorectal surgeons for their excellent response to the survey.

Author information

Authors and Affiliations

  1. Department of Gastroenterology, Christchurch Hospital and Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand

    Richard B. Gearry M.B.Ch.B., Murray L. Barclay M.D., F.R.A.C.P., Bruce A. Chapman M.B.Ch.B., F.R.A.C.P., Judith A. Collett M.B.Ch.B., F.R.A.C.P. & Michael J. Burt Ph.D., F.R.A.C.P.

  2. Department of Surgery, Christchurch Hospital and Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand

    Christopher J. Wakeman M.B.Ch.B. & Frank A. Frizelle M.B.Ch.B., M.Med.Sc., F.R.A.C.S.

Authors
  1. Richard B. Gearry M.B.Ch.B.
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  2. Christopher J. Wakeman M.B.Ch.B.
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  3. Murray L. Barclay M.D., F.R.A.C.P.
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  4. Bruce A. Chapman M.B.Ch.B., F.R.A.C.P.
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  5. Judith A. Collett M.B.Ch.B., F.R.A.C.P.
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  6. Michael J. Burt Ph.D., F.R.A.C.P.
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  7. Frank A. Frizelle M.B.Ch.B., M.Med.Sc., F.R.A.C.S.
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Corresponding author

Correspondence to Richard B. Gearry M.B.Ch.B..

Additional information

Supported by a grant from the Canterbury Medical Research Foundation.

APPENDIX 1

APPENDIX 1

Screening Colonoscopy in Ulcerative Colitis (UC) Questionnaire

Do you look after patients with Ulcerative Colitis? Yes / No

Do you perform colonoscopy? Yes / No

  1. 1.

    What is the definition of dysplasia?

  2. A

    A cytologic change secondary to severe inflammation

  3. B

    A term synonymous with “atypia”

  4. C

    An unequivocal neoplastic change

  5. D

    A preneoplastic change in the epithelium

  6. 2.

    How long after diagnosis do you recommend surveillance colonoscopy be commenced for UC patients with pancolitis?

  7. A

    5y

  8. B

    8y

  9. C

    10y

  10. D

    15y

  11. E

    20y

  12. F

    Not at all

  13. 3.

    How frequently do you recommend surveillance colonoscopy once started?

  14. A

    6 monthly

  15. B

    Yearly

  16. C

    2 yearly

  17. D

    3 yearly

  18. E

    Once only

  19. F

    Not at all

  20. 4.

    In which of the following group(s) do you recommend surveillance colonoscopy (Circle as many options as appropriate):

  21. A

    Pancolitis

  22. B

    Left-sided disease only

  23. C

    Proctitis only

  24. D

    Crohn’s disease with predominant colitis

  25. E

    Not at all

  26. 5.

    Regarding your approach to surveillance colonoscopy:

At how many different sites do you take biopsies?

How many biopsies do you take at each site?

  1. 6.

    If Low Grade Dysplasia is found at colonoscopy, what do you recommend?

  2. A

    Repeat colonoscopy < 6/12

  3. B

    Repeat colonoscopy in 6/12 – I year

  4. C

    Repeat colonoscopy in 1 year

  5. D

    Refer to surgeon for colectomy

  6. E

    Other

  7. 7.

    If High Grade Dysplasia is found at colonoscopy, what do you recommend?

  8. A

    Repeat colonoscopy < 6/12

  9. B

    Repeat colonoscopy in 6/12 – I year

  10. C

    Repeat colonoscopy in 1 year

  11. D

    Refer to surgeon for colectomy

  12. E

    Other

  13. 8.

    If High Grade Dysplasia is found at endoscopy, what is the risk of finding invasive malignancy if colectomy is performed?

  14. A

    < 1 percent

  15. B

    1 – 10 percent

  16. C

    11 – 20 percent

  17. D

    21 – 30 percent

  18. E

    31 – 40 percent

  19. F

    > 40 percent

  20. G

    Unsure

  21. 9.

    If Low Grade Dysplasia is found at endoscopy, what is the risk of finding invasive malignancy if colectomy is performed?

  22. A

    < 1 percent

  23. B

    1 – 10 percent

  24. C

    11 – 20 percent

  25. D

    21 – 30 percent

  26. E

    31 – 40 percent

  27. F

    > 40 percent

  28. G

    Unsure

  29. 10.

    Do two pathologists review all diagnoses of dysplasia at your institution? Y / N

  30. 11.

    Would you recommend colectomy in the following situations in a patient who has had UC for 15 years?

  31. A

    Dysplasia is present and associated with a mass lesion Y / N

  32. B

    High Grade Dysplasia is present, but there is no mass lesion Y / N

  33. C

    Low Grade Dysplasia is present, but no mass lesion Y / N

  34. 12.

    Do you ever offer colectomy to patients as a means of preventing colorectal cancer if their colitis is quiescent?

  35. A

    At 5 years Y / N

  36. B

    At 8 years Y / N

  37. C

    At 15 years Y / N

  38. D

    At 20 years Y / N

  39. E

    Never

  40. 13.

    To which of the following groups do you belong?

  41. A

    Gastroenterologist (hospital catchment < 100,000 people)

  42. B

    Gastroenterologist (hospital catchment > 100,000 people)

  43. C

    General Surgeon (hospital catchment < 100,000 people)

  44. D

    General Surgeon (hospital catchment > 100,000 people)

  45. E

    Colorectal Surgeon

  46. F

    Colorectal Trainee

  47. G

    Gastroenterology Trainee

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Gearry, R., Wakeman, C., Barclay, M. et al. Surveillance for Dysplasia in Patients With Inflammatory Bowel Disease: A National Survey of Colonoscopic Practice in New Zealand. Dis Colon Rectum 47, 314–322 (2004). https://doi.org/10.1007/s10350-003-0049-y

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  • DOI: https://doi.org/10.1007/s10350-003-0049-y

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