Introduction
Treatment targets of ulcerative colitis (UC) have evolved to include not only endoscopic but also histologic remission. However, the concept of histological activity is still in its early days. We aimed to capture the attitudes towards UC histology and the uptake of standardized reporting of endoscopy and histology of UC in daily practice.
Aims & Methods
We conducted a cross-sectional survey of physicians involved in the care of IBD worldwide. The survey included 21 questions divided into 3 sections. The first recorded demographics, specialty, and level of experience of participants; the second covered clinical practices and attitudes towards the use and reporting of endoscopy, and the third of histology.
Results
Participants: In total 359 physicians, from 60 countries (54.4% Europe, 24.4% Asia, 12.9% South America, 3.7% North America, 3.2% Africa, and 1.4% Oceania) responded; 87% were gastroenterologists, the remainder other specialists involved in the care of IBD. The majority practiced in academic hospitals (54.5%) or tertiary centers (22.1%), and only around one-fifth worked in secondary hospitals (12.8%) or local practices (8.1%).
Endoscopy: When performing endoscopy in quiescent UC, 72.1% of respondents reported taking biopsies also to assess microscopic activity, while 16.8% only for dysplasia detection, and 10.4% just in case of suspicious lesions; the average number of biopsies was 10.8 (SD 7.34, range 0 to 36). In the case of active UC, the percentage of operators collecting biopsies increased to 93.6%.
Endoscopy reports included a validated score in 91.9% of cases. Mayo was nearly always used (90%), with a large difference from the second most common score UCEIS (26.5%); other indices accounted for 1.7%. Of note, except for 1 respondent, all scores different from Mayo were used in addition to, and not instead of, Mayo. When restricting the analysis to participants working in high-volume centers (>500 UC patients cared for per year) all but one (117/118) reported using the Mayo score to grade endoscopic activity, and 32% (38/117) used also other scores in addition to Mayo, mainly UCEIS.
Histology: Centers represented in the survey were roughly equally split between those with a pathologist dedicated to IBD (46.2%) and those without (51%). UC histology was used by nearly all respondents (90.5%) for initial diagnosis, 72% to monitor disease course, 62.4% to determine microscopic extension, 59.9% to confirm deep remission when considering stopping treatment, and 42.3% to increase/optimize treatment. Nevertheless, 77.2% of participants reported that standard histological indices were not routinely available, although 21.7% of these used scores in selected cases, such as clinical trials or research. Among those who used (or worked in a center that used) standard scores (160/357) the choice of which index was mixed: 64.4% (103/160) used the Nancy index, followed by Geboes 31.9% (51/160), and Robarts 20.6% (33/160), a minority applied other scores.
The majority of respondents welcomed as useful or very useful an artificial intelligence system to automate scoring of endoscopy (69%) or histology (73%).
Conclusion
UC histology reports are less standard than endoscopy ones. Most physicians consider histological activity useful when managing UC and would welcome artificial intelligence systems to automate endoscopic and histological scoring.
Disclosure
OMN has served as a speaker for Janssen, Ferring, Takeda, Pfizer, Fresenius Kabi
MI has received research grants and equipment loans from Pentax USA, Olympus, and Fujifilm; is partially funded by NIHR Birmingham Biomedical Research Centre at the University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham.
LPB reports personal fees from Galapagos, AbbVie, Janssen, Genentech, Ferring, Tillots, Celltrion, Takeda, Pfizer, Index Pharmaceuticals, Sandoz, Celgene, Biogen, Samsung Bioepis, Inotrem, Al-lergan, MSD, Roche, Arena, Gilead, Amgen, BMS, Vifor, Norgine, Mylan, Lilly, Fresenius Kabi, OSE Immunotherapeutics, Enthera, Theravance, Pandion Therapeutics, Gossamer Bio, Viatris, Thermo Fisher; grants from Abbvie, MSD, Takeda, Fresenius Kabi; stock options: CTMA.
SG has served as consultant, Steering committee member, Advisory Board Member and Drug Monitoring committee member for Janssen, Pfizer, Takeda, Abbvie, BMS, Gilead, Galapagos, Celltrion, Eli Lilly, Ferring.
SD has served as a speaker, consultant and advisory board member for Schering Plough, Abbott (AbbVie) Laboratories, Merck and Co, UCB Pharma, Ferring, Cellerix, Millenium Takeda, Nycomed, Pharmacosmos, Actelion, Alfa Wasserman, Genentech, Grunenthal, Pfizer, AstraZeneca, Novo Nordisk, Vifor and Johnson and Johnson.
Remaining authors declare no relevant conflict of interest.