Study Does Not Support Intensified Screening of Vulvar or Vaginal Malignancies in IBD

Although inflammatory bowel disease (IBD) patients are at higher risk of HPV-related cancers, the data did not support intensified screening for vulvar or vaginal malignancies in female IBD patients, according to a study published in Digestive and Liver Disease.¹

However earlier onset cancer was reported, and lymphomas were detected in some patients, which tends to be rare in the genital tract. 

“A high percentage of HPV-related tumors might explain the younger age at diagnosis. HPV is strongly associated with higher rates of vaginal cancer in the general population, and other research suggests that IBD patients are at an increased risk for other cancers including cervical cancer,” investigator Maxine D. Rouvroye, MD, PhD candidate, of Amsterdam UMC, Vrije Universiteit Amsterdam, and Amsterdam Gastroenterology & Metabolism, said in a press release.² “Unfortunately, our data on HPV status are incomplete, as HPV status was analyzed in very few cases.”

Using the Dutch nationwide network and registry of histopathology and cytopathology from 1991 to 2015, researchers retrieved histopathological data of all IBD patients with a vulvar or vaginal (pre-)cancerous lesion and medical history was retrieved from patient records. Additionally, data from the Central Office for Statistics, the Dutch Comprehensive cancer organization, and the IBDSL cohort were obtained to calculate the standardized and age-adjusted incidence rates.

Overall, 55 patients met the inclusion criteria. A standardized incidence rate of 1.2 (95% CI, 0.8-1.7) for vulvar and vaginal carcinoma among adult females with IBD was calculated, which did not significantly differ from the general population. The use of immunosuppressive therapy did not increase the occurrence of vulvovaginal malignancy, nor did it affect the recurrence rate. However, immunosuppressive drugs ever-users were found to be, on average, 11 years younger at the time of their gynecological diagnosis. 

Within the study cohort, 67% of the women with vulvovaginal cancers had Crohn’s disease, versus 33% with ulcerative colitis. Researchers indicated that one potential contributing factor to this could be the use of immunosuppressive drugs earlier and more frequently in the disease course. Even though in this study immunosuppressive therapy did not appear to be a risk factor, a larger sample size could alter this outcome. 

In an editorial commentary, Vito Annese, MD, from the Valiant Clinic & American Hospital in Dubai, said, “these malignancies are clearly more frequent in Crohn's disease patients, were frequently very advanced at the time of diagnosis, and sometimes atypical. Although the authors did not find evidence for more advanced screening yet, it is cautious to recommend yearly gynecological surveillance starting at 40, especially in patients with Crohn's disease who are under immunosuppressive therapy.”³

The authors indicated that regardless of a general awareness among gastroenterologists of an elevated risk of HPV-related neoplasia in IBD, screening for cervical cancer and HPV-vaccination in female IBD patients remains suboptimal. Further, given that IBD patients in general are at higher risk of developing HPV-related oral cavity malignancies, this highlights the importance of screening for HPV and vaccination against high-risk HPV in females as well as males, especially in IBD. 

References:

1. Rouvroye MD, Jack GJ, Mom CH, et al. Vulvar and vaginal neoplasia in women with inflammatory bowel disease. Digestive and Liver Disease. doi:10.1016/j.dld.2019.10.002.

2. Immunosuppressive therapy for inflammatory bowel disease does not increase women’s risk of vulvar or vaginal cancer [news release]. Oxford. Published March 11, 2020. eurekalert.org/pub_releases/2020-03/e-itf031120.php. Accessed March 19, 2020. 

3. Annese V. IBD and malignancies: The gender matters. Digestive and Liver Disease. doi:10.1016/j.dld.2019.10.006.