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Guideline Summary
Guideline Title
AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease.
Bibliographic Source(s)
Farraye FA, Odze RD, Eaden J, Itzkowitz SH, McCabe RP, Dassopoulos T, Lewis JD, Ullman TA, James T 3rd, McLeod R, Burgart LJ, Allen J, Brill JV, AGA Institute Medical Position Panel on Diagnosis and Management of Colorectal. AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease. Gastroenterology. 2010 Feb;138(2):738-45. [1 reference] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Annually, the Clinical Practice and Quality Performance Committee (CPQMC) reviews all current American Gastroenterological Association (AGA) Institute medical position statements/guidelines and ranks the topics to determine if they are outdated. Those that are determined to be outdated are prioritized by the committee for revision or withdrawn/retired.

Scope

Disease/Condition(s)
  • Inflammatory bowel disease (ulcerative colitis, Crohn's disease)
  • Colorectal neoplasia (colorectal cancer)
Guideline Category
Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Clinical Specialty
Colon and Rectal Surgery
Family Practice
Gastroenterology
Internal Medicine
Oncology
Pathology
Surgery
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Guideline Objective(s)

To provide diagnostic and management strategies for patients with inflammatory bowel disease who have an increased risk of developing colorectal cancer

Target Population

Patients with inflammatory bowel disease (ulcerative colitis and Crohn's disease of the colon)

Interventions and Practices Considered

Diagnosis/Evaluation/Risk Assessment

  1. Evaluation of risk factors for colorectal cancer
  2. Identification and interpretation of dysplasia on histological samples
  3. Surveillance colonoscopy and biopsy
  4. Chromoendoscopy

Management/Prevention

  1. Surgery
    • Colectomy
    • Polypectomy
  2. Chemopreventive agents
    • Ursodeoxycholic acid
    • Aminosalicylates
Major Outcomes Considered
  • Risk of developing colorectal cancer or dysplasia
  • Sensitivity and efficacy of diagnostic tests
  • Efficacy of treatment
  • Progression rate

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

A search of the MEDLINE database was performed to identify relevant English language articles published in peer-reviewed journals. For this search, the terms dysplasia, colorectal cancer, surveillance, polyp, chemoprevention, chromoendoscopy, endoscopy, primary sclerosing cholangitis, risk factors, and children were searched in combination with the terms ulcerative colitis, Crohn's disease, Crohn's colitis, colitis, or inflammatory bowel disease. A manual search of the reference lists from the potentially relevant papers was performed to identify additional studies that may have been missed using the computer-assisted strategy. In most instances, the pathology studies represented retrospective case-control, or cohort studies, descriptive studies, reports of expert committees, or opinions of respected authorities in pathology practice.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

A series of questions were identified that are relevant for clinicians who manage patients with inflammatory bowel disease (IBD) at risk for colorectal neoplasia (Table 1 in the original guideline). For each question, a comprehensive literature search was conducted, pertinent evidence was reviewed, and the quality of relevant data was evaluated. The conclusions were based on the best available evidence or, in the absence of quality evidence, the expert opinion of the authors of the technical review (see "Availability of Companion Documents" field) and the medical position statement.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Strength of Recommendations*

Grade A indicates that the certainty of evidence is high that the magnitude of net benefits is substantial. The United States Preventive Services Task Force (USPSTF) recommends providing the service for the specific population.

Grade B indicates that the certainty of evidence is moderate that the magnitude of net benefits is either moderate or substantial, or that the certainty of evidence is high that the magnitude of net benefits is moderate. The USPSTF recommends providing the service for the specific population.

Grade C indicates that the certainty of the evidence is either high or moderate that the magnitude of net benefits is small. The USPSTF recommends against routinely providing the service for the specific population. There may be considerations that support providing the service in an individual patient.

Grade D indicates that the certainty of the evidence is high or moderate that the magnitude of net benefits is either zero or negative. The USPSTF recommends against providing the service for the specific population.

Grade I indicates that the evidence is insufficient to determine the relationship between benefits and harms (i.e., net benefit). The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service in the specific population.

*US Preventive Services Task Force Procedure Manual. AHRQ Publication No. 08-05118-EF, July 2008. Available at: http://www.uspreventiveservicestaskforce.org/methods.htm External Web Site Policy.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Not stated
Description of Method of Guideline Validation

Not applicable

Recommendations

Major Recommendations

Definitions for the recommendation grades (A, B, C, D, Insufficient) are provided at the end of the "Major Recommendations" field.

Are Patients with Inflammatory Bowel Disease (IBD) at Increased Risk for Colorectal Cancer (CRC)?

  • Patients with ulcerative colitis and Crohn's disease of the colon have an increased risk of developing CRC.

Are There Well-Substantiated Factors Other Than Dysplasia That Increase or Decrease the Risk of CRC in IBD?

  • Disease duration, more extensive disease, primary sclerosing cholangitis, and a positive family history of sporadic CRC are all associated with an increased risk of CRC.
  • Colonic strictures in patients with ulcerative colitis (UC) and/or a shortened colon, and/or multiple postinflammatory pseudopolyps increase the risk of CRC.
  • Inflammation is a risk factor for progression to colorectal neoplasia.

What Is the Natural History of Dysplasia?

  • In most cases, CRC in IBD develops from dysplasia.
  • Although imperfect, dysplasia is currently considered the best marker of CRC risk in IBD.

Should Colectomy Be Performed for Raised Dysplasia?

Grade A: High certainty that the magnitude of net benefits is substantial.

  • Patients with IBD and a non–adenoma-like dysplasia-associated lesion or mass should be treated with colectomy.
  • Patients with IBD and an adenoma-like dysplasia-associated lesion or mass, and no evidence of flat dysplasia elsewhere in the colon, can be managed safely by polypectomy and continued surveillance.

Should Colectomy Be Performed for Flat Dysplasia?

Grade A: There is high certainty that colectomy for flat high-grade dysplasia (HGD) treats undiagnosed synchronous cancer and prevents metachronous cancer.

Grade Insufficient: The current evidence is insufficient to assess the balance of benefits and harms of colectomy for flat low-grade dysplasia (LGD).

Is There Sufficient Rationale for Performing Surveillance Colonoscopy in Patients with IBD?

Grade B: There is moderate certainty that surveillance colonoscopy results in at least moderate reduction of CRC risk in patients with IBD.

  • Despite the lack of randomized controlled trials, surveillance colonoscopy is recommended for patients with IBD at increased risk for developing CRC.
  • Patients with extensive UC or CD of the colon are most likely to benefit from surveillance.

How Should Surveillance Colonoscopy Be Performed?

  • The technique of surveillance colonoscopy in patients with IBD should include extensive biopsies of all anatomic segments of colorectal mucosa.
  • Although there are inadequate data available to recommend optimal surveillance intervals, intervals of 1 to 3 years are suggested.
  • Careful inspection of the mucosa along with a sufficient number of biopsy specimens should be obtained from all anatomic segments of the colon.

What Role Do the Newer Imaging Techniques Play in Identifying and Managing Dysplasia?

  • The sensitivity of chromoendoscopy for detecting dysplasia is higher than white light endoscopy in the hands of endoscopists who have expertise with this technique.
  • The natural history of chromoendoscopically detected dysplasia is unknown.
  • Additional studies are needed to evaluate the efficiency of other imaging methods, such as narrow band imaging and confocal endomicroscopy, in detecting dysplasia.

Should Chemopreventive Agents Be Used to Lower the Risk of Developing Dysplasia or CRC in IBD?

Grade A: High certainty that the magnitude of net benefits is substantial.

  • Ursodeoxycholic acid has demonstrated a significant reduction in CRC in patients with UC who also have primary sclerosing cholangitis (PSC).

Grade B: Moderate certainty that the magnitude of net benefits is moderate.

  • Aminosalicylates are chemopreventive against CRC.

Grade D: High certainty that the magnitude of net benefits is negative.

  • Oral or topical corticosteroids, while demonstrating antineoplastic effects in 2 studies, are associated with too many side effects to warrant use as chemopreventive agents.

Grade Insufficient: No recommendation, insufficient evidence to recommend for or against the use of thiopurines, supplements, or statins.

  • Azathioprine or 6-mercaptopurine has not been consistently associated with lower rates of CRC.
  • Folic acid supplements, calcium, multivitamins, or statins have not been consistently associated with lower rates of CRC.

Should Molecular Markers Be Applied to Help Stratify Patients into Low-Risk and High-Risk Groups?

Grade Insufficient: No recommendation; insufficient evidence to recommend for or against the use of molecular markers.

  • Molecular markers should not be applied to help stratify patients into low-risk and high-risk groups at this time.

Definitions:

Strength of Recommendations*

Grade A indicates that the certainty of evidence is high that the magnitude of net benefits is substantial. The United States Preventive Services Task Force (USPSTF) recommends providing the service for the specific population.

Grade B indicates that the certainty of evidence is moderate that the magnitude of net benefits is either moderate or substantial, or that the certainty of evidence is high that the magnitude of net benefits is moderate. The USPSTF recommends providing the service for the specific population.

Grade C indicates that the certainty of the evidence is either high or moderate that the magnitude of net benefits is small. The USPSTF recommends against routinely providing the service for the specific population. There may be considerations that support providing the service in an individual patient.

Grade D indicates that the certainty of the evidence is high or moderate that the magnitude of net benefits is either zero or negative. The USPSTF recommends against providing the service for the specific population.

Grade I indicates that the evidence is insufficient to determine the relationship between benefits and harms (i.e., net benefit). The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service in the specific population.

*US Preventive Services Task Force Procedure Manual. AHRQ Publication No. 08-05118-EF, July 2008. Available at: http://www.uspreventiveservicestaskforce.org/methods.htm External Web Site Policy.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate management of patients with inflammatory bowel disease at risk of developing colorectal cancer

Potential Harms

Not stated

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Farraye FA, Odze RD, Eaden J, Itzkowitz SH, McCabe RP, Dassopoulos T, Lewis JD, Ullman TA, James T 3rd, McLeod R, Burgart LJ, Allen J, Brill JV, AGA Institute Medical Position Panel on Diagnosis and Management of Colorectal. AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease. Gastroenterology. 2010 Feb;138(2):738-45. [1 reference] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Feb
Guideline Developer(s)
American Gastroenterological Association Institute - Medical Specialty Society
Source(s) of Funding

American Gastroenterological Association Institute

Guideline Committee

American Gastroenterological Association Institute Clinical Practice and Quality Management Committee

Composition of Group That Authored the Guideline

The American Gastroenterological Association (AGA) Institute Medical Position Panel consisted of the authors of the technical review (Francis A. Farraye, MD, Boston, Massachusetts; Robert D. Odze, MD, Boston, Massachusetts; Jayne Eaden, MD, Coventry, England; Steven H. Itzkowitz, MD New York, New York), a community-based gastroenterologist (Robert P. McCabe, MD, Minnesota Gastroenterology), academic-based gastroenterologists (Themistocles Dassopoulos, MD; James D. Lewis, MD; and Thomas A. Ullman, MD), an insurance provider representative (Tom James III, MD, Physician Advisor, Strategic Advisory Group, Humana), a colon and rectal surgeon (Robin McLeod, MD, Mount Sinai Hospital-Canada), a pathologist (Lawrence J. Burgart, MD, Minnesota Gastroenterology), chair of the AGA Institute Clinical Practice and Quality Management Committee (John Allen, MD, Minnesota Gastroenterology), and chair of the Practice Management and Economics Committee (Joel V. Brill, MD, Predictive Health, LLC).

Financial Disclosures/Conflicts of Interest

The authors disclose the following: Dr Farraye has received research support from Prometheus Laboratories; is a consultant and a member of the speaker's bureau for Abbott, Centocor, Proctor & Gamble, Prometheus Laboratories, Salix, and Shire; and is a consultant for UCB. The remaining authors disclose no conflicts.

Guideline Status

This is the current release of the guideline.

Annually, the Clinical Practice and Quality Performance Committee (CPQMC) reviews all current American Gastroenterological Association (AGA) Institute medical position statements/guidelines and ranks the topics to determine if they are outdated. Those that are determined to be outdated are prioritized by the committee for revision or withdrawn/retired.

Guideline Availability

Electronic copies: Available from the Gastroenterology journal Web site.

Print copies: Available from the American Gastroenterological Association Institute, 4930 Del Ray Avenue, Bethesda, MD 20814.

Availability of Companion Documents

The following is available:

  • AGA technical review on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease. Gastroenterology 2010;138:746–774. Available from the Gastroenterology journal Web site External Web Site Policy.

Print copies: Available from American Gastroenterological Association Institute, 4930 Del Ray Avenue, Bethesda, MD 20814.

The following is also available:

Patient Resources

None available

NGC Status

This summary was completed by ECRI Institute on June 17, 2011. The information was verified by the guideline developer on October 27, 2011.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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