New Guidelines for Bowel Cancer Monitoring in IBD Patients

Medscape

07-05-2025

The British Society of Gastroenterology (BSG) has published new guidelines on colorectal cancer surveillance for patients with inflammatory bowel disease (IBD).
Published in the BMJ journal Gut , the guidance replaces the 2019 recommendations and reflects the latest evidence-based consensus.
The BSG stated that IBD patients are at elevated risk of developing and dying from colorectal cancer (CRC). This persists despite advanced IBD therapies yielding better inflammation control, along with better colonoscopic surveillance, and reductions in environmental risk factors.
GRADE-Based Evidence and Broad Expert Input
The new guidelines were developed using GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology, a Cochrane Collaboration-recommended systematic approach to rating the certainty of evidence in systematic reviews and other evidence syntheses.
A multidisciplinary, multi-centre team contributed to the guidelines. This included academics from the universities of Oxford, Newcastle, and Central Lancashire, as well as physicians, endoscopists, surgeons, specialist nurses, and patient representatives.
The team reviewed more than 7500 publications to create 73 statements aimed at supporting clinical decision-making and delivering best practice IBD colorectal surveillance in IBD.
Best Advice for Clinicians
Joint first author Professor James East, consultant gastroenterologist and endoscopist at the University of Oxford's Translational Gastroenterology and Liver Unit, said in a press release that the guidelines offer 'accurate, up-to-date advice for clinicians working with IBD patients', and give them 'the tools they need to give the best possible care and treatment for their patients'.
The document covers key areas such as how to discuss CRC risk with individual IBD patients, eligibility for surveillance, timing and frequency of colonoscopies, and how surveillance services should be structured.
Focus on Transparency and Individualised Care
Professor Morris Gordon, coauthor and director of the Biomedical Evidence Synthesis and Translations (BEST) unit at the University of Central Lancashire in Preston, said the team employed 'a significant shift in approach', stemming from the methods used and how these were applied to produce the document.
The guidelines 'fully applied the highest calibre of GRADE methods', Gordon told Medscape News UK .
While this international gold standard is universally accepted as the only viable option for guidelines, 'execution is often variable'. He explained that it is common in situations where evidence is poor for guideline groups to 'revert to eminence and opinion'. This approach risked misleading the audience in terms of the strength of the evidence.
Gordon highlighted the transparent use of GRADE methods to produce the updated guidelines. He noted that evidence graded using this method is clearly identified, and expert opinions or good practice statements are labelled separately. This enabled the team to be 'very transparent', helping clinicians understand not only the recommendations but also the strength and limitations of the supporting evidence.
One significant innovation is the operational use of a risk threshold calculator. This tool aims to support shared decision-making between clinicians and patients.
New Insights on Screening Techniques
The guidelines also address colonoscopy preparation. Evidence suggests that for bowel preparation before the procedure, a lower volume or no polyethylene glycol (PEG) solutions are equally effective and better tolerated by patients.
In terms of imaging, dye-based chromoendoscopy showed superior detection compared with high-definition white light alone. This may mark a significant shift in screening technique.
Risk-Based Surveillance Intervals
Catherine Winsor, director of services and evidence at Crohn's & Colitis UK, welcomed the new guidance as 'a huge step forward'.
She told Medscape News UK that the changes 'should detect more colorectal cancers at an earlier stage in patients with IBD'. While most people with IBD will not go on to develop colorectal cancer, early diagnosis of CRC is vital, as more than 9 in 10 people survive if diagnosed at stage one.
'The guidelines provide clear advice on the risk stratification of patients, and this stratification informs surveillance colonoscopy intervals,' Winsor explained. They recommend frequencies for surveillance colonoscopy according to patients' risk level:
High risk: every year
Intermediate risk: every 3 years
Low risk: every 5 years
Recommendations for Early Screening and Dysplasia Management
The BSG advises that all IBD patients undergo a colonoscopy approximately 8 years after symptom onset. Patients with primary sclerosing cholangitis should have a colonoscopy at diagnosis.
Chromoendoscopy is recommended for high-risk patients, as it improves dysplasia detection.
Winsor added that the guidelines 'include clear protocols for the subsequent treatment of dysplasia', with chromoendoscopy recommended as the preferred technique for surveillance of high-risk patients, as it enhances the detection of dysplasia.
The work was supported by the National Institute for Health and Care Research (NIHR), the Oxford Biomedical Research Centre, and the NIHR Newcastle Biomedical Research Centre.