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Not All Plant-based Diets Are Equal in IBD Risk Mitigation
BERLIN — according to the results of a large cohort study.
The study, which included both Crohn’s disease (CD) and ulcerative colitis (UC), also showed that diet quality may affect disease progression and surgery risk for individuals already diagnosed with IBD.
“Not all plant-based foods are equal — they don’t all have the same effect on health outcomes,” said study researcher, Judith Wellens, MD, PhD, gastroenterology resident at Leuven University Hospital in Belgium.
“We need to look at what people are eating more carefully because it isn’t black and white, with all plant-based food being good and animal-based food being bad,” said Wellens, who presented the data at the European Crohn’s and Colitis Organisation (ECCO) 2025 Congress.
Although she advocates for plant-based diets, Wellens stressed that “they need to be individualized to ensure the overall dietary quality is good. Just cutting out meat products is not very helpful. We think it is the unhealthy additions to some plant-based diets that drive the IBD risk.”
Is It the Plants or the Processed Ingredients?
“Preclinical studies have already taught us that plant-based diets alter the gut microbiota in a beneficial way. However, many diets promoted for IBD — for example the Crohn’s disease exclusion diet — contain ingredients that are animal based. This is confusing for patients and for clinicians,” said Wellens.
To look more closely at the question, she and her colleagues analyzed data for 187,888 participants from the UK Biobank and 341,539 participants from across eight European countries from the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. None of the participants had IBD at baseline.
Based on participant 24-hour dietary recalls, the researchers constructed plant-based diet indices (PDIs) with diets categorized as healthy (eg, whole grains, fruits, vegetables, legumes, and vegetarian protein alternatives) or unhealthy (eg, emulsifiers, refined grains, fries, fruit juices, sweets, desserts, sugar-sweetened beverages, and processed foods).
The primary outcome was the incidence of IBD (either CD or UC), whereas the secondary outcome was IBD-related surgery, thereby marking disease progression. Cox regression analysis estimated IBD risk and progression. Incidences of IBD were similar between the two cohorts.
In the UK Biobank cohort, 925 participants developed IBD over a median follow-up of 11.6 years. Participants who followed a healthy PDI had a 25% reduced IBD risk, whereas those who followed an unhealthy PDI had a 48% increased risk for disease development. Both CD and UC showed similar outcomes.
The EPIC cohort had a longer median follow-up time of 14.5 years, during which 548 people developed IBD. Healthy PDIs were linked to a 29% reduced risk for IBD, whereas unhealthy PDIs were associated with a 54% increased risk.
A healthy PDI halved the risk for surgery in participants from the UK Biobank, whereas an unhealthy PDI was associated with a twofold higher risk for surgery.
There were no significant associations between PDIs and other outcomes, such as cardiovascular disease, diabetes, or all-cause mortality.
The researchers also looked at the interactions between genetics and plant-based diets, but those results were not presented at the meeting.
However, Wellens said in an interview that people with a moderate to high risk for IBD based on their polygenetic risk score showed increased odds for IBD risk.
“We don’t test people for their genetic risk of IBD, but if people have close relatives with IBD, then there is probably an increased genetic risk of its development,” she added.
Commenting on the findings, James Lindsay, PhD, professor of inflammatory bowel disease, Queen Mary University of London in England, said that several recent epidemiological studies have highlighted “the negative impact of ultra-processed foods on increasing the risk of developing Crohn’s disease.”
Based on these studies, “one might assume that plant-based diets would be protective,” he said, however, the current study shows us “that plant-based diets are not all equal and there are unhealthy aspects to some.”
“Of course, showing that a diet is associated with an outcome is not the same as knowing that changing a diet will reduce the risk,” Lindsay added. “That requires a well-designed, carefully controlled trial.”
Wellens and Lindsay reported no relevant financial disclosures.
A version of this article appeared on Medscape.com.
BERLIN — according to the results of a large cohort study.
The study, which included both Crohn’s disease (CD) and ulcerative colitis (UC), also showed that diet quality may affect disease progression and surgery risk for individuals already diagnosed with IBD.
“Not all plant-based foods are equal — they don’t all have the same effect on health outcomes,” said study researcher, Judith Wellens, MD, PhD, gastroenterology resident at Leuven University Hospital in Belgium.
“We need to look at what people are eating more carefully because it isn’t black and white, with all plant-based food being good and animal-based food being bad,” said Wellens, who presented the data at the European Crohn’s and Colitis Organisation (ECCO) 2025 Congress.
Although she advocates for plant-based diets, Wellens stressed that “they need to be individualized to ensure the overall dietary quality is good. Just cutting out meat products is not very helpful. We think it is the unhealthy additions to some plant-based diets that drive the IBD risk.”
Is It the Plants or the Processed Ingredients?
“Preclinical studies have already taught us that plant-based diets alter the gut microbiota in a beneficial way. However, many diets promoted for IBD — for example the Crohn’s disease exclusion diet — contain ingredients that are animal based. This is confusing for patients and for clinicians,” said Wellens.
To look more closely at the question, she and her colleagues analyzed data for 187,888 participants from the UK Biobank and 341,539 participants from across eight European countries from the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. None of the participants had IBD at baseline.
Based on participant 24-hour dietary recalls, the researchers constructed plant-based diet indices (PDIs) with diets categorized as healthy (eg, whole grains, fruits, vegetables, legumes, and vegetarian protein alternatives) or unhealthy (eg, emulsifiers, refined grains, fries, fruit juices, sweets, desserts, sugar-sweetened beverages, and processed foods).
The primary outcome was the incidence of IBD (either CD or UC), whereas the secondary outcome was IBD-related surgery, thereby marking disease progression. Cox regression analysis estimated IBD risk and progression. Incidences of IBD were similar between the two cohorts.
In the UK Biobank cohort, 925 participants developed IBD over a median follow-up of 11.6 years. Participants who followed a healthy PDI had a 25% reduced IBD risk, whereas those who followed an unhealthy PDI had a 48% increased risk for disease development. Both CD and UC showed similar outcomes.
The EPIC cohort had a longer median follow-up time of 14.5 years, during which 548 people developed IBD. Healthy PDIs were linked to a 29% reduced risk for IBD, whereas unhealthy PDIs were associated with a 54% increased risk.
A healthy PDI halved the risk for surgery in participants from the UK Biobank, whereas an unhealthy PDI was associated with a twofold higher risk for surgery.
There were no significant associations between PDIs and other outcomes, such as cardiovascular disease, diabetes, or all-cause mortality.
The researchers also looked at the interactions between genetics and plant-based diets, but those results were not presented at the meeting.
However, Wellens said in an interview that people with a moderate to high risk for IBD based on their polygenetic risk score showed increased odds for IBD risk.
“We don’t test people for their genetic risk of IBD, but if people have close relatives with IBD, then there is probably an increased genetic risk of its development,” she added.
Commenting on the findings, James Lindsay, PhD, professor of inflammatory bowel disease, Queen Mary University of London in England, said that several recent epidemiological studies have highlighted “the negative impact of ultra-processed foods on increasing the risk of developing Crohn’s disease.”
Based on these studies, “one might assume that plant-based diets would be protective,” he said, however, the current study shows us “that plant-based diets are not all equal and there are unhealthy aspects to some.”
“Of course, showing that a diet is associated with an outcome is not the same as knowing that changing a diet will reduce the risk,” Lindsay added. “That requires a well-designed, carefully controlled trial.”
Wellens and Lindsay reported no relevant financial disclosures.
A version of this article appeared on Medscape.com.
BERLIN — according to the results of a large cohort study.
The study, which included both Crohn’s disease (CD) and ulcerative colitis (UC), also showed that diet quality may affect disease progression and surgery risk for individuals already diagnosed with IBD.
“Not all plant-based foods are equal — they don’t all have the same effect on health outcomes,” said study researcher, Judith Wellens, MD, PhD, gastroenterology resident at Leuven University Hospital in Belgium.
“We need to look at what people are eating more carefully because it isn’t black and white, with all plant-based food being good and animal-based food being bad,” said Wellens, who presented the data at the European Crohn’s and Colitis Organisation (ECCO) 2025 Congress.
Although she advocates for plant-based diets, Wellens stressed that “they need to be individualized to ensure the overall dietary quality is good. Just cutting out meat products is not very helpful. We think it is the unhealthy additions to some plant-based diets that drive the IBD risk.”
Is It the Plants or the Processed Ingredients?
“Preclinical studies have already taught us that plant-based diets alter the gut microbiota in a beneficial way. However, many diets promoted for IBD — for example the Crohn’s disease exclusion diet — contain ingredients that are animal based. This is confusing for patients and for clinicians,” said Wellens.
To look more closely at the question, she and her colleagues analyzed data for 187,888 participants from the UK Biobank and 341,539 participants from across eight European countries from the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. None of the participants had IBD at baseline.
Based on participant 24-hour dietary recalls, the researchers constructed plant-based diet indices (PDIs) with diets categorized as healthy (eg, whole grains, fruits, vegetables, legumes, and vegetarian protein alternatives) or unhealthy (eg, emulsifiers, refined grains, fries, fruit juices, sweets, desserts, sugar-sweetened beverages, and processed foods).
The primary outcome was the incidence of IBD (either CD or UC), whereas the secondary outcome was IBD-related surgery, thereby marking disease progression. Cox regression analysis estimated IBD risk and progression. Incidences of IBD were similar between the two cohorts.
In the UK Biobank cohort, 925 participants developed IBD over a median follow-up of 11.6 years. Participants who followed a healthy PDI had a 25% reduced IBD risk, whereas those who followed an unhealthy PDI had a 48% increased risk for disease development. Both CD and UC showed similar outcomes.
The EPIC cohort had a longer median follow-up time of 14.5 years, during which 548 people developed IBD. Healthy PDIs were linked to a 29% reduced risk for IBD, whereas unhealthy PDIs were associated with a 54% increased risk.
A healthy PDI halved the risk for surgery in participants from the UK Biobank, whereas an unhealthy PDI was associated with a twofold higher risk for surgery.
There were no significant associations between PDIs and other outcomes, such as cardiovascular disease, diabetes, or all-cause mortality.
The researchers also looked at the interactions between genetics and plant-based diets, but those results were not presented at the meeting.
However, Wellens said in an interview that people with a moderate to high risk for IBD based on their polygenetic risk score showed increased odds for IBD risk.
“We don’t test people for their genetic risk of IBD, but if people have close relatives with IBD, then there is probably an increased genetic risk of its development,” she added.
Commenting on the findings, James Lindsay, PhD, professor of inflammatory bowel disease, Queen Mary University of London in England, said that several recent epidemiological studies have highlighted “the negative impact of ultra-processed foods on increasing the risk of developing Crohn’s disease.”
Based on these studies, “one might assume that plant-based diets would be protective,” he said, however, the current study shows us “that plant-based diets are not all equal and there are unhealthy aspects to some.”
“Of course, showing that a diet is associated with an outcome is not the same as knowing that changing a diet will reduce the risk,” Lindsay added. “That requires a well-designed, carefully controlled trial.”
Wellens and Lindsay reported no relevant financial disclosures.
A version of this article appeared on Medscape.com.
FROM ECCO 2025
Model May Predict Which UC Patients Risk Rehospitalization
a preliminary modeling study suggests.
“Absence of a gastroenterologist consultation within the year prior to admission, male sex, shorter length of hospital stay, and narcotic prescription at the time of discharge were independently associated with the risk for 90-day rehospitalization for a UC-related indication,” study author Sanjay Murthy, MD, associate professor of gastroenterology at the University of Ottawa, Ontario, Canada, and staff gastroenterologist at the Inflammatory Bowel Disease Centre at The Ottawa Hospital, said in an interview.
“While some hospital readmissions are likely unavoidable, a subset of them, particularly readmissions that occur soon after discharge, may be preventable with early and intensive postdischarge outpatient management,” he said. “Identifying those who are at high risk for early readmission is a rational first step toward applying targeted outpatient interventions that reduce this risk.”
The study was published in The Journal of the Canadian Association of Gastroenterology.
Major Predictor Variables
The researchers conducted a retrospective study in adults with UC who were admitted to The Ottawa Hospital between 2009 and 2016 for a UC flare or UC-related complication, excluding bowel cancer. Using medical records and administrative health databases, they derived and validated a multivariable logistic regression model of 90-day UC-related rehospitalization risk.
Participants’ mean age at UC diagnosis was 35.3 years and 50.4% were men. In the year before the index hospitalization, 138 (55.6%) participants had a gastroenterologist visit, whereas 41 (16.5%) were hospitalized.
During the index hospitalization, 42 (16.9%) patients were newly diagnosed with UC, and 25 (10.1%) underwent intra-abdominal surgery. At discharge, 34 (13.7%) patients were prescribed an outpatient narcotic. The mean length of hospital stay was 9.97 days. Twenty-seven individuals (10.9%) were rehospitalized within 90 days of discharge.
Out of 35 variables, the model identified the following four as significant predictors of 90-day rehospitalization: gastroenterologist consultation within the prior year (adjusted odds ratio [aOR], 0.09), male sex (aOR, 3.77), length of hospital stay (aOR, 0.93), and discharge with narcotics prescription (aOR, 5.94).
The model had 77.8% sensitivity, 80.9% specificity, 33% positive predictive value, and 96.7% negative predictive value for predicting high vs low risk for 90-day hospital readmission.
The researchers noted several study limitations. The cohort was relatively small, which limited the statistical power for model building and identifying variable associations with the outcome. In addition, the study was conducted in a single tertiary care center, which limits its generalizability. Retrospective data may have affected the accuracy of the measurements, and information on some relevant variables was not available.
Nevertheless, Murthy said, “optimally applying our prediction model at the point of hospital discharge would have classified only about a quarter of individuals in our cohort as being at high-risk for 90-day readmission and potentially needing targeted early outpatient intervention, and this would have captured close to 80% of individuals who were destined for early readmission.”
“However, our research is still preliminary and requires considerably more work to ensure that the findings are suitable for application to clinical practice,” he added. “In the meantime, practitioners may reflect on the potential importance of the major predictor variables identified in our study within their practices.”
Careful Follow-Up Key
Rajiv Bhuta, MD, assistant professor of clinical gastroenterology and hepatology at Temple University and a gastroenterologist at Temple University Hospital, both in Philadelphia, Pennsylvania, commented on the study but was not involved in it.
“The model performed fairly well (c-statistic of 0.78) using four variables: Gastroenterologist consultation within the prior year (protective), male sex (higher risk), length of stay (marginally protective), and narcotic prescription at discharge (higher risk). These are intuitive predictors that align with prior literature on UC hospitalizations,” said Bhuta.
“From a clinical perspective, this type of tool could be useful for targeting high-risk patients for early outpatient interventions (eg, close gastroenterology follow-up and pain management strategies). The negative predictive value (96.7%) suggests that it is particularly good at identifying patients at low risk for rehospitalization, which may help prioritize resource allocation more efficiently. However, practical implementation will require external validation and integration into electronic medical records to automatically flag high-risk patients at discharge.”
In addition, Bhuta noted, “the study only examines patient data through 2016. Why have the last 8 years been excluded? Given the small sample size and the sea change in available inflammatory bowel disease therapies since 2016, there could be significantly different findings with more current data.”
Furthermore, there is a lack of specific data supporting the protective effect of a gastroenterology visit in the previous year, and the readmission rate was lower than that reported by others (10% vs 20%), which, he said “may skew their findings.”
“The strong protective effect of prior gastroenterologist visits underscores the importance of specialty proactive disease management in these complex patients,” Bhuta continued. “Narcotic prescriptions at discharge may indicate inadequate disease activity control, thus making these patients important targets for close follow-up. Narcotics are generally not required once successful disease control has been achieved with steroids or biologics.
“While promising, this tool should not yet replace clinical judgment until it undergoes external validation,” he concluded. “In the meantime, clinicians should focus on structured outpatient follow-up and careful discharge planning to minimize UC-related rehospitalizations.”
This study was funded by a grant provided to Murthy by the department of medicine at the University of Ottawa. Murthy and Bhuta declared having no relevant financial relationships.
A version of this article appeared on Medscape.com .
a preliminary modeling study suggests.
“Absence of a gastroenterologist consultation within the year prior to admission, male sex, shorter length of hospital stay, and narcotic prescription at the time of discharge were independently associated with the risk for 90-day rehospitalization for a UC-related indication,” study author Sanjay Murthy, MD, associate professor of gastroenterology at the University of Ottawa, Ontario, Canada, and staff gastroenterologist at the Inflammatory Bowel Disease Centre at The Ottawa Hospital, said in an interview.
“While some hospital readmissions are likely unavoidable, a subset of them, particularly readmissions that occur soon after discharge, may be preventable with early and intensive postdischarge outpatient management,” he said. “Identifying those who are at high risk for early readmission is a rational first step toward applying targeted outpatient interventions that reduce this risk.”
The study was published in The Journal of the Canadian Association of Gastroenterology.
Major Predictor Variables
The researchers conducted a retrospective study in adults with UC who were admitted to The Ottawa Hospital between 2009 and 2016 for a UC flare or UC-related complication, excluding bowel cancer. Using medical records and administrative health databases, they derived and validated a multivariable logistic regression model of 90-day UC-related rehospitalization risk.
Participants’ mean age at UC diagnosis was 35.3 years and 50.4% were men. In the year before the index hospitalization, 138 (55.6%) participants had a gastroenterologist visit, whereas 41 (16.5%) were hospitalized.
During the index hospitalization, 42 (16.9%) patients were newly diagnosed with UC, and 25 (10.1%) underwent intra-abdominal surgery. At discharge, 34 (13.7%) patients were prescribed an outpatient narcotic. The mean length of hospital stay was 9.97 days. Twenty-seven individuals (10.9%) were rehospitalized within 90 days of discharge.
Out of 35 variables, the model identified the following four as significant predictors of 90-day rehospitalization: gastroenterologist consultation within the prior year (adjusted odds ratio [aOR], 0.09), male sex (aOR, 3.77), length of hospital stay (aOR, 0.93), and discharge with narcotics prescription (aOR, 5.94).
The model had 77.8% sensitivity, 80.9% specificity, 33% positive predictive value, and 96.7% negative predictive value for predicting high vs low risk for 90-day hospital readmission.
The researchers noted several study limitations. The cohort was relatively small, which limited the statistical power for model building and identifying variable associations with the outcome. In addition, the study was conducted in a single tertiary care center, which limits its generalizability. Retrospective data may have affected the accuracy of the measurements, and information on some relevant variables was not available.
Nevertheless, Murthy said, “optimally applying our prediction model at the point of hospital discharge would have classified only about a quarter of individuals in our cohort as being at high-risk for 90-day readmission and potentially needing targeted early outpatient intervention, and this would have captured close to 80% of individuals who were destined for early readmission.”
“However, our research is still preliminary and requires considerably more work to ensure that the findings are suitable for application to clinical practice,” he added. “In the meantime, practitioners may reflect on the potential importance of the major predictor variables identified in our study within their practices.”
Careful Follow-Up Key
Rajiv Bhuta, MD, assistant professor of clinical gastroenterology and hepatology at Temple University and a gastroenterologist at Temple University Hospital, both in Philadelphia, Pennsylvania, commented on the study but was not involved in it.
“The model performed fairly well (c-statistic of 0.78) using four variables: Gastroenterologist consultation within the prior year (protective), male sex (higher risk), length of stay (marginally protective), and narcotic prescription at discharge (higher risk). These are intuitive predictors that align with prior literature on UC hospitalizations,” said Bhuta.
“From a clinical perspective, this type of tool could be useful for targeting high-risk patients for early outpatient interventions (eg, close gastroenterology follow-up and pain management strategies). The negative predictive value (96.7%) suggests that it is particularly good at identifying patients at low risk for rehospitalization, which may help prioritize resource allocation more efficiently. However, practical implementation will require external validation and integration into electronic medical records to automatically flag high-risk patients at discharge.”
In addition, Bhuta noted, “the study only examines patient data through 2016. Why have the last 8 years been excluded? Given the small sample size and the sea change in available inflammatory bowel disease therapies since 2016, there could be significantly different findings with more current data.”
Furthermore, there is a lack of specific data supporting the protective effect of a gastroenterology visit in the previous year, and the readmission rate was lower than that reported by others (10% vs 20%), which, he said “may skew their findings.”
“The strong protective effect of prior gastroenterologist visits underscores the importance of specialty proactive disease management in these complex patients,” Bhuta continued. “Narcotic prescriptions at discharge may indicate inadequate disease activity control, thus making these patients important targets for close follow-up. Narcotics are generally not required once successful disease control has been achieved with steroids or biologics.
“While promising, this tool should not yet replace clinical judgment until it undergoes external validation,” he concluded. “In the meantime, clinicians should focus on structured outpatient follow-up and careful discharge planning to minimize UC-related rehospitalizations.”
This study was funded by a grant provided to Murthy by the department of medicine at the University of Ottawa. Murthy and Bhuta declared having no relevant financial relationships.
A version of this article appeared on Medscape.com .
a preliminary modeling study suggests.
“Absence of a gastroenterologist consultation within the year prior to admission, male sex, shorter length of hospital stay, and narcotic prescription at the time of discharge were independently associated with the risk for 90-day rehospitalization for a UC-related indication,” study author Sanjay Murthy, MD, associate professor of gastroenterology at the University of Ottawa, Ontario, Canada, and staff gastroenterologist at the Inflammatory Bowel Disease Centre at The Ottawa Hospital, said in an interview.
“While some hospital readmissions are likely unavoidable, a subset of them, particularly readmissions that occur soon after discharge, may be preventable with early and intensive postdischarge outpatient management,” he said. “Identifying those who are at high risk for early readmission is a rational first step toward applying targeted outpatient interventions that reduce this risk.”
The study was published in The Journal of the Canadian Association of Gastroenterology.
Major Predictor Variables
The researchers conducted a retrospective study in adults with UC who were admitted to The Ottawa Hospital between 2009 and 2016 for a UC flare or UC-related complication, excluding bowel cancer. Using medical records and administrative health databases, they derived and validated a multivariable logistic regression model of 90-day UC-related rehospitalization risk.
Participants’ mean age at UC diagnosis was 35.3 years and 50.4% were men. In the year before the index hospitalization, 138 (55.6%) participants had a gastroenterologist visit, whereas 41 (16.5%) were hospitalized.
During the index hospitalization, 42 (16.9%) patients were newly diagnosed with UC, and 25 (10.1%) underwent intra-abdominal surgery. At discharge, 34 (13.7%) patients were prescribed an outpatient narcotic. The mean length of hospital stay was 9.97 days. Twenty-seven individuals (10.9%) were rehospitalized within 90 days of discharge.
Out of 35 variables, the model identified the following four as significant predictors of 90-day rehospitalization: gastroenterologist consultation within the prior year (adjusted odds ratio [aOR], 0.09), male sex (aOR, 3.77), length of hospital stay (aOR, 0.93), and discharge with narcotics prescription (aOR, 5.94).
The model had 77.8% sensitivity, 80.9% specificity, 33% positive predictive value, and 96.7% negative predictive value for predicting high vs low risk for 90-day hospital readmission.
The researchers noted several study limitations. The cohort was relatively small, which limited the statistical power for model building and identifying variable associations with the outcome. In addition, the study was conducted in a single tertiary care center, which limits its generalizability. Retrospective data may have affected the accuracy of the measurements, and information on some relevant variables was not available.
Nevertheless, Murthy said, “optimally applying our prediction model at the point of hospital discharge would have classified only about a quarter of individuals in our cohort as being at high-risk for 90-day readmission and potentially needing targeted early outpatient intervention, and this would have captured close to 80% of individuals who were destined for early readmission.”
“However, our research is still preliminary and requires considerably more work to ensure that the findings are suitable for application to clinical practice,” he added. “In the meantime, practitioners may reflect on the potential importance of the major predictor variables identified in our study within their practices.”
Careful Follow-Up Key
Rajiv Bhuta, MD, assistant professor of clinical gastroenterology and hepatology at Temple University and a gastroenterologist at Temple University Hospital, both in Philadelphia, Pennsylvania, commented on the study but was not involved in it.
“The model performed fairly well (c-statistic of 0.78) using four variables: Gastroenterologist consultation within the prior year (protective), male sex (higher risk), length of stay (marginally protective), and narcotic prescription at discharge (higher risk). These are intuitive predictors that align with prior literature on UC hospitalizations,” said Bhuta.
“From a clinical perspective, this type of tool could be useful for targeting high-risk patients for early outpatient interventions (eg, close gastroenterology follow-up and pain management strategies). The negative predictive value (96.7%) suggests that it is particularly good at identifying patients at low risk for rehospitalization, which may help prioritize resource allocation more efficiently. However, practical implementation will require external validation and integration into electronic medical records to automatically flag high-risk patients at discharge.”
In addition, Bhuta noted, “the study only examines patient data through 2016. Why have the last 8 years been excluded? Given the small sample size and the sea change in available inflammatory bowel disease therapies since 2016, there could be significantly different findings with more current data.”
Furthermore, there is a lack of specific data supporting the protective effect of a gastroenterology visit in the previous year, and the readmission rate was lower than that reported by others (10% vs 20%), which, he said “may skew their findings.”
“The strong protective effect of prior gastroenterologist visits underscores the importance of specialty proactive disease management in these complex patients,” Bhuta continued. “Narcotic prescriptions at discharge may indicate inadequate disease activity control, thus making these patients important targets for close follow-up. Narcotics are generally not required once successful disease control has been achieved with steroids or biologics.
“While promising, this tool should not yet replace clinical judgment until it undergoes external validation,” he concluded. “In the meantime, clinicians should focus on structured outpatient follow-up and careful discharge planning to minimize UC-related rehospitalizations.”
This study was funded by a grant provided to Murthy by the department of medicine at the University of Ottawa. Murthy and Bhuta declared having no relevant financial relationships.
A version of this article appeared on Medscape.com .
FROM THE JOURNAL OF THE CANADIAN ASSOCIATION OF GASTROENTEROLOGY
Choosing the Ideal Endoscopic Enteral Access Method: AGA Practice Update
At least 250,000 US hospitalized patients a year require enteral support using an artificial pathway into the gastrointestinal (GI) tract to deliver nutrition or medication. In light of this,
Covering indications, placement techniques, and management, the comprehensive document is a response to the increasing use of enteral access devices in chronic GI conditions. The update, published in Gastroenterology, addresses patient factors complicating placement decision-making such as thrombocytopenia, use of dual antiplatelet therapy, or performance of percutaneous access in the setting of cirrhosis.
“We provide clinical recommendations in these various scenarios understanding that the final decision-making is in the hands of the provider and care team,” said first author Dejan Micic, MD, a gastroenterologist and associate professor at University of Chicago Medical Center in Illinois at the time of the update (since relocated to Loyola University Medical Center in Chicago). “We hope this can serve a day-to-day purpose for clinical gastroenterologists and can be referenced as they encounter individuals with or needing an enteral access device.”
Traditionally, enteral access was reserved for patients with severe malnutrition or those unable to maintain oral intake. Recent recommendations emphasize early nutritional intervention including prehabilitation before major surgery, adjunctive therapy for oncology patients, and in specific inflammatory conditions such as Crohn’s disease. “These shifts recognize the role of enteral nutrition not only in preventing malnutrition but also as a therapeutic strategy,” Micic said in an interview.
There is, however, variability in the use of devices including the selection of appropriate units, technical aspects of placement, and subsequent management. “Such variability can lead to complications, suboptimal patient outcomes, and inefficiencies in care delivery,” Micic said.
He added that enteral access has been historically underemphasized in GI endoscopic training. “While procedural skill in placing devices such as percutaneous endoscopic gastrostomy, or PEG, tubes is often taught, a comprehensive understanding of the broader clinical context — such as proper patient selection, prevention of complications, and postplacement care — is not always thoroughly covered.”
The current update aims to bridge knowledge gaps with evidence-based-guidance. “It also underscores the importance of interdisciplinary collaboration with dietitians, nurses, and care givers to achieve the best outcomes for patients,” Micic said.
Commenting on the update but not involved with creating it, Shirley C. Paski, MD, MS, a gastroenterologist at the Cleveland Clinic, Ohio, called it timely, adding: “As GI training is becoming more subspecialized and interventional radiology has been able to provide enteral access, gastroenterology training in enteral access has declined to where some fellows are graduating with limited enteral access experience.”
Yet malnutrition remains a common consequence when GI disease is severe, chronic, or refractory to treatment, or in the setting of postsurgical anatomy, she added. “Enteral nutrition is increasingly being considered a therapeutic or adjunct treatment in some cases of Crohn’s disease or small intestinal bacterial overgrowth. Gastroenterologists need the endoscopic skill to secure enteral access tubes, particularly in more challenging anatomy.”
Also commenting on the document but not involved in it, Steven Shamah, MD, director of Endoscopy at Northwell Lenox Hill Hospital in New York City, said: “This should serve as a concise review for any general hospitalist or gastroenterologist to understand what we have and when we should offer the proper feeding tube options.” He stressed, however, that all gastroenterologists should be trained in the placing of all of tube options.
“The axiom ‘If the gut works, we should use it’ is something that I was taught when I was a medical student and it still holds true,” Shamah continued. “There’s been a jump in interventional procedures to assure continuity of the GI tract even in progressive malignancy. So there’s a rise in moving away from intravenous nutrition and a rise in tube-delivered enteral nutrition.” Options for reducing reflux and aspiration will likely take on more importance, he said.
Tubing Options
According to Micic and colleagues, recent data suggest a favorable safety profile of enteral feeding tubes placed endoscopically compared with surgical or radiologic placement. The illustrated AGA document outlines such approaches as synthetic flexible tubes placed into the stomach or small bowel via the oral (orogastric and oroenteral) or nasal routes (nasogastric [NG] and nasojejunal [NJ]) and percutaneous tubes accessing the stomach. The choice of tube, access point, delivery site, and feeding method varies with indication, expected duration of use, and patient anatomy, the authors stressed.
The update notes that NG and NJ tubes can be used immediately after confirmation of placement, most often with abdominal radiography. PEG tubes can be used immediately for medications and after 4 hours for tube feedings. A multidisciplinary team approach after placement provides improved patient care. “Dietitians assist with formula choice, volume, free water needs, and delivery method, and nurses and advanced practice clinicians assist with tube site assessment and troubleshooting,” the authors wrote.
Complications can occur but should be infrequent, Micic said. “Frankly, most complications can be predicted based on the duration of use and prevented with appropriate monitoring.” Common complications include tube dislodgement, clogging, site infections, buried bumper syndrome, and aspiration. “Minimizing these risks requires a thorough understanding of patient-specific factors, careful technique during placement, and ongoing monitoring after the device is in use,” he added.
Paski said the update aligns with established guidelines for enteral access but also offers suggestions to mitigate the risk of tube placement in patients in whom placement has traditionally been more challenging. “This is a helpful addition to the literature because if enteral access cannot be obtained in a patient unable to meet their needs orally, total paternal nutrition is the next and much more invasive step for nutrition support.”
She called the practice update a concise, comprehensive reference for trainees and experienced gastroenterologists to optimize placement conditions and reduce complication risk, noting that training in nutrition is suboptimal in many GI fellowships.
Becoming familiar with common and advanced enteral access techniques is within the armamentarium of all practicing gastroenterologists, the authors stated. Because malnutrition affects nearly all GI disorders, “understanding common routes of enteral access and the basic principles of nutrition support promotes the initiation of optimal enteral nutrition, mitigating the impact of malnutrition, and improving prognosis for patients at nutritional risk,” they wrote.
Micic served on the advisory board for Ironwood Pharmaceuticals and is on the speaker’s bureau for Takeda Pharmaceuticals. One coauthor served as a consultant for Merit Medical, Circa Scientific, and Aspero Medical. Paski and Shamah had disclosed no competing interests relevant to their comments.
A version of this article appeared on Medscape.com.
At least 250,000 US hospitalized patients a year require enteral support using an artificial pathway into the gastrointestinal (GI) tract to deliver nutrition or medication. In light of this,
Covering indications, placement techniques, and management, the comprehensive document is a response to the increasing use of enteral access devices in chronic GI conditions. The update, published in Gastroenterology, addresses patient factors complicating placement decision-making such as thrombocytopenia, use of dual antiplatelet therapy, or performance of percutaneous access in the setting of cirrhosis.
“We provide clinical recommendations in these various scenarios understanding that the final decision-making is in the hands of the provider and care team,” said first author Dejan Micic, MD, a gastroenterologist and associate professor at University of Chicago Medical Center in Illinois at the time of the update (since relocated to Loyola University Medical Center in Chicago). “We hope this can serve a day-to-day purpose for clinical gastroenterologists and can be referenced as they encounter individuals with or needing an enteral access device.”
Traditionally, enteral access was reserved for patients with severe malnutrition or those unable to maintain oral intake. Recent recommendations emphasize early nutritional intervention including prehabilitation before major surgery, adjunctive therapy for oncology patients, and in specific inflammatory conditions such as Crohn’s disease. “These shifts recognize the role of enteral nutrition not only in preventing malnutrition but also as a therapeutic strategy,” Micic said in an interview.
There is, however, variability in the use of devices including the selection of appropriate units, technical aspects of placement, and subsequent management. “Such variability can lead to complications, suboptimal patient outcomes, and inefficiencies in care delivery,” Micic said.
He added that enteral access has been historically underemphasized in GI endoscopic training. “While procedural skill in placing devices such as percutaneous endoscopic gastrostomy, or PEG, tubes is often taught, a comprehensive understanding of the broader clinical context — such as proper patient selection, prevention of complications, and postplacement care — is not always thoroughly covered.”
The current update aims to bridge knowledge gaps with evidence-based-guidance. “It also underscores the importance of interdisciplinary collaboration with dietitians, nurses, and care givers to achieve the best outcomes for patients,” Micic said.
Commenting on the update but not involved with creating it, Shirley C. Paski, MD, MS, a gastroenterologist at the Cleveland Clinic, Ohio, called it timely, adding: “As GI training is becoming more subspecialized and interventional radiology has been able to provide enteral access, gastroenterology training in enteral access has declined to where some fellows are graduating with limited enteral access experience.”
Yet malnutrition remains a common consequence when GI disease is severe, chronic, or refractory to treatment, or in the setting of postsurgical anatomy, she added. “Enteral nutrition is increasingly being considered a therapeutic or adjunct treatment in some cases of Crohn’s disease or small intestinal bacterial overgrowth. Gastroenterologists need the endoscopic skill to secure enteral access tubes, particularly in more challenging anatomy.”
Also commenting on the document but not involved in it, Steven Shamah, MD, director of Endoscopy at Northwell Lenox Hill Hospital in New York City, said: “This should serve as a concise review for any general hospitalist or gastroenterologist to understand what we have and when we should offer the proper feeding tube options.” He stressed, however, that all gastroenterologists should be trained in the placing of all of tube options.
“The axiom ‘If the gut works, we should use it’ is something that I was taught when I was a medical student and it still holds true,” Shamah continued. “There’s been a jump in interventional procedures to assure continuity of the GI tract even in progressive malignancy. So there’s a rise in moving away from intravenous nutrition and a rise in tube-delivered enteral nutrition.” Options for reducing reflux and aspiration will likely take on more importance, he said.
Tubing Options
According to Micic and colleagues, recent data suggest a favorable safety profile of enteral feeding tubes placed endoscopically compared with surgical or radiologic placement. The illustrated AGA document outlines such approaches as synthetic flexible tubes placed into the stomach or small bowel via the oral (orogastric and oroenteral) or nasal routes (nasogastric [NG] and nasojejunal [NJ]) and percutaneous tubes accessing the stomach. The choice of tube, access point, delivery site, and feeding method varies with indication, expected duration of use, and patient anatomy, the authors stressed.
The update notes that NG and NJ tubes can be used immediately after confirmation of placement, most often with abdominal radiography. PEG tubes can be used immediately for medications and after 4 hours for tube feedings. A multidisciplinary team approach after placement provides improved patient care. “Dietitians assist with formula choice, volume, free water needs, and delivery method, and nurses and advanced practice clinicians assist with tube site assessment and troubleshooting,” the authors wrote.
Complications can occur but should be infrequent, Micic said. “Frankly, most complications can be predicted based on the duration of use and prevented with appropriate monitoring.” Common complications include tube dislodgement, clogging, site infections, buried bumper syndrome, and aspiration. “Minimizing these risks requires a thorough understanding of patient-specific factors, careful technique during placement, and ongoing monitoring after the device is in use,” he added.
Paski said the update aligns with established guidelines for enteral access but also offers suggestions to mitigate the risk of tube placement in patients in whom placement has traditionally been more challenging. “This is a helpful addition to the literature because if enteral access cannot be obtained in a patient unable to meet their needs orally, total paternal nutrition is the next and much more invasive step for nutrition support.”
She called the practice update a concise, comprehensive reference for trainees and experienced gastroenterologists to optimize placement conditions and reduce complication risk, noting that training in nutrition is suboptimal in many GI fellowships.
Becoming familiar with common and advanced enteral access techniques is within the armamentarium of all practicing gastroenterologists, the authors stated. Because malnutrition affects nearly all GI disorders, “understanding common routes of enteral access and the basic principles of nutrition support promotes the initiation of optimal enteral nutrition, mitigating the impact of malnutrition, and improving prognosis for patients at nutritional risk,” they wrote.
Micic served on the advisory board for Ironwood Pharmaceuticals and is on the speaker’s bureau for Takeda Pharmaceuticals. One coauthor served as a consultant for Merit Medical, Circa Scientific, and Aspero Medical. Paski and Shamah had disclosed no competing interests relevant to their comments.
A version of this article appeared on Medscape.com.
At least 250,000 US hospitalized patients a year require enteral support using an artificial pathway into the gastrointestinal (GI) tract to deliver nutrition or medication. In light of this,
Covering indications, placement techniques, and management, the comprehensive document is a response to the increasing use of enteral access devices in chronic GI conditions. The update, published in Gastroenterology, addresses patient factors complicating placement decision-making such as thrombocytopenia, use of dual antiplatelet therapy, or performance of percutaneous access in the setting of cirrhosis.
“We provide clinical recommendations in these various scenarios understanding that the final decision-making is in the hands of the provider and care team,” said first author Dejan Micic, MD, a gastroenterologist and associate professor at University of Chicago Medical Center in Illinois at the time of the update (since relocated to Loyola University Medical Center in Chicago). “We hope this can serve a day-to-day purpose for clinical gastroenterologists and can be referenced as they encounter individuals with or needing an enteral access device.”
Traditionally, enteral access was reserved for patients with severe malnutrition or those unable to maintain oral intake. Recent recommendations emphasize early nutritional intervention including prehabilitation before major surgery, adjunctive therapy for oncology patients, and in specific inflammatory conditions such as Crohn’s disease. “These shifts recognize the role of enteral nutrition not only in preventing malnutrition but also as a therapeutic strategy,” Micic said in an interview.
There is, however, variability in the use of devices including the selection of appropriate units, technical aspects of placement, and subsequent management. “Such variability can lead to complications, suboptimal patient outcomes, and inefficiencies in care delivery,” Micic said.
He added that enteral access has been historically underemphasized in GI endoscopic training. “While procedural skill in placing devices such as percutaneous endoscopic gastrostomy, or PEG, tubes is often taught, a comprehensive understanding of the broader clinical context — such as proper patient selection, prevention of complications, and postplacement care — is not always thoroughly covered.”
The current update aims to bridge knowledge gaps with evidence-based-guidance. “It also underscores the importance of interdisciplinary collaboration with dietitians, nurses, and care givers to achieve the best outcomes for patients,” Micic said.
Commenting on the update but not involved with creating it, Shirley C. Paski, MD, MS, a gastroenterologist at the Cleveland Clinic, Ohio, called it timely, adding: “As GI training is becoming more subspecialized and interventional radiology has been able to provide enteral access, gastroenterology training in enteral access has declined to where some fellows are graduating with limited enteral access experience.”
Yet malnutrition remains a common consequence when GI disease is severe, chronic, or refractory to treatment, or in the setting of postsurgical anatomy, she added. “Enteral nutrition is increasingly being considered a therapeutic or adjunct treatment in some cases of Crohn’s disease or small intestinal bacterial overgrowth. Gastroenterologists need the endoscopic skill to secure enteral access tubes, particularly in more challenging anatomy.”
Also commenting on the document but not involved in it, Steven Shamah, MD, director of Endoscopy at Northwell Lenox Hill Hospital in New York City, said: “This should serve as a concise review for any general hospitalist or gastroenterologist to understand what we have and when we should offer the proper feeding tube options.” He stressed, however, that all gastroenterologists should be trained in the placing of all of tube options.
“The axiom ‘If the gut works, we should use it’ is something that I was taught when I was a medical student and it still holds true,” Shamah continued. “There’s been a jump in interventional procedures to assure continuity of the GI tract even in progressive malignancy. So there’s a rise in moving away from intravenous nutrition and a rise in tube-delivered enteral nutrition.” Options for reducing reflux and aspiration will likely take on more importance, he said.
Tubing Options
According to Micic and colleagues, recent data suggest a favorable safety profile of enteral feeding tubes placed endoscopically compared with surgical or radiologic placement. The illustrated AGA document outlines such approaches as synthetic flexible tubes placed into the stomach or small bowel via the oral (orogastric and oroenteral) or nasal routes (nasogastric [NG] and nasojejunal [NJ]) and percutaneous tubes accessing the stomach. The choice of tube, access point, delivery site, and feeding method varies with indication, expected duration of use, and patient anatomy, the authors stressed.
The update notes that NG and NJ tubes can be used immediately after confirmation of placement, most often with abdominal radiography. PEG tubes can be used immediately for medications and after 4 hours for tube feedings. A multidisciplinary team approach after placement provides improved patient care. “Dietitians assist with formula choice, volume, free water needs, and delivery method, and nurses and advanced practice clinicians assist with tube site assessment and troubleshooting,” the authors wrote.
Complications can occur but should be infrequent, Micic said. “Frankly, most complications can be predicted based on the duration of use and prevented with appropriate monitoring.” Common complications include tube dislodgement, clogging, site infections, buried bumper syndrome, and aspiration. “Minimizing these risks requires a thorough understanding of patient-specific factors, careful technique during placement, and ongoing monitoring after the device is in use,” he added.
Paski said the update aligns with established guidelines for enteral access but also offers suggestions to mitigate the risk of tube placement in patients in whom placement has traditionally been more challenging. “This is a helpful addition to the literature because if enteral access cannot be obtained in a patient unable to meet their needs orally, total paternal nutrition is the next and much more invasive step for nutrition support.”
She called the practice update a concise, comprehensive reference for trainees and experienced gastroenterologists to optimize placement conditions and reduce complication risk, noting that training in nutrition is suboptimal in many GI fellowships.
Becoming familiar with common and advanced enteral access techniques is within the armamentarium of all practicing gastroenterologists, the authors stated. Because malnutrition affects nearly all GI disorders, “understanding common routes of enteral access and the basic principles of nutrition support promotes the initiation of optimal enteral nutrition, mitigating the impact of malnutrition, and improving prognosis for patients at nutritional risk,” they wrote.
Micic served on the advisory board for Ironwood Pharmaceuticals and is on the speaker’s bureau for Takeda Pharmaceuticals. One coauthor served as a consultant for Merit Medical, Circa Scientific, and Aspero Medical. Paski and Shamah had disclosed no competing interests relevant to their comments.
A version of this article appeared on Medscape.com.
FROM GASTROENTEROLOGY
Navigating Esophageal Dysfunction in Immune and Infectious Disorders: AGA Clinical Practice Update
“Many different disorders can lead to esophageal dysfunction, which is characterized by symptoms including dysphagia, odynophagia, chest pain and heartburn. These symptoms can be caused either by immune or infectious conditions and can either be localized to the esophagus or part of a larger systemic process,” co–first author Emily McGowan, MD, PhD, with the division of allergy and immunology, University of Virginia School of Medicine, Charlottesville, said in an AGA podcast.
However, without a “high index of suspicion,” these conditions can be overlooked, leading to delays in diagnosis and unnecessary procedures. “With this clinical practice update, we wanted to help providers more readily recognize these conditions so that patients can be diagnosed and treated earlier in the course of their disease,” McGowan explained.
“This is a fantastic review that highlights how many different systemic disorders can affect the esophagus,” Scott Gabbard, MD, gastroenterologist and section head at the Center for Neurogastroenterology and Motility, Cleveland Clinic, Ohio, who wasn’t involved in the review, said in an interview.
“Honestly, for the practicing gastroenterologist, this is one of those reviews that I could envision someone either saving to his or her desktop for reference or printing it and pinning it next to his or her desk,” Gabbard said.
Best Practice Advice
The clinical practice update is published in Clinical Gastroenterology and Hepatology. It includes 10 “best practice advice” statements and a table highlighting “important” considerations when evaluating patients with esophageal dysfunction.
The review authors note that esophageal dysfunction may result from localized infections — most commonly Candida, herpes simplex virus, and cytomegalovirus — or systemic immune-mediated diseases, such as systemic sclerosis (SSc), mixed connective tissue disease (MCTD), and eosinophilic esophagitis (EoE).
They advise clinicians to identify if there are risks for inflammatory or infectious possibilities for a patient’s esophageal symptoms and investigate for these disorders as a potential cause of esophageal dysfunction.
Once esophageal infection is identified, it’s important to identify whether accompanying signs and symptoms point to immunocompromise leading to a more systemic infection. Consultation with an infectious disease expert is recommended to guide appropriate treatment, the authors said.
If symptoms fail to improve after therapy for infectious esophagitis, the patient should be evaluated for refractory infection or additional underlying sources of esophageal and immunologic dysfunction is advised.
It’s also important to recognize that patients with EoE who continue to have symptoms of esophageal dysfunction despite histologic and endoscopic disease remission, may develop a motility disorder and evaluation of esophageal motility may be warranted, the authors said.
In patients with histologic and endoscopic features of lymphocytic esophagitis, treatment of lymphocytic-related inflammation with proton-pump inhibitor (PPI) therapy or swallowed topical corticosteroids and esophageal dilation as needed should be considered.
In patients who present with esophageal symptoms in the setting of hypereosinophilia (absolute eosinophil count > 1500 cells/uL), the authors advise further workup of non-EoE eosinophilic gastrointestinal disease, hypereosinophilic syndrome, and eosinophilic granulomatosis with polyangiitis should be considered, with consultation with an allergy/immunology specialist if helpful.
In patients with rheumatologic diseases, especially SSc and MCTD, it’s important to be aware that esophageal symptoms can occur because of involvement of the esophageal muscle layer, resulting in dysmotility and/or incompetence of the lower esophageal sphincter, they said.
In the setting of Crohn’s disease, some patients can develop esophageal involvement from inflammation, stricturing, or fistulizing changes with granulomas seen histologically. Esophageal manifestations of Crohn’s disease tend to occur in patients with active intestinal disease.
In patients with dermatologic diseases of lichen planus or bullous disorders, dysphagia can occur because of endoscopically visible esophageal mucosal involvement. Esophageal lichen planus, in particular, can occur without skin involvement and can be difficult to define on esophageal histopathology.
The authors also advise clinicians to consider infectious and inflammatory causes of secondary achalasia during initial evaluation.
“Achalasia and EoE might coexist more commonly than what gastroenterologists think, especially in younger patients,” co–first author Chanakyaram Reddy, MD, a gastroenterologist with Baylor University Medical Center, Dallas, Texas, said in the AGA podcast.
He noted that in a recent population-based study, the estimated relative risk of EoE was over 30-fold higher in patients with achalasia aged ≤ 40 years.
“In any suspected achalasia case, it would be wise to obtain biopsies throughout the entire esophagus when the patient is off confounding medications such as PPI therapy to establish if significant esophageal eosinophilia is coexistent,” Reddy said.
“If EoE-level eosinophilia is found, it would be reasonable to consider treating medically for EoE prior to committing to achalasia-specific interventions, which often involve permanent disruption of the esophageal muscle layer,” he added.
Gabbard said this review helps the clinician think beyond gastroesophageal reflux disease (GERD) — the most common cause of esophageal dysfunction — and consider other causes for esophageal dysfunction.
“We are seeing more complex disorders affect the esophagus. It’s not just GERD and you absolutely need a high index of suspicion because you can find varying disorders to blame for many esophageal symptoms that could otherwise be thought to be just reflux,” he said.
This research had no commercial funding. Disclosures for the authors are listed with the original article. Gabbard had no relevant disclosures.
A version of this article appeared on Medscape.com.
“Many different disorders can lead to esophageal dysfunction, which is characterized by symptoms including dysphagia, odynophagia, chest pain and heartburn. These symptoms can be caused either by immune or infectious conditions and can either be localized to the esophagus or part of a larger systemic process,” co–first author Emily McGowan, MD, PhD, with the division of allergy and immunology, University of Virginia School of Medicine, Charlottesville, said in an AGA podcast.
However, without a “high index of suspicion,” these conditions can be overlooked, leading to delays in diagnosis and unnecessary procedures. “With this clinical practice update, we wanted to help providers more readily recognize these conditions so that patients can be diagnosed and treated earlier in the course of their disease,” McGowan explained.
“This is a fantastic review that highlights how many different systemic disorders can affect the esophagus,” Scott Gabbard, MD, gastroenterologist and section head at the Center for Neurogastroenterology and Motility, Cleveland Clinic, Ohio, who wasn’t involved in the review, said in an interview.
“Honestly, for the practicing gastroenterologist, this is one of those reviews that I could envision someone either saving to his or her desktop for reference or printing it and pinning it next to his or her desk,” Gabbard said.
Best Practice Advice
The clinical practice update is published in Clinical Gastroenterology and Hepatology. It includes 10 “best practice advice” statements and a table highlighting “important” considerations when evaluating patients with esophageal dysfunction.
The review authors note that esophageal dysfunction may result from localized infections — most commonly Candida, herpes simplex virus, and cytomegalovirus — or systemic immune-mediated diseases, such as systemic sclerosis (SSc), mixed connective tissue disease (MCTD), and eosinophilic esophagitis (EoE).
They advise clinicians to identify if there are risks for inflammatory or infectious possibilities for a patient’s esophageal symptoms and investigate for these disorders as a potential cause of esophageal dysfunction.
Once esophageal infection is identified, it’s important to identify whether accompanying signs and symptoms point to immunocompromise leading to a more systemic infection. Consultation with an infectious disease expert is recommended to guide appropriate treatment, the authors said.
If symptoms fail to improve after therapy for infectious esophagitis, the patient should be evaluated for refractory infection or additional underlying sources of esophageal and immunologic dysfunction is advised.
It’s also important to recognize that patients with EoE who continue to have symptoms of esophageal dysfunction despite histologic and endoscopic disease remission, may develop a motility disorder and evaluation of esophageal motility may be warranted, the authors said.
In patients with histologic and endoscopic features of lymphocytic esophagitis, treatment of lymphocytic-related inflammation with proton-pump inhibitor (PPI) therapy or swallowed topical corticosteroids and esophageal dilation as needed should be considered.
In patients who present with esophageal symptoms in the setting of hypereosinophilia (absolute eosinophil count > 1500 cells/uL), the authors advise further workup of non-EoE eosinophilic gastrointestinal disease, hypereosinophilic syndrome, and eosinophilic granulomatosis with polyangiitis should be considered, with consultation with an allergy/immunology specialist if helpful.
In patients with rheumatologic diseases, especially SSc and MCTD, it’s important to be aware that esophageal symptoms can occur because of involvement of the esophageal muscle layer, resulting in dysmotility and/or incompetence of the lower esophageal sphincter, they said.
In the setting of Crohn’s disease, some patients can develop esophageal involvement from inflammation, stricturing, or fistulizing changes with granulomas seen histologically. Esophageal manifestations of Crohn’s disease tend to occur in patients with active intestinal disease.
In patients with dermatologic diseases of lichen planus or bullous disorders, dysphagia can occur because of endoscopically visible esophageal mucosal involvement. Esophageal lichen planus, in particular, can occur without skin involvement and can be difficult to define on esophageal histopathology.
The authors also advise clinicians to consider infectious and inflammatory causes of secondary achalasia during initial evaluation.
“Achalasia and EoE might coexist more commonly than what gastroenterologists think, especially in younger patients,” co–first author Chanakyaram Reddy, MD, a gastroenterologist with Baylor University Medical Center, Dallas, Texas, said in the AGA podcast.
He noted that in a recent population-based study, the estimated relative risk of EoE was over 30-fold higher in patients with achalasia aged ≤ 40 years.
“In any suspected achalasia case, it would be wise to obtain biopsies throughout the entire esophagus when the patient is off confounding medications such as PPI therapy to establish if significant esophageal eosinophilia is coexistent,” Reddy said.
“If EoE-level eosinophilia is found, it would be reasonable to consider treating medically for EoE prior to committing to achalasia-specific interventions, which often involve permanent disruption of the esophageal muscle layer,” he added.
Gabbard said this review helps the clinician think beyond gastroesophageal reflux disease (GERD) — the most common cause of esophageal dysfunction — and consider other causes for esophageal dysfunction.
“We are seeing more complex disorders affect the esophagus. It’s not just GERD and you absolutely need a high index of suspicion because you can find varying disorders to blame for many esophageal symptoms that could otherwise be thought to be just reflux,” he said.
This research had no commercial funding. Disclosures for the authors are listed with the original article. Gabbard had no relevant disclosures.
A version of this article appeared on Medscape.com.
“Many different disorders can lead to esophageal dysfunction, which is characterized by symptoms including dysphagia, odynophagia, chest pain and heartburn. These symptoms can be caused either by immune or infectious conditions and can either be localized to the esophagus or part of a larger systemic process,” co–first author Emily McGowan, MD, PhD, with the division of allergy and immunology, University of Virginia School of Medicine, Charlottesville, said in an AGA podcast.
However, without a “high index of suspicion,” these conditions can be overlooked, leading to delays in diagnosis and unnecessary procedures. “With this clinical practice update, we wanted to help providers more readily recognize these conditions so that patients can be diagnosed and treated earlier in the course of their disease,” McGowan explained.
“This is a fantastic review that highlights how many different systemic disorders can affect the esophagus,” Scott Gabbard, MD, gastroenterologist and section head at the Center for Neurogastroenterology and Motility, Cleveland Clinic, Ohio, who wasn’t involved in the review, said in an interview.
“Honestly, for the practicing gastroenterologist, this is one of those reviews that I could envision someone either saving to his or her desktop for reference or printing it and pinning it next to his or her desk,” Gabbard said.
Best Practice Advice
The clinical practice update is published in Clinical Gastroenterology and Hepatology. It includes 10 “best practice advice” statements and a table highlighting “important” considerations when evaluating patients with esophageal dysfunction.
The review authors note that esophageal dysfunction may result from localized infections — most commonly Candida, herpes simplex virus, and cytomegalovirus — or systemic immune-mediated diseases, such as systemic sclerosis (SSc), mixed connective tissue disease (MCTD), and eosinophilic esophagitis (EoE).
They advise clinicians to identify if there are risks for inflammatory or infectious possibilities for a patient’s esophageal symptoms and investigate for these disorders as a potential cause of esophageal dysfunction.
Once esophageal infection is identified, it’s important to identify whether accompanying signs and symptoms point to immunocompromise leading to a more systemic infection. Consultation with an infectious disease expert is recommended to guide appropriate treatment, the authors said.
If symptoms fail to improve after therapy for infectious esophagitis, the patient should be evaluated for refractory infection or additional underlying sources of esophageal and immunologic dysfunction is advised.
It’s also important to recognize that patients with EoE who continue to have symptoms of esophageal dysfunction despite histologic and endoscopic disease remission, may develop a motility disorder and evaluation of esophageal motility may be warranted, the authors said.
In patients with histologic and endoscopic features of lymphocytic esophagitis, treatment of lymphocytic-related inflammation with proton-pump inhibitor (PPI) therapy or swallowed topical corticosteroids and esophageal dilation as needed should be considered.
In patients who present with esophageal symptoms in the setting of hypereosinophilia (absolute eosinophil count > 1500 cells/uL), the authors advise further workup of non-EoE eosinophilic gastrointestinal disease, hypereosinophilic syndrome, and eosinophilic granulomatosis with polyangiitis should be considered, with consultation with an allergy/immunology specialist if helpful.
In patients with rheumatologic diseases, especially SSc and MCTD, it’s important to be aware that esophageal symptoms can occur because of involvement of the esophageal muscle layer, resulting in dysmotility and/or incompetence of the lower esophageal sphincter, they said.
In the setting of Crohn’s disease, some patients can develop esophageal involvement from inflammation, stricturing, or fistulizing changes with granulomas seen histologically. Esophageal manifestations of Crohn’s disease tend to occur in patients with active intestinal disease.
In patients with dermatologic diseases of lichen planus or bullous disorders, dysphagia can occur because of endoscopically visible esophageal mucosal involvement. Esophageal lichen planus, in particular, can occur without skin involvement and can be difficult to define on esophageal histopathology.
The authors also advise clinicians to consider infectious and inflammatory causes of secondary achalasia during initial evaluation.
“Achalasia and EoE might coexist more commonly than what gastroenterologists think, especially in younger patients,” co–first author Chanakyaram Reddy, MD, a gastroenterologist with Baylor University Medical Center, Dallas, Texas, said in the AGA podcast.
He noted that in a recent population-based study, the estimated relative risk of EoE was over 30-fold higher in patients with achalasia aged ≤ 40 years.
“In any suspected achalasia case, it would be wise to obtain biopsies throughout the entire esophagus when the patient is off confounding medications such as PPI therapy to establish if significant esophageal eosinophilia is coexistent,” Reddy said.
“If EoE-level eosinophilia is found, it would be reasonable to consider treating medically for EoE prior to committing to achalasia-specific interventions, which often involve permanent disruption of the esophageal muscle layer,” he added.
Gabbard said this review helps the clinician think beyond gastroesophageal reflux disease (GERD) — the most common cause of esophageal dysfunction — and consider other causes for esophageal dysfunction.
“We are seeing more complex disorders affect the esophagus. It’s not just GERD and you absolutely need a high index of suspicion because you can find varying disorders to blame for many esophageal symptoms that could otherwise be thought to be just reflux,” he said.
This research had no commercial funding. Disclosures for the authors are listed with the original article. Gabbard had no relevant disclosures.
A version of this article appeared on Medscape.com.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Best Practices When Using POEM to Treat Achalasia: AGA Clinical Update
The American Gastroenterological Association (AGA) has released
“Any patient suspected to have achalasia, or difficulty swallowing for that matter, should undergo a comprehensive diagnostic workup, and that should include clinical history, review of medication, as well as tests. The diagnosis should not be based on isolated tests but on the clinical picture as a whole,” first author Dennis Yang, MD, AGAF, with the Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, noted in an AGA podcast about the update.
The clinical practice update, published in Gastroenterology, includes 12 “best practice advice” statements.
Since its introduction to clinical practice more than a decade ago, POEM has matured and gained widespread acceptance because of its efficacy and safety profile.
POEM has at least similar outcomes to laparoscopic Heller myotomy and pneumatic dilation for type I and type II achalasia with better results for those with type III achalasia, Yang noted.
“However, besides disease phenotype, we need to remember that choosing the right treatment for the patient is going to be based on multiple factors including patient characteristics as well as local expertise,” Yang added.
In terms of technical considerations, the update states that both anterior and posterior tunnel approaches demonstrate comparable success and postprocedure reflux rates. Tunnel orientation should be tailored to the patient’s surgical history and endoscopist’s preference.
It further states that optimal length of the myotomy in the esophagus and cardia, as it pertains to treatment efficacy and risk for postprocedure reflux, remains to be determined.
Adjunct techniques, including real-time intraprocedure functional luminal impedance planimetry, may be considered to tailor or confirm the adequacy of the myotomy.
Same-day discharge after POEM can be considered in select patients who meet discharge criteria. Patients with advanced age, significant comorbidities, poor social support, and/or access to specialized care should be considered for hospital admission, irrespective of symptoms.
The update notes that specific guidelines on the role and extent of antibiotic prophylaxis before and after POEM are lacking. A single dose of antibiotics at the time of POEM “may be sufficient” for antibiotic prophylaxis.
In terms of immediate post-POEM care, the update notes that the clinical impact of routine esophagram or endoscopy immediately post-POEM remains unclear. Testing can be considered based on local practice preferences and in cases in which intraprocedural events or postprocedural findings warrant further evaluation.
Proton pump inhibitors are recommended immediately following POEM, as gastroesophageal reflux disease (GERD) is common following POEM, occurring in up to 65% of cases.
Routine endoscopic surveillance is advised to monitor GERD, disease progression, and esophageal cancer risk, which is significantly higher in achalasia patients.
“Just like diabetes and hypertension, we need to remember that achalasia is a chronic disease and long-term postprocedural surveillance is strongly encouraged to monitor disease progression as well as potential complications of reflux,” Yang said.
He noted that surveillance should be considered irrespective of patient symptoms because many of these patients may remain asymptomatic.
“Primary gastroenterologists should have a very low threshold in referring the patient back to the POEM endoscopist or any specialized esophageal center because the ideology of symptoms in these patients can be quite difficult to tease out and often require comprehensive diagnostic workup,” Yang said.
Evidence for POEM in esophagogastric outflow obstruction and other nonachalasia spastic motility disorders is limited and should only be considered on a case-by-case basis after other less invasive approaches have been exhausted, the update states.
For perspective on the POEM clinical practice update, this news organization spoke with Mouen Khashab, MD, director of therapeutic endoscopy, Johns Hopkins University, Baltimore, Maryland.
“The document is very well written and comprehensive,” Khashab said.
However, Khashab said he would have liked to see greater emphasis on the value or role of a short myotomy in the esophagus and cardia.
“There is level I evidence that the short esophageal myotomy is equivalent to a long esophageal myotomy for type I and II achalasia. When you do a short myotomy, you save procedure time and there is potentially a lower incidence of blown-out myotomy or BOM,” Khashab said.
Khashab also noted that a long myotomy on the gastric side “likely increases the risk of reflux disease, and therefore a limited myotomy on the gastric side likely also is advantageous.”
This research had no commercial funding. Yang serves as a consultant for Boston Scientific, Olympus, FujiFilm, Microtech, Medtronic, 3D-Matrix, and Neptune Medical, and has received research support from Microtech and 3D-Matrix. Khashab had no relevant disclosures.
A version of this article appeared on Medscape.com .
The American Gastroenterological Association (AGA) has released
“Any patient suspected to have achalasia, or difficulty swallowing for that matter, should undergo a comprehensive diagnostic workup, and that should include clinical history, review of medication, as well as tests. The diagnosis should not be based on isolated tests but on the clinical picture as a whole,” first author Dennis Yang, MD, AGAF, with the Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, noted in an AGA podcast about the update.
The clinical practice update, published in Gastroenterology, includes 12 “best practice advice” statements.
Since its introduction to clinical practice more than a decade ago, POEM has matured and gained widespread acceptance because of its efficacy and safety profile.
POEM has at least similar outcomes to laparoscopic Heller myotomy and pneumatic dilation for type I and type II achalasia with better results for those with type III achalasia, Yang noted.
“However, besides disease phenotype, we need to remember that choosing the right treatment for the patient is going to be based on multiple factors including patient characteristics as well as local expertise,” Yang added.
In terms of technical considerations, the update states that both anterior and posterior tunnel approaches demonstrate comparable success and postprocedure reflux rates. Tunnel orientation should be tailored to the patient’s surgical history and endoscopist’s preference.
It further states that optimal length of the myotomy in the esophagus and cardia, as it pertains to treatment efficacy and risk for postprocedure reflux, remains to be determined.
Adjunct techniques, including real-time intraprocedure functional luminal impedance planimetry, may be considered to tailor or confirm the adequacy of the myotomy.
Same-day discharge after POEM can be considered in select patients who meet discharge criteria. Patients with advanced age, significant comorbidities, poor social support, and/or access to specialized care should be considered for hospital admission, irrespective of symptoms.
The update notes that specific guidelines on the role and extent of antibiotic prophylaxis before and after POEM are lacking. A single dose of antibiotics at the time of POEM “may be sufficient” for antibiotic prophylaxis.
In terms of immediate post-POEM care, the update notes that the clinical impact of routine esophagram or endoscopy immediately post-POEM remains unclear. Testing can be considered based on local practice preferences and in cases in which intraprocedural events or postprocedural findings warrant further evaluation.
Proton pump inhibitors are recommended immediately following POEM, as gastroesophageal reflux disease (GERD) is common following POEM, occurring in up to 65% of cases.
Routine endoscopic surveillance is advised to monitor GERD, disease progression, and esophageal cancer risk, which is significantly higher in achalasia patients.
“Just like diabetes and hypertension, we need to remember that achalasia is a chronic disease and long-term postprocedural surveillance is strongly encouraged to monitor disease progression as well as potential complications of reflux,” Yang said.
He noted that surveillance should be considered irrespective of patient symptoms because many of these patients may remain asymptomatic.
“Primary gastroenterologists should have a very low threshold in referring the patient back to the POEM endoscopist or any specialized esophageal center because the ideology of symptoms in these patients can be quite difficult to tease out and often require comprehensive diagnostic workup,” Yang said.
Evidence for POEM in esophagogastric outflow obstruction and other nonachalasia spastic motility disorders is limited and should only be considered on a case-by-case basis after other less invasive approaches have been exhausted, the update states.
For perspective on the POEM clinical practice update, this news organization spoke with Mouen Khashab, MD, director of therapeutic endoscopy, Johns Hopkins University, Baltimore, Maryland.
“The document is very well written and comprehensive,” Khashab said.
However, Khashab said he would have liked to see greater emphasis on the value or role of a short myotomy in the esophagus and cardia.
“There is level I evidence that the short esophageal myotomy is equivalent to a long esophageal myotomy for type I and II achalasia. When you do a short myotomy, you save procedure time and there is potentially a lower incidence of blown-out myotomy or BOM,” Khashab said.
Khashab also noted that a long myotomy on the gastric side “likely increases the risk of reflux disease, and therefore a limited myotomy on the gastric side likely also is advantageous.”
This research had no commercial funding. Yang serves as a consultant for Boston Scientific, Olympus, FujiFilm, Microtech, Medtronic, 3D-Matrix, and Neptune Medical, and has received research support from Microtech and 3D-Matrix. Khashab had no relevant disclosures.
A version of this article appeared on Medscape.com .
The American Gastroenterological Association (AGA) has released
“Any patient suspected to have achalasia, or difficulty swallowing for that matter, should undergo a comprehensive diagnostic workup, and that should include clinical history, review of medication, as well as tests. The diagnosis should not be based on isolated tests but on the clinical picture as a whole,” first author Dennis Yang, MD, AGAF, with the Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, noted in an AGA podcast about the update.
The clinical practice update, published in Gastroenterology, includes 12 “best practice advice” statements.
Since its introduction to clinical practice more than a decade ago, POEM has matured and gained widespread acceptance because of its efficacy and safety profile.
POEM has at least similar outcomes to laparoscopic Heller myotomy and pneumatic dilation for type I and type II achalasia with better results for those with type III achalasia, Yang noted.
“However, besides disease phenotype, we need to remember that choosing the right treatment for the patient is going to be based on multiple factors including patient characteristics as well as local expertise,” Yang added.
In terms of technical considerations, the update states that both anterior and posterior tunnel approaches demonstrate comparable success and postprocedure reflux rates. Tunnel orientation should be tailored to the patient’s surgical history and endoscopist’s preference.
It further states that optimal length of the myotomy in the esophagus and cardia, as it pertains to treatment efficacy and risk for postprocedure reflux, remains to be determined.
Adjunct techniques, including real-time intraprocedure functional luminal impedance planimetry, may be considered to tailor or confirm the adequacy of the myotomy.
Same-day discharge after POEM can be considered in select patients who meet discharge criteria. Patients with advanced age, significant comorbidities, poor social support, and/or access to specialized care should be considered for hospital admission, irrespective of symptoms.
The update notes that specific guidelines on the role and extent of antibiotic prophylaxis before and after POEM are lacking. A single dose of antibiotics at the time of POEM “may be sufficient” for antibiotic prophylaxis.
In terms of immediate post-POEM care, the update notes that the clinical impact of routine esophagram or endoscopy immediately post-POEM remains unclear. Testing can be considered based on local practice preferences and in cases in which intraprocedural events or postprocedural findings warrant further evaluation.
Proton pump inhibitors are recommended immediately following POEM, as gastroesophageal reflux disease (GERD) is common following POEM, occurring in up to 65% of cases.
Routine endoscopic surveillance is advised to monitor GERD, disease progression, and esophageal cancer risk, which is significantly higher in achalasia patients.
“Just like diabetes and hypertension, we need to remember that achalasia is a chronic disease and long-term postprocedural surveillance is strongly encouraged to monitor disease progression as well as potential complications of reflux,” Yang said.
He noted that surveillance should be considered irrespective of patient symptoms because many of these patients may remain asymptomatic.
“Primary gastroenterologists should have a very low threshold in referring the patient back to the POEM endoscopist or any specialized esophageal center because the ideology of symptoms in these patients can be quite difficult to tease out and often require comprehensive diagnostic workup,” Yang said.
Evidence for POEM in esophagogastric outflow obstruction and other nonachalasia spastic motility disorders is limited and should only be considered on a case-by-case basis after other less invasive approaches have been exhausted, the update states.
For perspective on the POEM clinical practice update, this news organization spoke with Mouen Khashab, MD, director of therapeutic endoscopy, Johns Hopkins University, Baltimore, Maryland.
“The document is very well written and comprehensive,” Khashab said.
However, Khashab said he would have liked to see greater emphasis on the value or role of a short myotomy in the esophagus and cardia.
“There is level I evidence that the short esophageal myotomy is equivalent to a long esophageal myotomy for type I and II achalasia. When you do a short myotomy, you save procedure time and there is potentially a lower incidence of blown-out myotomy or BOM,” Khashab said.
Khashab also noted that a long myotomy on the gastric side “likely increases the risk of reflux disease, and therefore a limited myotomy on the gastric side likely also is advantageous.”
This research had no commercial funding. Yang serves as a consultant for Boston Scientific, Olympus, FujiFilm, Microtech, Medtronic, 3D-Matrix, and Neptune Medical, and has received research support from Microtech and 3D-Matrix. Khashab had no relevant disclosures.
A version of this article appeared on Medscape.com .
FROM GASTROENTEROLOGY
New Risk Score Might Improve HCC Surveillance Among Cirrhosis Patients
, based to a recent phase 3 biomarker validation study.
The Prognostic Liver Secretome Signature with Alpha-Fetoprotein plus Age, Male Sex, Albumin-Bilirubin, and Platelets (PAaM) score integrates both molecular and clinical variables to effectively classify cirrhosis patients by their risk of developing HCC, potentially sparing low-risk patients from unnecessary surveillance, lead author Naoto Fujiwara, MD, PhD, of the University of Texas Southwestern Medical Center, Dallas, and colleagues reported.
“Hepatocellular carcinoma risk stratification is an urgent unmet need for cost-effective screening and early detection in patients with cirrhosis,” the investigators wrote in Gastroenterology. “This study represents the largest and first phase 3 biomarker validation study that establishes an integrative molecular/clinical score, PAaM, for HCC risk stratification.”
The PAaM score combines an 8-protein prognostic liver secretome signature with traditional clinical variables, including alpha-fetoprotein (AFP) levels, age, sex, albumin-bilirubin levels, and platelet counts. The score stratifies patients into high-, intermediate-, and low-risk categories.
The PAaM score was validated using 2 independent prospective cohorts in the United States: the statewide Texas Hepatocellular Carcinoma Consortium (THCCC) and the nationwide Hepatocellular Carcinoma Early Detection Strategy (HEDS). Across both cohorts, 3,484 patients with cirrhosis were followed over time to assess the development of HCC.
In the Texas cohort, comprising 2,156 patients with cirrhosis, PAaM classified 19% of patients as high risk, 42% as intermediate risk, and 39% as low risk. The annual incidence of HCC was significantly different across these groups, with high-risk patients experiencing a 5.3% incidence rate, versus 2.7% for intermediate-risk patients and 0.6% for low-risk patients (P less than .001). Compared with those in the low-risk group, high-risk patients had sub-distribution hazard ratio (sHR) of 7.51 for developing HCC, while intermediate-risk patients had an sHR of 4.20.
In the nationwide HEDS cohort, which included 1,328 patients, PAaM similarly stratified 15% of participants as high risk, 41% as intermediate risk, and 44% as low risk. Annual HCC incidence rates were 6.2%, 1.8%, and 0.8% for high-, intermediate-, and low-risk patients, respectively (P less than .001). Among these patients, sub-distribution hazard ratios for HCC were 6.54 for high-risk patients and 1.77 for intermediate-risk patients, again underscoring the tool’s potential to identify individuals at elevated risk of developing HCC.
The PAaM score outperformed existing models like the aMAP score and the PLSec-AFP molecular marker alone, with consistent superiority across a diverse range of cirrhosis etiologies, including metabolic dysfunction–associated steatotic liver disease (MASLD), alcohol-associated liver disease (ALD), and cured hepatitis C virus (HCV) infection.
Based on these findings, high-risk patients might benefit from more intensive screening strategies, Fujiwara and colleagues suggested, while intermediate-risk patients could continue with semi-annual ultrasound-based screening. Of note, low-risk patients—comprising about 40% of the study population—could potentially avoid frequent screenings, thus reducing healthcare costs and minimizing unnecessary interventions.
“This represents a significant step toward the clinical translation of an individual risk-based HCC screening strategy to improve early HCC detection and reduce HCC mortality,” the investigators concluded.This study was supported by various the National Cancer Institute, Veterans Affairs, the Japan Society for the Promotion of Science, and others. The investigators disclosed additional relationships with Boston Scientific, Sirtex, Bayer, and others.
Nancy S. Reau, MD, AGAF, of RUSH University in Chicago, highlighted both the promise and challenges of the PAaM score for HCC risk stratification, emphasizing that current liver cancer screening strategies remain inadequate, with only about 25% of patients receiving guideline-recommended surveillance.
“An easy-to-apply cost effective tool could significantly improve screening strategies, which should lead to earlier identification of liver cancer—at a time when curative treatment options are available,” Reau said.
PAaM, however, may be impractical for routine use.
“A tool that classifies people into 3 different screening strategies and requires longitudinal applications and re-classification could add complexity,” she explained, predicting that “clinicians aren’t going to use it correctly.
Reau was particularly concerned about the need for repeated assessments over time.
“People change,” she said. “A low-risk categorization by PAaM at the age of 40 may no longer be relevant at 50 or 60 as liver disease progresses.”
Although the tool is “exciting,” Reau suggested that it is also “premature” until appropriate reclassification intervals are understood.
She also noted that some patients still develop HCC despite being considered low risk, including cases of HCC that develop in non-cirrhotic HCV infection or MASLD.
Beyond the above clinical considerations, Dr. Reau pointed out several barriers to implementing PAaM in routine practice, starting with the under-recognition of cirrhosis. Even if patients are identified, ensuring both clinicians and patients adhere to screening recommendations remains a challenge.
Finally, financial considerations may pose obstacles.
“If some payers cover the tool and others do not, it will be very difficult to implement,” Dr. Reau concluded.
Reau reported no conflicts of interest.
Nancy S. Reau, MD, AGAF, of RUSH University in Chicago, highlighted both the promise and challenges of the PAaM score for HCC risk stratification, emphasizing that current liver cancer screening strategies remain inadequate, with only about 25% of patients receiving guideline-recommended surveillance.
“An easy-to-apply cost effective tool could significantly improve screening strategies, which should lead to earlier identification of liver cancer—at a time when curative treatment options are available,” Reau said.
PAaM, however, may be impractical for routine use.
“A tool that classifies people into 3 different screening strategies and requires longitudinal applications and re-classification could add complexity,” she explained, predicting that “clinicians aren’t going to use it correctly.
Reau was particularly concerned about the need for repeated assessments over time.
“People change,” she said. “A low-risk categorization by PAaM at the age of 40 may no longer be relevant at 50 or 60 as liver disease progresses.”
Although the tool is “exciting,” Reau suggested that it is also “premature” until appropriate reclassification intervals are understood.
She also noted that some patients still develop HCC despite being considered low risk, including cases of HCC that develop in non-cirrhotic HCV infection or MASLD.
Beyond the above clinical considerations, Dr. Reau pointed out several barriers to implementing PAaM in routine practice, starting with the under-recognition of cirrhosis. Even if patients are identified, ensuring both clinicians and patients adhere to screening recommendations remains a challenge.
Finally, financial considerations may pose obstacles.
“If some payers cover the tool and others do not, it will be very difficult to implement,” Dr. Reau concluded.
Reau reported no conflicts of interest.
Nancy S. Reau, MD, AGAF, of RUSH University in Chicago, highlighted both the promise and challenges of the PAaM score for HCC risk stratification, emphasizing that current liver cancer screening strategies remain inadequate, with only about 25% of patients receiving guideline-recommended surveillance.
“An easy-to-apply cost effective tool could significantly improve screening strategies, which should lead to earlier identification of liver cancer—at a time when curative treatment options are available,” Reau said.
PAaM, however, may be impractical for routine use.
“A tool that classifies people into 3 different screening strategies and requires longitudinal applications and re-classification could add complexity,” she explained, predicting that “clinicians aren’t going to use it correctly.
Reau was particularly concerned about the need for repeated assessments over time.
“People change,” she said. “A low-risk categorization by PAaM at the age of 40 may no longer be relevant at 50 or 60 as liver disease progresses.”
Although the tool is “exciting,” Reau suggested that it is also “premature” until appropriate reclassification intervals are understood.
She also noted that some patients still develop HCC despite being considered low risk, including cases of HCC that develop in non-cirrhotic HCV infection or MASLD.
Beyond the above clinical considerations, Dr. Reau pointed out several barriers to implementing PAaM in routine practice, starting with the under-recognition of cirrhosis. Even if patients are identified, ensuring both clinicians and patients adhere to screening recommendations remains a challenge.
Finally, financial considerations may pose obstacles.
“If some payers cover the tool and others do not, it will be very difficult to implement,” Dr. Reau concluded.
Reau reported no conflicts of interest.
, based to a recent phase 3 biomarker validation study.
The Prognostic Liver Secretome Signature with Alpha-Fetoprotein plus Age, Male Sex, Albumin-Bilirubin, and Platelets (PAaM) score integrates both molecular and clinical variables to effectively classify cirrhosis patients by their risk of developing HCC, potentially sparing low-risk patients from unnecessary surveillance, lead author Naoto Fujiwara, MD, PhD, of the University of Texas Southwestern Medical Center, Dallas, and colleagues reported.
“Hepatocellular carcinoma risk stratification is an urgent unmet need for cost-effective screening and early detection in patients with cirrhosis,” the investigators wrote in Gastroenterology. “This study represents the largest and first phase 3 biomarker validation study that establishes an integrative molecular/clinical score, PAaM, for HCC risk stratification.”
The PAaM score combines an 8-protein prognostic liver secretome signature with traditional clinical variables, including alpha-fetoprotein (AFP) levels, age, sex, albumin-bilirubin levels, and platelet counts. The score stratifies patients into high-, intermediate-, and low-risk categories.
The PAaM score was validated using 2 independent prospective cohorts in the United States: the statewide Texas Hepatocellular Carcinoma Consortium (THCCC) and the nationwide Hepatocellular Carcinoma Early Detection Strategy (HEDS). Across both cohorts, 3,484 patients with cirrhosis were followed over time to assess the development of HCC.
In the Texas cohort, comprising 2,156 patients with cirrhosis, PAaM classified 19% of patients as high risk, 42% as intermediate risk, and 39% as low risk. The annual incidence of HCC was significantly different across these groups, with high-risk patients experiencing a 5.3% incidence rate, versus 2.7% for intermediate-risk patients and 0.6% for low-risk patients (P less than .001). Compared with those in the low-risk group, high-risk patients had sub-distribution hazard ratio (sHR) of 7.51 for developing HCC, while intermediate-risk patients had an sHR of 4.20.
In the nationwide HEDS cohort, which included 1,328 patients, PAaM similarly stratified 15% of participants as high risk, 41% as intermediate risk, and 44% as low risk. Annual HCC incidence rates were 6.2%, 1.8%, and 0.8% for high-, intermediate-, and low-risk patients, respectively (P less than .001). Among these patients, sub-distribution hazard ratios for HCC were 6.54 for high-risk patients and 1.77 for intermediate-risk patients, again underscoring the tool’s potential to identify individuals at elevated risk of developing HCC.
The PAaM score outperformed existing models like the aMAP score and the PLSec-AFP molecular marker alone, with consistent superiority across a diverse range of cirrhosis etiologies, including metabolic dysfunction–associated steatotic liver disease (MASLD), alcohol-associated liver disease (ALD), and cured hepatitis C virus (HCV) infection.
Based on these findings, high-risk patients might benefit from more intensive screening strategies, Fujiwara and colleagues suggested, while intermediate-risk patients could continue with semi-annual ultrasound-based screening. Of note, low-risk patients—comprising about 40% of the study population—could potentially avoid frequent screenings, thus reducing healthcare costs and minimizing unnecessary interventions.
“This represents a significant step toward the clinical translation of an individual risk-based HCC screening strategy to improve early HCC detection and reduce HCC mortality,” the investigators concluded.This study was supported by various the National Cancer Institute, Veterans Affairs, the Japan Society for the Promotion of Science, and others. The investigators disclosed additional relationships with Boston Scientific, Sirtex, Bayer, and others.
, based to a recent phase 3 biomarker validation study.
The Prognostic Liver Secretome Signature with Alpha-Fetoprotein plus Age, Male Sex, Albumin-Bilirubin, and Platelets (PAaM) score integrates both molecular and clinical variables to effectively classify cirrhosis patients by their risk of developing HCC, potentially sparing low-risk patients from unnecessary surveillance, lead author Naoto Fujiwara, MD, PhD, of the University of Texas Southwestern Medical Center, Dallas, and colleagues reported.
“Hepatocellular carcinoma risk stratification is an urgent unmet need for cost-effective screening and early detection in patients with cirrhosis,” the investigators wrote in Gastroenterology. “This study represents the largest and first phase 3 biomarker validation study that establishes an integrative molecular/clinical score, PAaM, for HCC risk stratification.”
The PAaM score combines an 8-protein prognostic liver secretome signature with traditional clinical variables, including alpha-fetoprotein (AFP) levels, age, sex, albumin-bilirubin levels, and platelet counts. The score stratifies patients into high-, intermediate-, and low-risk categories.
The PAaM score was validated using 2 independent prospective cohorts in the United States: the statewide Texas Hepatocellular Carcinoma Consortium (THCCC) and the nationwide Hepatocellular Carcinoma Early Detection Strategy (HEDS). Across both cohorts, 3,484 patients with cirrhosis were followed over time to assess the development of HCC.
In the Texas cohort, comprising 2,156 patients with cirrhosis, PAaM classified 19% of patients as high risk, 42% as intermediate risk, and 39% as low risk. The annual incidence of HCC was significantly different across these groups, with high-risk patients experiencing a 5.3% incidence rate, versus 2.7% for intermediate-risk patients and 0.6% for low-risk patients (P less than .001). Compared with those in the low-risk group, high-risk patients had sub-distribution hazard ratio (sHR) of 7.51 for developing HCC, while intermediate-risk patients had an sHR of 4.20.
In the nationwide HEDS cohort, which included 1,328 patients, PAaM similarly stratified 15% of participants as high risk, 41% as intermediate risk, and 44% as low risk. Annual HCC incidence rates were 6.2%, 1.8%, and 0.8% for high-, intermediate-, and low-risk patients, respectively (P less than .001). Among these patients, sub-distribution hazard ratios for HCC were 6.54 for high-risk patients and 1.77 for intermediate-risk patients, again underscoring the tool’s potential to identify individuals at elevated risk of developing HCC.
The PAaM score outperformed existing models like the aMAP score and the PLSec-AFP molecular marker alone, with consistent superiority across a diverse range of cirrhosis etiologies, including metabolic dysfunction–associated steatotic liver disease (MASLD), alcohol-associated liver disease (ALD), and cured hepatitis C virus (HCV) infection.
Based on these findings, high-risk patients might benefit from more intensive screening strategies, Fujiwara and colleagues suggested, while intermediate-risk patients could continue with semi-annual ultrasound-based screening. Of note, low-risk patients—comprising about 40% of the study population—could potentially avoid frequent screenings, thus reducing healthcare costs and minimizing unnecessary interventions.
“This represents a significant step toward the clinical translation of an individual risk-based HCC screening strategy to improve early HCC detection and reduce HCC mortality,” the investigators concluded.This study was supported by various the National Cancer Institute, Veterans Affairs, the Japan Society for the Promotion of Science, and others. The investigators disclosed additional relationships with Boston Scientific, Sirtex, Bayer, and others.
FROM GASTROENTEROLOGY
Fecal Hemoglobin Levels From Negative FITs Signal CRC Risk
, according to a large international dose-response meta-analysis.
Although the association with neoplasia decreased as f-Hb levels rose, the findings support the development of risk-stratified screening strategies based on these concentrations, according to researchers led by Danica M.N. van den Berg, MSc, a PhD candidate and econometrics researcher in the Department of Public Health at Erasmus MC, University Medical Center in Rotterdam, the Netherlands.
Higher f-Hb concentrations in prior negative screening tests are strongly associated with an increased risk of detecting colorectal neoplasia in subsequent screenings, van den Berg said in an interview. “Gastroenterologists and other clinicians should consider the value of f-Hb concentrations in refining screening protocols and personalizing patient care to detect colorectal neoplasia earlier and more accurately.”
Published in Gastroenterology, the study was prompted by prior research showing individuals with f-Hb concentrations just below the positivity cutoff had an elevated CRC risk vs those with low or no f-Hb. “However, global variations in FIT positivity cutoffs and f-Hb category definitions complicated cross-study comparisons,” van den Berg said. Given the lack of an established dose-response relationship, the study aimed to clarify how f-Hb levels in previous screenings correlate with colorectal neoplasia detection. “Understanding this relationship is crucial for developing risk-stratified colorectal cancer screening strategies based on prior FIT results, which could improve the harm-benefit balance of screening,” she said.
According to van den Berg, f-Hb concentrations could help determine optimal CRC screening intervals by identifying higher-risk individuals who could benefit from more frequent testing, while those with lower concentrations could be screened less frequently.
Study Details
The systematic review and meta-analysis are the first to focus on the dose-response relationship between f-Hb levels in prior FIT screenings and colorectal neoplasia detection, van den Berg said. It included 13 ethnically diverse studies published during 2011-2023 with 4,493,223 individuals from Spain, France, the Netherlands, Taiwan, Denmark, Scotland, Ireland, Korea, Italy, and Norway. Most studies were cohort-based, and one was a randomized controlled trial.
All studies demonstrated a positive association between f-Hb in previous screenings and colorectal neoplasia detection. Almost all reported the f-Hb concentration measured in the prior screening round, while one study combined the f-Hb concentration of two previous screening rounds by using the cumulative f-Hb value. There was, however, wide variability in the stool positivity cut-offs in the included studies, ranging from 10 μg f-Hb/g to 80 μg f-Hb/g.
With an overall effect size of 0.69 (95% CI, 0.59-0.79), pooled analysis revealed that in the next screening round, individuals with f-Hb concentrations in stool of 5, 10, 20, and 40 μg/g had a threefold, fivefold, eightfold, and 13-fold higher risk for colorectal neoplasia, respectively, vs individuals showing 0 μg/g. Although there was significant study heterogeneity (I2 = 97.5%, P < .001), sensitivity analyses confirmed the consistency of findings. Interestingly, subgroup analyses indicated that f-Hb concentrations from a previous negative test were especially predictive of advanced neoplasia in subsequent screenings.
“This is a strategy worth pursuing and evaluating in the United States,” said gastroenterologist Theodore R. Levin, MD, a research scientist at Kaiser Permanente Division of Research in Northern California, commenting on the study but not involved in it. “However, there is no currently available FIT brand in the US that reports f-Hb concentration. All FITs in the US report as a qualitative positive-negative result.”
The Dutch investigation aligns with prior studies demonstrating a positive association between f-Hb concentrations in previous screenings and the detection of colorectal neoplasia. “Our working hypothesis was that risk increases in a decreasing manner as f-Hb concentrations rise, and the findings supported this hypothesis,” van den Berg said.
Other research has projected f-Hb level risk stratification to be effective and perhaps cost-effective in reducing delayed diagnosis of CRC.
Feasibility of Implementation
In large national screening programs in Europe, Asia, and Australia, as well as those of Kaiser Permanente and the Veterans Health Administration in the United States, information on f-Hb concentrations is already available.
“Therefore, incorporating an Hb-based approach should be relatively easy and affordable,” van den Berg said, and may help to optimize resource use while maintaining high detection rates. “However, the more critical question is whether such an approach would be acceptable to the target population.” To that end, randomized controlled trials in Italy and the Netherlands are offering tailored invitation intervals based on prior f-Hb concentrations and may provide insight into the real-world application of risk-stratified screening.
Among the many variables to be considered in the context of population-wide screening are cost-effectiveness, acceptability, and practicality, as well as invitation intervals, positivity cut-off levels, and start and stop ages for screening. “A key focus will be understanding the acceptability of risk-stratified colorectal cancer screening based on f-Hb among the target population and addressing any information needs they may have, as these are critical factors for successful implementation,” said van den Berg. Her group is currently studying the most effective and cost-effective risk-based strategy for CRC screening based on f-Hb levels.
The authors cautioned that since individuals with undetectable f-Hb levels make up the majority of those with negative FIT results, care must be taken that reducing screening frequency for this low-risk group does not lead to unfavorable outcomes at the population level.
This study was funded by the Dutch Organization for Scientific Research, which had no role in study design, data collection, analysis, interpretation, or writing.
The authors declared no competing interests. Levin disclosed no competing interests relevant to his comments.
A version of this article appeared on Medscape.com.
, according to a large international dose-response meta-analysis.
Although the association with neoplasia decreased as f-Hb levels rose, the findings support the development of risk-stratified screening strategies based on these concentrations, according to researchers led by Danica M.N. van den Berg, MSc, a PhD candidate and econometrics researcher in the Department of Public Health at Erasmus MC, University Medical Center in Rotterdam, the Netherlands.
Higher f-Hb concentrations in prior negative screening tests are strongly associated with an increased risk of detecting colorectal neoplasia in subsequent screenings, van den Berg said in an interview. “Gastroenterologists and other clinicians should consider the value of f-Hb concentrations in refining screening protocols and personalizing patient care to detect colorectal neoplasia earlier and more accurately.”
Published in Gastroenterology, the study was prompted by prior research showing individuals with f-Hb concentrations just below the positivity cutoff had an elevated CRC risk vs those with low or no f-Hb. “However, global variations in FIT positivity cutoffs and f-Hb category definitions complicated cross-study comparisons,” van den Berg said. Given the lack of an established dose-response relationship, the study aimed to clarify how f-Hb levels in previous screenings correlate with colorectal neoplasia detection. “Understanding this relationship is crucial for developing risk-stratified colorectal cancer screening strategies based on prior FIT results, which could improve the harm-benefit balance of screening,” she said.
According to van den Berg, f-Hb concentrations could help determine optimal CRC screening intervals by identifying higher-risk individuals who could benefit from more frequent testing, while those with lower concentrations could be screened less frequently.
Study Details
The systematic review and meta-analysis are the first to focus on the dose-response relationship between f-Hb levels in prior FIT screenings and colorectal neoplasia detection, van den Berg said. It included 13 ethnically diverse studies published during 2011-2023 with 4,493,223 individuals from Spain, France, the Netherlands, Taiwan, Denmark, Scotland, Ireland, Korea, Italy, and Norway. Most studies were cohort-based, and one was a randomized controlled trial.
All studies demonstrated a positive association between f-Hb in previous screenings and colorectal neoplasia detection. Almost all reported the f-Hb concentration measured in the prior screening round, while one study combined the f-Hb concentration of two previous screening rounds by using the cumulative f-Hb value. There was, however, wide variability in the stool positivity cut-offs in the included studies, ranging from 10 μg f-Hb/g to 80 μg f-Hb/g.
With an overall effect size of 0.69 (95% CI, 0.59-0.79), pooled analysis revealed that in the next screening round, individuals with f-Hb concentrations in stool of 5, 10, 20, and 40 μg/g had a threefold, fivefold, eightfold, and 13-fold higher risk for colorectal neoplasia, respectively, vs individuals showing 0 μg/g. Although there was significant study heterogeneity (I2 = 97.5%, P < .001), sensitivity analyses confirmed the consistency of findings. Interestingly, subgroup analyses indicated that f-Hb concentrations from a previous negative test were especially predictive of advanced neoplasia in subsequent screenings.
“This is a strategy worth pursuing and evaluating in the United States,” said gastroenterologist Theodore R. Levin, MD, a research scientist at Kaiser Permanente Division of Research in Northern California, commenting on the study but not involved in it. “However, there is no currently available FIT brand in the US that reports f-Hb concentration. All FITs in the US report as a qualitative positive-negative result.”
The Dutch investigation aligns with prior studies demonstrating a positive association between f-Hb concentrations in previous screenings and the detection of colorectal neoplasia. “Our working hypothesis was that risk increases in a decreasing manner as f-Hb concentrations rise, and the findings supported this hypothesis,” van den Berg said.
Other research has projected f-Hb level risk stratification to be effective and perhaps cost-effective in reducing delayed diagnosis of CRC.
Feasibility of Implementation
In large national screening programs in Europe, Asia, and Australia, as well as those of Kaiser Permanente and the Veterans Health Administration in the United States, information on f-Hb concentrations is already available.
“Therefore, incorporating an Hb-based approach should be relatively easy and affordable,” van den Berg said, and may help to optimize resource use while maintaining high detection rates. “However, the more critical question is whether such an approach would be acceptable to the target population.” To that end, randomized controlled trials in Italy and the Netherlands are offering tailored invitation intervals based on prior f-Hb concentrations and may provide insight into the real-world application of risk-stratified screening.
Among the many variables to be considered in the context of population-wide screening are cost-effectiveness, acceptability, and practicality, as well as invitation intervals, positivity cut-off levels, and start and stop ages for screening. “A key focus will be understanding the acceptability of risk-stratified colorectal cancer screening based on f-Hb among the target population and addressing any information needs they may have, as these are critical factors for successful implementation,” said van den Berg. Her group is currently studying the most effective and cost-effective risk-based strategy for CRC screening based on f-Hb levels.
The authors cautioned that since individuals with undetectable f-Hb levels make up the majority of those with negative FIT results, care must be taken that reducing screening frequency for this low-risk group does not lead to unfavorable outcomes at the population level.
This study was funded by the Dutch Organization for Scientific Research, which had no role in study design, data collection, analysis, interpretation, or writing.
The authors declared no competing interests. Levin disclosed no competing interests relevant to his comments.
A version of this article appeared on Medscape.com.
, according to a large international dose-response meta-analysis.
Although the association with neoplasia decreased as f-Hb levels rose, the findings support the development of risk-stratified screening strategies based on these concentrations, according to researchers led by Danica M.N. van den Berg, MSc, a PhD candidate and econometrics researcher in the Department of Public Health at Erasmus MC, University Medical Center in Rotterdam, the Netherlands.
Higher f-Hb concentrations in prior negative screening tests are strongly associated with an increased risk of detecting colorectal neoplasia in subsequent screenings, van den Berg said in an interview. “Gastroenterologists and other clinicians should consider the value of f-Hb concentrations in refining screening protocols and personalizing patient care to detect colorectal neoplasia earlier and more accurately.”
Published in Gastroenterology, the study was prompted by prior research showing individuals with f-Hb concentrations just below the positivity cutoff had an elevated CRC risk vs those with low or no f-Hb. “However, global variations in FIT positivity cutoffs and f-Hb category definitions complicated cross-study comparisons,” van den Berg said. Given the lack of an established dose-response relationship, the study aimed to clarify how f-Hb levels in previous screenings correlate with colorectal neoplasia detection. “Understanding this relationship is crucial for developing risk-stratified colorectal cancer screening strategies based on prior FIT results, which could improve the harm-benefit balance of screening,” she said.
According to van den Berg, f-Hb concentrations could help determine optimal CRC screening intervals by identifying higher-risk individuals who could benefit from more frequent testing, while those with lower concentrations could be screened less frequently.
Study Details
The systematic review and meta-analysis are the first to focus on the dose-response relationship between f-Hb levels in prior FIT screenings and colorectal neoplasia detection, van den Berg said. It included 13 ethnically diverse studies published during 2011-2023 with 4,493,223 individuals from Spain, France, the Netherlands, Taiwan, Denmark, Scotland, Ireland, Korea, Italy, and Norway. Most studies were cohort-based, and one was a randomized controlled trial.
All studies demonstrated a positive association between f-Hb in previous screenings and colorectal neoplasia detection. Almost all reported the f-Hb concentration measured in the prior screening round, while one study combined the f-Hb concentration of two previous screening rounds by using the cumulative f-Hb value. There was, however, wide variability in the stool positivity cut-offs in the included studies, ranging from 10 μg f-Hb/g to 80 μg f-Hb/g.
With an overall effect size of 0.69 (95% CI, 0.59-0.79), pooled analysis revealed that in the next screening round, individuals with f-Hb concentrations in stool of 5, 10, 20, and 40 μg/g had a threefold, fivefold, eightfold, and 13-fold higher risk for colorectal neoplasia, respectively, vs individuals showing 0 μg/g. Although there was significant study heterogeneity (I2 = 97.5%, P < .001), sensitivity analyses confirmed the consistency of findings. Interestingly, subgroup analyses indicated that f-Hb concentrations from a previous negative test were especially predictive of advanced neoplasia in subsequent screenings.
“This is a strategy worth pursuing and evaluating in the United States,” said gastroenterologist Theodore R. Levin, MD, a research scientist at Kaiser Permanente Division of Research in Northern California, commenting on the study but not involved in it. “However, there is no currently available FIT brand in the US that reports f-Hb concentration. All FITs in the US report as a qualitative positive-negative result.”
The Dutch investigation aligns with prior studies demonstrating a positive association between f-Hb concentrations in previous screenings and the detection of colorectal neoplasia. “Our working hypothesis was that risk increases in a decreasing manner as f-Hb concentrations rise, and the findings supported this hypothesis,” van den Berg said.
Other research has projected f-Hb level risk stratification to be effective and perhaps cost-effective in reducing delayed diagnosis of CRC.
Feasibility of Implementation
In large national screening programs in Europe, Asia, and Australia, as well as those of Kaiser Permanente and the Veterans Health Administration in the United States, information on f-Hb concentrations is already available.
“Therefore, incorporating an Hb-based approach should be relatively easy and affordable,” van den Berg said, and may help to optimize resource use while maintaining high detection rates. “However, the more critical question is whether such an approach would be acceptable to the target population.” To that end, randomized controlled trials in Italy and the Netherlands are offering tailored invitation intervals based on prior f-Hb concentrations and may provide insight into the real-world application of risk-stratified screening.
Among the many variables to be considered in the context of population-wide screening are cost-effectiveness, acceptability, and practicality, as well as invitation intervals, positivity cut-off levels, and start and stop ages for screening. “A key focus will be understanding the acceptability of risk-stratified colorectal cancer screening based on f-Hb among the target population and addressing any information needs they may have, as these are critical factors for successful implementation,” said van den Berg. Her group is currently studying the most effective and cost-effective risk-based strategy for CRC screening based on f-Hb levels.
The authors cautioned that since individuals with undetectable f-Hb levels make up the majority of those with negative FIT results, care must be taken that reducing screening frequency for this low-risk group does not lead to unfavorable outcomes at the population level.
This study was funded by the Dutch Organization for Scientific Research, which had no role in study design, data collection, analysis, interpretation, or writing.
The authors declared no competing interests. Levin disclosed no competing interests relevant to his comments.
A version of this article appeared on Medscape.com.
FROM GASTROENTEROLOGY
Random Biopsy Improves IBD Dysplasia Detection, With Caveats
according to a recent review and meta-analysis.
Random biopsies collected in studies after 2011 provided limited additional yield, suggesting that high-definition equipment alone may be sufficient to achieve a high detection rate, lead author Li Gao, MD, of Air Force Medical University, Xi’an, China, and colleagues reported. In contrast, patients with primary sclerosing cholangitis (PSC) consistently benefited from random biopsy, offering clearer support for use in this subgroup.
“Random biopsy has been proposed as a strategy that may detect dysplastic lesions that cannot be identified endoscopically, thus minimizing the occurrence of missed colitis-associated dysplasia during colonoscopy,” the investigators wrote in Clinical Gastroenterology and Hepatology. However, the role of random biopsies in colonoscopic surveillance for patients with IBD remains a topic of ongoing debate.”
The SCENIC guidelines remain inconclusive on the role of random biopsy in IBD surveillance, the investigators noted, while other guidelines recommend random biopsy with high-definition white light endoscopy, but not chromoendoscopy.
The present meta-analysis aimed to characterize the impact of random biopsy on dysplasia detection. The investigators aggregated prospective and retrospective studies published in English through September 2023, all of which compared random biopsy with other surveillance techniques and reported the proportion of dysplasia detected exclusively through random biopsy.
“To the best of our knowledge, this systematic review and meta-analysis was the first comprehensive summary of the additional yield of random biopsy during colorectal cancer surveillance in patients with IBD,” Dr. Gao and colleagues noted.
The final dataset comprised 37 studies with 9,051 patients undergoing colorectal cancer surveillance for IBD. Patients had diverse baseline characteristics, including different proportions of ulcerative colitis and Crohn’s disease, as well as varying prevalence of PSC, a known risk factor for colorectal neoplasia.
The pooled additional yield of random biopsy was 10.34% in per-patient analysis and 16.20% in per-lesion analysis, meaning that approximately 1 in 10 patients and 1 in 6 lesions were detected exclusively through random biopsy. Despite these benefits, detection rates were relatively low: 1.31% per patient and 2.82% per lesion.
Subgroup analyses showed a decline in random biopsy additional yield over time. Studies conducted before 2011 reported an additional yield of 14.43% in per-patient analysis, compared to just 0.42% in studies conducted after 2011. This decline coincided with the widespread adoption of high-definition endoscopy.
PSC status strongly influenced detection rates throughout the study period. In patients without PSC (0%-10% PSC prevalence), the additional yield of random biopsy was 4.83% in per-patient analysis and 11.23% in per-lesion analysis. In studies where all patients had PSC, the additional yield increased dramatically to 56.05% and 45.22%, respectively.
“These findings highlight the incremental benefits of random biopsy and provide valuable insights into the management of endoscopic surveillance in patients with IBD,” the investigators wrote. “Considering the decreased additional yields in studies initiated after 2011, and the influence of PSC, endoscopy centers lacking full high-definition equipment should consider incorporating random biopsy in the standard colonoscopy surveillance for IBD patients, especially in those with PSC.”This study was supported by the National Key R&D Program of China, the Key Research and Development Program of Shaanxi Province, and the Nanchang High-Level Scientific and Technological Innovation Talents “Double Hundred Plan” project. The investigators disclosed no conflicts of interest.
Patients with inflammatory bowel diseases (IBD) with colonic involvement are at two- to threefold increased risk of colorectal cancer (CRC), compared with the general population. The development and progression of dysplasia in these patients with IBD does not follow the typical adenoma-carcinoma sequence; rather, patients with IBD at increased risk of colorectal cancer may have field cancerization changes. Historically, these mucosal changes have been difficult to visualize endoscopically, at least with standard definition endoscopes. As a result, systematic, four-quadrant, random biopsies — 8 in each segment of the colon, totaling to 32 biopsies — are recommended for dysplasia detection. The practice has been adopted and accepted widely. Over time, there have been significant advancements in the management of IBD, with improved colonoscopic resolution, adjunct surveillance techniques, focus on quality of colonoscopic exams and evolution of treatments and treatment targets, and these have resulted in a reduction in the risk of CRC in patients with IBD. The value of random biopsies for dysplasia surveillance in patients with colonic IBD has been questioned.
In this context, the systematic review and meta-analysis from Gao and colleagues provides critical insights into the yield of random biopsies for dysplasia surveillance in patients with IBD. Through a detailed analysis of 37 studies published between 2003 to 2023, with 9051 patients who underwent dysplasia surveillance with random biopsies, they ascertained the incremental yield of random biopsies. Overall, 1.3% of patients who underwent random biopsies were detected to have dysplasia. Of these, 1 in 10 patients were detected to have dysplasia only on random biopsies. On per-lesion analysis, one in six dysplastic lesions were only detected on random biopsies. Interestingly, this yield of random biopsies varied markedly depending on the era, as a surrogate for quality of colonoscopies. In studies that fully enrolled and published before 2011 (majority of patients recruited in the 1990s to early 2000s), the per-patient incremental yield of random biopsies was 14%; this dropped precipitously to 0.4% in studies published after 2011 (majority of patients recruited in late 2000s to 2010s). The incremental yield of random biopsies remained markedly high in studies with a high proportion of patients with primary sclerosing cholangitis (PSC), a condition consistently associated with a four- to sixfold higher risk of CRC in patients with IBD.
These findings lend support to the notion that improvements in endoscopy equipment with wide adoption of high-definition white-light colonoscopes and an emphasis on quality of endoscopic examination may be leading to better endoscopic detection of previously “invisible” dysplastic lesions, leading to a markedly lower incremental yield of random biopsies in the current era. This questions the utility of routinely collecting 32 random biopsies during a surveillance exam for a patient with IBD at increased risk of CRC (as long as a thorough high-quality exam is being performed), though there may be subpopulations such as patients with PSC where there may be benefit. Large ongoing trials comparing the yield of targeted biopsies vs random and targeted biopsies in patients with IBD undergoing dysplasia surveillance with high-definition colonoscopes will help to definitively address this question.
Siddharth Singh, MD, MS, is associate professor of medicine and director of the UCSD IBD Center in the division of gastroenterology, University of California, San Diego. He declares no conflicts of interest relative to this article.
Patients with inflammatory bowel diseases (IBD) with colonic involvement are at two- to threefold increased risk of colorectal cancer (CRC), compared with the general population. The development and progression of dysplasia in these patients with IBD does not follow the typical adenoma-carcinoma sequence; rather, patients with IBD at increased risk of colorectal cancer may have field cancerization changes. Historically, these mucosal changes have been difficult to visualize endoscopically, at least with standard definition endoscopes. As a result, systematic, four-quadrant, random biopsies — 8 in each segment of the colon, totaling to 32 biopsies — are recommended for dysplasia detection. The practice has been adopted and accepted widely. Over time, there have been significant advancements in the management of IBD, with improved colonoscopic resolution, adjunct surveillance techniques, focus on quality of colonoscopic exams and evolution of treatments and treatment targets, and these have resulted in a reduction in the risk of CRC in patients with IBD. The value of random biopsies for dysplasia surveillance in patients with colonic IBD has been questioned.
In this context, the systematic review and meta-analysis from Gao and colleagues provides critical insights into the yield of random biopsies for dysplasia surveillance in patients with IBD. Through a detailed analysis of 37 studies published between 2003 to 2023, with 9051 patients who underwent dysplasia surveillance with random biopsies, they ascertained the incremental yield of random biopsies. Overall, 1.3% of patients who underwent random biopsies were detected to have dysplasia. Of these, 1 in 10 patients were detected to have dysplasia only on random biopsies. On per-lesion analysis, one in six dysplastic lesions were only detected on random biopsies. Interestingly, this yield of random biopsies varied markedly depending on the era, as a surrogate for quality of colonoscopies. In studies that fully enrolled and published before 2011 (majority of patients recruited in the 1990s to early 2000s), the per-patient incremental yield of random biopsies was 14%; this dropped precipitously to 0.4% in studies published after 2011 (majority of patients recruited in late 2000s to 2010s). The incremental yield of random biopsies remained markedly high in studies with a high proportion of patients with primary sclerosing cholangitis (PSC), a condition consistently associated with a four- to sixfold higher risk of CRC in patients with IBD.
These findings lend support to the notion that improvements in endoscopy equipment with wide adoption of high-definition white-light colonoscopes and an emphasis on quality of endoscopic examination may be leading to better endoscopic detection of previously “invisible” dysplastic lesions, leading to a markedly lower incremental yield of random biopsies in the current era. This questions the utility of routinely collecting 32 random biopsies during a surveillance exam for a patient with IBD at increased risk of CRC (as long as a thorough high-quality exam is being performed), though there may be subpopulations such as patients with PSC where there may be benefit. Large ongoing trials comparing the yield of targeted biopsies vs random and targeted biopsies in patients with IBD undergoing dysplasia surveillance with high-definition colonoscopes will help to definitively address this question.
Siddharth Singh, MD, MS, is associate professor of medicine and director of the UCSD IBD Center in the division of gastroenterology, University of California, San Diego. He declares no conflicts of interest relative to this article.
Patients with inflammatory bowel diseases (IBD) with colonic involvement are at two- to threefold increased risk of colorectal cancer (CRC), compared with the general population. The development and progression of dysplasia in these patients with IBD does not follow the typical adenoma-carcinoma sequence; rather, patients with IBD at increased risk of colorectal cancer may have field cancerization changes. Historically, these mucosal changes have been difficult to visualize endoscopically, at least with standard definition endoscopes. As a result, systematic, four-quadrant, random biopsies — 8 in each segment of the colon, totaling to 32 biopsies — are recommended for dysplasia detection. The practice has been adopted and accepted widely. Over time, there have been significant advancements in the management of IBD, with improved colonoscopic resolution, adjunct surveillance techniques, focus on quality of colonoscopic exams and evolution of treatments and treatment targets, and these have resulted in a reduction in the risk of CRC in patients with IBD. The value of random biopsies for dysplasia surveillance in patients with colonic IBD has been questioned.
In this context, the systematic review and meta-analysis from Gao and colleagues provides critical insights into the yield of random biopsies for dysplasia surveillance in patients with IBD. Through a detailed analysis of 37 studies published between 2003 to 2023, with 9051 patients who underwent dysplasia surveillance with random biopsies, they ascertained the incremental yield of random biopsies. Overall, 1.3% of patients who underwent random biopsies were detected to have dysplasia. Of these, 1 in 10 patients were detected to have dysplasia only on random biopsies. On per-lesion analysis, one in six dysplastic lesions were only detected on random biopsies. Interestingly, this yield of random biopsies varied markedly depending on the era, as a surrogate for quality of colonoscopies. In studies that fully enrolled and published before 2011 (majority of patients recruited in the 1990s to early 2000s), the per-patient incremental yield of random biopsies was 14%; this dropped precipitously to 0.4% in studies published after 2011 (majority of patients recruited in late 2000s to 2010s). The incremental yield of random biopsies remained markedly high in studies with a high proportion of patients with primary sclerosing cholangitis (PSC), a condition consistently associated with a four- to sixfold higher risk of CRC in patients with IBD.
These findings lend support to the notion that improvements in endoscopy equipment with wide adoption of high-definition white-light colonoscopes and an emphasis on quality of endoscopic examination may be leading to better endoscopic detection of previously “invisible” dysplastic lesions, leading to a markedly lower incremental yield of random biopsies in the current era. This questions the utility of routinely collecting 32 random biopsies during a surveillance exam for a patient with IBD at increased risk of CRC (as long as a thorough high-quality exam is being performed), though there may be subpopulations such as patients with PSC where there may be benefit. Large ongoing trials comparing the yield of targeted biopsies vs random and targeted biopsies in patients with IBD undergoing dysplasia surveillance with high-definition colonoscopes will help to definitively address this question.
Siddharth Singh, MD, MS, is associate professor of medicine and director of the UCSD IBD Center in the division of gastroenterology, University of California, San Diego. He declares no conflicts of interest relative to this article.
according to a recent review and meta-analysis.
Random biopsies collected in studies after 2011 provided limited additional yield, suggesting that high-definition equipment alone may be sufficient to achieve a high detection rate, lead author Li Gao, MD, of Air Force Medical University, Xi’an, China, and colleagues reported. In contrast, patients with primary sclerosing cholangitis (PSC) consistently benefited from random biopsy, offering clearer support for use in this subgroup.
“Random biopsy has been proposed as a strategy that may detect dysplastic lesions that cannot be identified endoscopically, thus minimizing the occurrence of missed colitis-associated dysplasia during colonoscopy,” the investigators wrote in Clinical Gastroenterology and Hepatology. However, the role of random biopsies in colonoscopic surveillance for patients with IBD remains a topic of ongoing debate.”
The SCENIC guidelines remain inconclusive on the role of random biopsy in IBD surveillance, the investigators noted, while other guidelines recommend random biopsy with high-definition white light endoscopy, but not chromoendoscopy.
The present meta-analysis aimed to characterize the impact of random biopsy on dysplasia detection. The investigators aggregated prospective and retrospective studies published in English through September 2023, all of which compared random biopsy with other surveillance techniques and reported the proportion of dysplasia detected exclusively through random biopsy.
“To the best of our knowledge, this systematic review and meta-analysis was the first comprehensive summary of the additional yield of random biopsy during colorectal cancer surveillance in patients with IBD,” Dr. Gao and colleagues noted.
The final dataset comprised 37 studies with 9,051 patients undergoing colorectal cancer surveillance for IBD. Patients had diverse baseline characteristics, including different proportions of ulcerative colitis and Crohn’s disease, as well as varying prevalence of PSC, a known risk factor for colorectal neoplasia.
The pooled additional yield of random biopsy was 10.34% in per-patient analysis and 16.20% in per-lesion analysis, meaning that approximately 1 in 10 patients and 1 in 6 lesions were detected exclusively through random biopsy. Despite these benefits, detection rates were relatively low: 1.31% per patient and 2.82% per lesion.
Subgroup analyses showed a decline in random biopsy additional yield over time. Studies conducted before 2011 reported an additional yield of 14.43% in per-patient analysis, compared to just 0.42% in studies conducted after 2011. This decline coincided with the widespread adoption of high-definition endoscopy.
PSC status strongly influenced detection rates throughout the study period. In patients without PSC (0%-10% PSC prevalence), the additional yield of random biopsy was 4.83% in per-patient analysis and 11.23% in per-lesion analysis. In studies where all patients had PSC, the additional yield increased dramatically to 56.05% and 45.22%, respectively.
“These findings highlight the incremental benefits of random biopsy and provide valuable insights into the management of endoscopic surveillance in patients with IBD,” the investigators wrote. “Considering the decreased additional yields in studies initiated after 2011, and the influence of PSC, endoscopy centers lacking full high-definition equipment should consider incorporating random biopsy in the standard colonoscopy surveillance for IBD patients, especially in those with PSC.”This study was supported by the National Key R&D Program of China, the Key Research and Development Program of Shaanxi Province, and the Nanchang High-Level Scientific and Technological Innovation Talents “Double Hundred Plan” project. The investigators disclosed no conflicts of interest.
according to a recent review and meta-analysis.
Random biopsies collected in studies after 2011 provided limited additional yield, suggesting that high-definition equipment alone may be sufficient to achieve a high detection rate, lead author Li Gao, MD, of Air Force Medical University, Xi’an, China, and colleagues reported. In contrast, patients with primary sclerosing cholangitis (PSC) consistently benefited from random biopsy, offering clearer support for use in this subgroup.
“Random biopsy has been proposed as a strategy that may detect dysplastic lesions that cannot be identified endoscopically, thus minimizing the occurrence of missed colitis-associated dysplasia during colonoscopy,” the investigators wrote in Clinical Gastroenterology and Hepatology. However, the role of random biopsies in colonoscopic surveillance for patients with IBD remains a topic of ongoing debate.”
The SCENIC guidelines remain inconclusive on the role of random biopsy in IBD surveillance, the investigators noted, while other guidelines recommend random biopsy with high-definition white light endoscopy, but not chromoendoscopy.
The present meta-analysis aimed to characterize the impact of random biopsy on dysplasia detection. The investigators aggregated prospective and retrospective studies published in English through September 2023, all of which compared random biopsy with other surveillance techniques and reported the proportion of dysplasia detected exclusively through random biopsy.
“To the best of our knowledge, this systematic review and meta-analysis was the first comprehensive summary of the additional yield of random biopsy during colorectal cancer surveillance in patients with IBD,” Dr. Gao and colleagues noted.
The final dataset comprised 37 studies with 9,051 patients undergoing colorectal cancer surveillance for IBD. Patients had diverse baseline characteristics, including different proportions of ulcerative colitis and Crohn’s disease, as well as varying prevalence of PSC, a known risk factor for colorectal neoplasia.
The pooled additional yield of random biopsy was 10.34% in per-patient analysis and 16.20% in per-lesion analysis, meaning that approximately 1 in 10 patients and 1 in 6 lesions were detected exclusively through random biopsy. Despite these benefits, detection rates were relatively low: 1.31% per patient and 2.82% per lesion.
Subgroup analyses showed a decline in random biopsy additional yield over time. Studies conducted before 2011 reported an additional yield of 14.43% in per-patient analysis, compared to just 0.42% in studies conducted after 2011. This decline coincided with the widespread adoption of high-definition endoscopy.
PSC status strongly influenced detection rates throughout the study period. In patients without PSC (0%-10% PSC prevalence), the additional yield of random biopsy was 4.83% in per-patient analysis and 11.23% in per-lesion analysis. In studies where all patients had PSC, the additional yield increased dramatically to 56.05% and 45.22%, respectively.
“These findings highlight the incremental benefits of random biopsy and provide valuable insights into the management of endoscopic surveillance in patients with IBD,” the investigators wrote. “Considering the decreased additional yields in studies initiated after 2011, and the influence of PSC, endoscopy centers lacking full high-definition equipment should consider incorporating random biopsy in the standard colonoscopy surveillance for IBD patients, especially in those with PSC.”This study was supported by the National Key R&D Program of China, the Key Research and Development Program of Shaanxi Province, and the Nanchang High-Level Scientific and Technological Innovation Talents “Double Hundred Plan” project. The investigators disclosed no conflicts of interest.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Suboptimal Diets Tied to Global Doubling of GI Cancer Cases
according to a recent study.
Writing in Gastroenterology, researchers led by Li Liu, PhD, of the department of epidemiology and biostatistics, Ministry of Education Key Lab of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology in Wuhan, China, reported that excessive consumption of processed meats (the biggest culprit), insufficient fruit intake, and insufficient whole grain intake were the leading dietary risk factors. In addition, the number of diet-related cases doubled from 1990 to 2018.
“In regions with limited access to healthy foods, policy interventions like taxing unhealthy foods and subsidizing nutritious options may help shift dietary patterns and reduce cancer risk,” Liu said in an interview.
The study examined meta-analyses from 184 countries in seven regions for the period 1990-2018 looking at rates of six major GI cancers: colorectal, liver, esophageal, pancreatic, and gallbladder/biliary tract. Among these, the age-standardized incidence of liver, pancreatic, and colorectal increased significantly over the past 3 decades.
The research team used a comparative risk assessment model to estimate the impact of diet on GI cancer independent of energy intake and adiposity. Although the principal dietary risk factors varied across individual cancers, suboptimal intake of the three aforementioned components was responsible for 66.51% of all diet-attributable GI cancers in 2018. The global mean processed meat consumption was 17 g/d in 2018, falling to a low in South Asia of 3 g/d.
The investigators also found diet-linked cancer incidence positively correlated with the Sociodemographic Index (SDI), an integrated measure of national development, income, and fertility. Incidence varied across world regions, with the highest proportion of cases in Central and Eastern Europe, Central Asia, Latin America, the Caribbean, and in high-income countries. The findings support the development of targeted diet-related public health interventions in various regions and nations to reduce GI cancer incidence, the authors wrote.
Among the study’s specific findings:
- In 2018, 21.5% (95% uncertainty interval [UI], 19.1-24.5) of incident GI cancer cases globally were attributable to suboptimal diets, a relatively stable proportion since 1990 (22.4%; 95% UI, 19.7-25.6).
- Absolute diet-attributable cases doubled from 580,862 (95% UI, 510,658-664,076) in 1990 to 1,039,877 (95% UI, 923,482-1,187,244) in 2018.
- Excessive processed meat consumption (5.9%; 95% UI, 4.2%-7.9%), insufficient fruit intake (4.8%; 95% UI, 3.8%-5.9%), and insufficient whole grain intake (3.6%; 95% UI, 2.8%-5.1%) were the most significant dietary risk factors in 2018 — a shift from 1990 when the third major concern was insufficient non-starchy vegetable intake.
Given the well-established link between diet and GI cancers, the incidence findings came as no surprise. “However, the dramatic doubling of diet-attributable cases over the past few decades was truly unexpected,” Liu said. “This increase can likely be attributed to global population growth and aging. While aging is an irreversible process, we can still reduce the growing burden of diet-related GI cancers by focusing on modifiable behaviors, particularly through targeted dietary interventions.”
A Modifiable Risk Factor
Commenting on the analysis but not involved in it, Andrew T. Chan, MD, MPH, a professor of medicine at Harvard Medical School and a gastroenterologist at Massachusetts General Hospital, both in Boston, noted that his own group’s studies also support the association of diet with an increased risk for GI cancers, particularly colorectal cancers.
“Although much work needs to be done to clarify the precise mechanisms underlying this association, there are substantial data that diet may cause changes in the gut microbiome, which in turn promotes cancer,” Chan said in an interview. “Going forward, we are working to develop strategies in which diet is modified to mitigate the risk of cancer associated with suboptimal diets.”
In other study findings, Liu’s group observed that two regional groups, Central and Eastern Europe, Central Asia, Latin America, and the Caribbean, as well as high-income countries, bore the top three diet-attributable burdens worldwide in 2018, all driven mostly by an upward-trending excess of processed meat.
By regions, Central and Eastern Europe and Central Asia experienced the highest attributable burden across regions in 1990 (31.6%; UI, 27.0%-37.4%) and 2018 (31.6%; UI, 27.3%-36.5%).
As for the impact of the SDI, the authors explained that diet-attributable GI cancer burden was higher among adults with higher education and living in urban areas than among those with lower education and rural residency. “Some dietary habits tended to be worse in higher-SDI countries, specifically, higher consumption of processed meats,” they wrote.
Although the proportional attributable GI incidence remains relatively stable, they added, the doubling of absolute cases from 1990 to 2018, along with the discrepancies between urbanicity and countries/regions, supports more targeted preventive measures.
And while the diet-GI cancer connection is clear, they agreed with Chan in that “the precise pathogenesis from suboptimal diets to these cancers remains unclear and requires further basic studies to clarify the mechanism.”
In the meantime, the findings “underscore the urgent need for proactive public health interventions. Diet, as a modifiable risk factor, still offers substantial potential for improvement,” Liu said.
This study was funded by the National Natural Science Foundation of China and the American Cancer Society. The authors and Chan disclosed no relevant conflicts of interest.
A version of this article appeared on Medscape.com.
according to a recent study.
Writing in Gastroenterology, researchers led by Li Liu, PhD, of the department of epidemiology and biostatistics, Ministry of Education Key Lab of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology in Wuhan, China, reported that excessive consumption of processed meats (the biggest culprit), insufficient fruit intake, and insufficient whole grain intake were the leading dietary risk factors. In addition, the number of diet-related cases doubled from 1990 to 2018.
“In regions with limited access to healthy foods, policy interventions like taxing unhealthy foods and subsidizing nutritious options may help shift dietary patterns and reduce cancer risk,” Liu said in an interview.
The study examined meta-analyses from 184 countries in seven regions for the period 1990-2018 looking at rates of six major GI cancers: colorectal, liver, esophageal, pancreatic, and gallbladder/biliary tract. Among these, the age-standardized incidence of liver, pancreatic, and colorectal increased significantly over the past 3 decades.
The research team used a comparative risk assessment model to estimate the impact of diet on GI cancer independent of energy intake and adiposity. Although the principal dietary risk factors varied across individual cancers, suboptimal intake of the three aforementioned components was responsible for 66.51% of all diet-attributable GI cancers in 2018. The global mean processed meat consumption was 17 g/d in 2018, falling to a low in South Asia of 3 g/d.
The investigators also found diet-linked cancer incidence positively correlated with the Sociodemographic Index (SDI), an integrated measure of national development, income, and fertility. Incidence varied across world regions, with the highest proportion of cases in Central and Eastern Europe, Central Asia, Latin America, the Caribbean, and in high-income countries. The findings support the development of targeted diet-related public health interventions in various regions and nations to reduce GI cancer incidence, the authors wrote.
Among the study’s specific findings:
- In 2018, 21.5% (95% uncertainty interval [UI], 19.1-24.5) of incident GI cancer cases globally were attributable to suboptimal diets, a relatively stable proportion since 1990 (22.4%; 95% UI, 19.7-25.6).
- Absolute diet-attributable cases doubled from 580,862 (95% UI, 510,658-664,076) in 1990 to 1,039,877 (95% UI, 923,482-1,187,244) in 2018.
- Excessive processed meat consumption (5.9%; 95% UI, 4.2%-7.9%), insufficient fruit intake (4.8%; 95% UI, 3.8%-5.9%), and insufficient whole grain intake (3.6%; 95% UI, 2.8%-5.1%) were the most significant dietary risk factors in 2018 — a shift from 1990 when the third major concern was insufficient non-starchy vegetable intake.
Given the well-established link between diet and GI cancers, the incidence findings came as no surprise. “However, the dramatic doubling of diet-attributable cases over the past few decades was truly unexpected,” Liu said. “This increase can likely be attributed to global population growth and aging. While aging is an irreversible process, we can still reduce the growing burden of diet-related GI cancers by focusing on modifiable behaviors, particularly through targeted dietary interventions.”
A Modifiable Risk Factor
Commenting on the analysis but not involved in it, Andrew T. Chan, MD, MPH, a professor of medicine at Harvard Medical School and a gastroenterologist at Massachusetts General Hospital, both in Boston, noted that his own group’s studies also support the association of diet with an increased risk for GI cancers, particularly colorectal cancers.
“Although much work needs to be done to clarify the precise mechanisms underlying this association, there are substantial data that diet may cause changes in the gut microbiome, which in turn promotes cancer,” Chan said in an interview. “Going forward, we are working to develop strategies in which diet is modified to mitigate the risk of cancer associated with suboptimal diets.”
In other study findings, Liu’s group observed that two regional groups, Central and Eastern Europe, Central Asia, Latin America, and the Caribbean, as well as high-income countries, bore the top three diet-attributable burdens worldwide in 2018, all driven mostly by an upward-trending excess of processed meat.
By regions, Central and Eastern Europe and Central Asia experienced the highest attributable burden across regions in 1990 (31.6%; UI, 27.0%-37.4%) and 2018 (31.6%; UI, 27.3%-36.5%).
As for the impact of the SDI, the authors explained that diet-attributable GI cancer burden was higher among adults with higher education and living in urban areas than among those with lower education and rural residency. “Some dietary habits tended to be worse in higher-SDI countries, specifically, higher consumption of processed meats,” they wrote.
Although the proportional attributable GI incidence remains relatively stable, they added, the doubling of absolute cases from 1990 to 2018, along with the discrepancies between urbanicity and countries/regions, supports more targeted preventive measures.
And while the diet-GI cancer connection is clear, they agreed with Chan in that “the precise pathogenesis from suboptimal diets to these cancers remains unclear and requires further basic studies to clarify the mechanism.”
In the meantime, the findings “underscore the urgent need for proactive public health interventions. Diet, as a modifiable risk factor, still offers substantial potential for improvement,” Liu said.
This study was funded by the National Natural Science Foundation of China and the American Cancer Society. The authors and Chan disclosed no relevant conflicts of interest.
A version of this article appeared on Medscape.com.
according to a recent study.
Writing in Gastroenterology, researchers led by Li Liu, PhD, of the department of epidemiology and biostatistics, Ministry of Education Key Lab of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology in Wuhan, China, reported that excessive consumption of processed meats (the biggest culprit), insufficient fruit intake, and insufficient whole grain intake were the leading dietary risk factors. In addition, the number of diet-related cases doubled from 1990 to 2018.
“In regions with limited access to healthy foods, policy interventions like taxing unhealthy foods and subsidizing nutritious options may help shift dietary patterns and reduce cancer risk,” Liu said in an interview.
The study examined meta-analyses from 184 countries in seven regions for the period 1990-2018 looking at rates of six major GI cancers: colorectal, liver, esophageal, pancreatic, and gallbladder/biliary tract. Among these, the age-standardized incidence of liver, pancreatic, and colorectal increased significantly over the past 3 decades.
The research team used a comparative risk assessment model to estimate the impact of diet on GI cancer independent of energy intake and adiposity. Although the principal dietary risk factors varied across individual cancers, suboptimal intake of the three aforementioned components was responsible for 66.51% of all diet-attributable GI cancers in 2018. The global mean processed meat consumption was 17 g/d in 2018, falling to a low in South Asia of 3 g/d.
The investigators also found diet-linked cancer incidence positively correlated with the Sociodemographic Index (SDI), an integrated measure of national development, income, and fertility. Incidence varied across world regions, with the highest proportion of cases in Central and Eastern Europe, Central Asia, Latin America, the Caribbean, and in high-income countries. The findings support the development of targeted diet-related public health interventions in various regions and nations to reduce GI cancer incidence, the authors wrote.
Among the study’s specific findings:
- In 2018, 21.5% (95% uncertainty interval [UI], 19.1-24.5) of incident GI cancer cases globally were attributable to suboptimal diets, a relatively stable proportion since 1990 (22.4%; 95% UI, 19.7-25.6).
- Absolute diet-attributable cases doubled from 580,862 (95% UI, 510,658-664,076) in 1990 to 1,039,877 (95% UI, 923,482-1,187,244) in 2018.
- Excessive processed meat consumption (5.9%; 95% UI, 4.2%-7.9%), insufficient fruit intake (4.8%; 95% UI, 3.8%-5.9%), and insufficient whole grain intake (3.6%; 95% UI, 2.8%-5.1%) were the most significant dietary risk factors in 2018 — a shift from 1990 when the third major concern was insufficient non-starchy vegetable intake.
Given the well-established link between diet and GI cancers, the incidence findings came as no surprise. “However, the dramatic doubling of diet-attributable cases over the past few decades was truly unexpected,” Liu said. “This increase can likely be attributed to global population growth and aging. While aging is an irreversible process, we can still reduce the growing burden of diet-related GI cancers by focusing on modifiable behaviors, particularly through targeted dietary interventions.”
A Modifiable Risk Factor
Commenting on the analysis but not involved in it, Andrew T. Chan, MD, MPH, a professor of medicine at Harvard Medical School and a gastroenterologist at Massachusetts General Hospital, both in Boston, noted that his own group’s studies also support the association of diet with an increased risk for GI cancers, particularly colorectal cancers.
“Although much work needs to be done to clarify the precise mechanisms underlying this association, there are substantial data that diet may cause changes in the gut microbiome, which in turn promotes cancer,” Chan said in an interview. “Going forward, we are working to develop strategies in which diet is modified to mitigate the risk of cancer associated with suboptimal diets.”
In other study findings, Liu’s group observed that two regional groups, Central and Eastern Europe, Central Asia, Latin America, and the Caribbean, as well as high-income countries, bore the top three diet-attributable burdens worldwide in 2018, all driven mostly by an upward-trending excess of processed meat.
By regions, Central and Eastern Europe and Central Asia experienced the highest attributable burden across regions in 1990 (31.6%; UI, 27.0%-37.4%) and 2018 (31.6%; UI, 27.3%-36.5%).
As for the impact of the SDI, the authors explained that diet-attributable GI cancer burden was higher among adults with higher education and living in urban areas than among those with lower education and rural residency. “Some dietary habits tended to be worse in higher-SDI countries, specifically, higher consumption of processed meats,” they wrote.
Although the proportional attributable GI incidence remains relatively stable, they added, the doubling of absolute cases from 1990 to 2018, along with the discrepancies between urbanicity and countries/regions, supports more targeted preventive measures.
And while the diet-GI cancer connection is clear, they agreed with Chan in that “the precise pathogenesis from suboptimal diets to these cancers remains unclear and requires further basic studies to clarify the mechanism.”
In the meantime, the findings “underscore the urgent need for proactive public health interventions. Diet, as a modifiable risk factor, still offers substantial potential for improvement,” Liu said.
This study was funded by the National Natural Science Foundation of China and the American Cancer Society. The authors and Chan disclosed no relevant conflicts of interest.
A version of this article appeared on Medscape.com.
FROM GASTROENTEROLOGY
Promising New Blood Test for Colorectal Cancer Screening
, the largest study of any blood-based CRC screening test.
With continued optimization, this blood test “may provide a convenient, effective option for colorectal cancer screening in the intended use population,” said Aasma Shaukat, MD, MPH, AGAF, with New York University Grossman School of Medicine in New York City.
CRC screening rates remain suboptimal, with nearly 40% of eligible adults in the United States not up to date with screening, noted Shaukat, who presented the study results at the American Society of Clinical Oncology (ASCO) Gastrointestinal Cancers Symposium 2025 in San Francisco.
Blood-based testing offers a promising complementary approach that may boost patient adherence among unscreened individuals, she added.
The study evaluated the clinical performance of the investigational blood-based screening test in 27,010 adults aged ≥ 45 years at average-risk for CRC. Patients with no personal history of cancer, colorectal adenoma, or inflammatory bowel disease, as well as no family history of CRC or hereditary gastrointestinal cancer syndromes were eligible for the study.
Participants had blood drawn before bowel preparation for colonoscopy, and the blood test results were measured against colonoscopy findings.
The primary endpoints included sensitivity for CRC, specificity for advanced colorectal neoplasia, and negative and positive predictive value for advanced colorectal neoplasia. A secondary endpoint was sensitivity for advanced precancerous lesions.
The blood-based screening test met all primary endpoints, with a sensitivity for CRC of 79.2% and a specificity for advanced colorectal neoplasia of 91.5%, Shaukat reported at a conference briefing. Negative predictive value for advanced colorectal neoplasia was 90.8%, though the positive predictive value was only 15.5% and sensitivity for advanced precancerous lesions, a secondary endpoint, was 12.5%.
Similar results were achieved in a prespecified analysis in which performance of the blood test was weighted to match US census data for sex and age distributions. Sensitivity for CRC was 81.1%, specificity was 90.4%, and negative predictive value for advanced colorectal neoplasia was 90.5%; but the positive predictive value was 15.5%, and the sensitivity for advanced precancerous lesions was 13.7%.
This type of analysis provides “a snapshot of how [the test] would perform in the US population,” Shaukat explained, adding that the sensitivity for CRC and advanced precursor lesions was “lower than expected and will continue to be optimized in future research and development.”
It will also be important to determine when the test should be repeated and how often and to look at the determinants around cost and comparative effectiveness, she said. Modeling and other outcome studies — which will be forthcoming in the future years — could help shed some light on these questions.
Briefing moderator Julie Gralow, MD, ASCO chief medical officer, said it will be important to compare how this new blood test compares with Guardant Health’s Shield CRC blood test that was approved in 2024. Although there’s no study directly comparing the new blood test to Shield, data from the ECLIPSE study reported that Shield had 83% sensitivity for CRC and 90% specificity for advanced neoplasia, but only 13% sensitivity for advanced precancerous lesions — which appears similar, so far, to findings reported for the new blood test.
But any screening is better than no screening, and with further study, this blood test may “add another tool to our toolkit,” said Pamela Kunz, MD, director of the Center for Gastrointestinal Cancers at Smilow Cancer Hospital and Yale Cancer Center, New Haven, Connecticut, who spoke at the briefing. Kunz said she is eager to see some of the future work optimizing the sensitivity and subsequent analyses that look at differences by race and ethnicity.
The study had no specific funding. Shaukat consults for Freenome Holdings and Iterative Health. Kunz declared ties with Ipsen, Novartis, Genentech/Roche, Amgen, Crinetics Pharmaceuticals, Natera, HUTCHMED, and ITM Isotope Technologies Munich. Gralow declared consulting or advisory roles with Genentech/Roche.
A version of this article appeared on Medscape.com .
, the largest study of any blood-based CRC screening test.
With continued optimization, this blood test “may provide a convenient, effective option for colorectal cancer screening in the intended use population,” said Aasma Shaukat, MD, MPH, AGAF, with New York University Grossman School of Medicine in New York City.
CRC screening rates remain suboptimal, with nearly 40% of eligible adults in the United States not up to date with screening, noted Shaukat, who presented the study results at the American Society of Clinical Oncology (ASCO) Gastrointestinal Cancers Symposium 2025 in San Francisco.
Blood-based testing offers a promising complementary approach that may boost patient adherence among unscreened individuals, she added.
The study evaluated the clinical performance of the investigational blood-based screening test in 27,010 adults aged ≥ 45 years at average-risk for CRC. Patients with no personal history of cancer, colorectal adenoma, or inflammatory bowel disease, as well as no family history of CRC or hereditary gastrointestinal cancer syndromes were eligible for the study.
Participants had blood drawn before bowel preparation for colonoscopy, and the blood test results were measured against colonoscopy findings.
The primary endpoints included sensitivity for CRC, specificity for advanced colorectal neoplasia, and negative and positive predictive value for advanced colorectal neoplasia. A secondary endpoint was sensitivity for advanced precancerous lesions.
The blood-based screening test met all primary endpoints, with a sensitivity for CRC of 79.2% and a specificity for advanced colorectal neoplasia of 91.5%, Shaukat reported at a conference briefing. Negative predictive value for advanced colorectal neoplasia was 90.8%, though the positive predictive value was only 15.5% and sensitivity for advanced precancerous lesions, a secondary endpoint, was 12.5%.
Similar results were achieved in a prespecified analysis in which performance of the blood test was weighted to match US census data for sex and age distributions. Sensitivity for CRC was 81.1%, specificity was 90.4%, and negative predictive value for advanced colorectal neoplasia was 90.5%; but the positive predictive value was 15.5%, and the sensitivity for advanced precancerous lesions was 13.7%.
This type of analysis provides “a snapshot of how [the test] would perform in the US population,” Shaukat explained, adding that the sensitivity for CRC and advanced precursor lesions was “lower than expected and will continue to be optimized in future research and development.”
It will also be important to determine when the test should be repeated and how often and to look at the determinants around cost and comparative effectiveness, she said. Modeling and other outcome studies — which will be forthcoming in the future years — could help shed some light on these questions.
Briefing moderator Julie Gralow, MD, ASCO chief medical officer, said it will be important to compare how this new blood test compares with Guardant Health’s Shield CRC blood test that was approved in 2024. Although there’s no study directly comparing the new blood test to Shield, data from the ECLIPSE study reported that Shield had 83% sensitivity for CRC and 90% specificity for advanced neoplasia, but only 13% sensitivity for advanced precancerous lesions — which appears similar, so far, to findings reported for the new blood test.
But any screening is better than no screening, and with further study, this blood test may “add another tool to our toolkit,” said Pamela Kunz, MD, director of the Center for Gastrointestinal Cancers at Smilow Cancer Hospital and Yale Cancer Center, New Haven, Connecticut, who spoke at the briefing. Kunz said she is eager to see some of the future work optimizing the sensitivity and subsequent analyses that look at differences by race and ethnicity.
The study had no specific funding. Shaukat consults for Freenome Holdings and Iterative Health. Kunz declared ties with Ipsen, Novartis, Genentech/Roche, Amgen, Crinetics Pharmaceuticals, Natera, HUTCHMED, and ITM Isotope Technologies Munich. Gralow declared consulting or advisory roles with Genentech/Roche.
A version of this article appeared on Medscape.com .
, the largest study of any blood-based CRC screening test.
With continued optimization, this blood test “may provide a convenient, effective option for colorectal cancer screening in the intended use population,” said Aasma Shaukat, MD, MPH, AGAF, with New York University Grossman School of Medicine in New York City.
CRC screening rates remain suboptimal, with nearly 40% of eligible adults in the United States not up to date with screening, noted Shaukat, who presented the study results at the American Society of Clinical Oncology (ASCO) Gastrointestinal Cancers Symposium 2025 in San Francisco.
Blood-based testing offers a promising complementary approach that may boost patient adherence among unscreened individuals, she added.
The study evaluated the clinical performance of the investigational blood-based screening test in 27,010 adults aged ≥ 45 years at average-risk for CRC. Patients with no personal history of cancer, colorectal adenoma, or inflammatory bowel disease, as well as no family history of CRC or hereditary gastrointestinal cancer syndromes were eligible for the study.
Participants had blood drawn before bowel preparation for colonoscopy, and the blood test results were measured against colonoscopy findings.
The primary endpoints included sensitivity for CRC, specificity for advanced colorectal neoplasia, and negative and positive predictive value for advanced colorectal neoplasia. A secondary endpoint was sensitivity for advanced precancerous lesions.
The blood-based screening test met all primary endpoints, with a sensitivity for CRC of 79.2% and a specificity for advanced colorectal neoplasia of 91.5%, Shaukat reported at a conference briefing. Negative predictive value for advanced colorectal neoplasia was 90.8%, though the positive predictive value was only 15.5% and sensitivity for advanced precancerous lesions, a secondary endpoint, was 12.5%.
Similar results were achieved in a prespecified analysis in which performance of the blood test was weighted to match US census data for sex and age distributions. Sensitivity for CRC was 81.1%, specificity was 90.4%, and negative predictive value for advanced colorectal neoplasia was 90.5%; but the positive predictive value was 15.5%, and the sensitivity for advanced precancerous lesions was 13.7%.
This type of analysis provides “a snapshot of how [the test] would perform in the US population,” Shaukat explained, adding that the sensitivity for CRC and advanced precursor lesions was “lower than expected and will continue to be optimized in future research and development.”
It will also be important to determine when the test should be repeated and how often and to look at the determinants around cost and comparative effectiveness, she said. Modeling and other outcome studies — which will be forthcoming in the future years — could help shed some light on these questions.
Briefing moderator Julie Gralow, MD, ASCO chief medical officer, said it will be important to compare how this new blood test compares with Guardant Health’s Shield CRC blood test that was approved in 2024. Although there’s no study directly comparing the new blood test to Shield, data from the ECLIPSE study reported that Shield had 83% sensitivity for CRC and 90% specificity for advanced neoplasia, but only 13% sensitivity for advanced precancerous lesions — which appears similar, so far, to findings reported for the new blood test.
But any screening is better than no screening, and with further study, this blood test may “add another tool to our toolkit,” said Pamela Kunz, MD, director of the Center for Gastrointestinal Cancers at Smilow Cancer Hospital and Yale Cancer Center, New Haven, Connecticut, who spoke at the briefing. Kunz said she is eager to see some of the future work optimizing the sensitivity and subsequent analyses that look at differences by race and ethnicity.
The study had no specific funding. Shaukat consults for Freenome Holdings and Iterative Health. Kunz declared ties with Ipsen, Novartis, Genentech/Roche, Amgen, Crinetics Pharmaceuticals, Natera, HUTCHMED, and ITM Isotope Technologies Munich. Gralow declared consulting or advisory roles with Genentech/Roche.
A version of this article appeared on Medscape.com .
FROM ASCO GI 2025