Cancer in Inflammatory Bowel Disease

Emily Steinhagen, MD, FACS, FASCRS

Patients with inflammatory bowel disease (IBD) are at increased risk of developing cancer as a sequalae of uncontrolled, long-term inflammation. The cancer risk increases with disease duration. Efforts to achieve and maintain remission of IBD are therefore important not only for health and quality of life, but also to decrease the risk of carcinoma. The evolution of surgery for IBD and our understanding of the relationship between IBD and cancer is a fascinating story that provides context for our current practice standards.

The varied phenotype of IBD means that each patient has a different risk profile and their surveillance and treatment should be considered on an individual basis within existing guidelines. Small bowel adenocarcinoma is rare overall, and can occur sporadically, in the context of Lynch syndrome or Crohn's disease. It can be difficult to diagnose and devastating due to the overall poor prognosis but is even worse in patients with Crohn's disease. On the other hand, patients with Crohn's disease or ulcerative colitis may be diagnosed with dysplasia and undergo surgery before they even develop cancer, representing a success in the surveillance protocols. Certain subsets of patients such as those with primary sclerosing cholangitis are at especially increased risk and require more frequent surveillance.

Fortunately, improvements in medical therapy and surveillance techniques seem to have decreased the risk of cancer for IBD patients overall. This may be attributed to improved options for medical management, the shift in the goal of treatment to endoscopic remission rather than clinical remission, and improved endoscopic techniques that enable detection and even treatment of dysplastic lesions. Guidelines for surgery for dysplasia in colitis have also changed over time and continue to evolve.

When cancer does occur in IBD patients, the usual oncologic treatment algorithms are typically followed. However, in some cases the standard of care includes multiple treatment options and the role and status of their IBD should be considered. Radiation for rectal cancer improves local control, but if a restorative proctocolectomy is planned, long-term functional outcomes are different than they are for patients undergoing proctectomy with coloanal anastomosis for sporadic cancers. Therefore, shared decision making between the multidisciplinary treatment team and patients is crucially important. Patients may choose to undergo neoadjuvant chemotherapy without radiation or consider permanent ileostomy instead of a pouch. For patients who undergo restorative proctocolectomy for dysplasia or failure of medical management, there is still a risk of developing cancer in their pouches. This can include the anorectal cuff or the pouch body itself. This is such a rare occurrence that the literature about it is scant and the optimal surveillance regimen is not well defined.

In this issue of Clinics in Colon and Rectal Surgery, “Cancer in Inflammatory Bowel Disease,” expert authors discuss the risks of cancer, surveillance, and treatment strategies for these complex, multifaceted disease processes. The aim of this edition is to provide experienced viewpoints around the data for patients with IBD and cancer. Most of these problems should be treated in the context of a multidisciplinary care team to discuss and consider treatment strategies from a variety of perspectives. Each patient scenario is unique and requires careful thought about the best treatment strategies. We hope these perspectives provide you with updated, high-quality information to help guide your discussions with these unique patients.

Publication History

Article published online:
15 March 2023