The challenges of fighting any disease in middle-income and low-income countries, such as Pakistan, are greater than those encountered in the Western world and this is especially so for a disease like cancer. March is colorectal cancer awareness month, an opportunity for healthcare providers, in particular general physicians, to play their part in addressing the unique challenges of fighting colorectal cancer in Pakistan. Cancer is, in the main, a sporadic disease, but some cancers, including colorectal cancer, can be diagnosed at an earlier stage by screening programmes, which aim to detect cancers before they become clinically apparent. As many in our country transition to a more “Western”, and sedentary, lifestyle, with a diet rich in highly processed foods, and as our population ages, the incidence of colorectal cancer (CRC) is expected to increase in Pakistan. There is an urgent need to act now and adopt preventive strategies to reduce morbidity and mortality from colorectal cancer in Pakistan in years to come.
In many more developed countries, mass screening programmes for colorectal cancer, focusing on early detection and treatment in a timely manner, are now in place. However, limited resources and, variable systems of healthcare delivery have meant that mass screening for colorectal cancer has been a virtually unachievable goal in Pakistan. In such a situation, the onus of responsibility to educate the public about the early symptoms of colorectal cancer rests firmly with physicians.
In many countries, screening for colorectal cancer in adults is recommended using faecal occult blood testing (FOBT), commencing at 50 years of age and continuing until 75 years of age. This test can detect the presence of minute amounts of blood not visible to the naked eye. A general physician may be the first point of contact for a patient with suspected colorectal cancer. It is important that doctors do not simply dismiss symptoms associated with colorectal cancer, such as bleeding with the stool, as due to a benign condition such as haemorrhoids. If a patient has a positive FOBT test, or if he reports the presence of visible blood in his stool, doctors should rule out CRC by recommending an endoscopic procedure, such as a flexible sigmoidoscopy or colonoscopy.
This is a test in which a flexible camera is inserted into the large bowel to examine it from within, and during which a sample, known as a biopsy, can be taken from any suspicious lesions encountered. This can play a crucial role in diagnosing pre-cancerous lesions, as well as cancers which have not yet become clinically evident, when they are most likely to be completely curable.
Some patients are in a higher risk category for CRC, by virtue of their age, or because of a family history of colorectal cancer in a first degree relative. All such patients should also undergo screening. While the normal interval for FOBT testing in the UK is two-yearly, screening with endoscopy (sigmoidoscopy or colonoscopy) is recommended every five to ten years. However, some people may need to be tested earlier than age 50, or more frequently, if they or a close family member have had colorectal polyps or colorectal cancer, if they have inflammatory bowel disease, such as Crohn’s disease or ulcerative colitis, or a genetic syndrome such as familial adenomatous polyposis or hereditary non-polyposis colorectal cancer (also known as Lynch syndrome). As stated earlier, the changing lifestyle In Pakistan is expected to increase the incidence of colorectal cancer in our country, and perhaps to result in presentation at an earlier age, and there are some data from the Shaukat Khanum Cancer Registry to support this.
All physicians can help by educating their patients about the importance of colorectal cancer screening and the various options, ranging from non-invasive to more invasive screening tools, that are widely available for this in our country. Hesitancy, embarrassment and fear of the costs involved are all some of the factors which reduce patient uptake of these modalities for screening. A sympathetic physician can do much to explain the options available – a stool test is relatively cheap, and affordable by many – and can also remind patients that the cost of screening is negligible when compared to the cost of treating advanced cancer.
Another challenge in Pakistan is a lack of gastroenterology facilities and limited numbers of trained physicians, especially female gastroenterologists, who might help promote screening amongst women in our conservative culture. The situation with regard to training is gradually improving, with a number of new training programmes having been recognised by the College of Physicians and Surgeons of Pakistan over the last two decades. Especially heartening is the increase in the number of women in training, and increasingly in leadership positions, in the gastroenterology community in Pakistan.
We all need to play our part in creating awareness about colorectal cancer, highlighting the fact that this is an entirely curable disease if diagnosed early, that screening, which detects disease before the patient has any symptoms, is widely available in our country, and in fighting the ignorance, fear and irrational taboos that prevent patients from seeking care until their disease is at an advanced stage.