NICE has today (Wednesday 23 March) published a new guideline on colonoscopic surveillance[1] for the prevention of colorectal cancer in people with ulcerative colitis[2], Crohn's disease[3] or adenomas[4]. Colonoscopic surveillance in people with inflammatory bowel disease (IBD, which covers ulcerative colitis and Crohn's disease) or adenomas can detect problems early, and potentially prevent progression to colorectal cancer[5].

Adults with IBD or with adenomas are at higher risk of developing colorectal cancer than the general population. Colorectal cancer is the third most common cancer in the UK, with approximately 32,300 new cases diagnosed and 14,000 deaths in England and Wales each year. Around half of the people diagnosed with colorectal cancer survive for at least 5 years after diagnosis[6].

It is estimated that between 0.15% to 0.30% of people in England and Wales have either ulcerative colitis or Crohn's disease. The risk of developing colorectal cancer for people with ulcerative colitis is estimated as 2% after 10 years, 8% after 20 years and 18% after 30 years of disease. The risk of developing colorectal cancer for people with Crohn's disease is considered to be similar to that for people with ulcerative colitis.

The guideline recommends that colonoscopic surveillance should be offered to people with IBD whose symptoms started 10 years ago and who have:

• ulcerative colitis (but not proctitis[7]alone) or
• Crohn's colitis[8]involving more than one segment of colon.

A baseline colonoscopy[9] should be offered, with chromoscopy[10] and a targeted biopsy of any abnormal areas, to people with IBD who are being considered for colonoscopic surveillance to determine their risk of developing colorectal cancer. The guideline also recommends that people with IBD should be offered subsequent colonoscopic surveillance based on their risk of developing colorectal cancer as determined at their last complete colonoscopy:

• Low risk: offer colonoscopy with chromoscopy at five years.
• Intermediate risk: offer colonoscopy with chromoscopy at three years.
• High risk: offer colonoscopy with chromoscopy at one year.

A repeat colonoscopy should be offered with chromoscopy if the colonoscopy is incomplete. Colonoscopic surveillance should also be considered for people who have had adenomas removed and are at low, intermediate or high risk of developing colorectal cancer. The findings at adenoma removal should be used to determine people's risk of developing colorectal cancer, and subsequent surveillance steps. A repeat colonoscopy should again be offered if it is deemed incomplete, and consulting a more experienced colonoscopist should also be considered. Computed tomographic colonography[11] (CTC) should be considered as a single examination if colonoscopy is not clinically appropriate (for example, because of comorbidity or because colonoscopy cannot be tolerated). A double contrast barium enema[12] as a single examination is recommended if a CTC is not available or not appropriate. These two options should be considered for ongoing surveillance if a colonoscopy remains clinically inappropriate.

Dr Judith Richardson, Associate Director, Centre for Clinical Practice said: “The evidence considered by the Guideline Development Group clearly shows that colonoscopic surveillance in people at high risk of developing colorectal cancer can detect precancerous changes early, and potentially prevent progression to cancer. These guidelines will help make a real difference to those people affected by these serious diseases.”

Professor Peter Howdle, Emeritus Professor St James's University Hospital, Leeds and Guideline Development Group Chair said: “I was delighted to be involved in the development of these important guidelines, which will complement the work already done in this area. They will mean that people with ulcerative colitis, Crohn's disease or adenomas can expect a more consistent provision of colonoscopic surveillance services, that, as well as being of high quality, are available when they need them. I am confident that this will help in the prevention and early detection of colorectal cancer.”

Professor Jon Rhodes, President, The British Society of Gastroenterology said: "There is currently some variation in clinical practice of colonoscopic surveillance within the NHS, therefore the British Society of Gastroenterology welcome these guidelines, which will aid healthcare professionals caring for people at high risk of developing colorectal cancer in primary and secondary care. Patients will, I am sure, benefit greatly from these new guidelines.”

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Notes to Editors

About the guideline

• The guideline is available from Wednesday 23 March on the NICE website at: www.nice.org.uk/guidance/CG118

Related guidelines

• A previous NICE clinical guideline on improving outcomes in colorectal cancer, (NICE cancer service guidance, 2004) is available at: csgcc
• NICE interventional procedure guidance 101 (2004), on wireless capsule endoscopy for investigation of the small bowel is available at: ipg101

Guidelines under development

NICE is developing the following related guidelines:

• NICE clinical guideline on the diagnosis and management of colorectal cancer. Publication expected October 2011. More information is available at: /guidance/indevelopment/gid-cgwave162
• NICE clinical guideline on the management of Crohn's disease. Publication expected December 2012. More information is available at: cg152

About NICE

1. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health

2. NICE produces guidance in three areas of health:

• public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
• health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
• clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

3. NICE produces standards for patient care:

• quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
• Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients

4. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates and accredits high quality health guidance, research and information to help health professionals deliver the best patient care through NHS Evidence.

[1] Colonoscopic surveillance is performed to examine and detect abnormalities in the colon.

[2] Ulcerative colitis is a type of inflammatory bowel disease (IBD) that affects the lining of the large intestine (colon) and rectum.

[3] Crohn's disease is a chronic inflammatory condition of unknown cause affecting any part of the gastrointestinal tract (gut).

[4] An adenoma is a benign tumour of glandular origin.

[5] For people who are not in these high-risk groups, the NHS Bowel Cancer Screening Programme (www.cancerscreening.nhs.uk/bowel/publications/nhsbcsp-guidance-note-01.html) offers screening using faecal occult blood testing every 2 years to all men and women aged 60-74 years. People undergoing colonoscopic surveillance are not generally offered screening as part of the Bowel Cancer Screening programme.

[6] NICE clinical guideline 118 on colonoscopic surveillance.

[7] Proctitis is inflammation of the anus and rectum.

[8]Crohn's colitis is inflammation of the large intestine caused by Crohn's disease.

[9] A baseline colonoscopy is a colonoscopic examination in which measurements are taken (after a run-in period where applicable). The results of subsequent colonoscopies can be compared with the baseline colonoscopy.

[10] A chromoscopy is the application of dyes onto the surface of the mucosal lining to enhance mucosal irregularities.

[11] Computed tomographic colonography (virtual colonoscopy). NICE interventional procedure guidance 129 (2005).

12] A double contrast barium enema is a series of x-rays of the colon and rectum taken after the patient is given an enema, followed by an injection of air. The barium outlines the intestines on the x-rays, allowing any abnormal growths to be visible.