Cancer Prevention in IBD

People with inflammatory bowel disease (IBD) who have long‑standing colitis face a higher risk of colorectal cancer. The good news is that high‑quality colonoscopy, done on the right schedule, finds precancerous changes early and allows safe removal. This article explains who is at risk, when surveillance should start, how often to repeat it, and which advanced endoscopic tools improve detection and treatment. (pubmed.ncbi.nlm.nih.gov)

Key takeaways

• Start colonoscopic surveillance about 8 years after diagnosis of colonic IBD, and right away if primary sclerosing cholangitis (PSC) is present. (gastro.org)

• Interval depends on risk: yearly for high risk, every 2–3 years for intermediate risk, every 5 years for low risk. (pmc.ncbi.nlm.nih.gov)

• High‑definition scopes plus dye‑spray chromoendoscopy or virtual chromoendoscopy increase dysplasia detection. (gastro.org)

• Most visible precancerous lesions can be removed endoscopically, avoiding surgery. (gastro.org)

• Keeping inflammation quiet lowers cancer risk over time. (pubmed.ncbi.nlm.nih.gov)

Why cancer risk is higher in IBD

Chronic inflammation can drive changes in the colon lining that lead to dysplasia, which is an early precancerous change. The risk rises with longer disease duration, greater extent of colon involvement, and ongoing inflammation. Other strong risk factors include PSC and a first‑degree relative with colorectal cancer. Sustained mucosal healing reduces this risk compared with persistent inflammation. (pubmed.ncbi.nlm.nih.gov)

Who needs surveillance and when it starts

• Ulcerative colitis beyond the rectum and Crohn’s disease with at least one third to one half of the colon involved should enter a surveillance program.

• Begin surveillance about 8 years after diagnosis of colonic disease. Those with PSC should start at PSC diagnosis and repeat frequently. People with isolated proctitis follow average‑risk population screening. (gastro.org)

How often: risk‑tiered intervals

These tiers reflect aligned guidance from major societies. Individual plans can vary based on findings, quality of prior exams, and response to therapy. (pmc.ncbi.nlm.nih.gov)

What makes a high‑quality surveillance colonoscopy

• Use a high‑definition colonoscope, ensure excellent bowel prep, and carefully wash and inspect the mucosa.

• Control active inflammation first when possible, since healing improves visibility and lowers risk.

• Take targeted biopsies of any irregular area. When dye‑spray chromoendoscopy is not used, many experts still add random biopsies in higher‑risk settings such as PSC or when visibility is limited. (gastro.org)

Advanced endoscopic options that improve detection

• Dye‑spray chromoendoscopy (CE): Sprays indigo carmine or methylene blue to highlight subtle lesions. Compared with standard white‑light exams, CE detects more dysplasia. Many guidelines suggest CE, even with high‑definition equipment, particularly if there is a history of dysplasia. (guidelinecentral.com)

• Virtual chromoendoscopy: Narrow‑band imaging, blue‑laser imaging, or i‑scan can be used with high‑definition scopes as a suitable alternative when dye is not practical. Evidence continues to evolve, and practices differ by center. (gastro.org)

When dysplasia is found: remove if endoscopically resectable

Most visible, well‑demarcated lesions can be removed during colonoscopy:

• Polypoid lesions: Often removed with endoscopic mucosal resection (EMR).

• Flat or nonpolypoid lesions: May need advanced techniques, including en bloc EMR or endoscopic submucosal dissection (ESD), in expert hands.

• After complete removal, surveillance is preferred over colectomy, with short‑interval follow‑up for larger or high‑grade lesions. Surgery is considered if a lesion cannot be completely removed, if there is multifocal high‑grade dysplasia, or if cancer is suspected. (gastro.org)

Special situations

• Primary sclerosing cholangitis: Highest risk group. Use high‑definition surveillance with biopsies starting at diagnosis, typically every 1–2 years, including in adolescents with PSC‑IBD. (journals.lww.com)

• Post‑colectomy pouch (IPAA): Routine pouch surveillance is usually every 5 years, but yearly if there was prior colorectal dysplasia or cancer or if PSC is present. (e-guide.ecco-ibd.eu)

What not to rely on

• Stool tests (FIT, stool DNA): These are designed for average‑risk screening and are not substitutes for colonoscopic surveillance in IBD. Colonoscopy remains the recommended method for surveillance in colitis. (gastro.org)

• CT colonography: Not routinely used for IBD surveillance and does not permit biopsy or removal. (aafp.org)

Prevention beyond the scope

• Aim for deep remission. Lower inflammation over time lowers dysplasia risk. Treat‑to‑target strategies that achieve mucosal healing are protective. (pubmed.ncbi.nlm.nih.gov)

• Do not use high‑dose ursodiol to prevent colorectal cancer in PSC‑IBD; it has not shown benefit and has been linked to harm. (aasld.org)

• Healthy habits help overall colon health: do not smoke, maintain a balanced diet, stay active, and keep up with vaccinations and routine care. [Editor note: source required]

FAQs

Does everyone with ulcerative colitis need special cancer surveillance

Only those with colitis beyond the rectum do. Isolated proctitis follows average‑risk population screening. (gastro.org)

Is chromoendoscopy necessary at every exam

High‑definition white‑light colonoscopy is the minimum. Many centers add dye‑spray or virtual chromoendoscopy to boost detection, especially after any prior dysplasia. (guidelinecentral.com)

If a precancerous lesion is removed, how soon is the next colonoscopy

After complete resection, follow‑up often occurs in 3–12 months depending on size, grade, and features. The interval then lengthens if exams remain negative. Plans are individualized. (pmc.ncbi.nlm.nih.gov)

Do medicines prevent cancer

Medicines that control inflammation are key because healing lowers risk. No medicine is used solely as a chemopreventive drug for colorectal cancer in IBD. (pubmed.ncbi.nlm.nih.gov)

What about people with PSC

They are the highest‑risk group. Start surveillance at PSC diagnosis and repeat every 1–2 years with expert endoscopy. (journals.lww.com)