“Ulcerative colitis is a chronic disease that most physicians opt to treat with medications, as opposed to surgery,” said the study’s lead author Meenakshi Bewtra, MD, PhD, MPH, assistant professor of Medicine and Epidemiology at Penn. “This new finding highlights a potential unrecognized advantage of a surgical approach to the disease.”
Ulcerative colitis is a type of inflammatory bowel disease characterized by inflammation in the colon, or the large intestine. The inflammation can cause abdominal discomfort, bleeding, and diarrhea. It affects as many as 700,000 Americans, according to the Crohn’s & Colitis Foundation of America. Men and women are equally affected, with most patients diagnosed by their mid-30s.
The convention in treatment of UC is that surgery is considered a treatment of last resort. However, medical treatments, involving immunosuppressant and steroid drugs, come with significant side effects, and can increase the risk of infection and some cancers. These medications effectively control the disease in less than 50 percent of patients.
In a retrospective study, Bewtra and colleagues analyzed data from the Centers for Medicare and Medicaid Services (CMS) to examine whether patients with advanced UC pursuing elective colectomy – in which surgeons remove the patient’s colon — had improved survival compared to similar patients pursuing chronic drug therapy. The researchers defined advanced UC as those patients who had had at least one hospitalization for UC, had two or more corticosteroid prescriptions within a 90-day period, or had any prescription for immunosuppressant therapy.
The study identified 32,833 UC patients 18 years of age and older who had at least six months of Medicare/Medicaid eligibility and who fit the inclusion criteria. Of these, 830 underwent elective colectomy and the remaining 32,003 were managed on drug therapies.
Mortality rates associated with elective colectomy and medical therapy were 34 and 54 per 1,000 person-years, respectively, thus showing that elective colectomy was associated with an improved survival rate. A person-year is a measure of survival that is equivalent to the number of years a person is followed multiplied by the number of subjects in the study. In further analysis, the survival benefit seemed greatest in patients age 50 and over. The findings also suggested a benefit for surgery in those patients who could not sustain a disease remission – defined as stable disease without the need for hospitalization or changes to drug therapy — on immunosuppressant therapy, but further work is needed to confirm these results.
“With this new knowledge, physicians should be empowered to begin a dialogue about surgery earlier in their patients’ course of treatment,” Bewtra said. “Many patients are afraid of surgical therapy for UC. This study should help them to understand that the benefits of surgery may extend beyond just reducing the symptoms of uncontrolled UC.”
This research was supported by NIH grant (K08 DK084347-01), (K24 DK078228) and the Agency for Healthcare Research and Quality (R01HS018517)
Additional Penn authors include James D. Lewis, MD, MSCE; Craig W Newcomb, MS; Qufei Wu, MS; Lang Chen, PhD; Fenglong Xie, MS; Jason A. Roy, PhD; Cary B. Aarons, MD; Mark T. Osterman, MD, MSCE; Kimberly A. Forde, MD, MHS; Jeffrey R. Curtis, MD, MS, MPH.
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