Medical decision analysis for the management of unifocal, flat, low-grade dysplasia in ulcerative colitis

Management of Dysplasia in Inflammatory Bowel Disease

Given the chronic nature of mucosal inflammation present in patients with inflammatory bowel disease (IBD), there is a high risk of dysplastic lesions progressing to cancer, in addition to a high risk of synchronous and/or metachronous cancers developing in those diagnosed with dysplasia. Due to this, consensus guidelines recommend regular surveillance. When visible dysplasia is encountered, options include endoscopic or surgical resection depending on characteristics of the lesion. Advancements in endoscopic tools increasingly allow for endoscopic removal when appropriate. Invisible dysplasia discovered on random biopsy should prompt referral to physicians who specialize in IBD. While surgical resection with proctocolectomy significantly decreases the risk of colorectal cancer, the risk must be balanced against the morbidity of surgery and quality-of-life concerns. Management of dysplasia in IBD patients requires complex decision-making that requires balance of patient values and goals of care with cancer-related risk factors.

Surgical Treatment in Ulcerative Colitis, Still Topical: A Narrative Review

In this paper, different studies were integrated to conclude the impact of ulcerative colitis (UC) on the patient's vital prognosis, specifically highlighting the association with colorectal cancer (CRC). These severe complications have led us to consider studying the role of preventive surgery in managing UC. This study reviewed total preventive colectomy in UC patients for preventing the onset of CRC, the role of surgery in UC management, and its potential as a definitive treatment for the condition. The study also emphasized the effectiveness of annual colonoscopic monitoring and preventive colectomy in reducing the incidence of colorectal cancer (CRC). It discussed the role of laparoscopic surgery in minimizing postoperative complications and highlighted that partial surgical resection of the colon can be a viable option, offering improved bowel function without increasing the risk of CRC-related mortality. Elective surgery has an important place in UC management by preventing the development of forms requiring emergency surgery. Although surgery can cure UC, it can lead to significant postoperative complications and adverse effects.

Colorectal cancer risk of flat low-grade dysplasia in inflammatory bowel disease: a systematic review and proportion meta-analysis

BACKGROUND

To date, the optimal management of patients with inflammatory bowel disease (IBD) and flat low-grade dysplasia (fLGD) of the colon or rectum remains controversial.

METHODS

A systematic review was reported in accordance with PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Patients diagnosed with fLGD on surveillance endoscopy were pooled from studies published between 2000 and 2020. Advanced neoplasia was defined by the presence of HGD, CRC or small bowel adenocarcinoma detected on subsequent surveillance endoscopy or from examination of resection specimens. We estimated the pooled annual incidence rate of colorectal cancer (CRC) and advanced neoplasia, and the risk factors associated with neoplastic progression.

RESULTS

We identified 24 articles and 738 IBD patients were diagnosed with fLGD on endoscopy. Two hundred thirty-six patients (32%) underwent immediate surgery with surgical specimens demonstrating CRC in 8 patients (pooled prevalence, 8.66%; 95% CI 3.58-19.46) and HGD (high grade dysplasia) in 11 patients (pooled prevalence, 13.97%; 95% CI 5.65-30.65). Five hundred-two patients (68%) underwent endoscopic surveillance with 63 patients with fLGD progressing to advanced neoplasia during endoscopic surveillance (38 HGD, 24 CRC and one patient developing small bowel adenocarcinoma). The mean duration of follow-up after fLGD diagnosis was 71 months (10.9-212). The pooled incidence of CRC and advanced neoplasia was 0.5 (95% CI 0.23-0.77) and 1.71 per 100 patient-year (95% CI 0.88-2.54) respectively. The use of corticosteroids and location of fLGD in the distal colon were significantly associated with neoplastic progression.

CONCLUSIONS

This study provides a summary incidence rate of CRC and advanced neoplasia in patients with IBD and fLGD to inform surgeons' and endoscopists' decision-making thus reducing potential ineffective treatments.

The Fate of Unifocal Versus Multifocal Low-Grade Dysplasia at the Time of Colonoscopy in Patients With IBD

BACKGROUND

Recommendations regarding management of colorectal dysplasia in the setting of IBD continue to evolve.

OBJECTIVE

This study aimed to determine the rate of progression from dysplasia to adenocarcinoma, specifically focusing on the differences in unifocal and multifocal low-grade dysplasia and dysplasia found on random biopsy versus targeted biopsies.

DESIGN

This is a retrospective review.

SETTING

This study was conducted at an IBD referral center.

PATIENTS

All adult patients (≥18 years of age) with a known diagnosis of either ulcerative colitis or Crohn's disease, who underwent a surveillance colonoscopy between January 1, 2010 and January 1, 2019, were selected.

MAIN OUTCOMES MEASURES

The primary outcomes measured were the progression of dysplasia and the risk factors for progression.

RESULTS

A total of 23,751 surveillance colonoscopies were performed among 12,289 patients between January 1, 2010 and January 1, 2019. The mean age at colonoscopy was 52.1 years (SD 16.9 years), 307 patients (2.5%) had a history of primary sclerosing cholangitis, and 3887 (3.15%) had a family history of colorectal cancer. There was a total of 668 patients (5.4%) with low-grade dysplasia, 76 patients (0.62%) with high-grade dysplasia, and 68 patients (0.55%) with adenocarcinoma in the series. The 1-, 2-, and 5-year cumulative incidence rate of progressing from low-grade dysplasia to high-grade dysplasia were 1.6%, 4.8%, and 7.8%. The 1- and 2-year cumulative incidence rates of progressing from low-grade dysplasia to adenocarcinoma were 0.7% and 1.6%. There were no significant differences in unifocal and multifocal progression. Primary sclerosing cholangitis, ulcerative colitis, male sex, and advanced age were all found to be significant risk factors for neoplasia on multivariable analysis.

LIMITATIONS

A retrospective database was a source of information.

CONCLUSION

Progression of low-grade dysplasia to adenocarcinoma, regardless of its being unifocal or multifocal, remains very low in the setting of adequate surveillance and medical management. The presence of multifocal low-grade dysplasia should not change the decision making to pursue ongoing endoscopic surveillance versus proctocolectomy. Patients who had primary sclerosing cholangitis with dysplasia found on random biopsies may be at highest risk for dysplasia progression. See Video Abstract at http://links.lww.com/DCR/A649.

EL DESENLACE DE LA DISPLASIA DE BAJO GRADO UNIFOCAL VERSUS MULTIFOCAL DURANTE LA COLONOSCOPIA EN PACIENTES CON ENFERMEDAD INFLAMATORIA INTESTINAL

ANTECEDENTES:Las recomendaciones para el tratamiento de la displasia colorrectal en el contexto de la enfermedad inflamatoria intestinal siguen evolucionando.OBJETIVO:Determinar la tasa de progresión de displasia a adenocarcinoma, centrándose específicamente en las diferencias en displasia de bajo grado unifocal y multifocal, y displasia encontradas en biopsias aleatorias versus biopsias dirigidas.DISEÑO:Revisión retrospectiva.ÁMBITO:Centro de referencia de EII.PACIENTES:Todos los pacientes adultos (> 18 años) con un diagnóstico comprobado de colitis ulcerosa o enfermedad de Crohn que se sometieron a una colonoscopia de vigilancia entre el 1 de enero de 2010 y el 1 de enero de 2019.PRINCIPALES VARIABLES ANALIZADAS:Progresión de la displasia y factores de riesgo de progresión.RESULTADOS:Se realizaron un total de 23.751 colonoscopias de vigilancia en 12.289 pacientes entre el 1/1/2010 y el 1/1/2019. La edad media en el momento de la colonoscopia fue de 52,1 años (DE 16,9 años), 307 pacientes (2,5%) tenían antecedentes de colangitis esclerosante primaria y 3887 (3,15%) tenían antecedentes familiares de cáncer colorrectal. Hubo un total de 668 pacientes (5,4%) con displasia de bajo grado, 76 pacientes (0,62%) con displasia de alto grado y 68 pacientes (0,55%) con adenocarcinoma en la serie. La tasa de incidencia acumulada de 1, 2, 5 años de progresión de displasia de bajo grado a displasia de alto grado fue del 1,6%, 4,8% y 7,8%. Las tasas de incidencia acumulada de 1 y 2 años de progresión de displasia de bajo grado a adenocarcinoma fueron 0,7% y 1,6%, respectivamente. No hubo diferencias significativas en la progresión unifocal y multifocal. Se encontró que la colangitis esclerosante primaria, la colitis ulcerosa, el sexo masculino y la edad avanzada eran factores de riesgo significativos de neoplasia en el análisis multivariable.LIMITACIONES:Base de datos retrospectiva.CONCLUSIÓN:La progresión de la displasia de bajo grado a adenocarcinoma, independientemente de que sea unifocal o multifocal, sigue siendo muy baja en el contexto de una vigilancia y un tratamiento médico adecuados. La presencia de displasia multifocal de bajo grado no debería cambiar la toma de decisión para continuar con vigilancia endoscópica continua o realizar la proctocolectomía. Los pacientes con colangitis esclerosante primaria y displasia encontrada en biopsias aleatorias pueden tener una mayor progresión de la displasia. Consulte Video Resumen en http://links.lww.com/DCR/A649.

Endoscopic submucosal dissection is safe and feasible, allowing for ongoing surveillance and organ preservation in patients with inflammatory bowel disease

AIM

Experience of endoscopic submucosal dissection (ESD) for colorectal lesions in the setting of inflammatory bowel disease (IBD) remains limited. The aim of this work was to determine the safety, feasibility and oncological outcomes of ESD in patients with IBD.

METHOD

A retrospective review of all adult patients (≥18 years) with a known diagnosis of either ulcerative colitis (UC) or Crohn's disease (CD) who underwent advanced colonoscopy and ESD between 1 January 2014 and 1 October 2020. Data collected included patient demographics, disease characteristics, pathological variables and procedure-related complication rates.

RESULTS

A total of 25 patients were included: 19 (76%) were male with a median age of 63 years and disease duration of more than 10 years. Sixteen had UC and nine had CD; the majority were taking corticosteroids, immunomodulators or monoclonal antibodies at the time of ESD. The median procedure time was 41 min and the majority (n = 18; 72%) utilized chromoendoscopy. The median lesion size was 30 mm: eight had low-grade dysplasia, nine had high-grade dysplasia and three had adenocarcinoma and underwent oncological resection. None had surgical intervention for complication of ESD or perforation. A total of 23 (88%) had a complete R0 resection. Over a median follow-up of 19 months, three were found to have dysplasia excised in polyps and none had subsequent adenocarcinoma.

CONCLUSION

ESD in the setting of IBD is safe and effective for complete removal of large neoplastic lesions, allowing for ongoing endoscopic surveillance and organ preservation rather than surgical intervention.

Sporadic adenoma or ulcerative colitis associated neoplasia? The endoscopist's information has an impact on diagnosis and patient management

BACKGROUND

Diagnosing low grade intraepithelial neoplasia (LGIN) in patients with ulcerative colitis (UC) is difficult. Distinguishing between sporadic adenoma (SA) and UC associated LGIN is even more challenging but has clinical impact. We aimed to examine, if the morphological distinction between both entities is reliably possible, how it influences patient's outcome and the role of the endoscopist in this decision with respect to current endoscopy classification schemes.

METHODS

Seven pathologists retrospectively reevaluated 425 cases of LGIN in UC patients, diagnosed between 2009 and 2017 with preceding expert consensus and follow up in two separate readings, based on published morphological differentiation criteria. In the first evaluation, the observers were blinded to any clinical data. In the second evaluation, they knew patients' age as well as endoscopic features. They also rated their subjective diagnostic certainty.

RESULTS

Diagnostic correctness improved significantly in the second assessment as did the pathologists' confidence in their diagnoses (p < 0.001 - p = 0.019). Knowledge of clinical and endoscopical data led to a higher percentage of SA (71.8% vs. 85.6%). UC associated LGIN showed significant earlier LGIN relapse as well as more high grade intraepithelial neoplasia and carcinoma during follow up (p < 0.001, p < 0.001, p = 0.005).

CONCLUSIONS

Distinction between SA and UC associated LGIN is important as it has an impact on patients' follow up and treatment. Morphological distinction remains difficult with moderate interobserver variability. Adequate clinical information significantly improves pathologists' diagnoses as well as their confidence in their diagnoses.

Cost Effectiveness of Endoscopic Resection vs Transanal Resection of Complex Benign Rectal Polyps

BACKGROUND & AIMS

Complex benign rectal polyps can be managed with transanal surgery or with endoscopic resection (ER). Though the complication rate after ER is lower than transanal surgery, recurrence is higher. Patients lost to follow up after ER might therefore be at increased risk for rectal cancer. We evaluated the costs, benefits, and cost effectiveness of ER compared to 2 surgical techniques for removing complex rectal polyps, using a 50-year time horizon-this allowed us to capture rates of cancer development among patients lost from follow-up surveillance.

METHODS

We created a Markov model to simulate the lifetime outcomes and costs of ER, transanal endoscopic microsurgery (TEM), and transanal minimally invasive surgery (TAMIS) for the management of a complex benign rectal polyp. We assessed the effect of surveillance by allowing a portion of the patients to be lost to follow up. We calculated the cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio or each intervention over a 50-year time horizon.

RESULTS

We found that TEM was slightly more effective than TAMIS and ER (TEM, 19.54 QALYs; TAMIS, 19.53 QALYs; and ER, 19.53 QALYs), but ER had a lower lifetime discounted cost (ER cost $7161, TEM cost $10,459, and TAMIS cost $11,253). TEM was not cost effective compared to ER, with an incremental cost-effectiveness ratio of $485,333/QALY. TAMIS was dominated by TEM. TEM became cost effective when the mortality from ER exceeded 0.63%, or if the loss to follow up rate exceeded 25.5%.

CONCLUSIONS

Using a Markov model, we found that ER, TEM, and TAMIS have similar effectiveness, but ER is less expensive, in management of benign rectal polyps. As the rate of loss to follow up increases, transanal surgery becomes more effective relative to ER.

Surgery versus surveillance in ulcerative colitis patients with endoscopically invisible low-grade dysplasia: a cost-effectiveness analysis

BACKGROUND AND AIMS

There is uncertainty regarding the optimal management of endoscopically invisible (flat) low-grade dysplasia in ulcerative colitis. Such a finding does not currently provide an automatic indication for colectomy; however, a recommendation of surveillance instead of surgery is controversial. The aim of this study was to determine the clinical and cost-effectiveness of colonoscopic surveillance versus colectomy for endoscopically invisible low-grade dysplasia of the colon in ulcerative colitis.

METHODS

A Markov model was used to evaluate the costs and health outcomes of surveillance and surgery over a 20-year timeframe. Outcomes evaluated were life years gained and quality-adjusted life years (QALYs). Cohorts of patients aged 25 to 75 were modeled, including estimates from a validated surgical risk calculator and considering none, 1, or both of 2 key comorbidities: heart failure and obstructive airway disease.

RESULTS

Surveillance is associated with more life years and QALYs compared with surgery from age 61 for those with no comorbidities, age 51 for those with 1 comorbidity and age 25 for those with 2 comorbidities. At the current United Kingdom National Institute for Health and Care Excellence threshold of $25,800 per QALY, ongoing surveillance was cost-effective at age 65 in those without comorbidities and at age 60 in those with either 1 or more comorbidities.

CONCLUSIONS

Surveillance can be recommended from age 65 for those with no comorbidities; however, in younger patients with typical postsurgical quality of life, colectomy may be more effective clinically and more cost-effective. The results were sensitive to the colorectal cancer incidence rate in patients under surveillance and to quality of life after surgery.

Stool DNA Analysis is Cost-Effective for Colorectal Cancer Surveillance in Patients With Ulcerative Colitis

BACKGROUND & AIMS

Patients with chronic ulcerative colitis are at increased risk for colorectal neoplasia (CRN). Surveillance by white-light endoscopy (WLE) or chromoendoscopy may reduce risk of CRN, but these strategies are underused. Analysis of DNA from stool samples (sDNA) can detect CRN with high levels of sensitivity, but it is not clear if this approach is cost-effective. We simulated these strategies for CRN detection to determine which approach is most cost-effective.

METHODS

We adapted a previously published Markov model to simulate the clinical course of chronic ulcerative colitis, the incidence of cancer or dysplasia, and costs and benefits of care with 4 surveillance strategies: (1) analysis of sDNA and diagnostic chromoendoscopy for patients with positive results, (2) analysis of sDNA with diagnostic WLE for patients with positive results, (3) chromoendoscopy with targeted collection of biopsies, or (4) WLE with random collection of biopsies. Costs were based on 2014 Medicare reimbursement. The primary outcome was the incremental cost-effectiveness ratio (incremental cost/incremental difference in quality-adjusted life-years) compared with no surveillance and a willingness-to-pay threshold of $50,000.

RESULTS

All strategies fell below the willingness-to-pay threshold at 2-year intervals. Incremental cost-effectiveness ratios were $16,362 per quality-adjusted life-year for sDNA analysis with diagnostic chromoendoscopy; $18,643 per quality-adjusted life-year for sDNA analysis with diagnostic WLE; $23,830 per quality-adjusted life-year for chromoendoscopy alone; and $27,907 per quality-adjusted life-year for WLE alone. In sensitivity analyses, sDNA analysis with diagnostic chromoendoscopy was more cost-effective than chromoendoscopy alone, up to a cost of $1135 per sDNA test. sDNA analysis remained cost-effective at all rates of compliance; when combined with diagnostic chromoendoscopy, this approach was preferred over chromoendoscopy alone, when the specificity of the sDNA test for CRN was >65%.

CONCLUSIONS

Based on a Markov model, surveillance for CRN is cost-effective for patients with chronic ulcerative colitis. Analysis of sDNA with chromoendoscopies for patients with positive results was more cost-effective than chromoendoscopy or WLE alone.

Systematic review: the financial burden of surgical complications in patients with ulcerative colitis

BACKGROUND

Patients undergoing colectomy for ulcerative colitis (UC) may experience complications associated with reduced quality of life (QoL), and maybe a considerable economic burden to healthcare systems. Appreciation of these burdens is important to evaluate the cost effectiveness of newer interventions for UC vs. colectomy.

AIM

To identify data representing resource utilisation or costs of complications arising from colorectal procedures in patients with UC, and data representing patient QoL, as reported by health state utility values (HSUVs).

METHODS

Embase, MEDLINE and The Cochrane Library were searched for studies (1995-2014) reporting resource use/costs of surgical complications, and HSUVs data in adult patients with UC, undergoing colorectal procedures. Conference proceedings (January 2011-January 2014) were hand-searched.

RESULTS

Twelve studies reported resource use/costs, and three reported HSUVs data in patients with UC experiencing surgical complications. Additional mean costs of postoperative complications ranged from $18 650/patient with complications at a 6-month follow-up (46% incidence) to $34 714/patient with complications over a 5-year period (49% incidence). Pouchitis, pouch failure and small bowel obstruction carried the greatest burden. Marked reductions in HSUVs were observed for patients with UC experiencing surgical complications, vs. patients with UC in a remission state.

CONCLUSIONS

There is a paucity of well reported studies on resource use/cost, and QoL burden of surgical complications in patients with UC. However, surgical complications represent a substantial burden both in terms of cost and of quality of life, with reoperations, physician fees, additional in-patient hospital stays and infertility treatment being the main cost drivers.

Colorectal cancer in colitis: a relic of the past?

The incidence of dysplasia and colorectal cancer in patients with long-standing colitis seems to be decreasing and controversy surrounds our detection and management strategies. Dysplasia is rarer, flatter, and smaller than in previous decades. Current surveillance guidelines, onerous in terms of colonoscopic workload and an emphasis on random biopsies, have yet to be shown to prevent colon cancers and colon cancer death in these patients. The evidence base for adjunct techniques such as chromoendoscopy is strong but adoption has been slow. We need to better risk-stratify patients with colitis and direct diminishing medical resources accordingly. Modulating dysplasia and cancer risk will involve optimizing medical therapies and focusing our colonoscopic efforts on those who will most likely benefit.

A risk-profiling approach for surveillance of inflammatory bowel disease-colorectal carcinoma is more cost-effective: a comparative cost-effectiveness analysis between international guidelines

BACKGROUND

Colonoscopic surveillance for neoplasia is recommended for patients with inflammatory bowel disease (IBD)-related colitis. However, data on cost-effectiveness predate current international guidelines.

OBJECTIVE

To compare cost-effectiveness based on contemporary data between the surveillance strategies of the American Gastroenterological Association (AGA) and British Society of Gastroenterology (BSG).

DESIGN

We constructed a Markov decision model to simulate the clinical course of IBD patients.

SETTING

We compared the 2 surveillance strategies for a base case of a 40-year-old colitis patient who was followed for 40 years.

PATIENTS

AGA surveillance distinguishes 2 groups: a high-risk group with annual surveillance and an average-risk group with biannual surveillance. BSG surveillance distinguishes 3 risk groups with yearly, 3-year, or 5-year surveillance.

INTERVENTIONS

Patients could move from a no-dysplasia state with colonoscopic surveillance to 1 of 3 states for which proctocolectomy was indicated: (1) dysplasia/local cancer, (2) regional/metastasized cancer, or (3) refractory disease. After proctocolectomy, a patient moved to a no-colon state without surveillance.

MAIN OUTCOME MEASUREMENTS

Direct costs of medical care, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.

RESULTS

BSG surveillance dominated AGA surveillance with $9846 per QALY. Both strategies were equally effective with 24.16 QALYs, but BSG surveillance was associated with lower costs because of fewer colonoscopies performed. Costs related to IBD, surgery, or cancer did not affect cost-effectiveness.

LIMITATIONS

The model depends on the accuracy of derived data, and the assumptions that were made to reflect real-life situations. Study conclusions may only apply to the U.S. health care system.

CONCLUSION

The updated risk-profiling approach for surveillance of IBD colorectal carcinoma by the BSG guideline appears to be more cost-effective.

Colorectal cancer surveillance in patients with inflammatory bowel disease and primary sclerosing cholangitis: an economic evaluation

BACKGROUND

The cost-effectiveness of annual colonoscopy for detection of colorectal neoplasia among patients with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC) is uncertain. The aim of this study was to determine whether annual colonoscopy among patients with IBD-PSC is cost-effective compared with less frequent intervals from the perspective of a publicly funded health care system.

METHODS

A cost-utility analysis using a Markov model was used to simulate a 35-year-old patient with a 10-year history of well-controlled IBD and a recent diagnosis of concomitant PSC. The following strategies were compared: no surveillance, colonoscopy every 5 years, biennial colonoscopy, and annual colonoscopy. Outcome measures included: costs, number of cases of dysplasia found, number of cancers found and missed, deaths, quality-adjusted life-years (QALYs) gained, and the incremental cost per QALY gained.

RESULTS

In the base-case analysis, no surveillance was the least expensive and least effective strategy. Compared with no surveillance, the cost per QALY of surveillance every 5 years was CAD $15,021. The cost per QALY of biennial surveillance compared with surveillance every 5 years was CAD $37,522. Annual surveillance was more effective than biennial surveillance, but at an incremental cost of CAD $174,650 per QALY gained compared with biennial surveillance.

CONCLUSIONS

More frequent colonoscopy screening intervals improve effectiveness (i.e., detects more cancers and prevents additional deaths), but at higher cost. Health systems must consider the opportunity costs associated with different surveillance colonoscopy intervals when deciding which strategy to implement among patients with IBD-PSC.

Surgical management of nonpolypoid colorectal lesions and strictures in colonic inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) and dysplasia have pathologic characteristics and risks different from those of patients with sporadic carcinomas. Therefore, surgical interventions need to be more aggressive than in sporadic cases. This article reviews the surgical management of nonpolypoid lesions, dysplasia, and strictures found in patients with IBD.

Cost-effectiveness analysis of chromoendoscopy for colorectal cancer surveillance in patients with ulcerative colitis

BACKGROUND

Recent studies report that the risk of colorectal cancer (CRC) among patients with ulcerative colitis (UC) may be lower than previously estimated. Although white-light endoscopy (WLE) with random biopsies is recommended for dysplasia detection in patients with UC, several studies reported increased detection of dysplasia by chromoendoscopy.

OBJECTIVE

To analyze the cost effectiveness of chromoendoscopy relative to WLE or no endoscopy for CRC surveillance in patients with UC.

DESIGN

Decision-analytic state-transition (Markov) model with Monte Carlo simulation.

SETTING

To simulate the clinical course of chronic UC, we estimated dysplasia and CRC incidence and progression, endoscopic test characteristics, stage-specific mortality rates, and costs from published literature and Medicare reimbursement data.

PATIENTS

Patients from a population-based age distribution with ulcerative colitis for ≥8 years.

INTERVENTION

We compared 3 different strategies at various surveillance intervals: chromoendoscopy with targeted biopsies, WLE with random biopsies, and no surveillance. The robustness of the model was assessed by using probabilistic sensitivity analysis. One-way sensitivity analyses were performed to evaluate individual variables, and 3-dimensional analysis was used to examine the effects of varying screening intervals.

MAIN OUTCOME MEASUREMENTS

Incremental cost-effectiveness ratio (ICER).

RESULTS

Chromoendoscopy was found to be more effective and less costly than WLE at all surveillance intervals. However, compared with no surveillance, chromoendoscopy was cost effective only at surveillance intervals of at least 7 years, with an ICER of $77,176. Chromoendoscopy was the most cost effective strategy at sensitivity levels >0.23 for dysplasia detection and cost <$2200, regardless of the level of sensitivity of WLE for dysplasia detection. The estimated population lifetime risk of developing CRC ranged from 2.5% (annual chromoendoscopy) to 5.9% (chromoendoscopy every 10 years).

LIMITATIONS

Estimates used for the model are based on best available data in the literature.

CONCLUSION

Chromoendoscopy is both more effective and less costly than WLE and becomes cost effective relative to no surveillance when performed at intervals of ≥7 years.

Managing risks of neoplasia in inflammatory bowel disease

Inflammatory bowel disease (IBD) has been linked with a variety of intestinal and extraintestinal cancers. This review summarizes the latest literature with regard to which cancers are truly linked with IBD and which are not, the absolute and relative risks of these cancers, how medications commonly prescribed for IBD affect this risk, and finally strategies for managing these risks. Physicians and health professionals may find this information useful for counseling and educating patients as well as for improving patient care.

Cancer surveillance in patients with primary sclerosing cholangitis

Primary sclerosing cholangitis (PSC) is a chronic fibroinflammatory syndrome involving the biliary tract, often accompanied by inflammatory bowel disease (IBD). This syndrome is a prototype disease linking chronic inflammation to carcinogenesis. Indeed, PSC is associated with an increased risk of cholangiocarcinoma (CCA), gallbladder cancer, hepatocellular carcinoma (HCC), and colorectal cancer. Herein, we review the risk for these malignancies in PSC and discuss rational cancer surveillance strategies for these patients. Where evidence is limited, we suggest a pragmatic approach. In this regard, we recommend interval screening for CCA with noninvasive imaging modalities and serum carbohydrate antigen 19-9 determinations annually. These imaging studies also serve to screen for gallbladder cancer and HCC. Screening for colorectal cancer is more firmly established in PSC patients with IBD and includes colonoscopy at the time of PSC diagnosis and, thereafter, at 1-2-year intervals. We also highlight areas where more information is required, such as management of biliary tract dysplasia and cancer chemoprevention in PSC.

Cancer surveillance strategies in ulcerative colitis: the need for modernization

The risk of colorectal cancer is increased in patients with long-standing ulcerative colitis. Traditional surveillance has centered around regular standard white-light colonoscopy, with multiple biopsies aimed at detecting dysplasia or the identification of early cancer. This has resulted in only a modest reduction in cancer incidence and mortality. A better understanding of disease risk factors may allow endoscopic resources to be more focused on patients at higher risk. In addition, advanced endoscopic techniques have the potential to improve dysplasia detection, minimize the need for routine biopsies, and allow for the removal of dysplastic lesions, avoiding the need for surgery. Techniques such as magnification colonoscopy, chromoendoscopy, narrow band imaging, autofluorescence, and confocal endomicroscopy may all have a role to play in improving the benefits of endoscopic surveillance. Revised endoscopic surveillance strategies are proposed, incorporating aspects of risk stratification, a well-established practice in noncolitis-related colorectal cancer screening, and some of these new technologies.

Inflammatory bowel disease-attributable costs and cost-effective strategies in the United States: a review

The United States spends more for healthcare than any other country in the world. With the rising prevalence of both Crohn's disease and ulcerative colitis, inflammatory bowel disease (IBD) represents the leading chronic gastrointestinal disease with increasing healthcare expenditures in the US. IBD costs have shifted from inpatient to outpatient care since the introduction of biologic therapies as the standard of care. Gastroenterologists need to be aware of the national cost burden of IBD and clinical practices that optimize cost-efficiency. This investigation offers a systematic review of the economics of IBD and evidence-based strategies for cost-effective management.