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Increased risk of large-bowel cancer in Crohn's disease with colonic involvement

Increased risk of large-bowel cancer in Crohn's disease with colonic involvement Lee Howatson Anderson MacLeod IB. Gastric 12. La Vecchia Decarli D’Avanzo Franceschi S. A 6. TV, D, AG, J, C, Negri E, A, B, Taylor in who have taken cimetidine. Lancet i: case-control of diet and cancer in Northern Int cancer 1979; study gastric Italy. J patients Cancer 1235-36. 1987; 40: 484-89. MRB. Gastric cancer after 13. Breslow NE. Statistical methods in cancer vol 1. The 7. Muscroft research, Hawker PC, TJ, Keighley NE, Day in with two Lancet of case-control studies. IARC Sci Publ 32: 5-338. cimetidine 1980; patient negative pre-treatment biopsies. analysis i: 709-10. 14. Osband Hamilton Shen et al. Successful tumour ME, D, Y-J, 1980; Sikora Freedman L. Gastric cancer and cimetidine: does with cimetidine in mice. Lancet i: 636-38. 8. Schotcher K, immunotherapy 1981; S, Lancet in matter? Lancet ii: 630-31. 15. Sidner RD. Antitumour effect of cimetidine? diagnosis 1981; Armitage JO, 1979; delay i: 9. Lawson MP. Cimetidine 882-83. Colin-Jones DG, Langman MJS, DH, Vessey Lindstrom HO. and cancer: from 16. gastric preliminary report post-marketing Flodgren P, Borgstrom S, Jonsson PE, C, Sjogren Br 285: 1311-13. Metastatic melanoma: induced combined surveillance study. Med J 1982; malignant regression by Lawson treatment with interferon and Cancer 10. Colin-Jones DG, DH, MP. cimetidine. Langman MJS, Vessey [HuIFN-&agr;(Le)] Int J surveillance of the of cimetidine: 12 month 32: 657-65. Postmarketing 1983; safety Br 286: 1713-16. 17. Marshall Mendelsohn Butler et al. Treatment of metastatic mortality report. 1983; ME, L, K, Med J Lawson MP. renal cell carcinoma with coumarin and cimetidine: 11. Colin-Jones DG, Langman MJS, DH, Vessey (1,2-benzopyrone) surveillance of the of cimetidine: a Clin Oncol 5: 862-66. Postmarketing safety mortality during pilot study. J 1987; third and second, fourth of follow Br 291: 18. Tonnesen Bulow et al. Effect of cimetidine on survival year up. Med J 1985; H, Knigge U, S, 1084-88. after cancer. Lancet ii: 990-92. gastric 1988; EPIDEMIOLOGY Increased risk of cancer in Crohn’s large-bowel involvement disease with colonic A cohort of 1655 with Crohn’s disease to the end of to an observation time of patients 1984, corresponding in care 1983 the health 1-60 from diagnosed during Uppsala years diagnosis. was followed with to region, Sweden, up respect the occurrence of cancer to the end of colorectal and methods Subjects 1984. 12 colorectal cancers were diagnosed, The cohort an increased overall risk of 2&middot;5. The relative yielding area chosen for the health care The was risk was similar for males and of study Uppsala region, females. Duration in which had 1-2 million inhabitants in 1965 and 1-3 million 1983. did not affect risk. Relative risk for follow-up Information about admitted to from 1965 to 1983 patients hospital disease of the terminal ileum was for 1&middot;0; only was extracted from the National Board of Health and Welfare terminal ileum and of colon 3&middot;2; and for colon parts which recorded dates of admission and inpatient register, discharge alone 5&middot;6. Patients in whom Crohn’s disease was and details of and diagnoses surgical procedures. before 30 with colonic diagnosed age any From the we selected all a inpatient register patients given involvement at had a relative risk diagnosis higher with Crohn’s a discharge disease, by using diagnosis compatible those at than older Swedish of ICD-7 codes (20&middot;9) diagnosed ages (2&middot;2). adaptation 572-00,572-09,572-11,572-20, and 572-21 for the 1965-68 and of ICD-8 codes 561 04, period and 569-02 for the 56210, 563-00, 56310, 56399, 56410, period 1969-83. To all with Introduction identify patients histopathological diagnosis of Crohn’s disease treated as or we also outpatients inpatients Until the late 1960s Crohn’s disease was not to be thought reviewed the records at the of clinical in the departments pathology associated with colorectal 15 cases of such an cancer, only in whom the examination of region. Any patient histopathological been in the world association had described literature.’ removed or surgically tissues, biopsy specimens, necropsy a Crohn’s disease was Since then three studiesz have described an increased risk aroused of identified. specimens suspicion charts were retrieved and scrutinised in The individual order to of colorectal cancer with Crohn’s disease. among patients confirm or the of Crohn’s use of the reject disease, diagnosis by One’ showed a mean at of colorectal younger age diagnosis criteria described Garland et all’ for definite and diagnostic by cancer Crohn’s disease than among patients among patients cases. The criteria for cases were probable diagnostic probable from the Several other general population. studies, however, made stricter the that a by adding prerequisite laparotomy report have found no association between Crohn’s disease and without a examination had to be followed positive histopathological cancer.6-9 The risk of colorectal cancer in large-bowel confirmation. by radiological with Crohn’s disease thus remains uncertain.1O patients with Crohn’s in 1469 disease the patients diagnosed period To more accurate risk we 1965-83 were identified 187 with estimates, Crohn’s provide investigated (incident cases). patients cohort of all 1656 population-based consisting patients with a of Crohn’s disease to 1983 in a diagnosis up strictly ADDRESSES of defined area in Sweden. We Department University Hospital, information on extent Surgery, gathered Sweden H -O and Centers Uppsala, (A Ekbom, MD, Adami, MD) of disease at at and diagnosis, age diagnosis, surgical for Disease Control, Atlanta, USA Helmick, MD, Georgia, (C carried out the procedures (eg, proctocolectomy) during of Zack, to Dr A. Ekbom, Surgery, MD) Correspondence Department We obtained S-751 85 follow-up period. virtually complete follow-up Hospital, Sweden. University Uppsala, 358 TABLE I-NO OF PATIENTS IN THE COHORT BY AGE AT TABLE III-COHORT STUDIES OF COLORECTAL CANCER IN EXTENT OF AND PERIOD OF DIAGNOSIS PATIENTS WITH CROHN’S DISEASE DIAGNOSIS, DISEASE, disease before 1965 and resident in the on Jan 1, diagnosed region were also identified none had a of 1965, cases); (prevalent diagnosis colorectal but all had had at least one consultation for cancer, included in the of number of at risk for computation person-years Crohn’s disease after Dec Information was in 1 31,1964. inadequate rectal cancer. The reverse was used for who had procedure patients and the 1655 females and 796 case, remaining patients (859 males) rectal and was thus still at risk for colon undergone only amputation were included in the The of the study. composition study cancer. is shown in table r. population of the number of at risk the Multiplication person-years by The were to one of four to the patients assigned groups according incidence rates the Swedish corresponding age-specific (from extent of the disease at disease confined to terminal diagnosis: (1) Cancer the numbers of cases of Registry) yielded expected disease confined to terminal ileum and of the ileum; (2) part colon; colorectal cancer in the cohort for successive of observation. years disease confined to the and other involvement (3) colon; (4) (eg, The standardised incidence ratio was used as a measure of (SIR) to the ileum with or without involvement of terminal proximal relative risk and was as the ratio of defined observed to expected terminal ileum in 2 and 3 were and The 830 colon). patients groups of of rectal numbers cases colon or cancer. The 95% confidence analysed together. interval was calculated on the that the (95% CI) assumption observed number of cases in each class followed a poisson Follow-up distribution. The cohort was at 30 or Numbers of for removal of the cases of ( < bowel, analysed by gender, age diagnosis operations large 30 and extent of disease at time of To detect colorectal and deaths were determined from the Swedish years), diagnosis. any cancer, selection bias in whom a was made before national record Patients who had a among patients diagnosis linkage system. undergone were a or rectal in 1965-83 1965, they initially analysed separately. proctocolectomy, colectomy, amputation A standardised ratio calculated from were identified from the Cases of colorectal mortality (SMR), inpatient register. cause of death from the of Causes of was cancer were also identified from a second the Swedish underlying Registry Death, source, used to and from colorectal cancer. Cancer and deaths from the of Causes of Death. compare morbidity mortality Registry, Registry Results Statistical analysis Colorectal cancer was in 12 the of the of The number at risk for diagnosed patients during computation person-years 5 times the colorectal cancer started at the time of of Crohn’s disease diagnosis follow-up period 1958-84,2-5 expected number of or in the first of in the Cancer for 4-9 cases CI The overall SMR was 1 -7 1958, year follow-up Registry, (95% 1 -3-4-3). (95% in whom the disease was earlier. Each in patients diagnosed subject CI observed = 5 Patients 0-5-3-9; deaths, expected = 3-0). was followed to date of of either diagnosis malignancy (Cancer whom the disease was before 1965 had a relative diagnosed date of death of Causes of date of Registry), (Registry Death), risk of 3-1 CI with 2-2 CI (95% 0-9-8-0), (95% compared or the date of the Patients who had operation, closing study. for those in whom the was made between 1 -0-43) diagnosis a the rectum intact were excluded undergone colectomy leaving 1965 and 1983. Because the excess risk was the two similar, from the calculation at risk for colon cancer but were of person-years in There 9 were further were groups merged analyses. TABLE II-STANDARDISED INCIDENCE RATIO OF cancers of the colon 95% CI and 3 (SIR) (SIR=29; 1-3-5-5) COLORECTAL CANCER IN CROHN’S DISEASE BY SEX AND cancers of the rectum CI 95% (SIR= 1-6; 0-3-4-8). EXTENT OF AT AGE AT AND DISEASE DIAGNOSIS, DIAGNOSIS, of in The excess risk colorectal cancer was similar males DURATION OF FOLLOW-UP and females Patients with Crohn’s disease (table n). confined to the terminal ileum had the risk of expected colorectal whereas those with the disease confined to cancer, the colon had a increased relative risk substantially 95% CI Those less than 30 old (SIR = 5-6; 2-1-12-2). years at had a relative risk than those at diagnosis higher diagnosed an older Duration of did not age. follow-up significantly influence the relative risk of colorectal cancer (table II). In those with colonic before any involvement, diagnosis the of 30 risk entailed a relative of 20-9 CI years age (95% with 2-2 CI in those who 6-8-48-7), compared (95% 0-6-5-7) were 30 or older. years Discussion This confirms the increased relative risk of colorectal study cancer in with Crohn’s disease. The excess risk was patients not different between cancer of the colon and significantly cancer of the or between males and females. Extent rectum, 359 in 6. Binder Hendriksen Kreiner S. Crohn’s disease&mdash;based determinant of this V, C, Prognosis of disease at was an important diagnosis on results from a from the of regional patient group county increased risk. The relative risk was 1-0 for those with Gut 1985; 26: 146-50. Copenhagen. confined to the terminal ileum at 3-2 for disease diagnosis, in disease. 7. Kvist et al. Crohn’s N, Jacobsen O, Norgaard P, Malignancy and of the and 56 for terminal ileum parts colon, Gastroenterol 21: 82-86. Scand J 1986; Zinsmeister AR. under 30 at 8. SF, Melton involvement of colon Patients Gollop JH, Phillips LJ III, Epidemiologic only. aged of disease: a in Olmsted Crohn’s aspects population-based study carried a risk than those substantially higher diagnosis 1943-1982. Gut 29: 49-56. 1988; County, Minnesota, older Those with colonic at ages. any diagnosed 9. Fireman Grossman Lilos et al. Intestinal cancer in with Z, A, P, patients at before 30 had the involvement Crohn’s disease. A in central Israel. diagnosis age largest population study Scand J Gastroenterol 24: 346-50. risk Duration of did not seem to 1989; relative (20-9). follow-up 10. Glotzer The risk of cancer in Crohn’s disease. DJ. Gastroenterology 1985; affect the risk estimates. 89: 438-41. Closer surveillance of with Crohn’s patients diagnosed 11. Garland Lilienfeld Markowitz CF, AM, Mendeloff AI, JA, Terrell KA, have led to a ascertainment of colorectal disease may higher Garland FC. Incidence rates of ulcerative colitis and Crohn’s disease in fifteen areas of the United States. in the 81: 1115-24. cancers than in the Gastroenterology 1981; study population general and earlier detection would be to population, expected the SMR in the two of reduce mortality. However, groups was not different. subjects significantly This underestimate the relative risk of study may REVIEW ARTICLE colorectal cancer because who had colectomies after patients from the health care would not moving away Uppsala region have been ascertained. the at Conversely, person-years risk, What is known about the and therefore the number of cases of colorectal expected cancer within the would have been overestimated cohort, of prevention congenital in whom the those was made before 1965 among diagnosis toxoplasmosis? but who had unascertained colectomies. the However, on our risk estimates is because small, impact probably from the was Date of onset of emigration region negligible. be more than date at symptoms might appropriate diagnosis to calculate duration of but reliable information follow-up, of onset of the is to retreive symptoms impossible The French for the of programme prevention retrospectively. consists of the toxoplasmosis congenital diagnosis The risk of colorectal cancer and Crohn’s disease varies and treatment with of acute infections spiramycin in studies and 4-3 to different greatly (from 20-0) (table III) and of all during monthly follow-up pregnancy on extent of at and may depend disease, age diagnosis, identified women. The flaw is seronegative major random variation. In the from the Clinic2 no study Mayo that in the of efficacy spiramycin preventing was older than 21 at and 80% had patient years diagnosis, contamination of the or at least in fetus, reducing colonic involvement. In the of the 63% Birmingham study4 the extent of the has never been infection, were under 30 of at patients years age diagnosis. in a evaluated randomised placebo-controlled one the risk of colorectal Only previous study analysed clinical trial. Its evaluation would the require in with disease before 30 at cancer Crohn’s by age patients mothers of children born to follow-up The relative risk of 20-0 those diagnosis.2 among younger contaminated for more than 6 during pregnancy in that is almost identical to our estimate than 30 study years a that is obtain in current months, difficult to goal of 20-9 in those with colonic involvement. In a recent study The cost of the practice. programme depends of the risk of colorectal cancer in ulcerative colitis on the of non-immune women largely proportion we found relative risks for the 15 (unpublished), age-group of Since the modes of childbearing age. to at of 14-2 for left-sided colitis and 33-1 1 years diagnosis contamination are known and are linked to living for The closeness of these latter risk estimates to pancolitis. it should be to reduce the risk of habits, possible those for Crohn’s disease with colonic involvement any infection health during pregnancy by adequate between that there is little difference suggests young patients to education. This is still be evaluated. approach with ulcerative colitis and Crohn’s disease with to respect would the risk of cancer. large-bowel Longer follow-up increase the of these risk estimates. accuracy and treatment of In recent the years, prevention congenital have aroused increased and national interest, toxoplasmosis We Dr Richard for valuable This work thank was Rothenberg help. have been a from the National Foundation for Ileitis and Colitis and several envisaged by supported by grant prevention programmes a Nanna Svartz grant. the United States’ and the United countries, including Kingdom.2 REFERENCES 1. ADDRESSES. of Medical Colonic cancer and Crohn’s disease. Gut 10: 651-54. Statistics, Gustave Jones JH. 1969; Department 2. France Weedon Shorter WF. Institute, Jeannel, Unit of DD, RG, Ilstrup DM, Huizenga KA, Taylor Roussy Villejuif, (D PhD), Crohn’s Research in Biostatistics and U263 disease and cancer. Med 289: 1099-103. Biomathematics, INSERM N Engl J 1973; 3. Greenstein Paris VII Paris of Sachar Smith Aufses AH. A University, (D AJ, DB, H, Janowitz HD, Costagliola, PhD), Department of Diseases and cancer risk in Crohn’s disease and ulcerative colitis. Tropical Hospital, comparison Parasitology, Piti&eacute;-Salp&eacute;tri&egrave;re Cancer 48: 2742-45. Paris MD, M Office of Communicable 1981; (G Niel, Danis, MD), 4. Waterhouse Diseases, National of Health, Paris Hubert, MD) Gyde SN, Prior P, JC, H, Department (B Macartney Thompson JAH, Allan RN. to Dr of Medical in Crohn’s disease. Gut 21: 1024-29. Jeannel, Malignancy 1980; Correspondence Dominique Department 5. Hamilton SR. Colorectal in Gustave rue Camille Desmoulins, carcinoma with Crohn’s disease. Statistics, Roussy Institute, patients 89: 398-407. France 1985; Villejuif CEDEX, Gastroenterology http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The Lancet Unpaywall

Increased risk of large-bowel cancer in Crohn's disease with colonic involvement

The LancetAug 1, 1990

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0140-6736
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Lee Howatson Anderson MacLeod IB. Gastric 12. La Vecchia Decarli D’Avanzo Franceschi S. A 6. TV, D, AG, J, C, Negri E, A, B, Taylor in who have taken cimetidine. Lancet i: case-control of diet and cancer in Northern Int cancer 1979; study gastric Italy. J patients Cancer 1235-36. 1987; 40: 484-89. MRB. Gastric cancer after 13. Breslow NE. Statistical methods in cancer vol 1. The 7. Muscroft research, Hawker PC, TJ, Keighley NE, Day in with two Lancet of case-control studies. IARC Sci Publ 32: 5-338. cimetidine 1980; patient negative pre-treatment biopsies. analysis i: 709-10. 14. Osband Hamilton Shen et al. Successful tumour ME, D, Y-J, 1980; Sikora Freedman L. Gastric cancer and cimetidine: does with cimetidine in mice. Lancet i: 636-38. 8. Schotcher K, immunotherapy 1981; S, Lancet in matter? Lancet ii: 630-31. 15. Sidner RD. Antitumour effect of cimetidine? diagnosis 1981; Armitage JO, 1979; delay i: 9. Lawson MP. Cimetidine 882-83. Colin-Jones DG, Langman MJS, DH, Vessey Lindstrom HO. and cancer: from 16. gastric preliminary report post-marketing Flodgren P, Borgstrom S, Jonsson PE, C, Sjogren Br 285: 1311-13. Metastatic melanoma: induced combined surveillance study. Med J 1982; malignant regression by Lawson treatment with interferon and Cancer 10. Colin-Jones DG, DH, MP. cimetidine. Langman MJS, Vessey [HuIFN-&agr;(Le)] Int J surveillance of the of cimetidine: 12 month 32: 657-65. Postmarketing 1983; safety Br 286: 1713-16. 17. Marshall Mendelsohn Butler et al. Treatment of metastatic mortality report. 1983; ME, L, K, Med J Lawson MP. renal cell carcinoma with coumarin and cimetidine: 11. Colin-Jones DG, Langman MJS, DH, Vessey (1,2-benzopyrone) surveillance of the of cimetidine: a Clin Oncol 5: 862-66. Postmarketing safety mortality during pilot study. J 1987; third and second, fourth of follow Br 291: 18. Tonnesen Bulow et al. Effect of cimetidine on survival year up. Med J 1985; H, Knigge U, S, 1084-88. after cancer. Lancet ii: 990-92. gastric 1988; EPIDEMIOLOGY Increased risk of cancer in Crohn’s large-bowel involvement disease with colonic A cohort of 1655 with Crohn’s disease to the end of to an observation time of patients 1984, corresponding in care 1983 the health 1-60 from diagnosed during Uppsala years diagnosis. was followed with to region, Sweden, up respect the occurrence of cancer to the end of colorectal and methods Subjects 1984. 12 colorectal cancers were diagnosed, The cohort an increased overall risk of 2&middot;5. The relative yielding area chosen for the health care The was risk was similar for males and of study Uppsala region, females. Duration in which had 1-2 million inhabitants in 1965 and 1-3 million 1983. did not affect risk. Relative risk for follow-up Information about admitted to from 1965 to 1983 patients hospital disease of the terminal ileum was for 1&middot;0; only was extracted from the National Board of Health and Welfare terminal ileum and of colon 3&middot;2; and for colon parts which recorded dates of admission and inpatient register, discharge alone 5&middot;6. Patients in whom Crohn’s disease was and details of and diagnoses surgical procedures. before 30 with colonic diagnosed age any From the we selected all a inpatient register patients given involvement at had a relative risk diagnosis higher with Crohn’s a discharge disease, by using diagnosis compatible those at than older Swedish of ICD-7 codes (20&middot;9) diagnosed ages (2&middot;2). adaptation 572-00,572-09,572-11,572-20, and 572-21 for the 1965-68 and of ICD-8 codes 561 04, period and 569-02 for the 56210, 563-00, 56310, 56399, 56410, period 1969-83. To all with Introduction identify patients histopathological diagnosis of Crohn’s disease treated as or we also outpatients inpatients Until the late 1960s Crohn’s disease was not to be thought reviewed the records at the of clinical in the departments pathology associated with colorectal 15 cases of such an cancer, only in whom the examination of region. Any patient histopathological been in the world association had described literature.’ removed or surgically tissues, biopsy specimens, necropsy a Crohn’s disease was Since then three studiesz have described an increased risk aroused of identified. specimens suspicion charts were retrieved and scrutinised in The individual order to of colorectal cancer with Crohn’s disease. among patients confirm or the of Crohn’s use of the reject disease, diagnosis by One’ showed a mean at of colorectal younger age diagnosis criteria described Garland et all’ for definite and diagnostic by cancer Crohn’s disease than among patients among patients cases. The criteria for cases were probable diagnostic probable from the Several other general population. studies, however, made stricter the that a by adding prerequisite laparotomy report have found no association between Crohn’s disease and without a examination had to be followed positive histopathological cancer.6-9 The risk of colorectal cancer in large-bowel confirmation. by radiological with Crohn’s disease thus remains uncertain.1O patients with Crohn’s in 1469 disease the patients diagnosed period To more accurate risk we 1965-83 were identified 187 with estimates, Crohn’s provide investigated (incident cases). patients cohort of all 1656 population-based consisting patients with a of Crohn’s disease to 1983 in a diagnosis up strictly ADDRESSES of defined area in Sweden. We Department University Hospital, information on extent Surgery, gathered Sweden H -O and Centers Uppsala, (A Ekbom, MD, Adami, MD) of disease at at and diagnosis, age diagnosis, surgical for Disease Control, Atlanta, USA Helmick, MD, Georgia, (C carried out the procedures (eg, proctocolectomy) during of Zack, to Dr A. Ekbom, Surgery, MD) Correspondence Department We obtained S-751 85 follow-up period. virtually complete follow-up Hospital, Sweden. University Uppsala, 358 TABLE I-NO OF PATIENTS IN THE COHORT BY AGE AT TABLE III-COHORT STUDIES OF COLORECTAL CANCER IN EXTENT OF AND PERIOD OF DIAGNOSIS PATIENTS WITH CROHN’S DISEASE DIAGNOSIS, DISEASE, disease before 1965 and resident in the on Jan 1, diagnosed region were also identified none had a of 1965, cases); (prevalent diagnosis colorectal but all had had at least one consultation for cancer, included in the of number of at risk for computation person-years Crohn’s disease after Dec Information was in 1 31,1964. inadequate rectal cancer. The reverse was used for who had procedure patients and the 1655 females and 796 case, remaining patients (859 males) rectal and was thus still at risk for colon undergone only amputation were included in the The of the study. composition study cancer. is shown in table r. population of the number of at risk the Multiplication person-years by The were to one of four to the patients assigned groups according incidence rates the Swedish corresponding age-specific (from extent of the disease at disease confined to terminal diagnosis: (1) Cancer the numbers of cases of Registry) yielded expected disease confined to terminal ileum and of the ileum; (2) part colon; colorectal cancer in the cohort for successive of observation. years disease confined to the and other involvement (3) colon; (4) (eg, The standardised incidence ratio was used as a measure of (SIR) to the ileum with or without involvement of terminal proximal relative risk and was as the ratio of defined observed to expected terminal ileum in 2 and 3 were and The 830 colon). patients groups of of rectal numbers cases colon or cancer. The 95% confidence analysed together. interval was calculated on the that the (95% CI) assumption observed number of cases in each class followed a poisson Follow-up distribution. The cohort was at 30 or Numbers of for removal of the cases of ( < bowel, analysed by gender, age diagnosis operations large 30 and extent of disease at time of To detect colorectal and deaths were determined from the Swedish years), diagnosis. any cancer, selection bias in whom a was made before national record Patients who had a among patients diagnosis linkage system. undergone were a or rectal in 1965-83 1965, they initially analysed separately. proctocolectomy, colectomy, amputation A standardised ratio calculated from were identified from the Cases of colorectal mortality (SMR), inpatient register. cause of death from the of Causes of was cancer were also identified from a second the Swedish underlying Registry Death, source, used to and from colorectal cancer. Cancer and deaths from the of Causes of Death. compare morbidity mortality Registry, Registry Results Statistical analysis Colorectal cancer was in 12 the of the of The number at risk for diagnosed patients during computation person-years 5 times the colorectal cancer started at the time of of Crohn’s disease diagnosis follow-up period 1958-84,2-5 expected number of or in the first of in the Cancer for 4-9 cases CI The overall SMR was 1 -7 1958, year follow-up Registry, (95% 1 -3-4-3). (95% in whom the disease was earlier. Each in patients diagnosed subject CI observed = 5 Patients 0-5-3-9; deaths, expected = 3-0). was followed to date of of either diagnosis malignancy (Cancer whom the disease was before 1965 had a relative diagnosed date of death of Causes of date of Registry), (Registry Death), risk of 3-1 CI with 2-2 CI (95% 0-9-8-0), (95% compared or the date of the Patients who had operation, closing study. for those in whom the was made between 1 -0-43) diagnosis a the rectum intact were excluded undergone colectomy leaving 1965 and 1983. Because the excess risk was the two similar, from the calculation at risk for colon cancer but were of person-years in There 9 were further were groups merged analyses. TABLE II-STANDARDISED INCIDENCE RATIO OF cancers of the colon 95% CI and 3 (SIR) (SIR=29; 1-3-5-5) COLORECTAL CANCER IN CROHN’S DISEASE BY SEX AND cancers of the rectum CI 95% (SIR= 1-6; 0-3-4-8). EXTENT OF AT AGE AT AND DISEASE DIAGNOSIS, DIAGNOSIS, of in The excess risk colorectal cancer was similar males DURATION OF FOLLOW-UP and females Patients with Crohn’s disease (table n). confined to the terminal ileum had the risk of expected colorectal whereas those with the disease confined to cancer, the colon had a increased relative risk substantially 95% CI Those less than 30 old (SIR = 5-6; 2-1-12-2). years at had a relative risk than those at diagnosis higher diagnosed an older Duration of did not age. follow-up significantly influence the relative risk of colorectal cancer (table II). In those with colonic before any involvement, diagnosis the of 30 risk entailed a relative of 20-9 CI years age (95% with 2-2 CI in those who 6-8-48-7), compared (95% 0-6-5-7) were 30 or older. years Discussion This confirms the increased relative risk of colorectal study cancer in with Crohn’s disease. The excess risk was patients not different between cancer of the colon and significantly cancer of the or between males and females. Extent rectum, 359 in 6. Binder Hendriksen Kreiner S. Crohn’s disease&mdash;based determinant of this V, C, Prognosis of disease at was an important diagnosis on results from a from the of regional patient group county increased risk. The relative risk was 1-0 for those with Gut 1985; 26: 146-50. Copenhagen. confined to the terminal ileum at 3-2 for disease diagnosis, in disease. 7. Kvist et al. Crohn’s N, Jacobsen O, Norgaard P, Malignancy and of the and 56 for terminal ileum parts colon, Gastroenterol 21: 82-86. Scand J 1986; Zinsmeister AR. under 30 at 8. SF, Melton involvement of colon Patients Gollop JH, Phillips LJ III, Epidemiologic only. aged of disease: a in Olmsted Crohn’s aspects population-based study carried a risk than those substantially higher diagnosis 1943-1982. Gut 29: 49-56. 1988; County, Minnesota, older Those with colonic at ages. any diagnosed 9. Fireman Grossman Lilos et al. Intestinal cancer in with Z, A, P, patients at before 30 had the involvement Crohn’s disease. A in central Israel. diagnosis age largest population study Scand J Gastroenterol 24: 346-50. risk Duration of did not seem to 1989; relative (20-9). follow-up 10. Glotzer The risk of cancer in Crohn’s disease. DJ. Gastroenterology 1985; affect the risk estimates. 89: 438-41. Closer surveillance of with Crohn’s patients diagnosed 11. Garland Lilienfeld Markowitz CF, AM, Mendeloff AI, JA, Terrell KA, have led to a ascertainment of colorectal disease may higher Garland FC. Incidence rates of ulcerative colitis and Crohn’s disease in fifteen areas of the United States. in the 81: 1115-24. cancers than in the Gastroenterology 1981; study population general and earlier detection would be to population, expected the SMR in the two of reduce mortality. However, groups was not different. subjects significantly This underestimate the relative risk of study may REVIEW ARTICLE colorectal cancer because who had colectomies after patients from the health care would not moving away Uppsala region have been ascertained. the at Conversely, person-years risk, What is known about the and therefore the number of cases of colorectal expected cancer within the would have been overestimated cohort, of prevention congenital in whom the those was made before 1965 among diagnosis toxoplasmosis? but who had unascertained colectomies. the However, on our risk estimates is because small, impact probably from the was Date of onset of emigration region negligible. be more than date at symptoms might appropriate diagnosis to calculate duration of but reliable information follow-up, of onset of the is to retreive symptoms impossible The French for the of programme prevention retrospectively. consists of the toxoplasmosis congenital diagnosis The risk of colorectal cancer and Crohn’s disease varies and treatment with of acute infections spiramycin in studies and 4-3 to different greatly (from 20-0) (table III) and of all during monthly follow-up pregnancy on extent of at and may depend disease, age diagnosis, identified women. The flaw is seronegative major random variation. In the from the Clinic2 no study Mayo that in the of efficacy spiramycin preventing was older than 21 at and 80% had patient years diagnosis, contamination of the or at least in fetus, reducing colonic involvement. In the of the 63% Birmingham study4 the extent of the has never been infection, were under 30 of at patients years age diagnosis. in a evaluated randomised placebo-controlled one the risk of colorectal Only previous study analysed clinical trial. Its evaluation would the require in with disease before 30 at cancer Crohn’s by age patients mothers of children born to follow-up The relative risk of 20-0 those diagnosis.2 among younger contaminated for more than 6 during pregnancy in that is almost identical to our estimate than 30 study years a that is obtain in current months, difficult to goal of 20-9 in those with colonic involvement. In a recent study The cost of the practice. programme depends of the risk of colorectal cancer in ulcerative colitis on the of non-immune women largely proportion we found relative risks for the 15 (unpublished), age-group of Since the modes of childbearing age. to at of 14-2 for left-sided colitis and 33-1 1 years diagnosis contamination are known and are linked to living for The closeness of these latter risk estimates to pancolitis. it should be to reduce the risk of habits, possible those for Crohn’s disease with colonic involvement any infection health during pregnancy by adequate between that there is little difference suggests young patients to education. This is still be evaluated. approach with ulcerative colitis and Crohn’s disease with to respect would the risk of cancer. large-bowel Longer follow-up increase the of these risk estimates. accuracy and treatment of In recent the years, prevention congenital have aroused increased and national interest, toxoplasmosis We Dr Richard for valuable This work thank was Rothenberg help. have been a from the National Foundation for Ileitis and Colitis and several envisaged by supported by grant prevention programmes a Nanna Svartz grant. the United States’ and the United countries, including Kingdom.2 REFERENCES 1. ADDRESSES. of Medical Colonic cancer and Crohn’s disease. Gut 10: 651-54. Statistics, Gustave Jones JH. 1969; Department 2. France Weedon Shorter WF. Institute, Jeannel, Unit of DD, RG, Ilstrup DM, Huizenga KA, Taylor Roussy Villejuif, (D PhD), Crohn’s Research in Biostatistics and U263 disease and cancer. Med 289: 1099-103. Biomathematics, INSERM N Engl J 1973; 3. Greenstein Paris VII Paris of Sachar Smith Aufses AH. A University, (D AJ, DB, H, Janowitz HD, Costagliola, PhD), Department of Diseases and cancer risk in Crohn’s disease and ulcerative colitis. Tropical Hospital, comparison Parasitology, Piti&eacute;-Salp&eacute;tri&egrave;re Cancer 48: 2742-45. Paris MD, M Office of Communicable 1981; (G Niel, Danis, MD), 4. Waterhouse Diseases, National of Health, Paris Hubert, MD) Gyde SN, Prior P, JC, H, Department (B Macartney Thompson JAH, Allan RN. to Dr of Medical in Crohn’s disease. Gut 21: 1024-29. Jeannel, Malignancy 1980; Correspondence Dominique Department 5. Hamilton SR. Colorectal in Gustave rue Camille Desmoulins, carcinoma with Crohn’s disease. Statistics, Roussy Institute, patients 89: 398-407. France 1985; Villejuif CEDEX, Gastroenterology

Journal

The LancetUnpaywall

Published: Aug 1, 1990

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