Root-cause Analyses of Missed Opportunities for the Diagnosis of Colorectal Cancer in Patients With Inflammatory Bowel Disease

Claire Gordon; Desmond Chee; Ben Hamilton; Neel M. Heerasing; Peter Hendy; Neil Chanchlani; Simeng Lin; Emma Wesley; Ian R. Daniels; Nishanthi Silva; Melanie Osborne; Nicholas A. Kennedy; James R. Goodhand; Tariq Ahmad


Aliment Pharmacol Ther. 2021;53(2):291-301. 

In This Article

Abstract and Introduction


Background: Colonoscopic surveillance in patients with inflammatory bowel disease (IBD) leads to earlier detection of colorectal cancer (CRC) and reduces CRC-associated mortality. However, it is limited by poor adherence in practice.

Aim: To identify missed opportunities to detect IBD-associated CRC at our hospital

Methods: We undertook root-cause analyses to identify patients with missed opportunities to diagnose IBD-associated CRC. We matched patients with IBD-associated CRC to patients with CRC in the general population to identify differences in staging at diagnosis and clinical outcomes.

Results: Compared with the general population, patients with IBD were at increased risk of developing CRC (odds ratio 2.7 [95% CI 1.6–3.9], P < 0.001). The mean incidence of IBD-associated CRC between 1998 and 2019 was 165.4 (IQR 130.4–199.4) per 100 000 patients and has not changed over the last 20 years. Seventy-eight patients had IBD-associated CRC. Forty-two (54%) patients were eligible for CRC surveillance: 12% (5/42) and 10% (4/42) patients were diagnosed with CRC at an appropriately timed or overdue surveillance colonoscopy, respectively. Interval cancers occurred in 14% (6/42) of patients; 64% (27/42) of patients had a missed opportunity for colonoscopic surveillance where root-cause analyses demonstrated that 10/27 (37%) patients known to secondary care had not been offered surveillance. Four (15%) patients had a delayed diagnosis of CRC due to failure to account for previous colonoscopic findings. Seventeen (63%) patients were managed by primary care including seven patients discharged from secondary care without a surveillance plan. Matched case-control analysis did not show significant differences in cancer staging or 10-year survival outcomes.

Conclusion: The incidence of IBD-associated CRC has remained static. Two-thirds of patients eligible for colonoscopic surveillance had missed opportunities to diagnose CRC. Surveillance programmes without comprehensive and fully integrated recall systems across primary and secondary care are set to fail.


Colonoscopic surveillance leads to the earlier detection of colorectal cancer (CRC) in patients with inflammatory bowel disease (IBD) and may reduce CRC-associated mortality.[1–4] International guidelines recommend that surveillance programs begin 8–10 years after diagnosis of IBD in all but those patients whose disease is limited to the ileum or rectum.[5–7] Thereafter, the surveillance interval is determined by the adequacy and endoscopic and/or histological findings of the previous colonoscopy. However, the effectiveness of colonoscopic surveillance in routine practice has been questioned because of poor adherence to surveillance protocols outside of clinical trials.[8,9]

Root-cause analyses were developed originally to recognise factors that cause variation in performance in high-risk organisations including aviation and nuclear power.[10,11] In healthcare, they have been applied to complex systems to understand why adverse outcomes occur. To prevent CRC, at-risk patients should be enrolled into surveillance programs so that pre-malignant lesions can be detected and completely resected. Because CRC can be diagnosed shortly after a normal colonoscopy, the World Endoscopy Organisation has constructed a root-cause analysis framework to identify why, so-called post-colonoscopy cancers, occur.[12,13] Using this tool to report factors linked to post-colonoscopy cancers in a mixed cohort of surveillance patients, the authors from an academic endoscopy centre in the UK, recommend extra vigilance in patients with IBD.[13]

We sought to define the proportion of patients diagnosed with an IBD-associated CRC who had had a missed opportunity for colorectal surveillance and whether this influenced stage at diagnosis of CRC or survival outcomes.