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Abstract
BACKGROUND Observational studies have described racial differences in inflammatory bowel disease (IBD) genetics, clinical manifestations, and outcomes. Whether race impacts response to biologics in IBD is unclear. We conducted a post hoc analysis of phase 2 and 3 randomized clinical trials in ulcerative colitis to evaluate the effect of race on response to golimumab. METHODS We analyzed pooled individual-level data from induction and maintenance trials of golimumab through the Yale Open Data Access Project. The primary outcome was clinical response. Secondary outcomes were clinical remission and endoscopic healing. Multivariable logistic regression was performed comparing White vs racial minority groups (Asian, Black, or other race), adjusting for potential confounders. RESULTS There were 1006 participants in the induction (18% racial minority) and 783 participants in the maintenance (17% racial minority) trials. Compared with White participants, participants from racial minority groups had significantly lower clinical response (adjusted odds ratio [aOR], 0.43; 95% confidence interval [CI], 0.28-0.66), clinical remission (aOR, 0.41; 95% CI, 0.22-0.77), and endoscopic healing (aOR, 0.48; 95% CI, 0.31-0.74) at week 6. Participants from racial minority groups also had significantly lower clinical remission (aOR, 0.46; 95% CI, 0.28-0.74) and endoscopic healing (aOR, 0.63; 95% CI, 0.41-0.96) at week 30. There were no racial differences in placebo response rates. CONCLUSIONS Ulcerative colitis participants from racial minority groups were less likely to achieve clinical response, clinical remission, and endoscopic healing with golimumab compared with White participants in induction and maintenance trials. Further studies are needed to understand the impact of race on therapeutic response in IBD.
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Affiliation(s)
- Ruby Greywoode
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Francesca Petralia
- Department of Genetics and Genomic Sciences, Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas A Ullman
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jean Frederic Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ryan C Ungaro
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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2
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Abstract
Longstanding and extensive ulcerative colitis (UC) are associated with the subsequent development of colorectal cancer (CRC). This article summarizes key strategies for colonoscopic surveillance, the most widely used and evidence-based method of CRC prevention. As currently constituted and practiced, surveillance examinations every 1 to 3 years with lesion detection and removal using high-definition endoscopic systems with or without pancolonic spray-dye chromoendoscopy is the best method for mitigating the development of CRC morbidity and mortality. For patients with primary sclerosing cholangitis with UC, surveillance should begin at the time of diagnosis and colonoscopy should be performed annually.
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Affiliation(s)
- Wendy Rabbenou
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, 33030 Rochambeau Avenue, Bronx, NY 10461, USA
| | - Thomas A Ullman
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, 33030 Rochambeau Avenue, Bronx, NY 10461, USA.
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3
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Shah SC, Glass J, Giustino G, Hove JRT, Castaneda D, Torres J, Kumar A, Elman J, Ullman TA, Itzkowitz SH. Statin Exposure Is Not Associated with Reduced Prevalence of Colorectal Neoplasia in Patients with Inflammatory Bowel Disease. Gut Liver 2019; 13:54-61. [PMID: 30400722 PMCID: PMC6346999 DOI: 10.5009/gnl18178] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/29/2018] [Accepted: 07/07/2018] [Indexed: 12/21/2022] Open
Abstract
Background/Aims Statins have been postulated to lower the risk of colorectal neoplasia. No studies have examined any possible chemopreventive effect of statins in patients with inflammatory bowel disease (IBD) undergoing colorectal cancer (CRC) surveillance. This study examined the association of statin exposure with dysplasia and CRC in patients with IBD undergoing dysplasia surveillance colonoscopies. Methods A cohort of patients with IBD undergoing colonoscopic surveillance for dysplasia and CRC at a single academic medical center were studied. The inclusion criteria were IBD involving the colon for 8 years (or any colitis duration if associated with primary sclerosing cholangitis [PSC]) and at least two colonoscopic surveillance exams. The exclusion criteria were CRC or high-grade dysplasia (HGD) prior to or at enrollment, prior colectomy, or limited (<30%) colonic disease. The primary outcome was the frequency of dysplasia and/or CRC in statin-exposed versus nonexposed patients. Results A total of 642 patients met the inclusion criteria (57 statin-exposed and 585 nonexposed). The statin-exposed group had a longer IBD duration, longer follow-up period, and more colonoscopies but lower inflammatory scores, less frequent PSC and less use of thiopurines and biologics. There were no differences in low-grade dysplasia, HGD, or CRC development during the follow-up period between the statin-exposed and nonexposed groups (21.1%, 5.3%, 1.8% vs 19.2%, 2.9%, 2.9%, respectively). Propensity score analysis did not alter the overall findings. Conclusions In IBD patients undergoing surveillance colonoscopies, statin use was not associated with reduced dysplasia or CRC rates. The role of statins as chemopreventive agents in IBD remains controversial.
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Affiliation(s)
- Shailja C Shah
- Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA.,The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jason Glass
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gennaro Giustino
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joren R Ten Hove
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Daniel Castaneda
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joana Torres
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Gastroenterology, Surgical Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Akash Kumar
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jordan Elman
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas A Ullman
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steven H Itzkowitz
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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4
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Ten Hove JR, Shah SC, Shaffer SR, Bernstein CN, Castaneda D, Palmela C, Mooiweer E, Elman J, Kumar A, Glass J, Axelrad J, Ullman TA, Colombel JF, Torres J, van Bodegraven AA, Hoentjen F, Jansen JM, de Jong ME, Mahmmod N, van der Meulen-de Jong AE, Ponsioen CY, van der Woude CJ, Itzkowitz SH, Oldenburg B. Consecutive negative findings on colonoscopy during surveillance predict a low risk of advanced neoplasia in patients with inflammatory bowel disease with long-standing colitis: results of a 15-year multicentre, multinational cohort study. Gut 2019; 68:615-622. [PMID: 29720408 DOI: 10.1136/gutjnl-2017-315440] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/31/2018] [Accepted: 03/01/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Surveillance colonoscopy is thought to prevent colorectal cancer (CRC) in patients with long-standing colonic IBD, but data regarding the frequency of surveillance and the findings thereof are lacking. Our aim was to determine whether consecutive negative surveillance colonoscopies adequately predict low neoplastic risk. DESIGN A multicentre, multinational database of patients with long-standing IBD colitis without high-risk features and undergoing regular CRC surveillance was constructed. A 'negative' surveillance colonoscopy was predefined as a technically adequate procedure having no postinflammatory polyps, no strictures, no endoscopic disease activity and no evidence of neoplasia; a 'positive' colonoscopy was a technically adequate procedure that included at least one of these criteria. The primary endpoint was advanced colorectal neoplasia (aCRN), defined as high-grade dysplasia or CRC. RESULTS Of 775 patients with long-standing IBD colitis, 44% (n=340) had >1 negative colonoscopy. Patients with consecutive negative surveillance colonoscopies were compared with those who had at least one positive colonoscopy. Both groups had similar demographics, disease-related characteristics, number of surveillance colonoscopies and time intervals between colonoscopies. No aCRN occurred in those with consecutive negative surveillance, compared with an incidence rate of 0.29 to 0.76/100 patient-years (P=0.02) in those having >1 positive colonoscopy on follow-up of 6.1 (P25-P75: 4.6-8.2) years after the index procedure. CONCLUSION Within this large surveillance cohort of patients with colonic IBD and no additional high-risk features, having two consecutive negative colonoscopies predicted a very low risk of aCRN occurrence on follow-up. Our findings suggest that longer surveillance intervals in this selected population may be safe.
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Affiliation(s)
- Joren R Ten Hove
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Shailja C Shah
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
- Division of Gastroenterology and Hepatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Seth R Shaffer
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Charles N Bernstein
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Daniel Castaneda
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Carolina Palmela
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Erik Mooiweer
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jordan Elman
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Akash Kumar
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Jason Glass
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Jordan Axelrad
- Division of Gastroenterology, Columbia University, New York, USA
| | - Thomas A Ullman
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | | | - Joana Torres
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
- Surgical Department, Gastroenterology Division, Hospital Beatriz Angelo, Loures, Lisboa, Portugal
| | - Adriaan A van Bodegraven
- Department of Gastroenterology and Hepatology, Vrije Universiteit Medical Center Amsterdam, Amsterdam, The Netherlands
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
| | - Frank Hoentjen
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen M Jansen
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis Amsterdam, Amsterdam, The Netherlands
| | - Michiel E de Jong
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nofel Mahmmod
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, St Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Andrea E van der Meulen-de Jong
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Cyriel Y Ponsioen
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam Medical Center, Amsterdam, Netherlands
| | - Christine J van der Woude
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, Netherlands
| | - Steven H Itzkowitz
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
- Dutch Initiative on Crohn and Colitis (ICC), The Netherlands
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5
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Shah SC, Ten Hove JR, Castaneda D, Palmela C, Mooiweer E, Colombel JF, Harpaz N, Ullman TA, van Bodegraven AA, Jansen JM, Mahmmod N, van der Meulen-de Jong AE, Ponsioen CY, van der Woude CJ, Oldenburg B, Itzkowitz SH, Torres J. High Risk of Advanced Colorectal Neoplasia in Patients With Primary Sclerosing Cholangitis Associated With Inflammatory Bowel Disease. Clin Gastroenterol Hepatol 2018; 16:1106-1113.e3. [PMID: 29378311 DOI: 10.1016/j.cgh.2018.01.023] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 12/20/2017] [Accepted: 01/12/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC, termed PSC-IBD) are at increased risk for colorectal cancer, but their risk following a diagnosis of low-grade dysplasia (LGD) is not well described. We aimed to determine the rate of advanced colorectal neoplasia (aCRN), defined as high-grade dysplasia and/or colorectal cancer, following a diagnosis of indefinite dysplasia or LGD in this population. METHODS We performed a retrospective, longitudinal study of 1911 patients with colonic IBD (293 with PSC and 1618 without PSC) who underwent more than 2 surveillance colonoscopies from 2000 through 2015 in The Netherlands or the United States (9265 patient-years of follow-up evaluation). We collected data on clinical and demographic features of patients, as well as data from each surveillance colonoscopy and histologic report. For each surveillance colonoscopy, the severity of active inflammation was documented. The primary outcome was a diagnosis of aCRN during follow-up evaluation. We also investigated factors associated with aCRN in patients with or without a prior diagnosis of indefinite dysplasia or LGD. RESULTS Patients with PSC-IBD had a 2-fold higher risk of developing aCRN than patients with non-PSC IBD. Mean inflammation scores did not differ significantly between patients with PSC-IBD (0.55) vs patients with non-PSC IBD (0.56) (P = .89), nor did proportions of patients with LGD (21% of patients with PSC-IBD vs 18% of patients with non-PSC IBD) differ significantly (P = .37). However, the rate of aCRN following a diagnosis of LGD was significantly higher in patients with PSC-IBD (8.4 per 100 patient-years) than patients with non-PSC IBD (3.0 per 100 patient-years; P = .01). PSC (adjusted hazard ratio [aHR], 2.01; 95% CI, 1.09-3.71), increasing age (aHR 1.03; 95% CI, 1.01-1.05), and active inflammation (aHR, 2.39; 95% CI, 1.63-3.49) were independent risk factors for aCRN. Dysplasia was more often endoscopically invisible in patients with PSC-IBD than in patients with non-PSC IBD. CONCLUSIONS In a longitudinal study of almost 2000 patients with colonic IBD, PSC remained a strong independent risk factor for aCRN. Once LGD is detected, aCRN develops at a higher rate in patients with PSC and is more often endoscopically invisible than in patients with only IBD. Our findings support recommendations for careful annual colonoscopic surveillance for patients with IBD and PSC, and consideration of colectomy once LGD is detected.
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Affiliation(s)
- Shailja C Shah
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Gastroenterology and Hepatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joren R Ten Hove
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Daniel Castaneda
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carolina Palmela
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Erik Mooiweer
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jean-Frédéric Colombel
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Noam Harpaz
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Thomas A Ullman
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ad A van Bodegraven
- Department of Gastroenterology and Hepatology, Vrije Universiteit Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis Amsterdam, Amsterdam, The Netherlands
| | - Nofel Mahmmod
- Department of Gastroenterology and Hepatology, St Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | | | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam Medical Center, Amsterdam, The Netherlands
| | - Christine J van der Woude
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bas Oldenburg
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven H Itzkowitz
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joana Torres
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York; Surgical Department, Gastroenterology Division, Hospital Beatriz Ângelo, Loures, Portugal.
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6
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Grossberg LB, Papamichael K, Feuerstein JD, Siegel CA, Ullman TA, Cheifetz AS. A Survey Study of Gastroenterologists' Attitudes and Barriers Toward Therapeutic Drug Monitoring of Anti-TNF Therapy in Inflammatory Bowel Disease. Inflamm Bowel Dis 2017; 24:191-197. [PMID: 29272486 DOI: 10.1093/ibd/izx023] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) may improve the efficacy and cost-effectiveness of anti-TNF therapy. A standardized approach of utilizing TDM has not been established. The objective of this study was to determine gastroenterologists' attitudes and barriers toward TDM of anti-TNF therapy in clinical practice. METHODS An 18-question survey was distributed to members of the American College of Gastroenterology and Crohn's and Colitis Foundation via email. We collected physician characteristics, practice demographics, and data regarding TDM use and perceived barriers to TDM. Factors associated with the use of TDM were determined by logistic regression analysis. RESULTS A total of 403 gastroenterologists from 42 US states (76.4% male) met inclusion criteria: 90.1% use TDM, mostly reactively for secondary loss of response (87.1%) and primary nonresponse (66%); 36.6% use TDM proactively. The greatest barriers to TDM implementation were uncertainty about insurance coverage (77.9%), high out-of-pocket patient costs (76.4%), and time lag from serum sample to result (38.5%). Factors independently associated with the use of TDM and proactive TDM were practice in an academic setting (P = 0.019), and more IBD patients seen per month (P = 0.015), and Crohn's and Colitis Foundation membership (P < 0.001), and more IBD patients on anti-TNF therapy per month (P = 0.006), respectively. If all barriers were removed, an additional one-third of physicians would apply proactive TDM. CONCLUSIONS Lack of insurance coverage, high out-of-pocket costs, and the time lag from test to result limit use of TDM in the United States. Validation of low-cost assays, point of care testing, and studies that standardize the use of TDM are needed to make TDM more commonplace.
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Affiliation(s)
- Laurie B Grossberg
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Joseph D Feuerstein
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Corey A Siegel
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Adam S Cheifetz
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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7
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Affiliation(s)
- Thomas A Ullman
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Ashish Atreja
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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8
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Ullman TA, Itzkowitz SH. Prognosis of Colorectal Cancer in Inflammatory Bowel Disease: Data from a State Registry. Dig Dis Sci 2017; 62:1850-1851. [PMID: 28374084 DOI: 10.1007/s10620-017-4557-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 03/28/2017] [Indexed: 12/09/2022]
Affiliation(s)
- Thomas A Ullman
- Icahn School of Medicine at Mount Sinai, New York City, NY, USA
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9
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Marion JF, Waye JD, Israel Y, Present DH, Suprun M, Bodian C, Harpaz N, Chapman M, Itzkowitz S, Abreu MT, Ullman TA, McBride RB, Aisenberg J, Mayer L. Chromoendoscopy Is More Effective Than Standard Colonoscopy in Detecting Dysplasia During Long-term Surveillance of Patients With Colitis. Clin Gastroenterol Hepatol 2016; 14:713-9. [PMID: 26656297 DOI: 10.1016/j.cgh.2015.11.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 08/24/2015] [Accepted: 11/12/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with colitis have an increased risk of colorectal cancer, compared with persons without colitis. Many studies have shown chromoendoscopy (CE) to be superior to standard methods of detecting dysplasia in patients with colitis at index examination. We performed a prospective, longitudinal study to compare standard colonoscopy vs CE in detecting dysplasia in patients with inflammatory bowel diseases in a surveillance program. METHODS We analyzed data from 68 patients (44 men, 24 women) diagnosed with ulcerative colitis (n = 55) or Crohn's disease (n = 13) at Mount Sinai Medical Center from September 2005 through October 2011. The patients were followed from June 2006 through October 2011 (median, 27.8 months); each patient was analyzed by random biopsy, targeted white light examination (WLE), and CE. Specimens were reviewed by a single blinded pathologist. The 3 methods were compared by using the generalized estimating equations method, and the odds ratios (ORs) for detection of dysplasia were calculated (primary outcome). Time to colectomy was analyzed by using the Cox model. RESULTS In the 208 examinations conducted, 44 dysplastic lesions were identified in 24 patients; 6 were detected by random biopsy, 11 by WLE, and 27 by CE. Ten patients were referred for colectomy, and no carcinomas were found. At any time during the study period, CE (OR, 5.4; 95% confidence interval [CI], 2.9-9.9) and targeted WLE (OR, 2.3; 95% CI, 1.0-5.3) were more likely than random biopsy analysis to detect dysplasia. CE was superior to WLE (OR, 2.4; 95% CI, 1.4-4.0). Patients identified as positive for dysplasia were more likely to need colectomy (hazard ratio, 12.1; 95% CI, 3.2-46.2). CONCLUSIONS In a prospective study of 68 patients with inflammatory bowel diseases, CE was superior to random biopsy or WLE analyses in detecting dysplasia in patients with colitis during an almost 28-month period. A negative result from CE examination was the best indicator of a dysplasia-free outcome, whereas a positive result was associated with earlier referral for colectomy.
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Affiliation(s)
- James F Marion
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Jerome D Waye
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Yuriy Israel
- Division of Gastroenterology and Hepatobiliary Diseases, New York Medical College, Valhalla, New York
| | - Daniel H Present
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Maria Suprun
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carol Bodian
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Noam Harpaz
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mark Chapman
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Steven Itzkowitz
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Maria T Abreu
- Division of Gastroenterology, University of Miami, Miami, Florida
| | - Thomas A Ullman
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Russell B McBride
- Department of Pathology and the Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - James Aisenberg
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lloyd Mayer
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
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10
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Tinsley A, Naymagon S, Mathers B, Kingsley M, Sands BE, Ullman TA. Early readmission in patients hospitalized for ulcerative colitis: incidence and risk factors. Scand J Gastroenterol 2016; 50:1103-9. [PMID: 25866237 DOI: 10.3109/00365521.2015.1020862] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Early readmission rates are becoming an integral measure of the quality of care for hospitalized patients with chronic diseases. The incidence and predictors of early readmission in patients with inflammatory bowel disease (IBD) are uncertain. Risk factors for readmission over the first few weeks may differ from those that influence re-hospitalization at later time points. We examined the incidence and predictors of both 30-day and 90-day readmissions among ulcerative colitis (UC) patients. MATERIALS AND METHODS A retrospective, cohort study was performed including all severe UC patients admitted to a tertiary-care hospital between January 2007 and December 2011. All-cause readmissions to the medical or surgical service within 30 and 90 days were recorded to allow the calculation of early readmission rates. We used multiple logistic regression to analyze demographic, hospital-related, general medical and IBD-specific factors as potential risk factors for readmission. RESULTS There were a total of 229 patients discharged following hospitalization for severe UC. The 30- and 90-day readmission rates were 11.7% and 20.5%, respectively. Forty-seven percent of early readmissions were for colectomy. In the 30-day analysis, only the presence of extensive colitis (odds ratio 3.59; 95% confidence interval [CI] 1.41-9.13) compared with left-sided disease was independently associated with readmission. Extensive colitis (3.09, 95% CI 1.33-7.08), albumin on admission (0.56, 0.31-0.99) and being admitted to a housestaff service (2.87, 95% CI 1.14-6.54), were independent predictors of readmission at 90 days. CONCLUSIONS Early readmission is common in IBD. Independent risk factors for early readmission included extensive colitis, admission albumin, and being admitted to a housestaff service.
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Affiliation(s)
- Andrew Tinsley
- Division of Gastroenterology and Hepatology, Penn State Hershey Medical Center , Hershey, PA 17033 , USA
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Naymagon S, Ullman TA. Chromoendoscopy and Dysplasia Surveillance in Inflammatory Bowel Disease: Past, Present, and Future. Gastroenterol Hepatol (N Y) 2015; 11:304-311. [PMID: 27482174 PMCID: PMC4962681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The evidence supporting the practice of dysplasia surveillance in inflammatory bowel disease (IBD) has remained sparse, and optimal detection strategies are still lacking. These issues, added to the declining incidence of dysplasia in IBD, have led to much debate over the diagnosis and management of dysplasia. White-light endoscopy with targeted and random biopsies remains the technique of choice for most practicing gastroenterologists. However, during the past decade, a surge of literature has questioned the efficacy of this strategy. Simultaneously, chromoendoscopy has emerged as an alternative, and perhaps superior, technique that has been included in some society guidelines. Nevertheless, many issues remain unclear, such as the best way to implement chromoendoscopy into everyday practice, whether there are any outcome benefits that can be attributed to the use of chromoendoscopy, and, perhaps most importantly, how to manage dysplasia uncovered by this and other advanced techniques. In this article, we discuss the various techniques currently available for dysplasia surveillance in IBD, with a focus on chromoendoscopy. Additionally, we highlight the overarching issues of setting appropriate endpoints and individualizing the care of patients with long-standing colitis.
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Affiliation(s)
- Steven Naymagon
- Dr Naymagon is an assistant professor of medicine and Dr Ullman is an associate professor of medicine in the Henry D. Janowitz Division of Gastroenterology at the Icahn School of Medicine at Mount Sinai in New York, New York
| | - Thomas A Ullman
- Dr Naymagon is an assistant professor of medicine and Dr Ullman is an associate professor of medicine in the Henry D. Janowitz Division of Gastroenterology at the Icahn School of Medicine at Mount Sinai in New York, New York
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Itzkowitz SH, Sands BE, Ullman TA, Rustgi AK. Mark Warren Babyatsky, MD (June 29, 1959-August 25, 2014). Gastroenterology 2014; 147:1189-90. [PMID: 25449021 DOI: 10.1053/j.gastro.2014.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Steven H Itzkowitz
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bruce E Sands
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Thomas A Ullman
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anil K Rustgi
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Naymagon S, Mikulasovich M, Gui X, Ullman TA, Harpaz N. Crohn's-like clinical and pathological manifestations of giant inflammatory polyposis in IBD: a potential diagnostic pitfall. J Crohns Colitis 2014; 8:635-40. [PMID: 24368253 DOI: 10.1016/j.crohns.2013.11.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 11/25/2013] [Accepted: 11/26/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Giant inflammatory polyposis (GIP), characterized by mass-like agglomerations of inflammatory polyps, is a rare complication of inflammatory bowel disease (IBD). We reviewed a series of cases of GIP to determine its diagnostic impact on the clinical and pathologic distinction between ulcerative colitis (UC) and colonic Crohn's disease (CD). METHODS All colons with GIP resected over a 13-year period were identified prospectively and the corresponding clinical and pathologic records were reviewed. RESULTS Twelve cases of GIP were identified, accounting for 0.8% of colectomies for IBD during the same time interval. Preoperatively, 6 (50%) patients were diagnosed with UC, 2 (17%) with CD and 4 (33%) with indeterminate colitis (IC). Postoperatively, 6 of the diagnoses (50%) were revised based on strict histopathologic criteria: all 4 diagnoses of IC to UC, one diagnosis of CD to UC, and one diagnosis of UC to CD, for a total of 10 diagnoses of UC (83%) and two of CD (17%). Significantly, 7 of 10 cases with postoperative diagnoses of UC (70%) had Crohn's-like transmural inflammation exclusively within the polyposis segments attributed to fecal entrapment and stasis and accounting for the Crohn's-like clinical complications in these cases. CONCLUSIONS This case series of GIP, the largest reported from a single center, highlights the high rate of Crohn's-like clinical and pathological manifestations of GIP and their potential to confound the accurate classification of patients with IBD. A diagnosis of UC should not be amended to CD based on the findings of the polyposis segment alone.
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Affiliation(s)
- Steven Naymagon
- Department of Medicine and The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, United States.
| | - Michael Mikulasovich
- Department of Pathology, Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, United States
| | - Xianyong Gui
- Department of Pathology and Laboratory Service, University of Calgary, Calgary, AB, Canada
| | - Thomas A Ullman
- Department of Medicine and The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, United States
| | - Noam Harpaz
- Department of Medicine and The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, United States; Department of Pathology, Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, United States
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Affiliation(s)
- Oren Bernheim
- The Dr Henry D Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, , New York, New York, USA
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Affiliation(s)
- Fernando S Velayos
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, California.
| | - Thomas A Ullman
- The Dr Henry D. Janowitz Division of Gastroenterology, The Mount Sinai Medical Center, New York, New York
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Ha C, Ullman TA, Siegel CA, Kornbluth A. Patients enrolled in randomized controlled trials do not represent the inflammatory bowel disease patient population. Clin Gastroenterol Hepatol 2012; 10:1002-7; quiz e78. [PMID: 22343692 DOI: 10.1016/j.cgh.2012.02.004] [Citation(s) in RCA: 231] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2011] [Revised: 01/03/2012] [Accepted: 02/06/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Multiple randomized controlled trials (RCTs) have been conducted to determine therapeutic efficacy of the biological agents for the inflammatory bowel diseases (IBD). However, the external validity of findings from RCTs might be compromised by their stringent selection criteria. We investigated the proportion of patients encountered during routine clinical practice who would qualify for enrollment into a pivotal RCT of biological agents for IBD. METHODS We performed a retrospective cohort study of adult patients with moderate-severe IBD who presented to a tertiary referral center. Inclusion and exclusion criteria were extracted from published RCTs of biologics approved by the Food and Drug Administration and applied to the study population. RESULTS Only 31.1% of 206 patients with IBD (34% with Crohn's disease [CD], 26% with ulcerative colitis) would have been eligible to participate in any of the selected RCTs. Patients would have been excluded because they had stricturing or penetrating CD, took high doses of steroids, had comorbidities or prior exposure to biologics, or received topical therapies. Of the trial-ineligible patients with ulcerative colitis, 23.3% had colectomies, and 31.7% received infliximab, with a 63.2% response rate. Approximately half (49.4%) of the 82 trial-ineligible patients with CD received biological therapies, with lower response rates (60%) than trial-eligible patients (89%; P = .03). CONCLUSIONS Most patients with moderate-severe IBD evaluated in an outpatient practice would not qualify for enrollment in a pivotal RCT of biological reagents; this finding raises important questions about their therapeutic efficacy beyond the clinical trial populations. Additional evaluation of the transparency of RCT design and selection criteria is needed to determine whether trial results can be generalized to the population.
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Affiliation(s)
- Christina Ha
- Division of Gastroenterology, The Johns Hopkins School of Medicine, Baltimore, Maryland 21287, USA.
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Trindade AJ, Morisky DE, Ehrlich AC, Tinsley A, Ullman TA. Current practice and perception of screening for medication adherence in inflammatory bowel disease. J Clin Gastroenterol 2011; 45:878-82. [PMID: 21555953 PMCID: PMC3156931 DOI: 10.1097/mcg.0b013e3182192207] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Accepted: 03/07/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Adherence to medication in inflammatory bowel disease (IBD) improves outcomes. Current practices of screening for adherence to IBD medications are unknown. The goal of this study was to determine current practice and perception of screening for medication adherence among US-based gastroenterologists. METHODS A survey was mailed electronically to gastroenterologists whose electronic-mail address was listed in the American College of Gastroenterology database. Physicians who cared for IBD patients were invited to answer. RESULTS About 6830 surveys were sent to gastroenterologists nationwide, and 395 physicians who cared for IBD patients completed the survey. The true response rate is unknown, as the number of physicians caring for IBD patients in the database is unknown. About 77% (n = 303) of physicians who responded stated they screen for adherence to medication. Of the 77% of physicians who screened for adherence, only 19% (n = 58) use accepted measures of screening for adherence (pill counts, prescription refill rates, or adherence surveys). The remaining 81% used patient interview to screen for adherence, a measure considered least accepted to determine adherence, as it overestimates adherence. The average number of IBD patients observed in 1 week had no statistical significance in predilection for screening (P = 0.82). Private practice physicians (P = 0.05), younger physicians (P = 0.03), and physicians with fewer years of experience (P = 0.02) all were more likely to screen. About 95% of responders thought determining a low adherer to medicine was important because an intervention can increase adherence. CONCLUSIONS The majority of gastroenterologists surveyed recognize that adherence to medication is important and improves outcomes. The majority of physicians in this study are screening for nonadherence in IBD, but are not using accepted measures for adherence detection. If this study truly reflects the majority of physicians nationwide, changing the way physicians screen for adherence, may detect more low adherers to medication.
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Affiliation(s)
- Arvind J Trindade
- Division of Gastroenterology, Department of Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Kappelman MD, Horvath-Puho E, Sandler RS, Rubin DT, Ullman TA, Pedersen L, Baron JA, Sørensen HT. Thromboembolic risk among Danish children and adults with inflammatory bowel diseases: a population-based nationwide study. Gut 2011; 60:937-43. [PMID: 21339206 DOI: 10.1136/gut.2010.228585] [Citation(s) in RCA: 213] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recommendations for venous thromboembolism (VTE) prophylaxis in patients with inflammatory bowel disease (IBD) can be refined by incorporating patient-specific risk factors. OBJECTIVES To determine the risk of deep venous thrombosis (DVT) and pulmonary embolism (PE) in children and adults with Crohn's disease and ulcerative colitis and evaluate whether this risk varies by age and/or presence of other risk factors. METHODS We performed a cohort study using Danish administrative data. Incidence rates of DVT and PE were calculated among patients with IBD and an age- and gender-matched comparison population and compared using Cox proportional hazards regression. We performed additional analyses stratifying by age, gender and disease type and restricting outcomes to unprovoked events (occurring without known malignancy, surgery, fracture/trauma or pregnancy). We next performed a nested case-control study to adjust for additional co-morbidities (congestive heart failure, diabetes, myocardial infarction and stroke) and the use of hormone replacement and antipsychotic medications. RESULTS The study included 49,799 patients with IBD (14,211 Crohn's disease, 35,229 ulcerative colitis) and 477,504 members of the general population. VTE risk was elevated in patients with IBD (HR=2.0 (95% CI 1.8 to 2.1) for total events, HR=1.6 (95% CI 1.5 to 1.8) for unprovoked events). Although the incidence of VTE increased with age, the RR was higher in younger patients. Among those ≤ 20 years old, HRs were 6.0 (95% CI 2.5 to 14.7) for DVT and 6.4 (95% CI 2.0 to 20.3) for PE. After further adjusting for co-morbidity and medication use in the case-control analysis, ORs for all events remained in the 1.5-1.8 range. DISCUSSION Patients with IBD have twice the incidence of PE or DVT as does the general population. This risk persisted after taking into account other VTE risk factors. Relative risks were particularly high at young ages, though actual incidence increased with age. These findings can further inform risk-benefit analysis of VTE prophylaxis.
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Affiliation(s)
- Michael D Kappelman
- Department of Pediatrics, Division of Paediatric Gastroenterology, University of North Carolina Chapel Hill, Chapel Hill, NC 27599, USA.
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Abstract
Patients with ulcerative colitis and Crohn's disease are at increased risk for developing colorectal cancer (CRC). Chronic inflammation is believed to promote carcinogenesis. The risk for colon cancer increases with the duration and anatomic extent of colitis and presence of other inflammatory disorders (such as primary sclerosing cholangitis), whereas it decreases when patients take drugs to reduce inflammation (such as mesalamine and steroids). The genetic features that lead to sporadic CRC-chromosome instability, microsatellite instability, and DNA hypermethylation-also occur in colitis-associated CRC. Unlike the normal colonic mucosa, cells of the inflamed colonic mucosa have these genetic alterations before there is any histologic evidence of dysplasia or cancer. The reasons for these differences are not known, but oxidative stress is likely to be involved. Reactive oxygen and nitrogen species produced by inflammatory cells can affect regulation of genes that encode factors that prevent carcinogenesis (such as p53, DNA mismatch repair proteins, and DNA base excision-repair proteins), transcription factors (such as nuclear factor-κB), or signaling proteins (such as cyclooxygenases). Administration of agents that cause colitis in healthy rodents or genetically engineered, cancer-prone mice accelerates development of colorectal tumors. Mice genetically prone to inflammatory bowel disease also develop CRC, especially in the presence of bacterial colonization. Individual components of the innate and adaptive immune response have also been implicated in carcinogenesis. These observations offer compelling support for the role of inflammation in colon carcinogenesis.
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Affiliation(s)
- Thomas A Ullman
- The Dr Henry D. Janowitz Division of Gastroenterology, Mount Sinai School of Medicine, New York, New York 10029, USA
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Khan KJ, Dubinsky MC, Ford AC, Ullman TA, Talley NJ, Moayyedi P. Efficacy of immunosuppressive therapy for inflammatory bowel disease: a systematic review and meta-analysis. Am J Gastroenterol 2011; 106:630-42. [PMID: 21407186 DOI: 10.1038/ajg.2011.64] [Citation(s) in RCA: 179] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES There remains controversy regarding the efficacy of thiopurine analogs (azathioprine (AZA) and 6-mercaptopurine (6-MP)), methotrexate (MTX), and cyclosporine for the treatment of inflammatory bowel disease (IBD). We performed an updated systematic review of the literature to clarify the efficacy of immunosuppressive therapy at inducing remission and preventing relapse in ulcerative colitis (UC) and Crohn's disease (CD). METHODS Only parallel group randomized controlled trials (RCTs) were considered eligible. Studies with adult IBD patients receiving immunosuppressive therapy compared with placebo for at least 14 days and up to 17 weeks for active disease, or at least 6 months in quiescent disease were analyzed. Two reviewers independently assessed eligibility and extracted data. The primary outcome was remission or relapse using an intention-to-treat analysis. The data were summarized using relative risk (RR) and pooled using a random effects model. RESULTS Data on MTX and cyclosporine in IBD were limited although there were some data to support the use of intramuscular MTX in CD but not UC. There were five trials of AZA/6-MP in 380 active CD patients and there was no significant effect of therapy inducing remission (RR=0.87; 95% confidence interval (CI)=0.71-1.06). In quiescent CD, there were two trials involving 198 patients with no significant benefit of active therapy preventing relapse compared with placebo (RR=0.64; 95% CI=0.34-1.23). There were, however, three additional AZA withdrawal trials in 163 patients that indicated continuing medication did prevent relapse (RR=0.39; 95% CI=0.21-0.74). There were two AZA RCTs in 130 active UC patients that suggested a trend for benefit of therapy, but this did not reach statistical significance (RR=0.85; 95% CI=0.71-1.01). In quiescent UC, there were three trials involving 127 patients and there was a statistically significant benefit of AZA preventing relapse (RR=0.60; 95% CI=0.37-0.95). CONCLUSIONS Most evidence relates to AZA/6-MP where there is no statistically significant benefit at inducing remission in active CD and UC. Thiopurine analogs may prevent relapse in quiescent UC and CD. However, there is a paucity of data for immunosuppressive therapy in IBD and more research is needed.
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Affiliation(s)
- Khurram J Khan
- Health Sciences Center, McMaster University, Hamilton, Ontario, Canada.
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Trindade AJ, Ehrlich A, Kornbluth A, Ullman TA. Are your patients taking their medicine? Validation of a new adherence scale in patients with inflammatory bowel disease and comparison with physician perception of adherence. Inflamm Bowel Dis 2011; 17:599-604. [PMID: 20848512 DOI: 10.1002/ibd.21310] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND To date no adherence survey has been validated in IBD. The aim was to administer an improved medication adherence survey to IBD patients, to validate the scale in IBD, and to compare the results to perceived adherence by the gastroenterologists. METHODS IBD patients were given the Morisky Medication Adherence Scale (MMAS-8). To validate the scale, prescription claim information, calculated as continuous single-interval medication availability (CSA) and mean possession ratio (MPR), was correlated to the MMAS-8 scale. Nonpersistence or low adherence was defined as a CSA or MPR<0.8. Treating gastroenterologists, blinded to the instrument, then assessed adherence in these patients. RESULTS Of 110 IBD patients in the study, MMAS-8 identified 54 patients as low adherers (LAs) to their IBD medication and 56 patients as medium or high adherers (MHAs). Eighty-five percent of LAs had nonpersistent fill rates, as per CSA, compared with 11% of MHAs. Physicians correctly classified 95% of patients who were MHAs but only 33% of LAs. Underestimation of adherence only occurred in 5% of patients, whereas overestimation occurred in 67% (P<0.0001). In a linear regression analysis, CSA was significantly correlated with disease activity score (P<0.001). CONCLUSIONS LAs are a challenge to identify. This study demonstrates that the MMAS-8 scale is a valid instrument for assessing medication adherence in IBD. This is the first adherence scale to be validated in IBD.
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Affiliation(s)
- Arvind J Trindade
- Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Mount Sinai School of Medicine, New York, New York 10029, USA.
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Ullman TA. Should chromoendoscopy be the standard of care in ulcerative colitis dysplasia surveillance? Gastroenterol Hepatol (N Y) 2010; 6:616-620. [PMID: 21103439 PMCID: PMC2978410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Thomas A Ullman
- Associate Professor of Medicine Director, IBD Center Mount Sinai Medical Center New York, New York
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Farraye FA, Odze RD, Eaden J, Itzkowitz SH, McCabe RP, Dassopoulos T, Lewis JD, Ullman TA, James T, McLeod R, Burgart LJ, Allen J, Brill JV. AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease. Gastroenterology 2010. [PMID: 20141808 DOI: 10.1053/jgastro200912037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Francis A Farraye
- Section of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
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Farraye FA, Odze RD, Eaden J, Itzkowitz SH, McCabe RP, Dassopoulos T, Lewis JD, Ullman TA, James T, McLeod R, Burgart LJ, Allen J, Brill JV. AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease. Gastroenterology 2010; 138:738-45. [PMID: 20141808 DOI: 10.1053/j.gastro.2009.12.037] [Citation(s) in RCA: 358] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Francis A Farraye
- Section of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
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Marion JF, Waye JD, Present DH, Israel Y, Bodian C, Harpaz N, Chapman M, Itzkowitz S, Steinlauf AF, Abreu MT, Ullman TA, Aisenberg J, Mayer L. Chromoendoscopy-targeted biopsies are superior to standard colonoscopic surveillance for detecting dysplasia in inflammatory bowel disease patients: a prospective endoscopic trial. Am J Gastroenterol 2008; 103:2342-9. [PMID: 18844620 DOI: 10.1111/j.1572-0241.2008.01934.x] [Citation(s) in RCA: 206] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Patients with extensive, longstanding chronic ulcerative or Crohn's colitis face greater risks of developing colorectal cancer. Current standard surveillance relies on detecting dysplasia using random sampling at colonoscopy but may fail to detect dysplasia in many patients. Dye spraying techniques have been reported to aid in detecting otherwise subtle mucosal abnormalities in the setting of colitis. We prospectively compared dye-spray technique using methylene blue to standard colonoscopic surveillance in detecting dysplasia. METHODS One hundred fifteen patients were referred to the Chromoendoscopy Study Group and prospectively screened for the study. One hundred two (64 M, 38 F) (79 UC 23 CC) patients meeting the inclusion criteria were enrolled. Following a standard bowel preparation, each patient was examined using standard office endoscopic equipment by three methods: (a) standard surveillance colonoscopy with four random biopsies every 10 cm (for a total of at least 32 samples); (b) a targeted biopsy protocol; and finally (c) methylene blue (0.01%) dye spray was segmentally applied throughout the colon and any pit-pattern abnormality or lesion rendered visible by the dye spray was targeted and biopsied. Each patient had a single examination, which included two passes of the colonoscope. Specimens were reviewed in a blinded fashion by a single gastrointestinal pathologist. The three methods were then compared with each patient serving as his or her own control. RESULTS Targeted biopsies with dye spray revealed significantly more dysplasia (16 patients with low grade and 1 patient with high grade) than random biopsies (3 patients with low-grade dysplasia) (P= 0.001) and more than targeted nondye spray (8 patients with low-grade and 1 patient with high-grade dysplasia) (P= 0.057). Targeted biopsies with and without dye spray detected dysplasia in 20 patients compared with 3 using Method (a) (P= 0.0002, two-tailed exact McNemar's Test). There were no adverse events. CONCLUSIONS Colonoscopic surveillance of chronic colitis patients using methylene blue dye-spray targeted biopsies results in improved dysplasia yield compared to conventional random and targeted biopsy methods. Accordingly, this technique warrants incorporation into clinical practice in this setting and consideration as a standard of care for these patients. The value of multiple random biopsies as a surveillance technique should be revisited.
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Affiliation(s)
- James F Marion
- Mount Sinai School of Medicine, New York, New York 10028-0517, USA
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Abstract
Biomarkers in inflammatory bowel disease (IBD) are needed to help in disease diagnosis, prognosis, and assessment of disease activity. The best serologic markers to date measure antibody responses to normal commensal flora. These antibody responses can provide prognostic information as well as clues to disease pathogenesis. There remains room for additional biomarkers to clarify the diagnosis for certain patients with indeterminate colitis or small bowel Crohn's disease (CD) with protean manifestations. In this issue of the Journal, Adams and colleagues describe the presence of antibodies against Bacteroides vulgatus in CD patients. This additional marker may complement existing disease markers. Future studies should address whether these antibodies can help categorize patients with indeterminate colitis or predict severity of CD.
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Rubin DT, Cruz-Correa MR, Gasche C, Jass JR, Lichtenstein GR, Montgomery EA, Riddell RH, Rutter MD, Ullman TA, Velayos FS, Itzkowitz S. Colorectal cancer prevention in inflammatory bowel disease and the role of 5-aminosalicylic acid: a clinical review and update. Inflamm Bowel Dis 2008; 14:265-74. [PMID: 17932965 DOI: 10.1002/ibd.20297] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A roundtable consensus meeting was held to consolidate current knowledge on the etiology of colorectal cancer in patients with inflammatory bowel disease and to review current strategies, both diagnostic and preventive, specifically addressing the role of 5-aminosalicylic acid. Specific topics that were addressed included: the epidemiology of colorectal cancer, including an assessment of risk factors and the impact of colonoscopy on colorectal cancer incidence and mortality; the origin and evolution of dysplasia nomenclature and the natural history of dysplasia; review of the experience of St. Mark's Hospital (London) as gleaned from its surveillance database; mechanisms by which 5-aminosalicylic acid is thought to exert a chemopreventive effect; the potential future role of 5-aminosalicylic acid in chemopreventive strategies; chemoprevention in familial adenomatous polyposis; and other future research directions. This article provides a comprehensive overview of the issues discussed and should act as a guide to shaping the design of future studies in this area.
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Affiliation(s)
- David T Rubin
- University of Chicago Medical Center, Chicago, IL 60637, USA.
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Ullman TA. Chromoendoscopy should be the standard method and more widely used for cancer surveillance colonoscopy in ulcerative colitis--con. Inflamm Bowel Dis 2007; 13:1273-4; discussion 1275-6. [PMID: 17567865 DOI: 10.1002/ibd.20194] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Thomas A Ullman
- Dr. Henry D. Janowitz Division of Gastroenterology, Mount Sinai School of Medicine, New York, New York 10029, USA.
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Terdiman JP, Steinbuch M, Blumentals WA, Ullman TA, Rubin DT. 5-Aminosalicylic acid therapy and the risk of colorectal cancer among patients with inflammatory bowel disease. Inflamm Bowel Dis 2007; 13:367-71. [PMID: 17206695 DOI: 10.1002/ibd.20074] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) affecting the colon are at increased risk of developing colorectal cancer (CRC). Published data are conflicting about whether 5-aminosalicylic acid (5-ASA) has chemopreventive properties against IBD-related carcinogenesis. The objective of this observational study was to determine if an association between 5-ASA therapy and CRC risk exists in IBD patients. METHODS Adult patients with a new CRC diagnosis (n = 18,440) were identified from 2 large administrative claims databases. For each case, 20 control patients with no record of CRC diagnosis or bowel surgery (n = 368,800) were identified. RESULTS An IBD diagnosis was associated with a 6- to 7-fold increased risk of CRC (ulcerative colitis, crude odds ratio [OR] = 6.72, 95% CI, 5.79-7.81; Crohn's disease, crude OR = 6.60, 95% CI, 5.56-7.82). Among patients with IBD (364 CRC cases, 1172 controls), exposure to 5-ASA therapy of any dose or duration during the 12 months before CRC diagnosis was not associated with a reduced risk of CRC (OR = 0.97; 95% CI, 0.77-1.23). However, there was a trend toward a decreased risk of CRC with increasing number of mesalamine prescriptions in the previous year, though statistical significance was not achieved (trend P = 0.08). CONCLUSIONS Treating IBD patients with 5-ASA medications was not found to have a protective effect against colitis-related CRC when assessed over a short period of exposure.
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Affiliation(s)
- Jonathan P Terdiman
- University of California, San Francisco, San Francisco, California 94143-1623, USA.
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Ullman TA. Low-Grade Colorectal Dysplasia and the Need for Colectomy. Gastroenterol Hepatol (N Y) 2006; 2:868-870. [PMID: 28331477 PMCID: PMC5359934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Thomas A Ullman
- Assistant Professor Division of Gastroenterology The Mount Sinai School of Medicine
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Abstract
PURPOSE OF REVIEW To describe recent findings in the literature aimed at decreasing systematic error in dysplasia surveillance in inflammatory bowel disease. RECENT FINDINGS Despite great promise, colonoscopic surveillance in inflammatory bowel disease has yet to be demonstrated to reduce colorectal cancer mortality. In part, this stems from a number of inherent systematic troubles, including low rates of observer agreement among pathologists; lack of consensus on the natural history of dysplasia, particularly low-grade dysplasia; the patchy nature of dysplasia, which leads to sampling error caused by insufficient biopsy by endoscopists; and incomplete patient follow-up. Recent publications that have focused on defining better the natural history of different levels of dysplasia and improving dysplasia identification at the time of colonoscopy may aid in overcoming the flaws of surveillance. The key recent findings include conflicting evidence on the relative danger of flat low-grade dysplasia, the safety of treating polypoid low-grade dysplasia as a benign adenoma in the absence of flat dysplasia in the rest of the colon or the surrounding mucosa, and preliminary support of chromoendoscopy to target dysplasia better during colonoscopy and to limit unnecessary nontargeted biopsies. SUMMARY These and other advances stand a reasonable chance of making surveillance a more accurate tool to discriminate between patients with chronic colitis likely to progress to advanced pathology and those less likely to do so. Such advances may result in effective surveillance in which both colorectal cancer mortality and unnecessary colectomy may be limited.
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Affiliation(s)
- Thomas A Ullman
- Mount Sinai School of Medicine, New York, New York 10029, USA.
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Abstract
Patients with ulcerative colitis (UC) and Crohn's colitis carry an increased risk for developing colorectal cancer (CRC). Patients with more extensive colitis, greater duration of disease, concomitant primary sclerosing cholangitis, and a family history of CRC are at greatest risk among UC patients. Young age at disease onset and greater inflammatory burden have also been proposed as risk factors. Maneuvers that limit the impact of cancer in colitis include prophylactic colectomy, which is unacceptable to most UC and Crohn's colitis patients, and dysplasia surveillance. Although recommended in a number of practice guidelines, surveillance has not yet been demonstrated to reduce CRC mortality or morbidity. A number of factors, including low levels of agreement among pathologists interpreting surveillance specimens, patients lost to follow-up, failure to recommend colectomy once dysplasia has been discovered, and others, hinder the success of surveillance. In an effort to compensate for the limitations of surveillance, chemoprevention and newer endoscopic and molecular techniques are being assessed for their effectiveness in augmenting or replacing conventional surveillance.
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Affiliation(s)
- Thomas A Ullman
- Henry D. Janowitz Division of Gastroenterology, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Abstract
BACKGROUND Patients with ulcerative colitis (UC) are at greater risk of developing colorectal cancer (CRC) than the general population. Both duration and extent of UC are important risk factors for CRC, as is the presence of primary sclerosing cholangitis, family history of CRC, and (in some studies) early age at diagnosis of UC. Efforts to reduce this risk have focused on colonoscopic surveillance as the best alternative to the more definitive, but less appealing, approach of prophylactic colectomy. However, spurred on by findings in the sporadic CRC literature, there has been a growing interest in a possible role for chemoprevention of CRC in patients with UC. EMPIRICAL STUDIES Published evidence to date indicates that 5-aminosalicylic acid agents are protective against the development of dysplasia and CRC. Oral, but not topical, steroids also appear to be chemoprotective, but their chronic use cannot be recommended for this indication. Ursodeoxycholic acid has been shown to reduce the risk of neoplasia in UC patients with primary sclerosing cholangitis. Evidence suggests, but does not prove, that folic acid is chemopreventive in patients with UC. Further studies are needed to fully define the chemoprotective role of these and other agents.
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Affiliation(s)
- Victoria J Croog
- Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Mount Sinai School of Medicine, One Gustave Levy Place, New York, NY 10029, USA
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Affiliation(s)
- Thomas A Ullman
- Dr. Henry D. Janowitz Division of Gastroenterology, Mount Sinai School of Medicine, New York, New York, USA.
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Affiliation(s)
- Thomas A Ullman
- Mount Sinai School of Medicine, One Gustave Levy Place, New York, NY 10029, USA.
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Affiliation(s)
- Thomas A Ullman
- Dr Henry D Janowitz Division of Gastroenterology, Mount Sinai School of Medicine, New York, New York, USA
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Abstract
Colorectal cancer (CRC) is a complication in both patients with longstanding ulcerative colitis and those with Crohn's disease. As with sporadic CRC, surgical therapy (with adjuvant chemotherapy in advanced disease) is the only effective treatment. Identifying risk factors for CRC in inflammatory bowel disease (IBD) should allow patients to receive appropriate medical, endoscopic, and surgical care to minimize CRC morbidity and mortality. Total proctocolectomy remains the most effective form of cancer prophylaxis in IBD patients, but because of the impact of this approach and the low absolute risk of cancer, clinicians seldom recommend it. Colonoscopic surveillance with systematic biopsies is used to detect mucosal dysplasia and thus identify those patients at greatest risk for developing CRC. Patients with dysplasia other than that in readily excised polyps should be referred for surgery. Although fraught with limitations, surveillance is the best method currently available for reducing CRC mortality and morbidity short of prophylactic colectomy. It will have to remain the standard of practice until better diagnostic tests are available. Surveillance should be offered and performed in the same manner for patients with Crohn's disease and ulcerative colitis. Chemoprevention may prove effective in the future, but currently used agents have only a modest benefit, if any. Adenocarcinoma of the small intestine occurs at an increased rate in patients with Crohn's disease of the bowel with longstanding small bowel involvement, but there are no current methods of early detection. Treatment is based on disease identified from evaluation of symptoms or incidental finding. Some extraintestinal cancers have been noted to occur at increased rates in series from referral centers but not in population-based studies.
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Affiliation(s)
- Thomas A. Ullman
- Dr. Henry D. Janowitz Division of Gastroenterology, Mount Sinai School of Medicine, Box 1069, One Gustave L. Levy Place, New York, NY 10029, USA.
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Abstract
OBJECTIVE The optimal strategy for the management of definite low grade dysplasia (LGD) detected in surveillance in ulcerative colitis (UC) is unknown, because the natural history of LGD has not been well described. METHODS We reviewed the Mayo Clinic records of patients with UC found to have flat LGD between 1990 and 1993 in whom a nonoperative strategy was pursued for 2 months or more. RESULTS Eighteen patients with UC and LGD were observed for a median of 32 months. Nine of 18 patients identified with UC and LGD developed advanced neoplastic lesions during follow-up, which were defined as adenocarcinoma, raised dysplasia, or high grade dysplasia. The cumulative incidence of progression to an advanced lesion was 33% at 5 yr (95% CI = 9-56%). Only one patient developed adenocarcinoma, diagnosed 74 months after his initial finding of LGD and 20 months after his last surveillance exam. Besides this patient, adenocarcinoma was not detected in the colectomy specimens of 13 other patients who underwent surgery. Colectomies were performed for dysplasia or cancer in seven patients, active colitis in five patients, and unknown reasons in two patients. Four patients did not have colectomies. CONCLUSIONS Neoplastic progression in patients with UC and LGD is common. Total proctocolectomy should be offered to all patients with flat LGD. Our study illustrates numerous pitfalls in the practice of surveillance.
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Affiliation(s)
- Thomas A Ullman
- The Dr. Henry D. Janowitz Division of Gastroenterology, Mount Sinai School of Medicine, New York, New York, USA
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Ullman TA. Markov Polo: finding the costs of Crohn's in an Olmstead County pool. Inflamm Bowel Dis 2000; 6:64-5. [PMID: 10701155 DOI: 10.1097/00054725-200002000-00015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- T A Ullman
- Henry D. Janowitz Division of Gastroenterology, Mount Sinai School of Medicine, New York, New York, USA
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