Editorial: Resecting Assumptions—Do Proctocolectomy Guidelines Hold Up?

Patients with inflammatory bowel disease (IBD) are at increased risk for colorectal cancer (CRC), particularly with high inflammatory burden or longstanding disease. Unlike sporadic CRC, IBD-associated CRC is more likely to arise from chronically inflamed mucosa and demonstrate different molecular features, potentially affecting prognosis or treatment 1. Therefore, patients with IBD are enrolled in strict surveillance programmes and, when cancer arises, are generally recommended to undergo more extensive surgery 2-4. Guidelines now state that segmental resection may be appropriate for older adults and those with elevated operative risks 5, 6. Despite this, surgical management and outcomes in IBD-CRC remain poorly studied. To address these knowledge gaps, Lundqvist and colleagues conducted a population-based cohort study of Swedish patients with stage I–III colon cancer with and without IBD. Of 35,640 patients with colon adenocarcinoma who underwent surgical resection with curative intent between 2007 and 2021, 1.9% had IBD 7. Compared to non-IBD patients, those with IBD were younger at diagnosis (median age 68 v 75 years) and had more right-sided and high-grade tumours. IBD duration at the time of surgery was 15.6 years in UC and 13.4 years in CD. Compared to patients without IBD, those with IBD were more likely to undergo proctocolectomy (9.9% v 0.3%) or subtotal colectomy (28.7% v 4.3%), and less likely to undergo segmental resection (61.3% v 95.4%). Incidental CRC diagnoses were also more common in patients with IBD (16.1% v 11.3%). Patients with IBD had lower cancer-specific survival, recurrence-free survival and overall survival at 5 years (69.0% v 72.6%; hazard ratio 1.38; 95% CI 1.21–1.57), even after adjusting for age, PSC and comorbidities. The article highlighted some important findings. Despite guideline recommendations, only 10% of all patients with IBD in this cohort underwent proctocolectomy. While patients < 50 years had higher rates of subtotal colectomy or proctocolectomy (69% v 39%), this was much higher than previously described from other countries 8. Although younger patients were more likely to undergo extensive surgery, they did not have improved survival outcomes than their non-IBD counterparts. Furthermore, the relatively low rate of metachronous high-grade dysplasia or secondary CRC (3.9% in IBD, 4.3% in non-IBD) aligns with data suggesting comparable results with segmental colectomy, and raises questions about the necessity for more aggressive surgical planning 9, 10. Ultimately, despite recommended dysplasia surveillance protocols, patients with IBD remain more likely to die of their cancer. This raises an uncomfortable but necessary question: if a very small minority of patients develop follow-up neoplasia over 5 years, is extensive prophylactic surgery justified? Non-adherence to surveillance, surgical referral delays or patient hesitation (factors not captured here) may contribute, but probably do not fully explain the survival gap. Nor do surgical differences, particularly with low risk of follow-up neoplasia. The impact of disease activity and severity also remains unclear. We must better understand why patients with IBD fare worse after cancer diagnosis. One thing is clear: it is time to abandon blanket surgical recommendations and move towards strategies rooted in patient preferences and real-world outcomes. Vasantham Chaudhary: writing – original draft, writing – review and editing, conceptualization. Jordan E. Axelrad: writing – original draft, writing – review and editing, conceptualization, supervision. Jordan E. Axelrad has received research grants from BioFire Diagnostics, Genentech, Janssen and Takeda; consultancy fees, honorarium or advisory board fees from Abbvie, Abivax, Adiso, Biomerieux, Bristol-Myers Squibb, Celltrion, Ferring, Fresenius, Janssen, Merck, Pfizer, Sanofi, Takeda and Vedanta. Vasantham Chaudhary has no conflicts. This article is linked to Lundqvist et al. papers. To view these articles, visit https://doi.org/10.1111/apt.70296 and https://doi.org/10.1111/apt.70351. The authors have nothing to report.