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decisions. For example, reporting the relative risk without also reporting the abso-
lute risk can skew a patient’s perception of the likelihood of an event occurring
and may deter someone from utilizing a medication that may offer improved qual-
ity of life and potential remission from their underlying disease. It is important to
use absolute as opposed to relative numbers and use actual odds rather than per-
centages (e.g., 5 per 1000 instead of 0.5%). Often, pictures can be used to repre-
sent numbers of patients at risk. This can help patients to understand the true
absolute risks of malignancy. Comparisons between risks should be presented
with a common denominator to avoid confusion. The more specific the clinician
can be when describing the likelihood of both risks and benefits, the more likely
the patient is to have a well-informed and realistic grasp of their options. Finally,
putting together the big picture for the patient in terms of quality of life benefits
both long term and on a day-to-day basis as opposed to a cumulative life risk can
be invaluable to a patient grappling with the decision to start a biologic or other
medical therapy [ 48 ].
Prevention of Complications of Immunosuppressive
Medications in IBD
There are three forms of prevention: primary, secondary, and tertiary prevention.
Primary prevention refers to prevention of development of a disease or complica-
tion, such as through vaccination. Secondary prevention refers to the ability to
detect disease earlier, when it may be easier to treat or manage, in order to prevent
disability. An example of secondary prevention would be screening programs,
such as those for colon cancer screening. Finally, tertiary prevention refers to mea-
sures that reduce the impact of long-term disease and disability, in order to maxi-
mize potential years. Each of these forms of prevention can be addressed for
patients with IBD.
For primary prevention of malignancy, there are opportunities to prevent both
cervical cancer and skin cancer. Recommendation of HPV vaccine for women age
11–26 can help to prevent cervical cancer. As we know that the mechanism of
increased skin cancer risk associated with thiopurines is photosensitivity to UV-A
light, recommendation for broad spectrum sunscreen use can help to prevent this
complication. For secondary prevention, colonoscopic surveillance based on
available guidelines to detect colonic dysplasia in those with long-standing
colonic inflammation can help prevent colorectal cancer through early identifica-
tion of dysplasia. For women, screening pap smears based on the US Preventive
Services Task Force (USPSTF) and American College of Obstetricians and
Gynecologists (ACOG) recommendations should be performed. Additionally,
consideration should be given for skin screening examinations among patients
with IBD on known higher-risk medications such as immunomodulators and
J.T. Hughes and M.D. Long