Sajjad Ahmad, Muhammad Mumtaz Khan


In February 2000, President Clinton of USA officially dedicated March as National Colon Cancer Awareness Month. Since then, it has grown to be a rallying point for the colon cancer community where thousands of patients, survivors, caregivers and advocates throughout the country join to spread colon cancer awareness by wearing blue, holding fund raising and education events, talking to friends and families about screening and much more.1
Each year 1.2 million people around the globe develop colorectal carcinoma (CRC) and half of these people usually die due to metastasis within a span of five years from the time of diagnosis. CRC is hence regarded as the second most common cause of cancer related death next to lung cancer. However when detected early, CRC is one of the most curable and preventable of cancers.2
According to estimates from the American Cancer Society, more than 95,000 new cases of colon cancer and about 40,000 new cases of rectal cancer were estimated to be diagnosed in the United States in 2016 in both sexes. Together, the disease was expected to be responsible for almost 50,000 deaths the same year.3 Excluding skin cancer, these numbers place colorectal cancer as the third most common cancer among US men and women. There is, however, good news about colorectal cancer in the United States; death rates associated with the disease have been dropping for several decades, and advances continue to be made in screening, prevention and treatment.3
Many Asian countries, including China, Japan, South Korea and Singapore, have experienced an increase of two to four times in the incidence of CRC during the past few decades. The rising trend in incidence and mortality from CRC is more striking in affluent than in poorer societies and differs substantially among ethnic groups.4
The exact cause of most CRCs is not known but there are many risk factors some of which are related to lifestyle and are modifiable while others include inherited genetic mutations. Early diagnosis is vital in treating CRC at an earlier stage and enable the patient to survive. New research suggests many ways of avoiding or reducing the risk of CRC, such as quitting smoking; adopting a healthy lifestyle including nutritious diet and exercise; minimizing consumption of red meat; limiting unhealthy fats; reducing alcohol consumption; and eating a lot of vegetables and fruits.5
Microscopically more than 90% of all CRCs are adenocarcinoma. Broadly the stage of a cancer is usually quoted as a number I, II, III, IV derived from the TNM value grouped by prognosis; a higher number indicates a more advanced cancer and a likely worse outcome.6
A 10 year data from 1992 to 2001 analyzed at Armed Forces Institute of Pathology, Rawalpindi, Pakistan, revealed that CRC was the 5th commonest malignancy in males and 4th in females.7 At Shaukat Khanum Memorial Cancer Hospital and Research Center (SKMCH & RC) among the top 10 malignancies seen in all age-groups and both sexes, from Dec. 1994 to Dec. 2015, CRC ranked 5th at 4.91%.8
A study, jointly carried out by The Aga Khan University Hospital, Dow University of Health Sciences and PNS Shifa Hospital in Karachi, Pakistan revealed that CRC in Pakistan commonly presents at an advanced stage with a male preponderance, and relatively mean younger age at presentation for males. Advanced stage and lymph node involvement along with poorly differentiated pathology were factors associated with poor long term survival. The authors stressed a need to reinforce awareness about CRC.9
Another study from Karachi, Pakistan also concluded that although CRC is usually a disease of older patients but it is increasingly becoming more common in younger population who present with more advanced disease and poorer prognosis. In this study 12 out of 23 (52.17%) patients operated for CRC were below 40 years of age and none of them had been diagnosed by screening colonoscopy.10
The above studies reflect that routine CRC screening and awareness about the disease does not exist in Pakistan. It is due to high illiteracy rate in rural areas where people are unaware of its importance. But even in urban areas with people having more access to specialized centers, routine CRC screening is not carried out and most of them are diagnosed at a very late stage.
It is time for us to wake up and launch a national multimedia campaign for awareness about CRC just like the Centers for Disease Control and Prevention (CDC) launched a multiyear, multimedia National CRC Action Campaign in USA by the name “Screen for Life”in March, 1999. It educates and informs men and women aged 50 and older about the importance of regular CRC screening.11
To carry out a successful CRC screening program in our country we must also remove the cultural barriers impeding its application. In our society cancer is regarded as a stigma and people hide it until it grows out of control. Patients also avoid biopsies and surgical procedures which make them an easy prey to quacks and pseudo-spiritual healers. Besides due to paucity of lady gastroenterologists, female patients are reluctant to have colonoscopy examination by male doctors in our conservative setup.
Overcoming all these barriers needs a concerted, organized and relentless effort at national level to minimize deaths due to CRC through mass education about benefits of screening.

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