scholarly journals Motion - Colonoscopic Surveillance is More Cost Effective than Colectomy in Patients with Ulcerative Colitis: Arguments for the Motion

2003 ◽  
Vol 17 (2) ◽  
pp. 119-121 ◽  
Author(s):  
Bret A Lashner
Keyword(s):  
Ulcerative Colitis ◽  
Cost Effective ◽  
Low Grade ◽  
Surveillance Colonoscopy ◽  
Case Control Studies ◽  
Colonoscopic Surveillance ◽  
Prophylactic Colectomy ◽  
Increased Risk ◽  
Surveillance Programs ◽  
Related Mortality

Patients with ulcerative colitis (UC) are at increased risk for colorectal cancer (CRC), especially those with longstanding disease, pancolitis or primary sclerosing cholangitis. The incidence of colitis- associated cancer is increasing, and the mortality rates from CRC are higher in UC patients than in the general population. Case control studies have demonstrated that surveillance colonoscopy reduces the risk of dying from CRC. A well conducted decision analysis found that surveillance colonoscopy decreases cancer-related mortality and increases life expectancy. The results with surveillance programs were almost as good as with prophylactic colectomy. A subsequent cost effectiveness analysis using the same model found that, compared with a policy of no surveillance, colonoscopic surveillance was more effective at preventing death from CRC and was less costly. The best strategy appears to be to perform colonoscopies every three years. The analysis also showed that colectomy should be recommended in patients with low-grade dysplasia. Patients at very high risk for CRC should undergo yearly colonoscopy, and patients who are concerned about the limitations of this technique should be offered prophylactic colectomy.

scholarly journals Motion - Colonoscopic Surveillance is more Cost Effective than Colectomy in Patients with Ulcerative Colitis: Arguments Against the Motion

2003 ◽  
Vol 17 (2) ◽  
pp. 122-124 ◽  
Author(s):  
Anders Ekbom
Keyword(s):  
Colorectal Cancer ◽  
Ulcerative Colitis ◽  
High Risk ◽  
Positive Family History ◽  
Case Series ◽  
Good Alternative ◽  
Surveillance Colonoscopy ◽  
Colonoscopic Surveillance ◽  
Prophylactic Colectomy ◽  
Surveillance Programs

There are insufficient data upon which to base recommendations about surveillance colonoscopy and prophylactic colectomy for the prevention of colorectal cancer in patients with ulcerative colitis. Case series, analyses of intermediate results and extrapolations from other patient groups do not constitute reliable evidence. Available studies are susceptible to several biases: the ’healthy worker’ effect, surveillance bias and selection bias. Patients who are enrolled in surveillance programs are more likely to be thoroughly evaluated beforehand, are more likely to be given a diagnosis of dysplasia or neoplasm even when asymptomatic and are more likely to comply with medical treatment, including maintenance anti-inflammatory medication. Comparisons of the rates of neoplasia or death between surveyed and nonsurveyed patients are, therefore, of questionable validity. Prophylactic colectomy, unlike surveillance colonoscopy, prevents death from colorectal cancer. Moreover, it is difficult to keep patients in surveillance programs, and those who withdraw from programs appear to be at high risk of developing cancer. Prophylactic colectomy should be strongly considered for patients with dysplasia, sclerosing cholangitis, longstanding pancolitis (especially if it began early in life) or a positive family history of colorectal cancer. This procedure is underused in clinical practice and is a good alternative to colonoscopic surveillance in high risk patients.

scholarly journals P397 Surveillance in ulcerative colitis: Can we predict the risk for intraepithelial neoplasia?

2020 ◽  
Vol 14 (Supplement_1) ◽  
pp. S368-S369
Author(s):  
J Estorninho ◽  
P Freire ◽  
S Lopes ◽  
M Ferreira ◽  
M Ferreira ◽  
...  
Keyword(s):  
Ulcerative Colitis ◽  
Disease Duration ◽  
Intraepithelial Neoplasia ◽  
Screening Colonoscopy ◽  
Low Grade ◽  
Surveillance Colonoscopy ◽  
High Quality ◽  
Increased Risk ◽  
History Of ◽  
Low Grade Dysplasia

Abstract Background Ulcerative colitis (UC) has been associated with an increased risk of colorectal cancer (CRC). Although dye spray chromoendoscopy showed superiority to standard colonoscopy in surveillance studies, with the availability of higher-resolution colonoscopes, the utility of chromoendoscopy (CE) has been questioned. We aimed to evaluate the risk of intraepithelial neoplasia (IN) after a high-quality screening colonoscopy (making use of CE or random biopsies (RB) and removing all detected lesions) in a population with longstanding UC and to identify potential risk factors for dysplasia incidence. Methods In a previous study, 145 patients with clinically and endoscopic longstanding (≥8 yr) distal/extensive UC without primary sclerosing cholangitis and/or history of IN were prospectively randomised to undergo CE or RB. In this study, after a median follow-up of 5 additional years, we evaluated subsequent IN incidence in these patients, submitted to surveillance colonoscopy. Patients without high-quality surveillance colonoscopy (with good bowel preparation and cecum intubation) using high-definition were excluded. Results One hundred and twenty-one patients were included. Nine had removed adenomas with low-grade dysplasia in the index colonoscopy. Now, in surveillance colonoscopy, we detected 9 (7.4%) IN: low-grade dysplasia was found in 8 (6.6%) patients and a colorectal adenocarcinoma in 1 (0.008%) patient. After multivariate analysis, IN was significantly associated with older age (68 vs. 52 years, p < 0.05) and higher disease duration (26 vs. 20 years, p < 0.05). No association was found between IN and previous detection of IN in screening colonoscopy sex, the CE or RB use in index colonoscopy, extent of disease, The presence of pseudopolyps, smoking habits, familial history of CRC or maintenance therapy for UC. Conclusion In this study, older patients and higher disease duration were associated with a higher risk of IN in surveillance colonoscopy.

Continuation of Anti-TNF in Patients With Ulcerative Colitis in Remission Is Not Cost-effective Compared With Treatment Withdrawal: A Markov Model

2020 ◽  
Author(s):  
Remi Mahmoud ◽  
Chris van Lieshout ◽  
Geert W J Frederix ◽  
Bindia Jharap ◽  
Bas Oldenburg
Keyword(s):  
Ulcerative Colitis ◽  
Health Care ◽  
Cost Effectiveness ◽  
Markov Model ◽  
Cost Effective ◽  
Health Care Expenditures ◽  
Increased Risk ◽  
The Cost ◽  
Cost Effectiveness Threshold ◽  
Effectiveness Threshold

Abstract Background and Aims Anti-tumour necrosis factor alpha [anti-TNF] treatment accounts for 31% of health care expenditures associated with ulcerative colitis [UC]. Withdrawal of anti-TNF in patients with UC in remission may decrease side effects and infections, while promoting cost containment. Approximately 36% of patients relapse within 12–24 months of anti-TNF withdrawal, but reintroduction of treatment is successful in 80% of patients. We aimed to evaluate the cost-effectiveness of continuation versus withdrawal of anti-TNF in patients with UC in remission. Methods We developed a Markov model comparing cost-effectiveness of anti-TNF continuation versus withdrawal, from a health care provider perspective. Transition probabilities were calculated from literature, or estimated by an expert panel of 11 gastroenterologists. Deterministic and probabilistic sensitivity analyses were performed to account for assumptions and uncertainty. The cost-effectiveness threshold was set at an incremental cost-effectiveness ratio of €80,000 per quality-adjusted life-year [QALY]. Results At 5 years, anti-TNF withdrawal was less costly [-€10,781 per patient], but also slightly less effective [-0.04 QALY per patient] than continued treatment. Continuation of anti-TNF compared with withdrawal costs €300,390/QALY, exceeding the cost-effectiveness threshold. Continued therapy would become cost-effective if the relapse rate following anti-TNF withdrawal was ≥43% higher, or if adalimumab or infliximab [biosimilar] prices fell below €87/40 mg and €66/100 mg, respectively. Conclusions Continuation of anti-TNF in UC patients in remission is not cost-effective compared with withdrawal. A stop-and-reintroduction strategy is cost-saving but is slightly less effective than continued therapy. This strategy could be improved by identifying patients at increased risk of relapse.

scholarly journals Progression of low-grade dysplasia to advanced neoplasia based on the location and morphology of dysplasia in ulcerative colitis patients with extensive colitis under colonoscopic surveillance

2013 ◽  
Vol 7 (12) ◽  
pp. e684-e691 ◽  
Author(s):  
Udayakumar Navaneethan ◽  
Ramprasad Jegadeesan ◽  
Norma G. Gutierrez ◽  
Preethi G.K. Venkatesh ◽  
Jeffrey P. Hammel ◽  
...  
Keyword(s):  
Ulcerative Colitis ◽  
Low Grade ◽  
Colonoscopic Surveillance ◽  
Advanced Neoplasia ◽  
Low Grade Dysplasia

scholarly journals Hypertensive Disorders of Pregnancy and Risk of Cardiovascular Disease-Related Morbidity and Mortality: A Systematic Review and Meta-Analysis

Cardiology ◽  
2020 ◽  
Vol 145 (10) ◽  
pp. 633-647
Author(s):  
Rong Wu ◽  
Tingting Wang ◽  
Runhui Gu ◽  
Dexiu Xing ◽  
Changxiang Ye ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Reference Group ◽  
Morbidity And Mortality ◽  
Significant Heterogeneity ◽  
Hypertensive Disorders Of Pregnancy ◽  
Case Control Studies ◽  
Hypertensive Disorders ◽  
Increased Risk ◽  
History Of ◽  
Related Mortality

Introduction: Several studies have demonstrated that there is a higher risk of cardiovascular disease (CVD) in women with a history of hypertensive disorders of pregnancy (HDP). However, effect sizes varied greatly between these studies, and a complete overview of the existing data in the literature is lacking. We aimed to evaluate the association between HDP and the risk of CVD-related morbidity and mortality. Methods: Systematic literature searches were conducted in several electronic databases from inception to July 2019. Exposure of interest was any type of HDP. Outcomes of interest included any CVD, CVD-related mortality, and hypertension. Results: Sixty-six cohort and 7 case-control studies involving >13 million women were included. The overall combined relative risks (RRs) for women with a history of HDP compared with the reference group were 1.80 (95% confidence interval [CI] 1.67–1.94) for any CVD, 1.66 (1.49–1.84) for coronary artery heart disease, 2.87 (2.14–3.85) for heart failure, 1.60 (1.29–2.00) for peripheral vascular disease, 1.72 (1.50–1.97) for stroke, 1.78 (1.58–2.00) for CVD-related mortality, and 3.16 (2.74–3.64) for hypertension. Significant heterogeneity was partially explained by all or part of the variables including type of exposure, follow-up time, geographic region, and sample source. Conclusions: Women with a history of HDP are at an increased risk of future CVD-related morbidity and mortality. Our study highlights the importance of life-long monitoring of cardiovascular risk factors in women with a history of HDP.

scholarly journals The Unsolved Problem of Surveillance for Colorectal Cancer in Ulcerative Colitis

1999 ◽  
Vol 13 (8) ◽  
pp. 655-660 ◽  
Author(s):  
Fabiola Delco ◽  
Amnon Sonnenberg
Keyword(s):  
Colorectal Cancer ◽  
Ulcerative Colitis ◽  
Cost Effective ◽  
Surveillance Program ◽  
Medical Evidence ◽  
New Techniques ◽  
Time Period ◽  
Number Of Patients ◽  
Increased Risk ◽  
Analytical Tools

The association between long standing extensive ulcerative colitis and the increased risk for developing colorectal cancer suggests that surveillance by frequent and regular colonoscopies may provide a means for reducing cancer-related morbidity and mortality. A crude calculation suggests that such a surveillance program would also be cost effective. None of several clinical trials, however, has been able to provide unequivocal evidence in favour of surveillance. The major reason for this failure relates to the prohibitively large number of patients with ulcerative colitis who need to be followed over a prolonged time period before statistically sound results would be obtained. Because models of decision analyses themselves have to rely on medical evidence, they cannot provide a substitute for deficient clinical data. The issue of surveillance colonoscopy cannot be resolved by the available knowledge or analytical tools. Hopefully, new techniques of surveillance or even a cure for ulcerative colitis will render the question mute of whether or not to screen patients with ulcerative colitis by frequent colonoscopy.

scholarly journals Repeated colonoscopic screening of patients with acromegaly: 15-year experience identifies those at risk of new colonic neoplasia and allows for effective screening guidelines

2010 ◽  
Vol 163 (1) ◽  
pp. 21-28 ◽  
Author(s):  
D Dworakowska ◽  
M Gueorguiev ◽  
P Kelly ◽  
J P Monson ◽  
G M Besser ◽  
...  
Keyword(s):  
Colonic Polyps ◽  
Adenomatous Polyps ◽  
Surveillance Colonoscopy ◽  
Normal Colon ◽  
Optimum Frequency ◽  
Colonoscopic Surveillance ◽  
Screening Guidelines ◽  
The Third ◽  
Increased Risk ◽  
High Prevalence

ObjectiveIt is suggested that patients with acromegaly have an increased risk of colorectal cancer and pre-malignant adenomatous polyps. However, the optimum frequency with which colonoscopic screening should be offered remains unclear.DesignTo determine the optimum frequency for repeated colonoscopic surveillance of acromegalic patients.MethodsWe retrospectively reviewed the case records of all patients with acromegaly seen in our centre since 1992: 254 patients had at least one surveillance colonoscopy, 156 patients had a second surveillance colonoscopy, 60 patients had a third surveillance colonoscopy and 15 patients had a fourth surveillance colonoscopy.ResultsThe presence of hyperplastic or adenomatous polyps was assessed in all patients, while one cancer was detected at the second surveillance. At the third surveillance, mean (±s.d.) serum IGF1 levels (ng/ml) in patients with hyperplastic polyps were significantly higher than those with normal colons (P<0.05). The presence of an adenoma rather than a normal colon at the first colonoscopy was associated with a significantly increased risk of adenoma at the second (odds ratio (OR) 4.4, 95% confidence interval (CI) 1.9–10.4) and at the third (OR 8.8, 95% CI 2.9–26.5) screens. Conversely, a normal colon at the first surveillance gave a high chance of normal findings at the second (78%) or third surveillance (78%), and a normal colon at the second colonoscopy was associated with normality at the third colonoscopy (81%).ConclusionsRepeated colonoscopic screening of patients with acromegaly demonstrated a high prevalence of new adenomatous and hyperplastic colonic polyps, dependent on both the occurrence of previous polyps and elevated IGF1 levels.

Malignant potential of colorectal neoplasms in Lynch syndrome: an analysis of 325 lesions endoscopically treated at a single institute

2021 ◽  
Author(s):  
Hiroyuki Hatamori ◽  
Akiko Chino ◽  
Masami Arai ◽  
Daisuke Ide ◽  
Shoichi Saito ◽  
...  
Keyword(s):  
Lynch Syndrome ◽  
Colorectal Neoplasms ◽  
Distal Colon ◽  
Lesion Size ◽  
Proximal Colon ◽  
Pathological Examination ◽  
Low Grade ◽  
Colonoscopic Surveillance ◽  
Increased Risk ◽  
Neoplastic Lesions

Abstract Background Patients with Lynch syndrome are at an increased risk of developing colorectal cancer, and the adenoma-carcinoma sequence is accelerated in these patients. However, the clinicopathological characteristics of colorectal neoplasms in Lynch syndrome patients are not well-known. Methods A total of 325 consecutive colorectal neoplasms were endoscopically removed from 68 patients with Lynch syndrome between June 2005 and May 2018 and retrospectively reviewed. Results Of the 325 lesions, 94 (29%), 220 (68%) and 11 (3%) were from patients with MLH1, MSH2 and MSH6 mutations, respectively. The median lesion size was 5 mm (range 2–40 mm), with 229 (71%) lesions having a non-polypoid morphology. The frequencies of advanced neoplasms, including high-grade adenomas, intramucosal carcinomas and submucosal invasive carcinomas were 14, 34, 97 and 93% for lesions with diameters of &lt;5, ≥5 and &lt;10, ≥10 and &lt;20, and ≥20 mm, respectively. The frequencies of advanced neoplasms in the proximal colon, distal colon and rectum did not significantly differ (36, 35 and 41%, respectively). Conclusions Our results suggest that the malignant transformation interval from low-grade adenomas to advanced neoplasms is similar in all parts of the colon. Furthermore, since one-third of neoplastic lesions with diameters of ≥5 and &lt;10 mm and most of those ≥10 mm were advanced neoplasms, we recommend that in Lynch syndrome patients, careful colonoscopic surveillance should be performed throughout the colon, and all neoplastic lesions, regardless of the size, should be subjected to detailed endoscopic examination, complete resection and detailed pathological examination.

scholarly journals Risk of colorectal adenomas and cancer in monoallelic carriers of MUTYH pathogenic variants: a single-centre experience

2021 ◽  
Author(s):  
R. Patel ◽  
P. McGinty ◽  
V. Cuthill ◽  
M. Hawkins ◽  
S. K. Clark ◽  
...  
Keyword(s):  
Colorectal Adenomas ◽  
Screening Colonoscopy ◽  
Low Grade ◽  
Surveillance Colonoscopy ◽  
Pathogenic Variants ◽  
Adenoma Detection ◽  
Increased Risk ◽  
Single Centre Experience ◽  
Current Guidance

Abstract Purpose The carrier frequency of MUTYH pathogenic variants in the population may be as high as one in 45. Some studies have found an increased risk of colorectal cancer (CRC) in monoallelic carriers of MUTYH pathogenic variants, but the role of early surveillance colonoscopy is not conclusive. This study aimed to assess the outcomes of colonoscopy surveillance in MUTYH carriers. Methods Patients, with a monoallelic pathogenic variant in MUTYH, found at cascade testing, were identified from the St Mark’s Hospital Polyposis Registry database. Findings at surveillance colonoscopy were reviewed. Results Two hundred and forty-nine carriers were identified, of whom 125 had undergone at least one surveillance colonoscopy. Twenty-eight patients (22%) developed at least one adenoma; all adenomas had low-grade dysplasia (LGD). The median age at first colonoscopy was 36 years (range 16–75 years). The median age at first adenoma detection was 43 years (range 22–75 years). The cumulative incidence of adenoma development by age 30, 40, 50, 60 and 70 years was 3.2%, 8.8%, 15.2%, 18.4% and 20.8%, respectively. No CRCs were observed. Conclusions Our cohort of monoallelic carriers of MUTYH pathogenic variants is a relatively younger group than adults entering population screening colonoscopy, but a high adenoma rate was not observed. No CRCs were detected, suggesting that current guidance that these individuals should be managed in the same way as the general population is reasonable.

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