Risk-stratified surveillance in inflammatory bowel disease

To the Editor: We read with interest Dr Wright's correspondence on the follow-up of patients with inflammatory bowel disease (IBD).[1] We concur that persistent intestinal inflammation is an important determinant of colorectal neoplasia in IBD, but believe that there are several additional factors that merit consideration when determining the appropriate role and frequency of surveillance.The recent ECCO-ESGAR-ESP-IBUS guidelines [2,3] emphasise regular assessment of disease activity using clinical review, biomarkers and endoscopy where appropriate, with therapeutic escalation directed towards achieving sustained inflammatory remission.The ultimate objective is not merely symptom control, but modification of the natural history of disease and reduction of longterm complications, including colorectal cancer.Surveillance strategies for IBD-associated colorectal cancer are similarly evolving and should not simply be determined by disease duration.They should be individualised according to cumulative inflammatory burden, disease extent, previous dysplasia, primary sclerosing cholangitis (PSC), family history of colorectal cancer and the achievement of sustained mucosal healing.[3] The recent British Society of Gastroenterology guideline [4] provides a contemporary framework for this risk-stratified approach, with surveillance intervals ranging from annual examinations in selected high-risk patients to substantially longer intervals, up to 10 years in the lowest-risk patients.[4] The situation is therefore more nuanced than the use of a 1-year surveillance interval being regarded as outdated might suggest: annual surveillance remains appropriate for some high-risk patients and should not be dismissed, but it should not be regarded as a default interval for the majority of patients with IBD.This changing understanding of colorectal cancer risk has also altered the purpose of surveillance.Rather than simply detecting dysplasia, surveillance now forms part of an integrated strategy that combines objective assessment of inflammatory control with targeted detection of neoplasia in those patients who remain at greatest risk.The application of these principles in South Africa (SA) is, however, influenced by the realities of our healthcare system.Although biological agents and small-molecule therapies have transformed IBD management internationally, access within much of the public sector remains limited.Consequently, many patients continue to receive conventional therapy, and may experience persistent or recurrent inflammation despite optimal management within these