European Evidence-based Consensus: Inflammatory Bowel Disease and Malignancies

Abstract

The global prevalence of cancer is increasing, largely as more patients are living into old age. Therefore, gastroenterologists caring for patients with inflammatory bowel disease [IBD] increasingly are managing patients with cancer, or a previous history of cancer. This often requires joint management with the patient’s oncologist, enabling case-by-case decision-making based on the characteristics and expected evolution of the index cancer. Previously, no European guidelines existed describing the impact of IBD on malignancy. For this reason, the European Crohn’s and Colitis Organisation [ECCO] Guidelines Committee [GuiCom] decided to elaborate a set of Consensus Statements on optimal risk/benefit strategies for treating IBD patients with cancer or a history of cancer. The development of clinical practice guidelines is expensive and time consuming, and it is the Committee’s hope that these statements will facilitate and accelerate future efforts to elaborate formal guidelines, providing useful information on areas for which evidence is lacking and where controlled studies are needed. The strategy used to produce the Consensus Statements involved five steps: 1. Two members of Guicom [VA and RE] identified four main topics that needed to be addressed: a] IBD and solid tumours; b] IBD and skin and haematological malignancies; c] malignancy related to therapy: risk and prevention; and d] management of IBD patients with a history of malignancy. During 2014, calls for participation in the drafting of consensus statements were issued to ECCO members, and selected oncologists known for their expertise and active research in the field were invited to join the Consensus. Participants were selected by the Committee, and four working groups were created, each composed of a chairperson [LE, RE, LB, and VA], two ECCO members including young members [Y-ECCO], and one or two experienced oncologists. The chairmen and their groups elaborated relevant questions on topics dealing with current practice and/or areas of controversy. Participants in the Consensus Process were asked to provide answers to the questions based on evidence from the literature and their own experience [Delphi procedure].1 2. Working in parallel, the four groups conducted a systematic review of the literature on their topic with the appropriate key words. The searches targeted Medline/PubMed and the Cochrane database, as well as other relevant sources. 3. Provisional statements on the group’s topic were drafted by the chairmen. These statements were then reviewed and commented on by members of the working group. With the aid of a web-based platform [www.cpg-development-org], the review process was later extended to applicants not included in the working groups and the ECCO national representatives [see Acknowledgments]. 4. In January 2015, a meeting [chaired by VA and RE] was held in Vienna to revise and approve the statements. Each statement was projected on a screen, discussed, and revised until a consensus was reached by > 80% of the participants at the meeting. The level of evidence supporting each statement was rated in accordance with the recommendations of the Oxford Centre for Evidence-based Medicine.2 In some areas where the level of evidence is generally low, expert opinion was included as appropriate. 5. The final document on each topic was written by the chairperson in conjunction with the members of his working group. Consensus guideline statements in bold are followed by comments on the evidence and opinion. Statements are intended to be read not in isolation but together with the qualifying comments in the accompanying text. The final text was edited by VA and RE to ensure consistency of style and terminology and then submitted to the participants for final approval. In addition, ECCO has diligently maintained a disclosure policy of potential conflicts of interests [CoI]. The conflict of interest declaration is based on a form used by the International Committee of Medical Journal Editors [ICMJE]. The CoI statement is not only stored at the ECCO Office and the editorial office of the Journal of Crohn’s and Colitis [JCC] but also open to public scrutiny on the ECCO website [https://www.ecco-ibd.eu/about-ecco/ecco-disclosures.html], providing a comprehensive overview of potential conflicts of interest of the consensus participants and guideline authors. Patients with IBD are at increased risk of developing colorectal cancer [CRC] (evidence level [EL] 1) which, in the case of ulcerative colitis [UC], varies with the extent and duration of the disease [EL 1], family history of CRC, and the presence/absence of primary sclerosing cholangitis [PSC] [EL 1]. Over the past 35 years, the risk of CRC in patients with IBD has not declined significantly, but the risk of dying from CRC has decreased [EL 1] Two recent meta-analyses of cohort studies have clarified the increased risk of CRC in patients with IBD. For those with Crohn’s disease [CD],3 the e