26October2023

Report on the update of the ECCO Guidelines on Inflammatory Bowel Disease and Malignancies

Hannah Gordon, GuiCom Member

Hannah Gordon
© ECCO

The second ECCO Guideline on Malignancy in IBD was published in JCC late last year, supported by working group leads Livia Biancone, Gionata Fiorino, Kostas Katsanos and Uri Kopylov. The ethos of this guideline was to couple evidence-based medicine with provision of practical advice, with a view to enhancing patient care worldwide. We worked alongside the ECCO Guidelines Team to undertake systematic reviews for each statement, selecting topics that are frequently relevant to patients with IBD as well as those which generate debate in the MDT.

Our working groups centred around risk of malignancy in IBD, cancer risk associated with IBD therapies and how to approach the management of IBD in patients with recent or active cancer. We discovered that it had been several years since ECCO reviewed the literature underpinning colorectal cancer surveillance [2], so we re-evaluated this area. ECCO continues to promote surveillance programmes in patients with colonic disease, with intervals determined by disease phenotype and additional risk factors. With the knowledge that IBD can be progressive, we also encourage a restaging colonoscopy 8 years after diagnosis to help guide the need for future surveillance, even in patients deemed low risk at diagnosis. We have also provided guidance on how to manage dysplasia when we find it, advocating a multidisciplinary approach including endoscopists, histopathologists and surgeons with specific expertise in IBD.

Interestingly, I am most often asked about the topics within this guideline with the lowest levels of evidence – management of IBD in patients with recent or active cancer. With an increase in IBD prevalence coupled with an aging population, we are more often seeing these patients in our clinics. Previously, international societies, including ECCO, have advised pausing immunosuppressive therapy for between two and five years following a cancer diagnosis [3]. This was largely due to fear of adverse cancer outcomes. However, we now have a growing body evidence that supports the safety of most immunosuppressive therapies in patients with prior cancer, with no clear associations between cancer relapse or new incident cancers. Of course, data must be interpreted with caution due to the relatively low numbers and heterogeneity in both cancer and IBD. However, when mitigating risk amidst uncertainty, it is also important to consider the risk of IBD flare itself. Both active disease and steroid use confer significant morbidity to our patients. Indeed, patients receiving hormone modulators or immune checkpoint inhibitors are at particularly high risk of flare [4, 5]. With this in mind, we have moved away from general avoidance of immunosuppressive therapies and towards an approach where uncertainty is acknowledged, with treatment decisions guided by IBD phenotype, input from the treating oncologist and patient wishes.

The full guideline can be accessed in JCC online: https://academic.oup.com/ecco-jcc/article/17/6/827/6931718.

References

  1. Gordon H, Biancone L, Fiorino G, et al. ECCO Guidelines on Inflammatory Bowel Disease and Malignancies. J Crohns Colitis 2023;17:827–54.
  2. Annese V, Daperno M, Rutter MD, et al. European evidence based consensus for endoscopy in inflammatory bowel disease. J Crohns Colitis 2013;7:982–1018.
  3. Annese V, Beaugerie L, Egan L, et al. European evidence-based consensus: Inflammatory bowel disease and malignancies. J Crohns Colitis 2015;9:945–65.
  4. Axelrad JE, Bazarbashi A, Zhou J, et al. Hormone therapy for cancer is a risk factor for relapse of inflammatory bowel diseases. Clin Gastroenterol Hepatol 2020;18:872–880 e1.
  5. Grimsdottir S, Attauabi M, Dahl EK, et al. Systematic review with meta-analysis: The impact of cancer treatments on the disease activity of inflammatory bowel diseases. J Crohns Colitis 2023;17:1139–53.

Posted in ECCO News, Committee News, Volume 18, Issue 3, GuiCom