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Keywords:

  • inflammatory bowel disease;
  • dysplasia;
  • surveillance;
  • colitis;
  • colorectal cancer

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix 1

Background

Physician adherence to guidelines for colorectal cancer (CRC) surveillance in inflammatory bowel disease (IBD) is often poor. This may lead to adverse patient outcomes and excess endoscopic workload.

Aims

To assess the attitudes and practice of IBD specialists in a tertiary centre towards colonoscopic surveillance.

Methods

First, a questionnaire evaluating attitudes and approach to CRC surveillance was issued to 36 clinicians at one tertiary referral hospital. Second, a retrospective audit of IBD surveillance colonoscopy practice over a 2-year period was performed.

Results

Questionnaire response rate was 97%. Sixty-nine per cent of respondents were aware of, and used, Australian guidelines. Surveillance was undertaken by all clinicians in patients with extensive colitis, 83% in patients with left-sided colitis and 51% in patients with proctitis. Seventy-six per cent used chromoendoscopy, and 47% took 10 to 20 random biopsies. Colectomy was considered appropriate in 0% for unifocal low-grade dysplasia, 35% for multifocal low-grade dysplasia and 83% for high-grade dysplasia. Sixty-six per cent would remove elevated dysplastic lesions endoscopically. The audit identified 103 surveillance colonoscopies in 81 patients. Chromoendoscopy was used in 21% of cases, and the median number of random biopsies was 13. Sixty-two per cent of colonoscopies were performed outside the guidelines in relation to colonoscopic frequency. Following colonoscopy, an appropriate recommendation for subsequent surveillance was documented in 40% of cases.

Conclusions

Knowledge and practice of CRC surveillance in IBD vary among specialist clinicians and often deviate from guidelines. Many clinicians perform surveillance earlier and more frequently than recommended. These findings have implications for patient outcomes and workload.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix 1

Patients with ulcerative colitis (UC) and Crohn disease (CD) have an increased risk of developing colorectal cancer (CRC) compared with the general population.[1-5] Several factors increase the risk of CRC in patients with inflammatory bowel disease (IBD), including disease duration[6] and extent,[7] severity of inflammation,[8, 9] concomitant primary sclerosing cholangitis (PSC)[10] and a family history of CRC.[11]

The most important known predictive factor for the development of CRC in IBD is the presence of mucosal dysplasia.[12] Colonoscopic surveillance aims to detect dysplasia prior to the development of invasive malignancy and to detect cancer at an early stage. While no randomised study has been conducted to demonstrate the efficacy or cost-effectiveness of colonoscopic surveillance in patients with IBD, various case–control studies have shown that surveillance in UC is associated with earlier cancer diagnosis, reduced overall death rates and improved cancer-related survival.[13-17]

Guidelines from various groups have endorsed surveillance colonoscopy in patients with IBD.[18-21] Contemporary guidelines have incorporated new developments in cancer surveillance, placing greater emphasis on clinical and endoscopic risk factors to stratify the intensity of surveillance. The use of improved endoscopic technology and technique, including chromoendoscopy, has improved diagnostic efficacy.[22-24] Certain dysplastic lesions are now considered amenable to endoscopic removal rather than requiring surgery.[25, 26]

Colonoscopic surveillance for cancer and dysplasia can be time consuming, expensive and invasive, all factors that may lead to poor patient and physician compliance. Difficulties in detecting and interpreting dysplasia, particularly in the setting of active inflammation, may result in diagnostic errors or uncertainty. Clinicians' lack of understanding and adherence to surveillance guidelines may reduce the efficacy of these programmes. Previous studies have suggested that adherence to existing guidelines varies widely among clinicians and is often inconsistent.[27-30] Recent revised guidelines from the UK, USA and Australia have increased emphasis on stratifying patients according to risk and have provided for the use of new endoscopic diagnostic technologies and treatments. We aimed to determine if specialists in a centre with a major focus on IBD are familiar with these developments and guidelines, and determine how they apply them in practice.

We surveyed all gastroenterologists and colorectal surgeons at St Vincent's Hospital, Melbourne, a tertiary referral centre for IBD, to determine their understanding of, and adherence to, Australian CRC surveillance guidelines published by the National Health and Medical Research Council in December 2011.[18] We also reviewed the files of 81 consecutive IBD patients undergoing cancer surveillance colonoscopy between November 2010 and December 2012. The aims of this study were to compare self-reported practice with actual practice, and compare current practice with local Australian guidelines.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix 1

Questionnaire

A confidential questionnaire was administered to all gastroenterologists, colorectal surgeons and their specialist trainees at St Vincent's Hospital, Melbourne, to assess their approach to CRC surveillance in patients with IBD. The questionnaire contained 21 multiple-choice questions with options for open responses (Appendix 1). Questions covered topics including attitudes to surveillance, starting surveillance, intervals between colonoscopies, colonoscopy and biopsy practice, and management of dysplasia.

Audit

A retrospective search of the endoscopy software database was performed to identify IBD patients undergoing surveillance colonoscopy at our institution between November 2010 and December 2012. Data concerning patient demographics, disease-related factors, risk factors for CRC, colonoscopy practice and management of dysplasia were extracted from the medical records and endoscopy reports. Timing of the current colonoscopy as well as recommendations for the subsequent colonoscopy were assessed and compared with Australian guidelines.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix 1

Questionnaire

Questionnaires were distributed to 36 clinicians, and 35 completed responses were received: 18 from gastroenterologists, 10 from advanced gastroenterology trainees and 7 from colorectal surgeons and their trainees.

Attitudes to surveillance colonoscopy in IBD

All respondents would perform surveillance colonoscopy for patients with UC, while 86% would perform surveillance colonoscopy for patients with CD. Sixty-nine per cent of respondents stated that they were aware of the Australian guidelines and that they use them regularly. Twenty-two per cent reported using other guidelines while three respondents would not use any guidelines.

Timing and frequency of surveillance

Participants were asked if and when they would initiate surveillance colonoscopy for patients with proctitis, left-sided colitis and extensive colitis (Fig. 1). Forty per cent of respondents would never initiate surveillance colonoscopy in patients with proctitis, whereas 34% and 23% would start 8–10 or 10–15 years after disease onset respectively. Most participants would initiate surveillance for left-sided colitis (57% of respondents) and extensive colitis (71% of respondents) 8–10 years after onset of disease. Clinicians were asked about the frequency of colonoscopic surveillance in patients with quiescent proctitis, left-sided colitis or extensive colitis in the absence of any additional risk factors for CRC (Fig. 2). Fifty-one per cent would continue surveillance in patients with proctitis, some as frequently as every 2 years. Eighty-three per cent would enrol patients with left-sided colitis in a surveillance programme while all respondents would do so for patients with extensive colitis. Most would recommend colonoscopy every 2 or 3 years in these settings.

figure

Figure 1. Timing of initial surveillance colonoscopy (years after diagnosis). (image), Proctitis; (image), left-sided colitis; (image), extensive colitis.

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figure

Figure 2. Frequency of colonoscopic surveillance. (image), Proctitis; (image), left-sided colitis; (image), extensive colitis.

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Colonoscopy practice

While 76% of respondents reported that they used chromoendoscopy, only 27% of respondents would use it frequently or always (Fig. 3a). All respondents would take targeted biopsies of suspicious lesions, but the number of additional random biopsies varied: 21% would take less than 10 random biopsies while most (47%) would take 10–20 random biopsies. When directly asked how often they would take 2–4 random biopsies per colonic segment, 80% reported doing this always or frequently (Fig. 3b).

figure

Figure 3. Use of chromoendoscopy and random biopsies. (a) Frequency that respondents reported using chromoendoscopy. (b) Frequency that respondents reported taking 2–4 random biopsies from each colonic segment (always = 100%; frequently ∼75%; sometimes ∼50%; infrequently ∼25%; never = 0% of surveillance colonoscopies).

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Management of dysplasia

Participants were asked how they would manage the findings (confirmed by two pathologists) of unifocal low-grade dysplasia (LGD), multifocal LGD or high-grade dysplasia (HGD) detected on random biopsies from flat colonic mucosa (Fig. 4). No respondents would recommend colectomy for patients with unifocal LGD, opting instead for more intensive colonoscopic surveillance. The management of multifocal LGD was more diverse with 35% of respondents stating that they would refer for colectomy and the remainder preferring to intensify surveillance. Most respondents (83%) would recommend colectomy for patients with HGD. When asked how they would manage the finding of an elevated dysplastic lesion within an area of inflammation, 66% of respondents would attempt to remove the lesion endoscopically, 14% would refer for colectomy and the remainder would intensify surveillance.

figure

Figure 4. Management of dysplasia. (image), Repeat colonoscopy <6 months; (image), repeat colonoscopy 6–12 months; (image), repeat colonoscopy in 12 months; (image), refer for colectomy; (image), remove lesion by polypectomy or endoscopic mucosal resection.

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Audit of practice

The endoscopy database contained 103 CRC surveillance colonoscopies performed on 81 IBD patients between November 2010 and December 2012. Patient characteristics are shown in Table 1.

Table 1. Characteristics of IBD patients undergoing colonoscopic surveillance
  1. a

    Disease extent was documented in 79 out of 81 patients. CD, Crohn's disease; CRC, colorectal cancer; IBD, inflammatory bowel disease; SD, standard deviation; UC, ulcerative colitis.

Male sex36 (44%)
Age (mean ± SD) (years)52.5 ± 16.0
Disease duration (mean ± SD) (years)16.7 ± 9.4
Age of disease onset (mean ± SD) (years)34.7 ± 15.0
Diagnosis 
Ulcerative colitis63/81 (78%)
Crohn's disease16/81 (20%)
Indeterminate colitis2/81 (2%)
Disease extenta 
Proctitis (UC)9/64 (14%) UC patients
Left-sided colitis (UC)11/64 (17%) UC patients
Extensive colitis (UC)44/64 (69%) UC patients
Terminal ileal (CD)1/15 (7%) CD patients
Colonic (CD)8/15 (53%) CD patients
Ileocolic (CD)6/15 (40%) CD patients
History of colonic surgery17/81 (21%)
Use of 5-aminosilicylates54/81 (67%)
Other risk factors for CRC 
Primary sclerosing cholangitis5/81 (6%)
Family history of CRC in 1st degree relative <501/81 (1%)
Structural changes29/81 (36%)
Personal history of flat dysplasia12/81 (15%)
Source of referral 
Public hospital clinic52/81 (64%)
Private rooms29/81 (36%)
Colonoscopic practice

Caecal intubation was achieved in 95% of colonoscopies. Both disease activity and extent were documented in 81% of reports. Chromoendoscopy was used in 21% of cases. The median number of random biopsies taken per colonoscopy was 13.

Colonoscopy findings and management

Of 1299 random biopsies, one case of multifocal LGD was identified. This patient was advised to have a repeat colonoscopy with chromoendoscopy and biopsies 3 months later. Two cases of indefinite dysplasia were found. Both patients remain under colonoscopic surveillance.

In seven patients, adenomatous lesions were identified in non-inflamed areas of colon. All lesions were removed endoscopically, and none contained advanced neoplastic changes. These lesions were all thought to be sporadic adenomas, and these patients remain under surveillance. In two patients, elevated lesions were detected within areas of inflammation. In both cases, histology revealed tubulovillous adenomas with LGD. The first patient was advised to undergo repeat colonoscopy in 3 months after successful polypectomy. The second patient with multifocal dysplasia was advised to undergo surgery.

One cancer was found during surveillance. A 56-year-old man with a 31-year history of steroid-dependent, chronically active, extensive UC and PSC was found to have active colitis with a raised, indistinct, sessile polyp in the descending colon. Biopsies revealed an invasive, poorly differentiated adenocarcinoma. There was also evidence of multifocal LGD and HGD on biopsies taken from areas of irregular nodular mucosa. Colonoscopy 17 months previously had shown active pancolitis with no evidence of dysplasia. The patient has declined surgical treatment.

Timing of colonoscopy and further recommendations

To determine whether practice at out institution was already in line with recommendations ultimately published in 2011 and whether the guidelines impacted on practice, we compared timing of the current colonoscopy as well as the recommendation for subsequent colonoscopy (where available) with Australian guidelines. We defined a deviation in time of 20% or less as being in keeping with the guidelines. Deviations of 21–50% and >50% were defined as minor and major deviations respectively. Of the 103 colonoscopies performed during the study period, 38% were performed at a time that was in keeping with the Australian guidelines (Fig. 5a). Of the 57 colonoscopies that were performed outside of the guidelines, 51% were performed sooner than recommended.

figure

Figure 5. Comparison with Australian guidelines. (a) Timing of current colonoscopy in relation to Australian guidelines. (image), ≤20% deviation from guidelines; (image), 21–50% deviation from guidelines; (image), >50% deviation from guidelines. (b) Recommendations for subsequent surveillance colonoscopy (where documented) in relation to Australian guidelines. (image), ≤20% deviation from guidelines; (image), 21–50% deviation from guidelines; (image), >50% deviation from guidelines.

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Recommendations for future surveillance colonoscopies were documented in only 63% of cases. Of these, 61% were in keeping with the Australian guidelines (Fig. 5b). Thus, a recommendation in line with Australian guidelines was documented in only 40% of all colonoscopies. Of the recommendations that deviated from the guidelines, 70% would result in colonoscopy being performed earlier than necessary.

Fifty-six per cent of recommendations made before publication were already in accordance with the Australian guidelines. This increased to 70% after publication (P = 0.18; not significant).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix 1

This study describes both the attitudes and practice of gastroenterologists and colorectal surgeons at a single tertiary hospital with regard to CRC surveillance in patients with IBD. The questionnaire response rate of 97% together with an audit of clinical practice ensures that this study provides a true reflection of the state of CRC surveillance at our institution. To our knowledge, this is the first study to compare self-reported CRC surveillance with actual clinical practice. We found that while clinical practice was broadly in keeping with self-reported practice, there still appears to be significant variation among clinicians as well as deviation from published guidelines.

Australian guidelines for CRC surveillance were updated in December 2011 and now contain a chapter on CRC surveillance in IBD.[18] Although our survey was conducted almost 12 months later, only two-thirds of respondents were aware of these guidelines and used them regularly.

This study looked at three critical components of CRC surveillance, including the timing of surveillance colonoscopy, colonoscopic practice and management of dysplasia.

Timing of surveillance colonoscopy

While all respondents stated that they would perform surveillance colonoscopy in patients with UC, 14% would not undertake surveillance in patients with Crohn colitis. The risk of CRC in patients with Crohn colitis appears similar to that in patients with UC,[3, 31] and recent guidelines advocate surveillance for these patients. In the absence of other risk factors, patients with proctitis or distal colitis are at low risk of developing CRC,[2] but screening colonoscopy is usually advocated 8–10 years after disease onset to ensure that there has been no proximal extension of colitis, a practice undertaken by only one-third of survey respondents. As long as inflammation has never extended proximal to the sigmoid colon, these patients do not require ongoing surveillance, yet just over half of the surveyed clinicians in our study recommended regular colonoscopies for patients with proctitis. According to Australian guidelines, patients with quiescent extensive UC and no other risk factors should begin surveillance 8–10 years after disease onset. While most respondents would begin surveillance after 8–10 years, 51% would opt for 2-yearly surveillance in these patients.

The validity of questionnaires may be limited by recall bias, as respondents may provide answers they feel are correct rather than representative of their actual practice. To complement our survey, we conducted an audit on 103 consecutive surveillance colonoscopies performed over a 2-year period. Thirty-seven per cent of colonoscopies were performed at a time that was in keeping with the Australian guidelines. A little over half of the 57 colonoscopies performed outside the Australian guidelines were performed sooner than recommended. Clinician recommendations for further surveillance after colonoscopy were in keeping with the Australian guidelines in 61% of colonoscopies; 70% of the remainder would have resulted in subsequent colonoscopy being performed sooner than necessary.

Overall, in our study, surveillance colonoscopy was often performed more frequently than required and, in some cases, in patients in whom the risk of CRC is too low to justify surveillance at all.

Colonoscopic practice

An effective surveillance programme not only relies on optimal timing and frequency of colonoscopic examination, but also the optimisation of colonoscopic practice to maximise diagnostic yield. It has been estimated that 33 biopsies are required to detect dysplasia with 90% probability,[32] but even then, only a tiny proportion of total surface area of the colon is sampled, and foci of dysplasia can easily be missed. Forty-seven per cent of participants in our questionnaire stated that they would take between 10 and 20 random biopsies with two respondents taking more than 30 biopsies. Our audit revealed that the mean number of random biopsies taken per colonoscopy was 13, lower than that reported in other studies.[28, 29, 33, 34] While this approach may help document the extent of histologically active disease, it remains insufficient to reliably detect dysplasia if present. Recent evidence suggests that most dysplastic lesions are visible at colonoscopy,[35-37] allowing biopsies to be targeted to suspicious lesions. Use of newer endoscopic techniques, such as chromoendoscopy, further increases the diagnostic yield.[38, 39] The role of random biopsies therefore remains controversial, with some experts believing that they should be abandoned and that standard practice should incorporate the use of chromoendoscopy and targeted biopsies of visibly abnormal mucosa. Others advocate taking of two to four random biopsies from flat mucosa in each colonic segment. While 76% of survey respondents reported using chromoendoscopy, only 21% of surveillance colonoscopies performed during the study period utilised chromoendoscopy. Eighty per cent of participants stated they take two to four random biopsies per colonic segment ‘always’ or ‘frequently’.

Management of dysplasia

The finding of HGD in flat mucosa is highly predictive of established or imminent carcinoma,[12] and most guidelines recommend colectomy in this situation. In our survey, most respondents would advocate colectomy for patients with HGD. Management of LGD in flat mucosa is more controversial, mainly due to uncertainty about its value in predicting established or future CRC, with rates of progression to advanced neoplasia varying among studies.[12, 40-44] This uncertainty is reflected in surveillance guidelines, which suggest that decisions regarding colectomy versus continued surveillance in the setting of flat LGD need to be made on an individual basis. It is generally agreed that the risk of CRC is higher in patients with multifocal than unifocal LGD. In our study, all respondents would continue, and most likely intensify, surveillance for patients with unifocal LGD, while the finding of multifocal LGD would prompt 35% of respondents to refer for colectomy. These results are in keeping with responses obtained in similar questionnaires performed in the UK and USA,[27, 33] but referral rates for colectomy were lower than those reported in other studies from New Zealand and the USA.[28, 34]

The majority of respondents (66%) in our study felt that endoscopic removal of an elevated dysplastic lesion in an area of inflammation was appropriate. Only 14% would refer for colectomy in this situation, unlike the colectomy referral rates ranging from 58% to 98% reported in other studies.[28, 29, 33] The low colectomy referral rate in our study may reflect a more recent paradigm shift, highlighted in the British, US and Australian guidelines, which suggests that elevated lesions, even in areas of inflammation, can be removed endoscopically without the need for surgery, provided that the lesion is removed in its entirety and that there is no dysplasia in biopsies taken from surrounding flat mucosa or elsewhere in the colon.[45-47]

The yield from random biopsies was low in our audit, with only one case of LGD and two cases of indefinite dysplasia identified from 1299 random biopsies taken from flat mucosa. Elevated dysplastic lesions were identified in nine patients, and most were removed endoscopically in keeping with responses obtained from the questionnaire and in line with published guidelines. One CRC was detected during surveillance. The patient had extensive, chronically active colitis and PSC, but colonoscopy 17 months earlier had not detected any dysplastic lesion. This case highlights the need for vigilance in patients at high risk for CRC.

We recognise that this study has several limitations. It was performed at a single tertiary referral centre with an expertise in IBD and interventional endoscopy, attracting a more complex patient load that may not be reflective of patient populations at other institutions or in the community. The audit was performed retrospectively and only included patients attending for surveillance colonoscopy during the study period. Part of the audit was conducted prior to publication of the Australian guidelines, and this may have led to a greater discordance between survey results and observed practice. Although the questionnaire was limited to a single institution, it included clinicians with a range of interests, experience and expertise, and did not focus purely on gastroenterologists with a subspecialty interest in IBD.

Overall, we found that gastroenterologists and surgeons at our institution offer CRC surveillance for most patients with IBD, but adherence to published guidelines is variable and there appears to be room for improvement. Similar conclusions were drawn from questionnaires performed in the Netherlands, New Zealand and the UK,[27-29] and a retrospective review of colonoscopic practice in Canada.[48] Many clinicians tend to err on the side of caution, often performing surveillance earlier and more frequently than recommended. Despite this study being performed at a single centre, we still found significant variation in attitudes and practices of clinicians, reflecting the difficulties doctors have in understanding, remembering and adhering to guidelines.

Conclusion

Guidelines from the major gastroenterological societies now appear consistent with their recommendations. They all place a major emphasis on risk stratification to determine ideal surveillance intervals on an individual basis, and incorporation of better endoscopic technique and new technologies to improve diagnostic efficacy. With better awareness, acceptance of and eventually adherence to guidelines, CRC surveillance practice could be optimised with the potential benefits of shorter endoscopy waiting lists, reduced patient risk, better patient compliance and improved cost-effectiveness. Ultimately, these benefits may also result in better outcomes with regard to diagnostic efficacy, patient management and survival.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix 1
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    Engelsgjerd M, Farraye FA, Odze RD. Polypectomy may be adequate treatment for adenoma-like dysplastic lesions in chronic ulcerative colitis. Gastroenterology 1999; 117: 12881294; discussion 1488–91.
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    Odze RD, Farraye FA, Hecht JL, Hornick JL. Long-term follow-up after polypectomy treatment for adenoma-like dysplastic lesions in ulcerative colitis. Clin Gastroenterol Hepatol 2004; 2: 534541.
  • 47
    Vieth M, Behrens H, Stolte M. Sporadic adenoma in ulcerative colitis: endoscopic resection is an adequate treatment. Gut 2006; 55: 11511155.
  • 48
    Kottachchi D, Yung D, Marshall JK. Adherence to guidelines for surveillance colonoscopy in patients with ulcerative colitis at a Canadian quaternary care hospital. Can J Gastroenterol 2009; 23: 613617.

Appendix 1

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Appendix 1

Questionnaire

  • 1. 
    Do you recommend surveillance colonoscopies for detection of dysplasia/cancer in your patients with ulcerative colitis?
    • a) 
      No
    • b) 
      Yes
  • 2. 
    Do you recommend surveillance colonoscopies for detection of dysplasia/cancer in your patients with Crohn's Disease?
    • a) 
      No
    • b) 
      Yes
  • 3. 
    Are you aware of the most recent Australian ‘Clinical Practice Guidelines for Surveillance Colonoscopy’ published in 2011, which includes specific recommendations regarding colonoscopic surveillance in inflammatory bowel disease?
    • a) 
      No
    • b) 
      Yes
  • 4. 
    Do you follow any of the published guidelines for colonoscopic surveillance of IBD patients?
    • a) 
      No
    • b) 
      Yes, Australian guidelines (NHMRC/Cancer Council Australia)
    • c) 
      Yes, US guidelines (American Gastroenterology Association)
    • d) 
      Yes, British guidelines (British Society of Gastroenterology)
    • e) 
      Other guidelines (please specify) … … … … …… … … … … … … … … … …. … … … .
  • 5. 
    When would you initiate surveillance colonoscopy for a patient with proctitis and no other risk factors for colorectal cancer?
    • a) 
      Never
    • b) 
      Less than 8 years after onset of disease
    • c) 
      8–10 years after onset of disease
    • d) 
      10–15 years after onset of disease
    • e) 
      Other (please specify) … … … … … … … …… … … … … … … … … … … … … … . .
  • 6. 
    When would you initiate surveillance colonoscopy for a patient with left-sided colitis (colitis distal to the splenic flexure) and no other risk factors for colorectal cancer?
    • a) 
      Never
    • b) 
      Less than 8 years after onset of disease
    • c) 
      8–10 years after onset of disease
    • d) 
      10–15 years after onset of disease
    • e) 
      Other (please specify) … … … … … … … … … … … … … … … … … … … … … … .
  • 7. 
    When would you initiate surveillance colonoscopy for a patient with extensive colitis (extending proximal to the splenic flexure) and no other risk factors for colorectal cancer?
    • a) 
      Never
    • b) 
      Less than 8 years after onset of disease
    • c) 
      8–10 years after onset of disease
    • d) 
      10–15 years after onset of disease
    • e) 
      Other (please specify) … … … … … … … … … … … … … … … … … … … … … .
  • 8. 
    How frequently would you recommend that patients with quiescent proctitis undergo surveillance colonoscopy in the absence of any dysplastic lesions or other risk factors (i.e. PSC, FHx of CRC)?
    • a) 
      No surveillance
    • b) 
      Yearly
    • c) 
      Every 2 years
    • d) 
      Every 3 years
    • e) 
      Every 4–5 years
    • f) 
      Other (please specify) … … … … … … … … … … … … … … … … … … … … … … .
  • 9. 
    How frequently would you recommend that patients with quiescent left-sided colitis (distal to the splenic flexure) undergo surveillance colonoscopy in the absence of any dysplastic lesions or other risk factors (i.e. PSC, FHx of CRC)?
    • a) 
      No surveillance
    • b) 
      Yearly
    • c) 
      Every 2 years
    • d) 
      Every 3 years
    • e) 
      Every 4–5 years
    • f) 
      Other (please specify) … … … … … … … … … … … … … … … … … … … … … … .
  • 10. 
    How frequently would you recommend that patients with quiescent extensive colitis (proximal to the splenic flexure) undergo surveillance colonoscopy in the absence of any dysplastic lesions or other risk factors (i.e. PSC, FHx of CRC)?
    • a) 
      No surveillance
    • b) 
      Yearly
    • c) 
      Every 2 years
    • d) 
      Every 3 years
    • e) 
      Every 4–5 years
    • f) 
      Other (please specify) … … … … … … … … … … … … … … … … … … … … … … .
  • 11. 
    Which of the following factors would influence your screening and surveillance protocol for patients with IBD (can choose more than one option)?
    • a) 
      Age of patient
    • b) 
      Extent of colitis
    • c) 
      Duration of disease
    • d) 
      Family history of colorectal cancer in first degree relative <50 years of age
    • e) 
      Family history of colorectal cancer in first degree relative >50 years of age
    • f) 
      Diagnosis of primary sclerosing cholangitis
    • g) 
      Presence of structural changes within the colon (e.g. pseudopolyps, stricture, tubular colon)
    • h) 
      History of adenomatous polyps
    • i) 
      History of dysplasia found on biopsies from flat mucosa
    • j) 
      Other (please specify) … … … … … … … … … … … … … … … … … … … … … … .
  • 12. 
    What is your approach to taking biopsies when performing surveillance colonoscopy in IBD patients?
    • a) 
      No biopsies
    • b) 
      Targeted biopsies of lesions only (no random biopsies)
    • c) 
      Targeted biopsies of lesions and <10 random biopsies
    • d) 
      Targeted biopsies of lesions and 10–20 random biopsies
    • e) 
      Targeted biopsies of lesions and 21–30 random biopsies
    • f) 
      Targeted biopsies of lesions and >30 random biopsies
  • 13. 
    How frequently do you take 2–4 random biopsies from flat mucosa in each colonic segment?
    • a) 
      Always (100% of surveillance colonoscopies)
    • b) 
      Frequently (∼75% of surveillance colonoscopies)
    • c) 
      Sometimes (∼50% of surveillance colonoscopies
    • d) 
      Infrequently (∼25% of surveillance colonoscopies)
    • e) 
      Never (0% of surveillance colonoscopies)
  • 14. 
    How frequently do you use chromoendoscopy when performing surveillance colonoscopy in patients with IBD?
    • a) 
      Always (100% of surveillance colonoscopies)
    • b) 
      Frequently (∼75% of surveillance colonoscopies)
    • c) 
      Sometimes (∼50% of surveillance colonoscopies
    • d) 
      Infrequently (∼25% of surveillance colonoscopies)
    • e) 
      Never (0% of surveillance colonoscopies)
  • 15. 
    What is your approach to the finding of unifocal low-grade dysplasia (confirmed by two pathologists) on a random biopsy from flat mucosa?
    • a) 
      Repeat colonoscopy <6 months
    • b) 
      Repeat colonoscopy 6–12 months
    • c) 
      Repeat colonoscopy in 12 months
    • d) 
      Refer for colectomy
    • e) 
      Other (please specify) … … … … … … … … … … … … … … … … … … … … … … .
  • 16. 
    What is your approach to the finding of multifocal low-grade dysplasia (confirmed by two pathologists) on random biopsies from flat mucosa?
    • a) 
      Repeat colonoscopy <6 months
    • b) 
      Repeat colonoscopy 6–12 months
    • c) 
      Repeat colonoscopy in 12 months
    • d) 
      Refer for colectomy
    • e) 
      Other (please specify) … … … … … … … … … … … … … … … … … … … … … … .
  • 17. 
    What is your approach to the finding of high-grade dysplasia (confirmed by two pathologists) on a random biopsy from flat mucosa?
    • a) 
      Repeat colonoscopy <6 months
    • b) 
      Repeat colonoscopy 6–12 months
    • c) 
      Repeat colonoscopy in 12 months
    • d) 
      Refer for colectomy
    • e) 
      Other (please specify) … … … … … … … … … … … … … … … … … … … … … … .
  • 18. 
    What is your approach to the finding of an elevated dysplastic lesion within an area of inflammation?
    • a) 
      Repeat colonoscopy <6 months
    • b) 
      Repeat colonoscopy 6–12 months
    • c) 
      Repeat colonoscopy in 12 months
    • d) 
      Remove lesion by polypectomy or endoscopic mucosal resection
    • e) 
      Refer for colectomy
    • f) 
      Other (please specify) … … … … … … … … … … … … … … … … … … … … … … .
  • 19. 
    When do you usually make a recommendation regarding the need for and timing of the next surveillance colonoscopy?
    • a) 
      At or directly after colonoscopy
    • b) 
      At the first subsequent clinical visit
    • c) 
      Shortly before next surveillance colonoscopy due
    • d) 
      Other (please specify) … … … … … … … … … … … … … … … … … … … … … .
  • 20. 
    Which one of the following best applies to you?
    • a) 
      Gastroenterologist
    • b) 
      Gastroenterology trainee (fellows/registrars)
    • c) 
      Surgeon/surgical trainee
  • 21. 
    Do you have a particular subspecialty interest in IBD?
    • a) 
      No
    • b) 
      Yes