Have Crohn’s? Here’s What You Should Know About Your Cancer Risk

Colon cancer
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As anyone with Crohn’s will admit, living with a chronic disease is a burden. The recurring pattern of feeling well, followed by painful flare-ups, can seem endless. With good medical care and some luck, the periods of good health will outweigh the flares.

So it does not seem right that some people with Crohn’s are at increased risk for cancer, but that is indeed the case. Even when bowel disease is well controlled or mild enough that surgery is unnecessary, cancer can make an unwanted appearance years—even decades—after Crohn’s is diagnosed.

Fortunately, not all Crohn’s patients need to worry. The risk is only increased by certain characteristics of the disease and its treatments.

The Crohn’s-Colitis Connection

About 20 percent of patients with Crohn’s disease have the form known as Crohn’s colitis. Unlike ulcerative colitis, which causes inflammation only in the colon and rectum, Crohn’s disease can cause tissue to become inflamed anywhere in the digestive tract.

Patients with Crohn’s colitis—particularly younger patients—are at increased risk for adenocarcinoma, the same type of carcinoma as colon cancer. This risk does not rise until 7 or 8 years after Crohn’s colitis is diagnosed. It tends to be more insidious in its onset than other colon cancers, often causing no symptoms until it is advanced. For this reason, patients with Crohn’s colitis must be kept under close surveillance even if they are doing well.

Until recently, colonoscopies with random biopsies were the gold standard for cancer surveillance.

The system was not ideal, however, because random biopsies can miss cancerous or precancerous lesions. Today, a more advanced method called chromoendoscopy is available. It involves instilling a methylene blue dye into the gastrointestinal tract during colonoscopy. The dye is absorbed by the areas of dysplasia, which can be composed of premalignant cells.

This makes them easy to see through an endoscope.

Crohn’s of the Small Intestine

The onset of cancer in a patient with Crohn’s of the small intestine is a rare complication. Unfortunately, it is impossible to surveil these patients, because the small bowel is difficult to access.

Most patients with Crohn’s of the small bowel who develop cancer are individuals whose disease has been stable for years, before they suddenly develop a bowel obstruction, abdominal distention or diarrhea. At this point, an imaging test such as a CT scan is used to look for an intestinal mass.

Rectal Stump Cancer

When the colon is removed, and the patient given an ileostomy, the rectum may be totally or partially preserved. This allows the bowel to be reconnected at a future date. Many patients feel so much better with an ileostomy that they postpone restoration or abandon the idea. However, I warn patients that the rectal stump can develop cancer and should be carefully watched with surveillance endoscopy. In general, the stump should be removed if patients are happy with their ileostomy and can tolerate surgery. This lowers their risk of developing cancer.

Fistulas and Abscesses

Perianal fistulas and abscesses resulting from longstanding Crohn’s disease increase the risk of developing squamous cell carcinoma (a form of skin cancer) or adenocarcinoma, the form of colon cancer mentioned above.

Cancer can develop at the site of an indwelling fistula or other chronic wound. Interestingly, it usually takes three or more decades for such cancers to develop. At this point, the patient can present with pain, bleeding, or a palpable perianal lump, and a biopsy usually confirms the presence of cancer.

Cancer Risk From Treatment

A new class of drugs known as biologic agents has revolutionized the treatment of Crohn’s disease. For many, biologics provide lasting relief they have not been able to obtain with conventional medication.

The downside to biologics is the small, but not insignificant, risk of developing lymphoma.

This risk does not mean biologics should not be used: It does mean the risk should be discussed and considered before making a decision to proceed with one.

If you develop lymphoma while taking a biologic, the drug will be stopped. After the lymphoma has been treated, you and your doctor can discuss how best to control your Crohn’s. In some cases of intestinal lymphoma, surgery can be the best treatment option.

What You Should Know

If you have Crohn’s disease, work as a team with your doctor to keep your disease under control. This will mean creating a schedule for colonoscopies and sticking with it, even if you remain healthy for long periods of time.

Don’t forget that many Crohn’s-related cancers tend to develop after years—even decades—have passed. By allowing your doctor to surveil your digestive tract, even when your symptoms are under control, you help ensure that any cancer will be discovered in its early stage, when the likelihood of cure is high.

Sources:

Bratcher JM, Korelitz BI. Toxicity of infliximab in the course of treatment of Crohn’s disease. Expert Opin Drug Saf. 2016 Jan;5(1):9-16.

Cahill C, Gordon PH, Petrucci A, Boutros M. Small bowel adenocarcinoma and Crohn’s disease: Any further ahead than 50 years ago? World J Gastroenterol. 2014 Sep 7;20(33):11486-95.

Laine L, Kaltenbach T, Barkun A, et al. SCENIC international consensus statement on surveillance and management of dysplasia in inflammatory bowel disease. Gastroenterology. 2015 Mar;148(3):639-651.e28.

Lavery IC, Jagelman DG. Cancer in the excluded rectum following surgery for inflammatory bowel disease. Dis Colon Rectum. 1982 Sep;25(6):522-24.

Shwaartz C, Munger JA, Deliz JR, et al. Fistula-associated anorectal cancer in the setting of Crohn’s disease. Dis Colon Rectum. 2016 Dec;59(12):1168-73.

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