1. 1 Yize R. Wang, MD, PhD, John R. Cangemi, MD, Edward V. Loftus Jr, MD and Michael F. Picco, MD, PhD Am J Gastroenterol 2013;108:444–449 F1 김혁 / Prof. 김효종

2. Introduction Colonoscopy is the predominant screening and diagnostic test for colorectal cancer Early / missed CRCs diagnosed 6 – 36 months after colonoscopy –Higher rate in the right colon –Generally considered missed lesions Patients with long standing inflammatory bowel disease (IBD) – Increased risk for CRC 2

3. Introduction Current guidelines : IBD patients with long standing left sided or extensive colitis –Intensive surveillance colonoscopy –Magnitude of CRC risk : controversial d/t Small study size and referral bias 3

4. Aim To compare the rate of early / missed CRCs after colonoscopy among older IBD and non-IBD patients To identify factors associated with early / missed CRCs 4

5. METHODS The Surveillance, Epidemiology and End- Results Medicare (SEER-Medicare) linked database 5 Inclusion Patients diagnosed with CRCs during 1998 – 2005 67 years or older at the time of a colonoscopy Diagnosed with CRC within 36 months ICD-9 codes for both Crohn’ s disease and UC Exclusion History of CRC or other cancer TNM stage : carcinoma in situ Two colonoscopies performed in the 36 months before CRC diagnosis Incomplete colonoscopy or colonoscopy with poor preparation

6. METHODS 6 Detected cancers : 0 - 6 months at after a colonoscopy Early / missed cancers : 6 – 36 months after a colonoscopy

7. RESULTS 7  55,008 CRC patients  54,160 Non-IBD  304 CD  544 UC

8. Figure 1. Rate of early/missed CRCs by inflammatory IBD status 8  Significant difference between older non-IBD and older IBD  No significant difference between CD and UC

9. Early/missed CRC location, tumor–node–metastasis (TNM) stage, and tumor grade by inflammatory IBD status 9  IBD patients were less likely right-sided  The difference in TNM stage or tumor grade was insignificant *P<0.05; **P<0.01 vs. non-IBD patients #P<0.05 vs. Crohn`s patients

10. RESULTS 10 3.7%  The effect of age : not linear  Positive association Female Non gastroendoscopist Family history of CRC Personal history of polyp

11. Limitation Reliance on ICD-9 diagnosis code for IBD –Bowel preparation quality and depth reached –Unknown length and extent of colitis among IBD patients –Potential under-diagnosis or mis-diagnosis of IBD 11

12. Conclusions The rate of early / missed CRCs after colonoscopy was three times as high as for older IBD patients compared with older non IBD patients. Early / missed CRCs among older IBD patients are more evenly distributed in the left and right colon. Our findings support intensive surveillance colonoscopy for older IBD patients, as recommended by current guidelines. 12