Colonoscopic surveillance for prevention of colorectal cancer in people with ulcerative colitis, Crohns disease or adenomas Implementing NICE guidance.

Colonoscopic surveillance for prevention of colorectal cancer in

people with ulcerative colitis, Crohn’s disease or adenomas

Implementing NICE guidance

March 2011

NICE clinical guideline 118

What this presentation covers

Background

Definitions

Epidemiology

Scope

Recommendations

Costs and savings

Discussion

Find out more

Background

• Adults with inflammatory bowel disease (IBD) or with adenomas have a higher risk of developing colorectal cancer than the general population.

• NICE has developed a short clinical guideline on the use of colonoscopic surveillance.

•The recommendations are broadly consistent with those in the 2010 British Society of Gastroenterology guidelines.

DefinitionsAdenoma

Baseline colonoscopy

Bowel preparation

Chromoscopy

Crohn’s disease

Colitis

Colonoscopy

Computed tomographic colonography

(CTC)

Inflammatory bowel disease

Sigmoidoscopy

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

Epidemiology

The prevalence of ulcerative colitis is approximately 100–200 per 100,000 and the annual incidence is 10–20 per 100,000.

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

The prevalence of Crohn's disease is 50 –100 per 100,000 and the annual incidence is 5–10 per 100,000.

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

Guideline Scope

The guideline covers adults with:

• inflammatory bowel disease

• adenomas in the colon or rectum

The key issues covered are:

• information and support needs of patients

• colonoscopic surveillance (conventional colonoscopy or chromoscopy) for prevention and early detection of colorectal cancer

• initiation of surveillance

• frequency of ongoing surveillance

Guideline recommendations

The recommendations cover three key areas:

•Providing information and support•people with IBD•people with adenomas.

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

Providing information and support: 1

Provide information tailored to the person’s needs.

What to discuss with people who are considering colonoscopic surveillance:

• potential benefits, limitations and risks particularly

- early detection and prevention of colorectal cancer

- quality of life and psychological outcomes.

Providing information and support: 2

Inform people who have been offered colonoscopy, CTC, or barium enema about the procedure, including:

• bowel preparation

• impact on everyday activities

• sedation

• potential discomfort

• risk of perforation and bleeding.

Providing information and support: 3

Discuss the potential benefits, limitations and risks of ongoing surveillance.

Base a decision to stop surveillance on potential benefits for the person, their preferences and comorbidity.

If findings at surveillance need treatment or referral, discuss options with the person and, if appropriate, their family or carers, giving them the opportunity to discuss any issues.

Offer:

Baseline colonoscopy with chromoscopy and targeted biopsy of any abnormal areas to people with IBD who are being considered for colonoscopic surveillance to determine their risk of developing colorectal cancer (see table 1).

Colonoscopic surveillance to people with IBD whose symptoms started 10 years ago and who have:

• ulcerative colitis (but not proctitis alone) or • Crohn’s colitis involving more than one segment of colon.

People with inflammatory bowel disease:1

Risk of developing colorectal cancer in people with IBD

Low risk:• extensive but quiescent ulcerative colitis or• extensive but quiescent Crohn’s colitis or• left-sided ulcerative colitis (but not proctitis alone) or Crohn’s colitis of a similar extent.Intermediate risk:• extensive ulcerative or Crohn’s colitis with mild active inflammation that has been confirmed endoscopically  or histologically or • post-inflammatory polyps or• family history of colorectal cancer in a first-degree relative aged 50 years or over.High risk:• extensive ulcerative or Crohn’s colitis with moderate or severe active inflammation that has been confirmed endoscopically or histologically or• primary sclerosing cholangitis (including after liver transplant) or• colonic stricture in the past 5 years or• any grade of dysplasia in the past 5 years or• family history of colorectal cancer in a first-degree relative aged under 50 years.

Table 1

People with inflammatory bowel disease: 2

Offer surveillance using colonoscopy with chromoscopy to people with IBD, based on risk:

•Low risk: offer at 5 years•Intermediate risk: offer at 3 years •High risk: offer at 1 year

Repeat colonoscopy if incomplete with more experienced colonoscopist if needed.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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People with adenomas: 1

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

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

Risk of developing colorectal cancer in people with adenomas

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

Table 2

People with adenomas: 2

Use the findings at adenoma removal to determine people’s risk of developing colorectal cancer:

• Offer colonoscopic surveillance to people who are at intermediate or high risk of developing colorectal cancer

• Consider colonoscopic surveillance for people who are at low risk of developing colorectal cancer

People with adenomas: 3

Repeat colonoscopy if incomplete, with more experienced colonoscopist if needed.

If colonoscopy is not clinically appropriate consider CTC, if not available or appropriate, consider double contrast barium enema.

Consider CTC or double contrast barium enema for ongoing surveillance if colonoscopy remains clinically inappropriate and discuss the risks and benefits with the person and their family or carers.

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

Low risk• One or two adenomas smaller than 10 mm

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

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

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

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

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Low risk• One or two adenomas smaller than 10 mm

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

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

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

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

Click here to go back to slide 22

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

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

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

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26)

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

Costs and savings

• Implementation of this guideline is considered unlikely to have a significant impact on NHS resources nationally where current BSG recommendations are being followed.

• The guideline was developed because of variations in clinical practice nationally.

• Organisations are therefore encouraged to review circumstances locally. A costing template has been developed to assist organisations in this process.

Discussion

• How do we identify people who should be included in a surveillance programme?

• Are the full range of tests, including CTC, available?

• How do we discuss potential benefits, limitations and risks with people who are considering colonoscopic surveillance and is this in line with the guideline?

• What information, including illustrations, is available about the surveillance programme?

Find out more

Visit www.nice.org.uk/guidance/CG118 for:

•the guideline •the quick reference guide•‘Understanding NICE guidance’•costing report and template/costing statement•audit support and baseline assessment tool

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