Syed Zaki Muhammad  ( 2nd Year Medical Student, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan )
Noor Fatima  ( 1st Year Medical Student, Liaquat National Hospital and Medical College, Karachi, Pakistan. )

https://doi.org/10.5455/JPMA.65781

 

 

Madam, in 2018, Asia contributed the greatest burden of Colorectal Cancer (CRC) in the world, with highest proportion of incidence and mortality per 100,000 population.¹ In Pakistan, there is non-availability of recent centralized data showing incidence and prevalence of CRC from all over the country. A meta-analysis from 2018 reported prevalence to be at 5%.² With an aging population and prevalence of CRC risk factors, such as increased westernized diet, smoking, obesity, and inflammatory bowel diseases,³ this low incidence might be an artifact, as supported by a recent study from 2019 reporting a rise in CRC across Asia.¹ CRC screening not only has reduced mortality by early diagnosis, but also has reduced incidence by detection and removal of pre-cancerous lesions. CRC screening modalities include stool-based faecal occult blood testing (FOBT), faecal immunochemical testing (FIT), and multitarget stool DNA, radiography based computed tomographic colonography, blood-based detection of mutated methylated septin9 DNA, and endoscopy based flexible sigmoidoscopy (FS) and colonoscopy.⁴ The US Preventive Services Task Force recommends that options for CRC screening include an annual FOBT or FIT, FS every 5 years, and colonoscopy every 10 years starting from age 50 till age 75.⁵ FOBT and FIT are simple tests while FS and colonoscopy require bowel preparation.⁴ Colonoscopy is not readily available in our setup and is expensive. However, it is considered the gold standard for screening with reported high sensitivity and specificity, and the definitive test when other tests are positive.⁴ Even though the incidence of CRC is rising, there is a lack of knowledge regarding the risk factors and symptoms of CRC among the general population.³ This is probably why patients neglect early symptoms and present with advanced stage disease. In a previous study conducted in Karachi, only 2.6% of participants aged 50 years and older had undergone CRC screening earlier, reflecting the barriers to CRC screening that include inadequate infrastructure and screening tests being expensive. Participants also considered being embarrassed by the procedure and a lack of awareness regarding screening as a barrier.³ Therefore, before CRC arises as a big health challenge, it is advised to devise a comprehensive prevention plan that includes CRC screening and mass awareness programmes that also address the barriers to screening. Risk stratification, using Cleveland Clinic test and NCI test that provide 10-year risk assessment, could be utilized to target individuals most likely to benefit from screening to improve cost-effectiveness.⁴

 

Disclaimer: None to declare.

Conflict of Interest: None to declare.

Funding Disclosure: None to declare.

 

References

 

1. Onyoh EF, Hsu WF, Chang LC, Lee YC, Wu MS, Chiu HM. The Rise of Colorectal Cancer in Asia: Epidemiology, Screening, and Management. Curr Gastroenterol Rep 2019; 21:36. doi: 10.1007/s11894-019-0703-8.

2. Idrees R, Fatima S, Abdul-Ghafar J, Raheem A, Ahmad Z. Cancer prevalence in Pakistan: meta-analysis of various published studies to determine variation in cancer figures resulting from marked population heterogeneity in different parts of the country. World J Surg Oncol 2018; 16:129. doi: 10.1186/s12957-018-1429-z.

3. Hasan F, Mahmood Shah SM, Munaf M, Khan MR, Marsia S, Haaris SM, et al. Barriers to Colorectal Cancer Screening in Pakistan. Cureus 2017; 9:e1477. doi: 10.7759/cureus.1477.

4. Issa IA, Noureddine M. Colorectal cancer screening: An updated review of the available options. World J Gastroenterol 2017; 23:5086-96. doi: 10.3748/wjg.v23.i28.5086.

5. Bibbins-Domingo K, Grossman DC, Curry SJ, Davidson KW, Epling JW Jr, Garcia FAR, et al. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA 2016; 315:2564-75. doi: 10.1001/jama.2016.5989.