Colorectal cancer: population-based screening is the choice

Colorectal cancer (CRC) is the commonest cancer in men, and second commonest cancer in women, in Malaysia. It is also third commonest cause of cancer deaths in Malaysia.  Among the ethnic groups, Chinese has the highest incidence rate (27.4 per hundred thousand population), followed by Malays and Indians (18.9 and 17.6 per hundred thousand population respectively).  There was a low percentage of Stage I CRC notified for both genders, compared to Stage II, III and Stage IV, which indicates that most CRC patients might have delayed screening.

Most CRCs take years to develop, thus the key to prevent CRC is regular screening. A local study reported that low symptom awareness was the factor that led to delay in screening. According to the national census, an estimated 5.6 million Malaysians aged 50 to 74 years were eligible for screening in 2018. Unfortunately, only less than one percent of them underwent the human haemoglobin immunochemical based FOBT (iFOBT) screening, with only 55.2% of those tested positive for iFOBT underwent colonoscopy. This may be due to the absence of nationally organised CRC screening.

In Southeast Asia region – countries like Singapore and Thailand have national CRC screening program. Meanwhile, Malaysia, Brunei and the Philippines only offer opportunistic CRC screening. The National Strategic Plan for Cancer Control Programme (2016-2020) outlined the need to implement an organised CRC screening, including the need for patient navigation services for those screened. However, the CRC screening programme in Malaysia is based on existing resources, at both government and private health facilities.

Since the CRC screening rate is very low in Malaysia, it is high time for the government to implement a population-based screening. In order to materialise this, engagement with all stakeholders from within the government and non-government organisations (NGOs) is crucial. This concerted effort has been successfully carried out by our neighbouring country, Singapore. Before their national screening programme was implemented, various organizations worked together in encouraging the public to undergo opportunistic CRC screening,  by providing free Faecal immunochemical test (FIT) kits to Singapore citizens and permanent residents 50 years or older. Since then, the Singapore Cancer Society reported that the coverage rate of opportunistic screening in 2008 was 38.9%. In September 2017, with enhanced screening subsidies, the government launched the Screen for Life programme to encourage more Singapore citizens to undergo screening and receive the necessary follow-up.

Malaysian government could also adopt the framework of other national programmes that had been successfully implemented, such as the National HPV immunisation programme, in order to carry out the population-level CRC screening programme. Nationwide campaign should be initiated, The Ministry of Health should also engage with NGOs as well as other government agencies in order to advocate the public to come forward for the screening. 

In summary, to increase the CRC screening rate in Malaysia, the population-based CRC screening is the best option.  

References:

1. National Cancer Registry Department M. Malaysia National Cancer Registry Report (MNCR) 2012-2016. National Cancer Institute: National Cancer Institute; 2019 June 2019.

2. Loh KW, Majid HA, Dahlui M, Roslani AC, Su TT. Sociodemographic predictors of recall and recognition of colorectal cancer symptoms and anticipated delay in help-seeking in a multiethnic Asian population. Asian Pac J Cancer Prev. 2013;14(6):3799-804.

3. Arunah Chandran D, Mustapha FI, Hassan RA. Overview of colorectal cancer screening programme in Malaysia. Med J Malaysia. 2020;75(3):235.

4. Lauby-Secretan B. IARC Handbooks of cancer prevention Volume 17: Colorectal cancer screening. Journal of Japan Gastroenterological Cancer Screening Society. 2020;58(Supplement2):704-.

5. MOH. National Strategic Plan for Cancer Control Programme 2016-2020: Non-Communicable Disease Section (NCD) Ministry of Health Malaysia; 2017.

6. IARC. Colorectal Cancer Screening. Lyon, France 2019.

The article was written by Dr Hadijah Binti Yunos (Doctor of Public Health candidate), Professor Dr Noran Naqiah Hairi and Professor Dr Moy Foong Ming. It was first published on 30 April 2021 on the SinChew website.