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The fear of developing colorectal cancer (CRC) when living with inflammatory bowel disease can weigh heavily on our minds as patients.

So Nigel and I resolved to get an expert guest on the podcast who could talk us (and our patient listeners) through the risks and how we can minimise them when living with Crohn's disease or ulcerative colitis.

Enter Professor James East! Prof East is a consultant gastroenterologist at the John Radcliffe Hospital in Oxford, UK and lead author of the British Society of Gastroenterology's updated guidelines.

Here's a summary of what we discussed in this episode:

GOOD NEWS FIRST
• Bowel cancer risk in IBD has fallen dramatically over the past 20 years
• Current risk: 1.4–1.7 times the general population (much lower than older estimates)
• In numbers: 75 in 1,000 IBD patients vs 50 in 1,000 general population

KEY RISK FACTORS
• Inflammation severity and disease extent (biggest drivers)
• "Smouldering" inflammation counts—even without symptoms
• Family history of bowel cancer (first-degree relative)
• Post-inflammatory polyps (markers of past severe inflammation)
• Primary sclerosing cholangitis (PSC)—annual surveillance needed from diagnosis
• Most patients start surveillance 8 years after symptom onset

YOUR MEDICATIONS PROTECT YOU
• Mesalazine and biologics (especially anti-TNFs) reduce cancer risk
• Benefits of controlling inflammation outweigh theoretical immune concerns
• Keep taking your treatment

SURVEILLANCE COLONOSCOPY
• Frequency: every 1–3 years depending on individual risk
• Well-controlled disease: may only need every 10 years
• First surveillance: typically 8 years after symptom onset (earlier with PSC or severe early disease)

MAKING COLONOSCOPY MORE TOLERABLE
• Lower-volume bowel prep (2 litres or less) now recommended—just as effective
• Options: Moviprep, Plenvu, Citrafleet, Picolax
• Generous sedation recommended for IBD patients
• Propofol deep sedation should be available if needed

LIFESTYLE CHANGES THAT HELP
• Stop smoking
• Maintain healthy weight
• Regular exercise
• Mediterranean-style diet: less red/processed meat, more fish, fruit, vegetables, olive oil

RED FLAGS—SEEK URGENT ADVICE FOR:
• Bleeding without diarrhoea
• Symptoms not responding to usual treatment
• Significant weight loss
• Severe pain or abdominal lump
• Anything that feels different from your normal IBD pattern

FUTURE DEVELOPMENTS
• Stool-based biomarker tests to reduce colonoscopy frequency
• AI technology for detecting precancerous changes
• Genetic tests to guide treatment decisions

Remember: surveillance offers protection and promotes good gut health. Early detection of precancerous changes prevents cancer; early cancer detection means cure is possible.

Nigel and I would like to thank Professor East sincerely for donating his time for the promotion of patient education in this important area.

Here is the link to the online colorectal cancer risk calculator mentioned in the episode: https://ibd-dysplasia-calculator.bmrc.ox.ac.uk/

Here is the link to the British Society of Gastroenterology's updated guidelines on colorectal cancer risk in IBD: https://www.bsg.org.uk/clinical-resource/bsg-guidelines-on-colorectal-surveillance-in-ibd

Follow Rachel at @bottomlineibd

Follow Nigel at @crohnoid

#27 Understanding colorectal cancer risk in IBD - with Professor James East

Wrestling the Octopus (IBD)