Cancer

& Inflammatory Bowel Disease (IBD)

KEY POINTS:

Persons with inflammatory bowel disease (IBD) are not at any increased risk for many common cancers like breast cancer, prostate cancer or lung cancer. There is an increased risk for colon (or bowel) cancer and in specific types of disease, small bowel cancer and bile duct cancer. The latter two cancers are very rare.
Screening looks for cancers before they cause symptoms and when they are most treatable.
Regular colon cancer screening is important in ulcerative colitis and for persons with Crohn’s disease with colon involvement. After 8 years of disease, colonoscopy every year (if certain risk factors are present) to every three years or more may be recommended.
Immune suppressive drugs are very helpful in treatment of IBD. People using some of these drugs have an increased risk for lymphoma, a rare cancer of lymph cells in the blood and lymph nodes. They also have an increased risk of skin cancer or cervical cancer.
All patients on the immune suppressive drugs azathioprine or 6-mercaptopurine should use sun screen regularly when exposed to the sun, because of the increased risk of skin cancer. They should report any unusual mole or skin bump to their doctor. Women, especially those who are using these immune suppressive drugs, should be regularly screened with PAP smears (at least once every 3 years) and young women should get HPV (human papilloma virus) vaccine.
Speak to your IBD doctor about recommended screening for cancer.
Risks of most types of cancer in the general population are reduced when you have a healthy lifestyle (no smoking, healthy exercise and eating, limited alcohol).

Colon cancer

People with ulcerative colitis or Crohn’s disease affecting the colon have an increased risk of colon cancer.
People with ulcerative colitis of the rectum only, are not an increased risk of colon cancer
People with Crohn’s disease that does not affect the colon do not have an increased risk of colon cancer.
Colon cancer is more common in older people and persons over age 65 are most likely to be diagnosed with colon cancer (whether or not they have IBD). Having a close family member (parent, brother or sister) who developed colon cancer is also associated with increased risk. Common symptoms of colon cancer are passing blood in the stool and developing anemia (low hemoglobin levels) which can be associated with fatigue. These symptoms can also be due to colitis itself and most people with early colon cancer have no symptoms. Hence regular colonoscopy screening is warranted.
Over a person’s lifetime the risk of dying from colon cancer is modest. About 30 in 1000 people without IBD and 60 in 1000 people with IBD will die from colon cancer.
The risk for colon cancer is increased with increasing number of years with IBD (the risk starts to rise after 8 years of disease). The risk is also increased if there is active inflammation that does not improve with treatment.
Patients with ulcerative colitis or Crohn’s disease that affects the colon will usually start to have screening colonoscopies at 8 years of disease. It is reasonable to repeat these colonoscopies approximately every 3 years if the disease is under good control. If other factors are present your doctor may recommend more frequent or less frequent screening colonoscopies.
Primary sclerosing cholangitis is a liver disease that develops in about 2 of 100 people with IBD. Common symptoms are jaundice (eyes or skin turning yellow), itching, and fevers. These people are at a particularly high risk of colon cancer. Regular screening colonoscopies are often recommended as soon as this liver disease is diagnosed (every 1 to 2 years).
Bile duct cancers are extremely rare. However, in a person with primary sclerosing cholangitis they are much more common (5 to 10 people with primary sclerosing cholangitis out of 100 will develop this over a lifetime). There is no increased risk of bile duct cancer among those with IBD without primary sclerosing cholangitis. Unfortunately, there are no proven methods to decrease risks of bile duct cancer in this liver disease. A common symptom is developing deeper jaundice (eyes or skin turning yellow).
Additional risk conditions for colon cancer in IBD. If the colitis is very active at the time of colonoscopy, then increased treatment may be advised and later repeating the colonoscopy. If a person has a close family member with colon cancer (especially at a younger age) then a screening colonoscopy is usually advised every 1-2 years. If there are many pseudopolyps (small lumps of tissue that are left from inflammation) in the colon, screening colonoscopy every 1-2 years may be recommended as pre-cancerous growths are harder to identify because of the pseudopolyps.
Screening colonoscopies at the intervals recommended by your doctor are the best way to reduce the risk of colon cancer. If colon cancer is found it is often at an earlier and more curable stage.
People with ileal Crohn’s disease are at risk for cancer of the ileum. However even in persons with Crohn’s disease this is a rare cancer. There are no specific surveillance approaches for this cancer.

Lymphoma

Lymphoma is a cancer of the lymph cells in the blood or lymph system. Approximately 2-3 out of every 1000 Canadians will develop lymphoma in their lifetime. Common symptoms are lumps that may be felt in the neck, armpits or groin, persistent fevers, and excess fatigue. Studies from Manitoba suggest that persons with Crohn’s disease (especially elderly males) are at somewhat increased risk for developing lymphoma.
Persons with IBD using immune suppressive drugs (such as azathioprine or 6-mercaptopurine) have an increased risk of lymphoma. There is no increased risk after stopping these drugs.
The use of anti-TNF medicines (such as infliximab or adalimumab) likely also has a small increased risk of lymphoma similar to that seen with the risk from immune suppressive drugs.
Most experts suggest that the benefits of these immune suppressive medicines outweigh the risk because having poorly controlled IBD has serious health effects also. Hence these drugs are widely prescribed in managing IBD and other inflammatory conditions.

Cervical cancer

There is no increased risk of getting cervical cancer or dysplasia (an abnormal cell condition that develops before cancer) in women with IBD.
About 7 in 1000 women in the general population will develop cervical cancer over their lifetime. Symptoms: Occasionally cervical cancer is associated with ongoing bleeding in between menstrual cycles bleeding or discharge through the vagina. Often women with cervical cancer or dysplasia have no symptoms. Identification is most often achieved on routine screening.
Users of the immune suppressive drugs such as azathioprine or 6-mercaptopurine are at increased risk for developing cervical dysplasia and cancer.
All women, especially those who use the immune suppressive drugs azathioprine or 6-mercaptopurine, should have regular PAP smears (at least once every 3 years) and consider getting HPV vaccine when young.

Skin cancer

Skin cancer is the most common form of cancer in the population. Most of these are less severe cancers that occur later in life and are quite treatable (basal cell and squamous cell skin cancers). The major risk factor for skin cancer is exposure to ultraviolet (UV) radiation from the sun or from tanning beds. The rate has increased considerably in recent years with more people focusing on tanning. Common symptoms are unusual new moles, skin bumps, or persisting skin sores or ulcers.
People using immune suppressive drugs used in IBD and various other health conditions have an increased risk of skin cancer and should make regular use of sun screen when exposed to sun.

References

Beaugerie L, Itzkowitz SH. Cancers complicating inflammatory bowel disease. New England Journal of Medicine. 2015 Apr 9;372(15):1441-52

Bernstein CN, Kliewer E, Wajda A, Blanchard JF. The incidence of cancer among patients with IBD: A population-based study. Cancer 2001; 91: 854-862.

Canadian Cancer Society’s Advisory Committee on Cancer Statistics. Canadian Cancer Statistics 2015. Toronto, ON: Canadian Cancer Society; 2015

Laine L, Kaltenbach T, Barkun A, McQuaid KR, Subramanian V, Soetikno R; SCENIC Guideline Development Panel. SCENIC international consensus statement on surveillance and management of dysplasia in inflammatory bowel disease. Gastroenterology. 2015;148(3):639-651.

Lemaitre M, Kirchgesn J, Rudnichi A, Carrat F, Zureik, M, Carbonnel F, Dray-Spira R. Association Between Use of Thiopurines or Tumor Necrosis Factor Antagonists Alone or in Combination and Risk of Lymphoma in Patients With Inflammatory Bowel Disease. JAMA 2017 Nov 7; 318(17): 1679–1686.

Singh H, Demers AA, Nugent Z, Mahmud S, Bernstein CN. Risk of cervical abnormalities in women with IBD: a population-based nested case-control study. Gastroenterology 2009; 136: 451-8.

Singh H, Nugent Z, Demers A, Bernstein CN. Increased risk of non-melanoma skin cancer among individuals with inflammatory bowel disease. Gastroenterology 2011; 141: 1612-1620.

Last reviewed: March 2020

For more information and fact sheets about IBD and its treatment please visit: http://www.crohnsandcolitis.ca

Disclaimer: This information is provided for educational purposes only. Always consult a qualified health care professional for your specific care.

Source: This summary provides scientifically accurate information. It was prepared in a research review by researchers with the IBD Clinical and Research Centre, University of Manitoba with assistance from colleagues in Canada and internationally.

Acknowledgement: Preparation of this material was supported by funding from the Canadian Institutes of Health Research.

©2016 Charles N. Bernstein, John R. Walker on behalf of Manitoba IBD Clinical and Research Centre. This work is licensed under a Creative Commons Attribution-nonCommercial-NoDerivs 2.5 Canada License. You are free to copy and distribute this material in its entirety as long as: 1) this material is not used in any way that suggests we endorse you or your use of the material, 2) this material is not used for commercial purposes, 3) this material is not altered in any way (no derivative works). View full license at http://creativecommons.org/licenses/by-nc-nd/2.5/ca/.