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

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Presentation on theme: "Colonoscopic surveillance for prevention of colorectal cancer in people with ulcerative colitis, Crohns disease or adenomas Implementing NICE guidance."— Presentation transcript:

1 Colonoscopic surveillance for prevention of colorectal cancer in people with ulcerative colitis, Crohns disease or adenomas Implementing NICE guidance March 2011 NICE clinical guideline 118

2 What this presentation covers Background Definitions Epidemiology Scope Recommendations Costs and savings Discussion Find out more

3 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.

4 Definitions Adenoma Baseline colonoscopy Bowel preparation Chromoscopy Crohns disease Colitis Colonoscopy Computed tomographic colonography (CTC) Inflammatory bowel disease Sigmoidoscopy Image reproduced with kind permission of Dr. Bruce Fox, Derriford Hospital, Plymouth

5 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.

6 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

7 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

8 Providing information and support: 1 Provide information tailored to the persons 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.

9 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.

10 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.

11 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 Crohns colitis involving more than one segment of colon. People with inflammatory bowel disease:1

12 Risk of developing colorectal cancer in people with IBD Low risk: extensive but quiescent ulcerative colitis or extensive but quiescent Crohns colitis or left-sided ulcerative colitis (but not proctitis alone) or Crohns colitis of a similar extent. Intermediate risk: extensive ulcerative or Crohns 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 Crohns 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

13 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

14 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 Crohns colitis or Left-sided ulcerative colitis (but not proctitis alone) or Crohns colitis of a similar extent Intermediate risk Extensive ulcerative or Crohns 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 Crohns 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 Crohns colitis involving more than one segment of colon Click here

15 Low risk Left-sided ulcerative colitis (but not proctitis alone) or Crohns colitis of a similar extent or Extensive but quiescent ulcerative or Crohns 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 Click here to go back to slide 14 Findings at follow-up Offer the next colonoscopy with chromoscopy based on the persons risk at the last complete colonoscopy: – low risk – offer at 5 years – intermediate risk – offer at 3 years – high risk – offer at 1 year

16 Intermediate risk Extensive ulcerative or Crohns 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 Click here to go back to slide 14 Findings at follow-up Offer the next colonoscopy with chromoscopy based on the persons risk at the last complete colonoscopy: – low risk – offer at 5 years – intermediate risk – offer at 3 years – high risk – offer at 1 year

17 High risk Extensive ulcerative or Crohns 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 persons risk at the last complete colonoscopy: – low risk – offer at 5 years – intermediate risk – offer at 3 years – high risk – offer at 1 year Click here to go back to slide 14Click here to move on to slide 18

18 People with adenomas: 1 Offer appropriate colonoscopic surveillance based on individuals risk of developing colorectal cancer determined at initial adenoma removal. Image reproduced with kind permission of Professor Marco Novelli, University College London

19 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

20 People with adenomas: 2 Use the findings at adenoma removal to determine peoples 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

21 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.

22 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 Click here Click here end algorithm and move on to next section (slide 26)

23 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 Click here to go back to slide 22

24 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

25 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. Click here to go back to slide 22Click here to move on to next section (slide 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

26 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.

27 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?

28 Find out more Visit www.nice.org.uk/guidance/CG118 for:www.nice.org.uk/guidance/CG118 the guideline the quick reference guide Understanding NICE guidance costing report and template/costing statement audit support and baseline assessment tool

29 What do you think? Did the implementation tool you accessed today meet your requirements, and will it help you to put the NICE guidance into practice? We value your opinion and are looking for ways to improve our tools. Please complete a short evaluation form by clicking here.here If you are experiencing problems accessing or using this tool, please email implementation@nice.org.ukimplementation@nice.org.uk To open the links in this slide set right click over the link and choose open link


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