Photo Credit: AII

Dr. Lindsay Hannan discusses findings that showed use of advanced medical therapy in ulcerative colitis have not improved resection or colorectal cancer rates.

In patients with ulcerative colitis (UC) who have undergone colectomy over the past two decades, the increased use of advanced medical therapies—biologicals and small molecules—have neither increased their time to resection nor changed their colorectal cancer rates. Patients receiving advanced therapies have also had higher incidental cancers rates and decreased colorectal cancer survival.

“This information should be in­corporated in clinical decisions when counseling patients on advanced therapies who are treatment-refractory for either cycling to yet another therapy line or instead opting for colectomy,” the researchers wrote in the Journal of Crohn’s and Colitis.

A Cohort Study in Two Referral Centers

The study team assessed 716 patients who underwent colectomy from 2003 to 2022 at two tertiary referral centers. Although the use of advanced therapies increased from 36.8% to 89.7% during that period, the median time to colec­tomy remained around 7 years. Colectomy and colorectal cancer was diagnosed in 72 patients (10.1%), with no significant change over time.

The 24 patients receiving advanced therapies had higher incidental cancer rates than the 48 who received no advanced medical therapies (37.5% vs 8.3%; P=0.002), which was associated with reduced colorectal cancer-related survival (HR for colorectal cancer-related death, 3.3 [95% CI, 1.17-9.4]; P=0.02).

An Outside Expert’s Perspective

Lindsay M. Hannan, MD, MSc, spoke with Physician’s Weekly (PW) about the study results and how the findings could impact colorectal cancer outcomes in patients with ulcerative colitis patients undergoing colectomy.

 PW: Why was it important to do this study?

Dr. Hannan: It’s important to observe trends over time, including prescribing patterns and changes in cancer incidence. This can lead to hypothesis generation and additional studies, which can lead to improvements in patient care over time.

What are the key takeaways for clinicians? 

This is a nicely performed observational study that gives additional insight into this unique population.

Patients with inflammatory bowel disease represent a distinct and important population among patients with colon cancer. There can be more challenges with treatment, including compounding toxicity with cancer-directed therapy, managing advanced medical therapy during treatment, and dealing with sequelae of more extensive surgical resection.

Did you find any of the results unexpected?

The proportion of patients with ulcerative colitis who were treated with advanced medical therapy increased across the study period, as did the time between initiation of advanced medical therapy and resection. What didn’t appear to change with time was time from ulcerative colitis diagnosis to resection and the proportion of patients diagnosed with colon cancer.

It’s hard to infer causal relationships in an observational analysis, and some important variables such as screening frequency, adherence to screening recommendations, frequency of ulcerative colitis flares, and quality of life, could not be measured.

How could the findings impact colorectal cancer outcomes?

For patients with ulcerative colitis undergoing colectomy, it would be preferable to undergo the procedure prior to the development of colorectal cancer. This is where good screening practices and predictive algorithms are crucial. Once there is a cancer diagnosis or a suspicion of cancer, a proper oncologic resection is indicated.

This study provides information that could be helpful in defining risk and therefore could inform any changes needed in screening practices and management guidelines in the future.

PW: Are any strengths or limitations noteworthy?

The study has a very nice sample size and extensive information about the use of advanced medical therapy in the study population. As acknowledged by the authors, the patients were drawn from two academic institutions, and it is uncertain if the observations are generalizable to patients treated in non-academic institutions or on other continents. The main limitation is the retrospective nature of the analysis. However, given the nature of the questions and the available data, it would not have been possible to approach it efficiently in another manner.

PW: What questions remain unanswered for you?

In this population of patients with higher risk of colon cancer, what other important predictive factors could be used to inform colectomy timing?   Are these results generalizable to other populations?