Gastroenterologists want cancer surveillance in IBD reforms

Gastroenterologists in Tasmania are calling for a formalised system of recall for CRC surveillance in IBD patients.

In a letter to the editor of Alimentary Pharmacology and Therapeutics clinicians from Royal Hobart Hospital’s Department of Gastroenterology say a standardised approach would mitigate the effects of practitioner variability in offering surveillance to patients – which remains high in Australia.

Dr Ralley Prentice and colleagues were responding to findings from a UK paper reporting that two‐thirds of patients eligible for colonoscopic surveillance in a single centre had missed opportunities to diagnose CRC.

Investigators from the IBD Pharmacogenetics Group at the University of Exeter in the UK say unchanging CRC rates among IBD patients in the UK may reflect poor integration between primary and secondary care services, impacting surveillance recall.

Patients in the study identified as missing surveillance opportunities were being cared for exclusively by their general practitioner with nearly half discharged by secondary care without a surveillance plan. 

The review also revealed that one‐third of IBD‐associated CRCs in the cohort were diagnosed in patients who were perceived to be at low‐risk because of limited disease duration or extent, where surveillance had not started.

Describing the findings as ‘concerning’ the UK investigators issued the dire warning that, without comprehensive and fully integrated recall systems across primary and secondary care, CRC Surveillance programs are set up to fail.

In Australia Dr Prentice and colleagues echoed the sentiment citing similar findings from Australian data.

They were referring to their recent retrospective review of adherence with Australian NHMRC guidelines for endoscopic surveillance for patients with IBD.

Between 2003 and 2018 121 patients were identified from a single institution who warranted endoscopic surveillance during follow up based on internationally accepted risk factors. 

Of these, only 37% and 34% were surveyed at recommended intervals with appropriately timed surveillance commencement when considering previous and current guideline recommendations, respectively.

Concerningly, the mean overdue time of those who were surveyed was 32 and 27 months, respectively.

 In only 34% of patients was a discussion with the patient of colorectal cancer risks documented in the medical records.

Taken together both studies illustrate the failure of current IBD-associated CRC surveillance, say the Royal Hobart Hospital gastroenterologists, who have been calling for institutional reform.

Flagging initiatives like nurse-led surveillance for high-risk patients that have been associated with  rates of CRC surveillance interval rates as high as 97%, Dr Prentice says both studies have identified a ‘rectifiable risk factor’ for IBD-related CRC: surveillance programs without integrated recall systems across primary and secondary care.

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