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International Liver Conference

1st September 2006.
Venue: Queen Mary & Westfield College, Mile End, London.

Cancer risk in Primary Sclerosing Cholangitis (PSC) by Dr Stephen D Ryder

The potential risk of developing cancers is a concern for many people with sclerosing cholangitis. Many studies have shown an increased risk of some cancer types in this disorder. The two areas where cancers are undoubtedly more common are cancers arising in the bile ducts and in the large bowel (colon).

Colon cancer is a relatively common cancer in developed societies; in the UK it is the fourth commonest cancer with many thousands of people developing it every year. The UK government has just introduced a bowel cancer-screening programme to try and combat this. People who have PSC do seem to have an increased risk of bowel cancer overall. This risk is mainly confined to people who also have ulcerative colitis. It is well known that the chronic damage to the bowel that is caused in ulcerative colitis does cause an increase in bowel cancer risk even in people who do not have PSC as well. This risk rises over time with the colitis and with increasing damage from having active colitis. Most people with long standing colitis (more than 10 years) are advised to ask about screening. This is normally carried out using colonoscopy to detect pre-cancerous changes within the bowel lining so that surgery can be offered before cancer develops.

There is quite strong evidence, which suggests if people have ulcerative colitis and PSC the risk of bowel cancer may be increased further and therefore screening using colonoscopy is usually recommended. This may be at yearly or two yearly intervals depending on the individuals risk. It is also sensible to adopt other strategies known to reduce cancer risk, stopping smoking and eating a health well balanced diet.

The second type of cancer, which is more common in people with PSC, is cancer of the bile ducts (cholangiocarcinoma). This arises because of the damage that the PSC causes to the bile ducts. Cholangiocarcinoma remains a relatively rare cancer and the absolute risk of this developing in people with PSC is still small. If it does develop it can affect the liver in a number of different ways, potentially causing jaundice, upper abdominal pain and weight loss. There is currently no reliable way of screening people for the development of cholangiocarcinoma although many doctors routinely check blood cancer markers (Ca 19.9, CEA) as a means of trying to provide an early marker of the disorder. If present the cancer is usually diagnosed by abdominal scanning (CT or MRI) or by endoscopy tests (ERCP). Treatments that can be offered are surgery, chemotherapy and more recently a technique called photodynamic therapy which treats cancer cells by exposing them to laser light.

While cancer risk is often a concern for many people with PSC it is possible to reduce some of the risk by appropriate changes to lifestyle and screening.