March is the Colorectal Cancer Awareness Month. This malignancy of the digestive tract is the 3rd most common cancer among Filipinos, despite it being one of the most treatable and preventable cancers. Colorectal cancer screening has been shown to reduce the risk of death by around 70%. The massive worldwide campaign for colorectal cancer screeninghas its beginnings in the United States in 2000.
In the Philippines, The Medical City and its doctors have been among the leading advocates for this cause since 2010, initiated by noted colorectal surgeon Dr. Manuel Francisco T. Roxas. The Medical City has been among the first institutions in the Philippines to champion this advocacy, as it continues to be at the forefront in the fight against colorectal cancer (CRC) for more than 10 years.
This fight against the world’s second deadliest cancer is an uphill battle in the Philippines. The lack of a national population-based CRC screening program and thebig financial burden of CRC screening on the patient are barriers to this campaign. In addition, several local health maintenance organizations (HMOs) still refuse to pay for CRC screening strategies. There is also an apparent lack of awareness among the primary health providers of the screening guidelines for colorectal cancer screening.
The Covid-19 Pandemic
The COVID-19 pandemic has been an unprecedented global health crisis that has severely challenged the provision of routine healthcare, including screening for colorectal cancer. These screening programs throughout the world ceased operating primarily due to fear of SARS-CoV2 transmission and from decreasing health care resources. There is a realrisk of spreading and being infected during an endoscopy examination, due to the potential aerosol-producing nature of these procedures. Colorectal cancer screening almost stood still in most parts of the world during the pandemic, except for places like Kaiser Permanente in California, USA. The professional societies initially recommended only emergent endoscopic procedures for symptomatic patients. Screening and surveillance procedures were mostly not performed duringthe pandemic period as these were considered elective.
The interruption of CRC screening and surveillance in many countriesduring the pandemic has resulted in a delayed diagnosis of colorectal cancer, possibly in a more advanced stage. Published articles have shown that delaying colonoscopy by >9 months after a positive Fecal Immunochemical Test (FIT) can lead to increased risk of CRC and advanced stage CRC.
Risk factors for colorectal cancer
Despite these challenges, we need to continue educating theprimary health care providers, our patients and the general public on the importance of colorectal cancer screening. I will discuss here the essentials of colorectal cancer and its screening.
Almost all of these colorectal cancers start as abnormal growths in the lining of the colon and rectum called polyps. These polyps grow slowly and may take around 10 years for some polyps to develop into cancer. However, not all polyps progress to cancer. The removal of these polyps reduces the risk of developing cancer.
These polyps and early cancer may not cause complaints, like rectal bleeding, constipation, and abdominal pain that are experienced by patients in later stages of cancer.
The most common individual-specific factors that increase risk for cancer in the colon and rectum are: 1) age greater than 50; 2) personal history of colorectal cancer or advanced polyps; 3) family history of cancer in the colon and rectum; 4) certain diseases, like Inflammatory Bowel Disease.
Age >50 is the most common risk factor for this cancer, as 90% of occur after the age of 50. A family history of a first-degree relative with CRC is increased two to three-fold.
There are also lifestyle habits that can be modified that likely contribute to the formation of this cancer: 1) cigarette smoking; 2) alcohol consumption; 3) obesity; 4) lack of exercise; 5)a diet that has high saturated fat, low fiber, and high red meat consumption.
Living a healthy lifestyle by avoiding smoking, not consuming excessive alcohol, regular exercise, and eating the right food all can lower your risk of cancer in the colon and rectum.
Colorectal cancer screening
In several countries, CRC screening is recommended for people starting the age of 50 years. Screening at an earlier age, usually at 40, is advocated in first-degree relatives of patients with colorectal cancer, and in those with other additional risk factors. Currently in the United States, a recommendation to startscreening the average-risk patients earlier at the age of 45 due to increasing incidence of colorectal cancer in younger individuals. The death of “Black Panther” star Chadwick Boseman last year brought the spotlight on colorectal cancer, when he died at a young age of 43.
The gold standard for CRC screening is a colonoscopy as it can detect and remove pre-cancerous polyps. The procedure involves a flexible fiber-optic scope with a camera that is inserted through the rectum and is carefully advanced to visualize the colon under mild anesthesia.
Some patients may not want to have an invasive test. A stool test called FIT is a good screening alternative. It detects only human blood and is specific for bleeding in the colon. The test is repeated every year if the initial test is negative. If the test is positive, a colonoscopy is needed to rule out the presence of cancer. In pandemic times, the FIT test may be used to stratify patients as to who need the colonoscopy more urgently than others, given the more limited health resources of our country during these times.
If we want a population-based screening program in the Philippines, FIT is the most appropriate method in the age of Universal Health Care and post-Covid Era to screen more Filipinos. This important preventive healthcare measure can cover more patients than using colonoscopy as the primary screening method, which is available only in urbanized areas.
The Augusto P. Sarmiento Cancer Institute (APSCI) is inviting you to attend the Forum “Best Practices in Colorectal Cancer Screening and the Challenges of Cancer Screening in the Covid-19 Pandemic and Beyond” on March 4, 2020 at 9:00 AM. Please check The Medical City Facebook account or call either 8988-1000 local 6214or 0916-241-4584 for more details.
Author’s Description: Dr. Jun R. Ruiz is a Philippine and American board-certified gastroenterologist and the lead advocate for colorectal cancer screening of the Augusto P. Sarmiento Cancer Institute of The Medical City.He finished his Gastroenterology Fellowship at the George Washington University Medical Center in D.C. He was part of the staff of the Gastroenterology Department in Kaiser Santa Clarain their successful colorectal cancer screening program of the Kaiser Permanente in Northern California from 2005 to 2013.