Colorectal Cancer Awareness Month -2019
The National Program for the Early Detection of Malignant Diseases is in line with the resolution on the prevention and control of malignant neoplasms, adopted by the World Health Organization at the 58th, Geneva 2005 meeting and with the EU recommendations (2003/878 / EU ) from 02.12.2003. The program for early detection of colorectal cancer involves screening, which significantly improves the health of the population, as a preventive measure to detect colon cancer in the initial phase or stage of the so-called. a lesion-a polyp, when the chances of healing and / or cure are much greater.
The guidelines and recommendations for screening CRC relate to a population with an average risk of this disease and no specific symptoms. Opportunistic screening with FOB tests is conducted in the Republic of Macedonia, and covers persons aged 50 to 74 years. Persons with already present symptoms, who have an increased or high risk of colorectal cancer, should undergo standard diagnostic procedures at an earlier age and be carried out at predetermined intervals.
The World Illustrations in the Occult Fecal Bleeding Test (FOBT) as a screening test for early detection of colon cancer were given in studies in the United States (New York, a 10-year follow-up conducted on 22,000 people showing a reduction in CRC mortality by 43%, the target population was those aged 40 years or more), the UK (Nottingham, a 7-8 year follow-up conducted on 152,850 people, a 15% reduction in CRD deaths, target population was 50 -74 years). Results from a 18-year study in Minnesota found that 46,000 respondents between the ages of 50-80 years showed a 33% reduction in CRC mortality if the test for occult fecal bleeding is repeated every year or 21% if the test is repeated for two years.
The program for early detection of colorectal cancer is effective in secondary prevention because the cancer of the colon most commonly develops from adenomatous polyps. Adenomas may occur anywhere along the colon after a series of mutations that cause the formation of epithelial neoplasia. Adenomas are rising and may develop high-grade dysplasia, but if they involve the submucosis become malignant. About 5-6% of the population develops the CRC. The transition from benign adenomas to malignant phase is a long process that lasts for about 10 years, enabling early detection and removal of pre-malignant lesions. The prognosis is much better if the cancer is detected in an asymptomatic or early symptomatic phase, because the tumor is usually localized, treatment is easier and increases the possibility of complete healing. When detected in the adenoma phase, the removal of the adenoma prevents the incidence rate of CRC. Even when cancer is detected at an early stage, the prognosis is significantly better than in a more advanced stage. The program for early detection of colorectal cancer significantly improves the health of the population, if it is well designed and summarized by the total target population.
The screening program can be successful only if in addition to activities aimed at early detection of CRC, conditions for adequate diagnosis, treatment and better quality of life of patients are provided. Organizing an early detection program for cancer is a multidisciplinary activity. Strong and indisputable broader social, political and financial support is needed, which guarantees the achievement of the set program goals.
- EPIDEMIOLOGICAL CONDITION
Incidence rates and colorectal cancer (CRC) incidence rates vary considerably throughout the world. Globally, CRC is the third most commonly diagnosed cancer in men and women, with 1.8 million new cases and 861,000 deaths in 2018, according to the World Health Organization database GLOBOCAN. The frequency of the disease is significantly higher in men than in women.
In the United States, incidence and mortality slowly but gradually decrease. Annually, about 145,600 new cases of colon cancer are diagnosed, of which 101,420 are colon, the rest being rectal carcinoma. Annually, some 50,630 Americans are dying from the CRC, with about 8% of all cancer deaths. According to the past applications in the Institute for Public Health, in 2017, we have 232 newly infected people from the CRC, and the same year 3715 people died from malignant neoplasms as the main cause of death. Malignant neoplasms are the second cause of death among the population in the Republic of Macedonia, in the structure of total deaths, immediately after diseases of the circulatory system.
Incidence – Globally, the regional incidence of CRC varies more than 10 times. The highest incidence rates are in Australia and New Zealand, Europe and North America, and the lowest rates are found in Africa and South Central Asia. These geographical differences are attributed to the differences in nutrition and the environment, which are imposed on the basis of genetically determined predispositions.
The low socioeconomic status (SES) is also associated with an increased risk for the development of the CRC; one study estimated that the risk was increased by approximately 30% in the lowest-eating population (SES) relative to the highest-eating population (SES). Potentially modified behaviors, such as physical inactivity, unhealthy eating, smoking and obesity, are considered to be a significant percentage (estimates from one-third to one-half), of the socio-economic risk disparity of the CRC. Lower screening rates for CRC are significant for the poorer population.
In the United States, the incidence rates of CRC are reduced by about 2 per cent per year. Incidence rates in most western countries were stable or increased during this period. By contrast, CRC incidence rates have rapidly increased in several historically low risk areas, including Spain and many countries in East Asia and Eastern Europe.
Age is the major risk factor for sporadic CRCs. Cancer of the colon is unusual 40 years ago; the incidence begins to increase significantly between the ages of 40 and 50, and the age-specific incidence rate increases every decade thereafter (image 1).
Recent data from the US Surveillance and Epidemiology database and other Western cancer registries suggest that the incidence of CRC increases in the group below 50 years, while decreasing in older groups. In the United States, the incidence of CRC in men and women under the age of 50 years is constantly increasing at a rate of 2 per cent per year from 1992 to 2013. Some registries report an increased incidence of CRC, even in young people aged 20 to 39, although the absolute incidence in this age group remains far less than in people aged 50+. Current literature suggests that over 86% of those diagnosed under the age of 50 are symptomatic in diagnosis, and this is associated with a more advanced stage in diagnosis and weaker outcomes. Currently, most guidelines do not recommend screening for asymptomatic individuals younger than 50 years unless they have a positive family history. However, in 2018, the American Cancer Society issued a “qualified” recommendation to begin screening for people with an average risk of CRC at the age of 45.
- RISK FACTORS
The risk of colorectal cancer increases after the age of 40, so that the CRC occurs in 90% of people over the age of 50 years. Any person over the age of 50 years carries a 5% risk of developing cancer of the colon by age 74, that is, a 2.5% risk of dying from bowel cancer. Symptoms that refer to colon cancer in the early stages are without symptoms, while in a more advanced stage, the following symptoms can be found: bleeding from the colon or bloody stool, change in bowel habits, stools that are thinner than usual, general problems in the stomach, such as bloating and cramps, diarrhea, constipation, or feeling that the movement in the colon is not completely complete, weakening without obvious cause, malaise, vomiting and anemia. Regarding the risk of CRC, all individuals are divided into: those with an average risk (as a general population), with a moderately increased risk and a high risk of developing colorectal cancer, so that the American Cancer Society issued a recommendation regarding the risk of monitoring of the entire population. Persons who have or some of their close relatives have had polyps and / or bowel cancer or if they suffer from certain inflammatory bowel diseases (ulcerous colitis, Crohn’s disease) fall into a group with moderately-increased risk.
High risk individuals who have some of the polyps syndromes and / or hereditary non-polyposis colorectal cancer (HNPCC) in the family. People with a history of cancer of the stomach, chest, ovary, urethra, bladder, kidneys, uterus, lung and prostate cancer also have an increased risk of developing colon cancer. Numerous epidemiological studies examined the impact of external factors (nutrition and hygiene-dietary regimen and physical activity) as risk factors that can contribute to the development of colon cancer. Obesity and diabetes are associated with moderately increased risk, while smoking is associated with an increased risk for CRC, and even more with the development of adenomas.
Prevention of CRC and early detection risks
There are several ways that can contribute to reducing the risk of developing colorectal cancer and other cancers.
- Nutrition
Studies have shown that less fatty foods, fiber-rich foods, large amounts of fresh fruits and vegetables (at least 5 servings a day) and full-grain cereals contribute to reducing the risk of colorectal cancer. Consumption of red meat and meat preparations is recommended at most once or twice a week.
- Physical activity
There is plenty of evidence to suggest that regular physical activity contributes to reducing the risk of colorectal cancer. At least 30 minutes of exercise is recommended at least 5 days a week. Exercises should contribute to speeding up the work of the heart. An example of this type of exercise is a quick walk or a climb up the hill.
- Healthy body weight
Every person needs to make an effort to maintain a healthy body weight. Changes in diet and regular physical activity can contribute to keeping body weight under control.
- Smoking
Smoking is one of the leading causes of CRC, smoking cessation reduces the risk of colon cancer as well as other cancers. Early detection of CRC can save life! People who fall into the category with an average risk of colorectal cancer should begin with regular screenings at the age of 50. Persons who have an increased risk should begin with regular screenings at an earlier age. Persons over 75 years old should consult their family doctor if they should continue with further screening.
- METHODS OF EARLY DISCOVERY OF COLORECTAL CAncer
Screening is a method for detecting disease before symptoms appear. Screening allows cancer detection at an early stage before it becomes invasive, the same applies to people with an average risk (as well as the general population). Screening aims to provide survival, reduce morbidity and improve the quality of life for those who develop cancer. His goal is to reduce the risk, but he does not diagnose disease. There are several methods of screening: annual – two-year tests for the occurrence of occult bleeding. Although a wide variety of different screening methods for colorectal cancer are theoretically available, studies aimed at identifying the most effective screening protocol for use in the general asymptomatic population are generally suggested for the occult bleeding detection or the so-called FOB test.
A test for occult bleeding in the stool proved to be an appropriate method for the early detection of colorectal cancer due to relatively simple application and relatively low cost.
Tests that reveal pre-cancerous and cancerous conditions and Screening intervals:
Occult bleeding detection test (FOBT) • Every year
Immunochemical Stomach Test (FIT) • Every year
DNA test for stool (sDNA) • Every year
Colonoscopy • Every 10 years
Virtual colonoscopy • Every 5 years
Flexible sigmoidoscopy • Every 5 years
Irigography • Every 5 years
An abnormal result of virtual colonoscopy or dual contrast barium enema, or a positive FOBT structure, immunochemical test and DNA test, should be monitored with colonoscopy.
- Colonoscopy
Colonoscopy is a modern diagnostic method, which directly under the control of the eye can completely examine the colon. This procedure is carried out with the help of a colonoscope, a flexible sterile tool with a finger thickness, which, thanks to its flexibility and optical fiber, provides reliable and accurate overview of the whole hose. Colonoscopy as an initial screening method is a more expensive and more invasive method than the FOB test. Colonoscopy plays a key role in any screening of colorectal cancer by presenting a gold standard to confirm any positive result obtained from other CRC screening methods. Colonoscopy is a sensitive method that reveals even the smallest changes, even less than 5 mm, so that all tumor changes can be detected at a very early stage. Most changes can be removed, so that colonoscopy, besides diagnostic, is a therapeutic method. Colonoscopy reveals 90-95% of all tumor changes in the colon and the rectum, but due to high prices, it is used to monitor people of moderate and high risk, as a diagnostic method, and in individuals with a positive FOB test. Currently, Poland is the only country in the EU that carries out colonoscopy as the only screening method in a population with an average risk at the national level.
- Flexible sigmoidoscopy
Flexible sigmoidoscopy is a review used to assess the lower colon (colon). Sigmoidoscopy does not allow to see the colon in its entirety. As a result, any form of bowel cancer or polyp in the deeper colon sites can not be detected by this procedure.
- Irigography
Irigography is performed in the same way as in the intestinal flushing. Barium sulphate solution is a special type of fluid, which is clearly seen on the X-ray. During the procedure, the barium-sulphate solution is inflated into the intestine and thus it is seen how the fluid moves through the intestine. It is useful to spot unusual gastric or intestinal infections.
- TREATMENT OF CRC
Treatment of CRC depends on the stage of the disease, tumor grade, patient’s age, its general condition and other factors.
Therapeutic options for colon cancer are:
- surgical treatment,
- radiotherapy (radiation therapy),
- chemotherapy,
- target (target) therapy.
Surgical treatment is the main and most common therapeutic option for colon cancer. Surgery plays an important role in the treatment of colon cancer.
The goal of surgical treatment is to remove the entire primary tumor with a part of the healthy intestine. It also removes lymph nodes that drain that part of the colon, and who follow the blood vessels that supply blood that part of the bowel. If adjacent tissues and organs are involved with the malignant process, they are also quickly removed. When cancer is locally advanced or metastasized, combined therapy (radiotherapy, chemotherapy and target-targeted therapy) is carried out.
Radiotherapy is a local therapy that destroys malignant cells only in the irradiated region. It is implemented with special machines (linear accelerators), which produce high-energy X-rays. The rays when they pass through the patient’s body from the outside is called external radiotherapy.
External radiotherapy is only used in the treatment of cancer of the rectum and does not apply to colon cancer. It is usually combined with other treatment modalities (surgery, chemotherapy, target therapy).
Chemotherapy is used with drugs called cytostatics. They act by blocking the division of cancer cells by inhibiting the growth and invasion of the cancer. Chemotherapy is applied to locally advanced and metastatic colon cancer. It is most often given in combination with other treatments.
Target therapy is a new effective therapy for advanced and metastatic colon cancer. It is administered with targeted drugs that selectively attack only malignant cells, but do not damage the healthy cells of the body. Targeted drugs are most often given in combination with classical cytostatics, and rarely alone as monotherapy.
- RECOMMENDATIONS
Malignant neoplasms are a great burden for society, both in the world and in our country. Treatment of patients from malignant neoplasms is a great burden and cost, both for the state and the patient, which is a particularly big problem in the less developed regions of the world, which includes R. Macedonia. For this reason, it is necessary to undertake systematic activities aimed at reducing morbidity and mortality from these diseases. Colorectal carcinoma enters the top five causes of death from malignant neoplasms in the R. Macedonia. To improve the overall situation, it is necessary to undertake the following activities:
- Procurement of new apparatus for colonoscopy in regions where there are no colonoscopes and training of professional staff for their work;
- Conclusion of an agreement between the Health Insurance Fund and the private clinics working in colonoscopy in the regions where there are no colonoscopes within the public health sector in order to obtain feedback and a true picture of the condition of the patients with CRC in the Republic of Macedonia. Macedonia;
- Removing or reducing the risk factors in the living and working environment of the population;
- Change in adult behavior, associated with eating habits, smoking and physical activity, as risk factors;
- Continuation of the CRC screening program in order to reduce the risk in the general population of the disease with CRC. Screening allows detection of malignant changes at an early stage, when the disease is still localized;
- Keep a registry of CRCs with a systematic, permanent and quality update of the newly acquired data. The register will enable adequate monitoring and evaluation of patients at the state level;
