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Experts release international consensus statement on surveillance, management of dysplasia in IBD
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An international multidisciplinary group has developed unifying consensus recommendations on surveillance and management of dysplasia in inflammatory bowel disease, simultaneously published in Gastrointestinal Endoscopy and Gastroenterology.
As mounting data on newer endoscopic methods for detecting dysplasia in patients with IBD has caused variation in guideline recommendations, the Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients International Consensus (SCENIC) Guideline Development Panel aimed to develop a consensus statement addressing optimal methods on how surveillance colonoscopy for detecting dysplasia should be performed, and how dysplasia identified at colonoscopy should be managed.
Tonya Kaltenbach
“We recognized that there was variable practice in the surveillance methods for dysplasia detection in patients with IBD and there were also variable guidelines, both within the US and internationally,” Tonya Kaltenbach, MD, MS, from the Veterans Affairs Palo Alto, who served on the panel, told Healio Gastroenterology. The need for an international consensus statement, she said, came from “an interest to provide a uniform recommendation” — namely on the use of chromoendoscopy for the detection of dysplasia.
In addition to evidence, she added, factors like feasibility, values and preferences, cost and quality of life impact are also considered in guideline development, and the SCENIC panel therefore included stakeholders from various perspectives, including IBD experts, endoscopic imaging experts, pathologists, patient representatives, nurses and methodologists.
Detection of dysplasia on surveillance colonoscopy
The panelists agreed that regarding the optimal methods for detecting colon dysplasia in patients with IBD on surveillance colonoscopy, the following recommendations could be made:
- High definition is recommended for surveillance with white-light colonoscopy;
- Chromoendoscopy is recommended rather than white-light colonoscopy for standard-definition surveillance;
- Chromoendoscopy is suggested rather than white-light colonoscopy for high-definition surveillance;
- Narrow-band imaging is not suggested over white-light colonoscopy for standard- or high-definition surveillance; and
- Narrow-band imaging is not suggested over chromoendoscopy for image-enhanced high-definition surveillance.
The panelists did not reach consensus on whether endoscopists should perform random biopsies when using high-definition white-light colonoscopy or chromoendoscopy. They also did not endorse autofluorescence imaging over white-light colonoscopy for high-definition surveillance due to low-quality evidence, and did not include confocal laser endomicroscopy due to its inability to be practically applied in IBD surveillance.
Management of dysplasia identified on surveillance colonoscopy
The panelists agreed that regarding the optimal management of dysplasia identified on endoscopic surveillance of patients with IBD, the following recommendations could be made:
- Surveillance colonoscopy is recommended over colectomy after complete removal of endoscopically resectable polypoid dysplastic lesions;
- Surveillance colonoscopy is suggested over colectomy after complete removal of endoscopically resectable nonpolypoid dysplastic lesions; and
- Referral to an endoscopist with expertise in IBD surveillance using chromoendoscopy with high-definition colonoscopy is suggested for patients with pathology-confirmed endoscopically invisible dysplasia.
Implementation and learning resources
According to Kaltenbach, implementation has historically been the most significant obstacle to developing a standardized guideline for these practices, specifically due to reservations regarding chromoendoscopy and endoscopic removal of identified dysplastic lesions.
“One of the next steps that will be key to bringing about the widespread practice of chromoendoscopy to survey these patients is teaching,” she said, and emphasized that open access learning resources are critical in this regard.
Accordingly, the panel created free educational resources to assist endoscopy professionals as they incorporate the recommendations. ASGE's “Chromoendoscopy with Targeted Biopsy to Detect Nonpolypoid Colorectal Neoplasms” video is available at the ASGE Online Learning Center. Additional resources, such as an atlas of endoscopic images of dysplastic lesions and a learning algorithm, are also accessible via the consensus statement paper. – by Adam Leitenberger
Disclosure: Kaltenbach reports she is a consultant and has received research support from Olympus. Please see the study for a full list of authors’ relevant financial disclosures.
Perspective
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Stephen B. Hanauer, MD
An international multidisciplinary group sought to develop unifying consensus recommendations addressing 1) how surveillance colonoscopy for detection of dysplasia should be performed and 2) how dysplasia identified at colonoscopy should be managed. Despite adherence to guideline development from the Institute of Medicine, the publication has been published as a “consensus statement” endorsed by the American Gastroenterological Association and the American Society for Gastrointestinal Endoscopy. The document was reviewed by the Practice Parameters Committee of the American College of Gastroenterology who recommended against endorsement. According to the NIH, "Consensus statements synthesize new information, largely from recent or ongoing medical research, that has implications for reevaluation of routine medical practices. They do not give specific algorithms or guidelines for practice."
In an accompanying editorial, Marion and Sands note that the SCENIC panel was convened out of concern that the current surveillance guidelines were not protecting patients with colitis from dying of colorectal cancer. However, data is accumulating that our current guidelines for surveillance in ulcerative colitis is working and that surveillance colonoscopies do reduce the risk of colon cancer mortality in IBD patients.
Furthermore, Marion and Sands identify numerous challenges in chromoendoscopy for colitis surveillance that include operator barriers such as training of gastroenterologists, fellows and staff, identification of clinically relevant lesions (there is a suggestion that small chromo-identified lesions may have a less aggressive course than white-light identified lesions), pathologist variability in identifying/grading dysplasia and varied endoscopic skills, as well as operational barriers such as availability and type of dye, time and prep requirements and impact of residual inflammation, patient acceptance, and, most important knowledge barriers including uncertain natural history of dysplasia detected by chromo, lack of well-defined population at risk, lack of risk stratification, uncertain implications of prior surveillance findings for management and residual uncertainty of appropriate surveillance intervals.
Detection of dysplasia was the primary endpoint of the SCENIC statement and the authors point out that detection of dysplasia is not clearly documented to improve clinical outcomes. Although, as mentioned, surveillance colonoscopies, no matter the technique, have been shown to improve CRC mortality in IBD.
While the American College of Gastroenterology supports many of the principles laid forth in the SCENIC document we believe that there are too many issues remaining to consider the consensus statement a guideline or standard of care. We applaud the SCENIC effort to produce an evidence-based update on surveillance techniques and concur that chromoendoscopy is currently the most sensitive means of detecting dysplasia. However, we believe that there is a need to address the remaining questions discussed by Marion and Sands, amongst others, before a standard of care guidance is accepted that chromoendoscopy is a requisite for routine surveillance in the setting of colitis.
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