With great interest and appreciation we read the comments made by Drs Ullman and Lazarev. We collected data on all colorectal carcinomas (CRCs) in inflammatory bowel disease (IBD) patients over a period of 15 years in Dutch tertiary referral centers. Our data, as Ullman et al correctly state, does not allow conclusions about the incidence rate of CRC. It does, however, permit evaluation of time intervals between the diagnosis of IBD and CRC in the setting in which it is most frequently seen, the referral center. Our data indicate that in this setting approximately 20% of CRCs occur in the first decade of IBD. Severity of disease is likely to be a risk factor for CRC and patients in referral centers will undoubtedly have more severe disease. Whether the severity of IBD is implicated in differences in time intervals between IBD diagnosis and development of CRC, however, is speculative and not supported by evidence from literature. Another point of criticism focuses on the inclusion of CRCs that were diagnosed simultaneously with IBD. We acknowledge that surveillance strategies will never prevent patients from developing these early CRCs. The most compelling argument for inclusion of these cases in our view, however, was to illustrate that disease duration is an unreliable indicator for start of surveillance. It is extremely difficult to estimate the time colon mucosa has been exposed to inflammation. A confirmed diagnosis of IBD, employing endoscopy and histology, is the most objective way, but probably underestimates the total exposure time. On the other hand, onset of symptoms may be more sensitive, but lacks specificity. We assume that patients who present with IBD and CRC simultaneously were suffering from asymptomatic colitis for a longer period of time. Moreover, it cannot be excluded that such a delay is a common phenomenon in all IBD patients. Based on our observations, we find fault with surveillance guidelines that consider IBD duration as the only variable dictating initiation of surveillance. Instead of a “one-size-fits-all” strategy, we advocate to stratify patients using known CRC risk factors in IBD such as a young age at diagnosis, severity of disease, primary sclerosing cholangitis, and the presence of pseudopolyps. In our opinion, these variables should be taken into consideration when deciding whether a patient should be enrolled in a surveillance regimen or not, and, if so, when surveillance should be initiated. Our results should not be seen as a reason for rigorous revision of current surveillance guidelines, but as indication for further refinement. Scope Early and Often in Ulcerative Colitis and Crohn's Colitis?GastroenterologyVol. 136Issue 2PreviewLutgens M, Vleggaar FP, Schipper M, et al. (Department of Gastroenterology and Hepatology, University Medical Center, Utrecht, The Netherlands). High frequency of early colorectal cancer in inflammatory bowel disease. Gut 2008;57:1246–51. Full-Text PDF