Thirty-year analysis of a colonoscopic surveillance program for neoplasia in ulcerative colitis.

BACKGROUND & AIMS: The value of colonoscopic surveillance for neoplasia in long-standing extensive ulcerative colitis remains controversial. This study reports on prospectively collected data from a surveillance program over a 30-year period. METHODS: Data were obtained from the prospective surveillance database, medical records, colonoscopy, and histology reports. The primary end point was defined as death, colectomy, withdrawal from surveillance, or census date (January 1, 2001). Follow-up information was obtained for patients who left the program. RESULTS: Six hundred patients underwent 2627 colonoscopies during 5932 patient-years of follow-up. The cecal intubation rate was 98.7%, with no significant complications. Seventy-four patients (12.3%) developed neoplasia, including 30 colorectal cancers (CRCs). There was no difference in median age at onset of colitis for those with or without CRC (P = .8, Mann-Whitney). The cumulative incidence of CRC by colitis duration was 2.5% at 20 years, 7.6% at 30 years, and 10.8% at 40 years. The 5-year survival rate was 73.3%. Sixteen of 30 cancers were interval cancers. CRC incidence decreased over time (r = -.40, P = .04; linear regression). CONCLUSIONS: Colonoscopic surveillance is safe and allows the vast majority of patients to retain their colon. Although two thirds of patients with potentially life-threatening neoplasia benefited from surveillance, the program was not wholly effective in cancer prevention. The cancer incidence, however, was considerably lower than in the majority of other studies, and was constant for up to 40 years of colitis duration, suggesting there is no need to intensify surveillance over time.

Severity of inflammation is a risk factor for colorectal neoplasia in ulcerative colitis.

BACKGROUND & AIMS: Patients with ulcerative colitis are at increased risk of colorectal cancer. It is widely believed that this is secondary to colonic inflammation. However, the severity of colonic inflammation has never been shown to be a risk factor. METHODS: We devised a case-control study of patients with long-standing extensive ulcerative colitis to examine various potential risk factors for neoplasia. All cases of colorectal neoplasia detected from our surveillance program between January 1, 1988, and January 1, 2002, were studied (n = 68). Each patient was matched with 2 control patients from the same surveillance population (n = 136). Matching was for sex, colitis extent, age at onset, duration of colitis, and year of index surveillance colonoscopy. Segmental colonoscopic and histological inflammation was recorded by using a simple score (0, normal; 1, quiescent/chronic inflammation; and 2, 3, and 4, mild, moderate, and severe active inflammation, respectively). Other data collected included history of primary sclerosing cholangitis, family history of colorectal cancer, and smoking and drug history (mesalamine 5-aminosalicylic acid, azathioprine, and folate). RESULTS: Univariate analysis showed a highly significant correlation between the colonoscopic (odds ratio, 2.5; P = 0.001) and histological (odds ratio, 5.1; P < 0.001) inflammation scores and the risk of colorectal neoplasia. No other factors reached statistical significance. On multivariate analysis, only the histological inflammation score remained significant (odds ratio, 4.7; P < 0.001). CONCLUSIONS: In long-standing extensive ulcerative colitis, the severity of colonic inflammation is an important determinant of the risk of colorectal neoplasia. Endoscopic and histological grading of inflammation could allow better risk stratification for surveillance programs.