Dr Rishi Fofaria (IBD)

Rishi Fofaria
Guts UK/Dr Falk 2019 Award Winner

Institution: St Mark’s Hospital & Academic Institute
Title: Investigating the role of pre-procedure stool-sampling to improve the quality of IBD cancer surveillance
Grant:  £5,149 Guts UK – Dr Falk SpR Trainee Audit/QI Award 2019

Summary:

Working in research over the last few years has given me a great enthusiasm for and understanding of the need for Quality Improvement in inflammatory bowel disease (IBD). One can provide excellent academic research but if the findings are not taken forward, implemented effectively on the ground and prospectively audited the patient will not realise any of the benefit.

Patients with IBD have a greater chance of developing bowel cancer and have regular camera tests as part of a surveillance program to spot pre-cancer changes (dysplasia) in their large bowel. However, surveillance camera tests rely on the use of dye sprays applied to clean and non-inflamed bowel to help spot these subtle changes.

A proportion of IBD patients are often asymptomatic but have an inflamed bowel when they arrive for their surveillance test which can make it difficult to spot dysplasia. These patients may have to come back to hospital for a repeat test which is costly, and not without risk; some may not be invited back or do not attend for a repeat test and are at potentially higher risk of developing dysplasia. Patients tell us often that they do not like colonoscopies or to be recalled for a test adding to their burden, which could already be quite significant.

Overall, up to 35% of patients with IBD-related bowel cancer had a supposedly reassuring camera test within the 3 years before their diagnosis. This would suggest that there may be a rapid progression of dysplasia after a surveillance procedure or more likely room to improve the quality of surveillance procedures to prevent ‘missed’ bowel cancers.

It therefore benefits everyone if we could improve the effectiveness of surveillance colonoscopy. However, currently there are few quality improvement initiatives targeting optimisation of IBD surveillance. Moreover, there are very few studies in the literature looking at optimising mucosal inflammation to improve pathology detection. By proactively assessing disease activity prior to scheduled surveillance, this may help to stratify patients who can be medically optimised to improve surveillance effectiveness as well as detecting asymptomatic patients who are at risk of an impending flare.

The aim of this study is to test whether an easy to use stool sample test (faecal calprotectin) and symptom-based questionnaire can predict whether patients will have an inflamed bowel at the time of their procedure. By identifying these patients there may be an opportunity to minimise the inflammation in their bowel to improve surveillance quality. This may also reduce the need for repeat investigations and reduce missed pathology and reduce the number of ineffective (and unpleasant) patient tests, optimise and reduce patient risk.

By carrying out this work, I hope that this may lead to the adoption of pre-procedure testing for all patients in an IBD surveillance programme around the UK as well as inspiring other quality improvement projects within IBD surveillance.

Improving the quality of IBD cancer surveillance is vitally important as these patients are at higher risk of developing bowel cancer. The funding from GUTS UK/Dr Falk will ensure we can carry out a pilot to predict which patients might be medically optimised prior to attending for a scheduled surveillance colonoscopy, improving safety and effectiveness.
‘I am so grateful to GUTS UK/Dr Falk for the opportunity to carry out this work which forms part of my overall research thesis and I hope it will also inspire further quality improvement work in this field.

Dr Rishi Fofaria