Gastroenterologists Hope to Change the Course of Disease in the Future

If gastroenterologists are able to predict at diagnosis the course of inflammatory bowel disease (IBD) it could drive better treatment decisions.

While it is a lofty goal, Andres Hurtado-Lorenzo, PhD, the Crohn’s & Colitis Foundation's Vice President of Translational Research, said within 10 years gastroenterology doctors could be able to accurately predict the course of disease at diagnosis and whether a patient will be vulnerable to additional complications and severe outcomes moving forward.

“I believe that we will be closer to have informed treatment decisions based on prognosis,” he said in an interview with HCPLive®. “Basically, the idea that would allow us to predict how aggressive the disease course is, how complicated the disease course is and based on that we can tailor the treatment in the best way so that we can initiate aggressive treatment in patients predicted to have aggressive disease courses or complications.”

The biggest realistic achievements that could occur in the next 10 years that will allow doctors to tailor treatment to disease course could be advent of prognostic and predictive tests, as well as the identification of biomarkers that can tell a story at the beginning of a diagnosis whether the patient will respond to certain treatment. While most of these tests are not yet available, Hurtado-Lorenzo said they will be in the next 10 year, completely upending how we currently treat IBD patients.

“I hope that at the end of the next 10 years, we are transitioning from treatment goals, that is more of a sense of symptomatic, to more disease modification goals and the use of objective measurements,” Hurtado-Lorenzo said. “We need to really modify the disease, so we can change the natural history of the disease and to achieve that, we are looking for more objective measurements.”

The ultimate goal will be for doctors to pinpoint shortly after diagnosing a patient with some form of IBD whether or not they will likely have a lot of complications or relapses to drive treatment decisions. This knowledge will enable doctors to begin high risk patients with biologics from the start, as opposed to a data scale lab approach that would begin the patients on several other medications before needing to settle on the biologics.

Hurtado-Lorenzo said an example of how you can do that is by focusing less on an individual symptom and more on improving something objective, such as mucosal healing. This concept is already begun to be clinically implemented and he expects it will continue to grow.

However, there are challenges that need to be hashed out in the next 10 years for the concept to become widespread in gastroenterology because it is difficult to define what an objective measure is.

“Is it that you want an endoscopic remission or is it that you want a histological remission or do you want both?” Hurtado-Lorenzo said. “We still need to define that, but I think by the end of the decade we might have a better definition of a treat-to-target and the implementation.”

A byproduct of the ability to prognostic disease course in individual patients will be more effective biologics. Hurtado-Lorenzo explained that the ability to test patients and predict complications will allow doctors to set proper biologic dose limits that will have efficacy in a way they are currently unable to do. This ultimately can spur new biologic options.

Currently, about 40% of IBD patients do not respond to biologics, meaning more research in biologics is needed in the next decade.

The knowledge of diseases like ulcerative colitis and Crohn’s disease is also expected to improve drastically over the course of the next 10 years. A closer examination of how things like diet, stress, and environmental factors could allow researchers to better develop treatments and predictive measures for disease course.

Outside of some major advancements in IBD treatment, investigators are predicting a big decade of advancements for other gastrointestinal diseases, such as gastrointestinal cancers and hepatitis C.

However, like most medicinal fields, there remains an income gap where some diseases are treated much better in higher income parts of the world than they are in lower income parts of the world.

Often gastrointestinal diseases have higher mortality rates in lower income countries, largely because of high rates of malnutrition and unsafe drinking water.

In an interview with HCPLive®, Mark Topazian, MD, of the Mayo Clinic and the World Gastroenterology Organization (WGO), said he sees signs that treatments and screening methods can improve in the next 10 years.

“Traditionally in low income places, either screening hasn't been feasible or available or we just don't know how to screen for some of these cancers no matter what the resource level is,” Topazian said. “And that’s all changing very rapidly.”

Not only is there a push for affordable options in some of the poorest areas of the world, there also is continuing growth on how diseases can present differently in different regions.

An example of this is seen in esophagus cancer, which presents in the US mainly in the form of adenocarcinoma, often arising from a condition called Barrett’s esophagus.

Doctors in the US often screen patients for Barrett’s esophagus using endoscopy, but new methods are becoming increasingly more common.

“Just this year, methods for screening the esophagus for Barrett's change, without endoscopy are coming to the forefront and are beginning even to enter clinical practice,” Topazian said. “So that’s really exciting.”

Another area of focus for Topazian is hepatitis C, where total eradication might actually be on the table in the next decade.

“Well, there's no question that we can cure hepatitis C in individual patients now,” he said. “I mean, there's there was a remarkable advent of this group of medical treatments that In over 95% of patients cure their chronic infection, it's really the first curable chronic viral infection of man, hepatitis C.”

Topazian explained that this is a worldwide push, which is evident by the fact that a number of countries have entered into partnerships with the US pharmaceutical industry to roll out population-based screenings and treatment for hepatitis C.

However, while some are confident in the eventual total eradication of hepatitis C, Topazian is less sure.

“I think our lesson with the lesson of polio is a cautionary tale,” he said. “I don't know that we'll ever get to 100% eradication, it would be great if we did. But clearly we can make major progress.”

In general, gastroenterologists were less optimistic (6.8/10) than their colleagues in other specialties, including cardiology (8.2/10) and psychiatry (7.8/10).