olorectal cancer (CRC), or the cancer of the large intestine, is one of the leading causes of morbidity and mortality globally. With two million new cases and one million deaths in 2020, this global burden is likely to increase in the coming years.

Asia has the highest burden of colorectal cancer. In Pakistan, although a national cancer registry does not exist and exact figures are lacking, various studies over the years have shown that the incidence of colorectal cancer is on the rise. A meta-analysis of published literature in 2018 showed the incidence of CRC in Pakistan ranges from 4 per cent to 6.8 per cent.

In order to develop an understanding of what colorectal cancer is, let’s have a look at some facts.

Like other diseases, there are some known risk factors for colorectal cancer. It also has certain signs and symptoms and treatment modalities.

The risk factors for colorectal cancer include: consuming an unhealthy diet, poor lifestyles, lack of physical activity, obesity, smoking and excessive use of alcohol. Having a history of inflammatory bowel disease, ulcerative colitis and Crohn’s disease, cancers of the uterus, breast or ovaries or a history of diabetes also puts one at a high risk of developing colon cancer. A positive family history of colorectal cancer and other familial/ inherited conditions can also lead to increased risk. Furthermore, the risk of cancer increases with age.

In terms of how sizeable intestinal cancer presents, here are some common features: patients can complain of weight loss, rectal bleeding, iron deficiency anaemia, changes in bowel habits or lump or mass or pain in the tummy. Therefore, a physician who initially sees patients must collect comprehensive data from patients presenting with the above signs or symptoms and carry out appropriate investigations and referrals to specialists. There are certain non-malignant conditions like irritable bowel syndrome, inflammatory bowel diseases and diverticular disease that can have symptoms and signs overlapping with the CRC. It is also important to be mindful of the fact that some patients may present with vague and non-specific symptoms, in which case physicians have to rely on the patient’s family history and signs and symptoms. Having trained family physicians or primary care physicians who can identify high-risk patients can play a key role in the early identification and prevention of CRCs. Such patients’ groups including their families can be counselled for participation in a screening programme.

Bowel cancer screening tests, for instance: faecal tests and colonoscopy are available; however, their optimal utilisation is lacking. Regular screening can detect cancers at an early stage so that the treatment can be more successful.

The risk is higher in those with a significant family history of bowel cancer or polyps (a projecting growth of tissue from a surface in the body, usually a mucous membrane). Certain conditions like inflammatory bowel disease or a history of adenomatous polyps increase the likelihood of developing cancer.

Early detection is the key to the successful treatment of bowel cancer. Treatment is also less complicated if cancer is diagnosed early. Those aged 50 and over should get bowel cancer screening every two years. CRC screening can be an effective strategy for detecting cancer in asymptomatic patients. In Pakistan, there are various barriers to screening programmes. These includes lack of awareness, logistic and financial issues, lack of screening facilities, cultural norms and myths regarding screening procedures and religious beliefs.

There is little publicity of CRC compared to other cancers, which could also be a reason for underestimating the associated morbidity and mortality. There is also a lack of data regarding the public awareness of CRC, the prevalence of current screening practices,

public attitudes towards screening and its health implications. Mass awareness campaigns need to be started at both community and health facilities to promote screening programmes.

Patient education, an essential part of the primary care system, empowers individuals. This feature needs to be supported through the establishment of a well-organised primary care system in the country.

Early symptoms of bowel cancer include blood in the stools or bleeding from the back passage, changes in bowel habits, abdominal pain, discomfort and bloating. Some people may present with a lump or mass in the tummy. Get yourself checked by a qualified physician, particularly if there are risk factors in personal or family history. Keep an eye on your symptoms and report any concerns.

Screening for colorectal cancers is not attainable without community participation. Moreover, training of health care workers especially primary care physicians/ general practitioners (GPs), availability of resources for screening, public awareness campaigns, having a robust primary care system and above all, commitment from policymakers and government is essential.

Dr Hina Jawaid is an associate professor in family medicine at the University of Health Sciences Lahore

Dr Abdul Jalil Khan is an assistant professor in family medicine at Khyber Medical University, Peshawar