Diverticular disease and colorectal cancer: incidental diagnosis or real association

Transcription

1 Diverticular disease and colorectal cancer: incidental diagnosis or real association Jaroslaw Regula Department of Gastroenterology Maria Sklodowska-Curie Memorial Cancer Centre Warsaw, Poland

2 Theoretical options 1) associated due to causal relationship 2) associated due to common risk factors and similar causes 3) separate entities, unrelated to each other 4) separate but somehow related - one may mask the other due to similar localization and cause diagnostic difficulties

3 Obviously, common features - similar epidemiology - increasing (although CRC more frequent in males) - increasing frequency with age - common in Western style populations - similar location in many cases: except Asian populations (diverticula frequent in right colon)

4 Older studies (before 2008) Morini S et al., J Cllin Gastroenterol 2008;42:763

5 Diverticulosis and adenomas Morini S et al., J Cllin Gastroenterol 2008;42:763

6 Suggested mechanism for the link - Chronic inflammation; especially SCAD (segmental colitis associated with diverticula) - Extracellular matrix alterations (eg. COX2, p53) may promote carinogenesis - Dysregulated cell proliferaion in DD (incrased abberant crypt foci) - Microbiome changes

7 Recent observations Risk of interval cancer in DD Cooper GS 2014 (USA) Risk of cancer in FOBT screened populations

8 DD and interval cancer (post-colonoscopy cancer) - US study - SEER registry and Medicare data - Patients with CRC >69 yrs old Group A: colonoscopy performed <6 month Group B: colonoscopy performed 6-36 month period (interval cancer group) Cooper GS et al., Dig Dis Sci 2014;59:2765

9 Results Group A Group B No. 53,647 4,192 DD diagnosed earlier 23,6% 51,2% Cooper GS et al., Dig Dis Sci 2014;59:2765

10 Oncogenic pathways - E - Cooper GS et al., Dig Dis Sci 2014;59:2765

11 Conclusions from this study Diverticulosis is associated with interval (postcolonoscopy cancer) Results are unclear issue requires further analyses Cooper GS et al., Dig Dis Sci 2014;59:2765

12 Puzzling observation from British Bowel Cancer Screening program Colonoscopies are performed for positive FOBT P< Tsiamoulos JZ et al. Colorectal Dis 2013;16:70

13 Possible explanations - higher probablity of positive FOBT in DD - under-reporting od DD in CRC patients - true protective role of DD (by change of microbiota (???) Tsiamoulos JZ et al. Colorectal Dis 2013;16:70

14 Recent large population-based studies - Granlund et al (Sweden) - Huang et al (Taiwan)

15 Nationwide, case control study, Period Cases: 41,037 CRC s from Cancer Register Controls: matched by gender, age Rate 1:2 Swedish Inpatient Register - searched for preceding hospitalizations for DD in both groups Granlund J et al. Aliment Pharmacol Ther 2011;34:675

16 Results Granlund J et al. Aliment Pharmacol Ther 2011;34:675

17 Granlund J et al. Aliment Pharmacol Ther 2011;34:675

18 Granlund J et al. Aliment Pharmacol Ther 2011;34:675

19 Granlund J et al. Aliment Pharmacol Ther 2011;34:675 Overall and cancer specific survival CRC - S OS

20 Huang WY et al. Clin GastroenterolHepatol 2014;12:1288 Nationwide population-based study Study period ,662 patients with dg of inpatient DD 182,488 matched by age, sex, year of hospitalisation controls with no dg of DD Rate 1:4 CRC diagnosis was searched until 2010

21 Baseline data Huang WY et al. Clin GastroenterolHepatol 2014;12:1288

22 All subjects Huang WY et al. Clin GastroenterolHepatol 2014;12:1288

23 After excluding 1st year of observation (for matched controls as well) Huang WY et al. Clin GastroenterolHepatol 2014;12:1288

24 Huang WY et al. Clin GastroenterolHepatol 2014;12:1288

25 Huang WY et al. Clin GastroenterolHepatol 2014;12:1288

26 Conclusions 1) Diverticular disease does not increase the risk of colon cancer after the first year of diagnosis. 2) Within the first year of diagnosis the association is strong, most probably due to difficulties with differential diagnosis and misclassifications and shared symptoms. 3) Colon cancer has to be excluded using modern techniques after the first episode of suspected diverticulitis.

27 2016 AGA guidelines Stollman N et al., Gastroenterology 2015;149:1944 Stratte LL et al., Gastroenterology 2015;149:1950

28 Finally DD and CRC are: separate diseases but somehow related