How Can Diagnostic Accuracy be Improved

It is possible that new molecular markers in conjunction with histologic dysplasia will improve the sensitivity of the surveillance and biopsy approach. Cancer surveillance may also be improved by better selection of patients for inclusion in surveillance programmes, using markers other than dysplasia to predict cancer. Molecular genetic research may produce better ways of selecting patients at greatest risk [27]. It may also produce a better premalignant marker than dysplasia and it can help in distinguishing col-itic dysplasia from other entities. Chromoendoscopy can improve the detection of dysplasia and may also be helpful in distinguishing colitic neoplasia from non-colitic neoplasia. Dye spraying of the colonic mucosa during colonoscopy (chromoendoscopy) combined with high-resolution colonoscopy using a magnifying colonoscope is another measure used to increase the detection rate of neoplastic lesions in patients with colitis [28, 29]. Many of these new methods may be promising but no technique has yet been convincing or has entered into routine clinical practice.

Last but not the least, it should be emphasised that, apart from a highly skilled endoscopist and histopathologist, for a program of surveillance to be efficient, it also has to rely on both the physician's and patient's compliance. There should be regular call back for all participating patients so that no patients are lost in follow-up.

Even then, cancer surveillance does not totally eliminate the risk of cancer. Despite many successful results, one must question as to whether colonoscopy surveillance, arguably efficacious for special clinic populations, is truly effective even in the community at large. In other words, will the results obtained from careful clinical trials - produced under ideal conditions - be reproducible when deployed in routine clinical practice? For example, it has been estimated, as a "best-case" scenario, that colonoscopic surveillance may decrease the incidence of cancer from 7-8% down to 0.5-1% and the author claims that no actual program is likely to enjoy such success. Therefore, "at risk" ulcerative colitis patients who are averse to take this cancer risk and who cannot accept the imperfect and in many respects inconvenient nature of colonoscopic surveillance, should be recommended for prophylactic colectomy.

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