By Jun R. Ruiz Jr., M.D.

Colorectal cancer is an important preventable and treatable cancer, as it ranks as the third most common cancer in the Philippines. In 2020, an estimated 17,364 new patients in the country were reported to be diagnosed with colon and rectal cancer.

The COVID-19 pandemic has severely challenged routine health care, including screening for colorectal cancer (CRC). The interruption of CRC screening had been reported to result in a delayed diagnosis of colon and rectal cancer, leading to a risk for advanced stage progression and poorer outcomes.

Even before the pandemic, there has been an increasing incidence of CRC in persons younger than 50 (young-onset colorectal cancer), especially among American patients. After a systematic analysis, the United States Preventive Services Task Force (USPSTF) changed its recommendations to begin screening average-risk persons for CRC from age 50 to 45. The applicability of these guidelines on Philippine patients remained unanswered.

What’s in store for Filipinos in the Universal Health Care Era?

For these relevant public health issues, the Augusto P. Sarmiento Cancer Institute (APSCI) of The Medical City organized a very successful virtual forum titled “CRC Screening 2022: What’s in Store for Filipinos in the Universal Health Care and Post-Pandemic Era” on March 4, 2022. This was a collaboration of The Medical City with the Department of Health (DOH). This webinar is in support of the hospital’s Colon Cancer Awareness Advocacy.

The symposium was moderated by Dr. Jun R. Ruiz, the Lead for the Colon Cancer Screening Advocacy Program. The speakers included Professor Jose D. Sollano (former president of both the Philippine Society of Gastroenterology, and Philippine Society of Digestive Endoscopy), Dr. Mark Anthony De Lusong (Assistant Division Chief of Gastroenterology of Philippine General Hospital), and Dr. Clarito Cairo, Jr. of the Department of Health (DOH).

The Impact of the Pandemic in Patient Outcomes

In his talk, Dr. De Lusong noted a drop to 58 percent in the number of colonoscopies performed at The Medical City in 2020 and a further drop to 48 percent in 2021 from the 2019 census, especially those done for screening—comparing pandemic to pre-pandemic times. Both the National Kidney and Transplant Institute, and the Philippine General Hospital also had comparable reductions in their numbers. This is understandably so, as both physicians and patients were anxious to be infected with COVID-19, as numerous endoscopic procedures were deemed to be elective and non-urgent.

During the pandemic, symptomatic patients were prioritized, and procedures for asymptomatic patients were deferred. Last year, the patients tended to wait than go to hospitals, and telemedicine consultations were increasingly availed. However, such patient behavior resulted in delay in seeing colorectal cancer patients, leading to more cancer in later stages being diagnosed, Dr. De Lusong added.

Is “45 the new 50 in CRC” in the Philippines?

The recommendation of lowering the screening age in the United States by the US Preventive Services Task Force was based on more recent American patient data and the government’s capacity of their healthcare resources to respond to these added needs. Americans have a much higher risk to CRC than Filipinos, owing to their genetics, Western diet and lifestyle, like obesity. In contrast, the Philippines is a low-resource country without even a national screening program in CRC. Do we automatically adopt these American guidelines, despite the big difference in genetics, environmental factors, and national government resources?

Prof. Sollano analyzed the data to answer this question whether "45 is the new 50 for screening average-risk Filipinos?" However, there is no data available yet in the Philippines that can demonstrate an increase in patients with young-onset CRC, unlike in Western medical literature. The screening guidelines of other Asia-Pacific countries are still recommending the start of screening at the age of 50. The cost-effectivity of lowering the age to 45 has not yet been demonstrated in the East. 

In building a colorectal cancer screening program, "the government needs data, infrastructure, personnel, and funds," Prof. Sollano emphasized. Without any clinical evidence, structured program or money from the national government, lowering the age of screening average-risk Filipinos for CRC may not yet be feasible in the Philippines.

Department of Health proposes a colorectal cancer screening program

It has been three years since the successful passage of the National Integrated Cancer Control Act (NICCA). The good news about NICCA is that PhilHealth is expanding its benefit packages to include screening for cancer.

Dr. Cairo of the DOH said that the department will be launching a national CRC screening program this year using Fecal Immunochemical Test (FIT) and colonoscopy in selected hospitals. The Cancer Assistance Fund will be used to procure the initial 50,000 FIT test kits to be given away for free to the eligible population.

This DOH initiative will help address the preventable and treatable aspect of CRC as a public health problem. Healthy lifestyle and appropriate screening will help us beat colorectal cancer.

About the author: Dr. Jun R. Ruiz is a Philippine and American board certified gastroenterologist at The Medical City. He is also the Lead for Colorectal Cancer Screening Program and the Programs and Advocacy of the APSCI of Cancer Institute.