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December 22, 2015 Editor-In-Chief Annals of Gastroenterology Dear Prof. Koutroubakis, On behalf of my co-authors and myself, I would like to submit by enclosure of this letter a revised version of this invited review, entitled, “Use of biologics and chemotherapy in patients with inflammatory bowel disesase and cancer”. The manuscript has been modified following the reviewers’ comments. Our responses are outlined in this point-by-point response letter. We hope the revised manuscript is in accordance with the very helpful comments of the reviewers and it is suitable for publication in Annals of Gastroenterology in the present form. We thank you for the review of our manuscript and look forward to your future decision. With regards, Hans Prenen, MD, PhD University Hospitals Leuven Department of Gastroenterology Digestive Oncology Unit Herestraat 49 B3000 Leuven, Belgium Phone: +32 16 34 42 18 Fax: +32 16 34 44 19 Email: [email protected] Reviewer A: I was wondering if the authors would consider the possibility to discuss also the aspect of pouch carcinoma at the sub-population of patients with IBD who have ileal pouch anal anastomosis at the section of IBD-related cancer. It would be very helpful to comment if there are data about the relative risk of pouch carcinoma after restorative proctocolectomy with ileal pouch anal anastomosis and if there is a need for specific surveillance for these patients. We thank the Reviewer for this excellent proposal. We have added a new subsection, “Colorectal cancer after colectomy in IBD patients” with all this information (Page 8-9). Reviewer B: 1. Page 6 / 33, lines 20 - 21: Kindly add the relevant reference as regarding the increased risk of CRC in patients with IBD in the presence of PSC. We thank the Reviewer for this remark. The reference has been added (Page 7). 2. Page 8 / 33, lines 6 - 13: The authors are kindly recommended to take into consideration the following reference and, modify appropriately if this is the case: a) Glynne-Jones R, Nilsson PJ, Aschele C, Goh V, Peiffert D, Cervantes A, Arnold D; European Society for Medical Oncology (ESMO); European Society of Surgical Oncology (ESSO); European Society of Radiotherapy and Oncology (ESTRO). Anal cancer: ESMO-ESSO-ESTRO clinical practice guidelines for diagnosis, treatment and follow-up. Eur J Surg Oncol. 2014 Oct;40(10):1165-76 Following the Reviewer’s suggestion, we have modified the text and added this reference (Page 9). 3. Pages 11 and 12 / 33, lines 21 – 24 and 1 - 6: Kindly suggested, a comment to be added as regarding the non-melanoma skin cancer. Interestingly, it has been associated with increased UV exposure and elevated levels of serum vitamin D, but oral intake of vitamin D has been linked to a reduced risk of melanoma; however both links have been inconsistent in various studies. a) Eide MJ, Johnson DA, Jacobsen GR, Krajenta RJ, Rao DS, Lim HW, Johnson CC. Vitamin D and nonmelanoma skin cancer in a health maintenance organization cohort. Arch Dermatol. 2011 Dec;147(12):1379-84. b) Gandini S, Raimondi S, Gnagnarella P, Doré JF, Maisonneuve P, Testori A. Vitamin D and skin cancer: a metaanalysis. Eur J Cancer. 2009 Mar;45(4):634-41. c) Tang JY, Fu T, Leblanc E, Manson JE, Feldman D, Linos E, Vitolins MZ, Zeitouni NC, Larson J, Stefanick ML. Calcium plus vitamin D supplementation and the risk of nonmelanoma and melanoma skin cancer: post hoc analyses of the women's health initiative randomized controlled trial. J Clin Oncol. 2011 Aug 1;29(22):3078-84. As it has been proposed by the Reviewer, we have added this information and the corresponding references (Page 13). 4. Page 12 / 33, lines 20 - 22: Kindly add the relevant reference as regarding the incidence of the disease as well as the etiologic role of human papillomavirus. a) Colombo N, Carinelli S, Colombo A, Marini C, Rollo D, Sessa C; ESMO Guidelines Working Group. Cervical cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2012 Oct;23 Suppl 7:vii27-32. We thank the Reviewer for this comment. We have added the text and the reference (Page 14). 5. Page 13 / 33, lines 10 – 14: Kindly add the relevant reference as regarding the two prophylactic human papillomavirus vaccines. a) Tjalma WA. There are two prophylactic human papillomavirus vaccines against cancer, and they are different. J Clin Oncol. 2015 Mar 10;33(8):964-5. Following the Reviewer’s suggestion, we have added the reference. Commercial names of the 2 prophylactic vaccines have also been included in the text (Page 15). 6. Page 14 / 33, lines 13 – 17: Kindly requested to add a reference as regarding the incidence of cancer in patients with IBD and in general population either. We thank the Reviewer for this remark. References have been added (Page 15). 7. Page 15 - 16 / 33, lines 22 – 24 and 1 – 24: Brief information could be provided concerning the clinical research in colorectal cancer and the use of immune checkpoint inhibitors. These treatments work by targeting molecules that serve as checks and balances on immune responses. Current available immunotherapies for colorectal cancer fall into seven broad categories: monoclonal antibodies, checkpoint inhibitors and immune modulators, cancer vaccines, adoptive cell therapy, oncolytic virus therapy, cytokines, and adjuvant immunotherapies. These therapies are still in early-phase clinical testing (phase I and II) for colorectal cancer, but their successful use in other types of cancers suggests that they may ultimately prove useful for colorectal cancer as well. a) Le DT, Uram JN, Wang H, Bartlett BR, Kemberling H, Eyring AD, Skora AD, Luber BS, Azad NS, Laheru D, Biedrzycki B, Donehower RC, Zaheer A, Fisher GA, Crocenzi TS, Lee JJ, Duffy SM, Goldberg RM, de la Chapelle A, Koshiji M, Bhaijee F, Huebner T, Hruban RH, Wood LD, Cuka N, Pardoll DM, Papadopoulos N, Kinzler KW, Zhou S, Cornish TC, Taube JM, Anders RA, Eshleman JR, Vogelstein B, Diaz LA Jr. PD-1 Blockade in Tumors with MismatchRepair Deficiency. N Engl J Med. 2015 Jun 25;372(26):2509-20. b) Singh PP, Sharma PK, Krishnan G, Lockhart AC. Immune checkpoints and immunotherapy for colorectal cancer. Gastroenterol Rep (Oxf). 2015 Nov;3(4):289-297. c) de Guillebon E, Roussille P, Frouin E, Tougeron D. Anti program death-1/anti program death-ligand 1 in digestive cancers. World J Gastrointest Oncol. 2015 Aug 15;7(8):95-101. d) Housseau F, Llosa NJ. Immune checkpoint blockade in microsatellite instable colorectal cancers: Back to the clinic. Oncoimmunology. 2015 Mar 19;4(6):e1008858. eCollection 2015. Following the Reviewer’s suggestion, we have added a new section “Immunotherapy” in which we have summarized the main lines of the immunotherapy (Pages 19-20). 8. Page 17 / 33, line 13: Kindly requested to add a reference as regarding the chemotherapyinduced diarrhea. e) Stein A, Voigt W, Jordan K. Chemotherapy-induced diarrhea: pathophysiology, frequency and guideline-based management. Ther Adv Med Oncol. 2010 Jan;2(1):51-63. f) Alimonti A, Satta F, Pavese I, Burattini E, Zoffoli V, Vecchione A. Prevention of irinotecan plus 5fluorouracil/leucovorin-induced diarrhoea by oral administration of neomycin plus bacitracin in first-line treatment of advanced colorectal cancer. Ann Oncol. 2003 May;14(5):805-6. We thank the Reviewer for this suggestion. We have added these references in the manuscript (Page 18).