Colorectal cancer is the third most common cancer in the Philippines. It is the second cancer-killer worldwide. In 2020, an estimated 17,364 new patients were reported to be diagnosed with colon and rectal cancer in the country.
The Covid-19 pandemic has been an unprecedented global health crisis that has severely challenged the provision of routine health care, including screening for colorectal cancer (CRC). The interruption of CRC screening in many countries, including in the Philippines, has resulted in the delayed diagnosis of colon and rectal cancer, increasing the chances for advanced stage progression and poorer outcomes.
Even before the pandemic, there has been an increasing incidence of colorectal cancer in persons younger than 50, especially among American patients. After a systematic analysis, the United States Preventive Services Task Force (USPSTF) recommended that the age for screening average-risk persons for colorectal cancer be lowered from 50 to 45. The applicability of these guidelines on Philippine patients remained unanswered.
What’s in store for Filipinos in the Universal Health Care Era?
For these socially relevant issues, the Augusto P. Sarmiento Cancer Institute (APSCI) of The Medical City organized a very successful virtual forum, in collaboration with the Department of Health, titled “Colorectal Cancer Screening 2022: What’s in Store for Filipinos in the Universal Health Care and Post-Pandemic Era” on March 4. This webinar is in support of the hospital’s Colon Cancer Awareness Advocacy in connection with the SCRAP Cancer Program of the Cancer Institute.
The symposium was moderated by yours truly, the Lead for the Colon Cancer Screening Advocacy Program. The speakers included Professor Jose D. Sollano, Dr. Mark Anthony De Lusong, and Dr. Clarito Cairo Jr.
The impact of the pandemic in patient outcomes
In his talk, Dr. De Lusong noted a drop of 58 percent in the number of colonoscopies performed at The Medical City in 2020. In 2021, a 48 percent drop was recorded as compared to the 2019 census. Both the National Kidney and Transplant Institute (NKTI) and the Philippine General Hospital also had comparable reductions in the number of colonoscopies performed, especially those done for screening, during the pandemic as compared to pre-pandemic times. This is understandably so, as both physicians and patients were anxious to be infected with Covid-19, as numerous endoscopic procedures (considered as are aerosolizing procedures) were deemed to be elective, and not urgent.
During the pandemic, symptomatic patients were prioritized, and procedures for asymptomatic patients were deferred. Last year, the patients tended to wait than go to hospitals, and telemedicine consultations were increasingly availed of. This patient behavior, however, resulted in delay in seeing colon cancer patients, leading to more cancer in later stages being diagnosed, Dr. De Lusong added.
Is “45 the new 50 in CRC” in the Philippines?
The recommendation of lowering the screening age in the US was based on more recent American patient data and the government’s capacity to respond to these added needs. Americans have a much higher risk to colon cancer than Filipinos, owing to their genetics, Western diet and lifestyle, like obesity. In contrast, the Philippines is a low-resource country without even a national screening program in CRC. Do we automatically adopt these American guidelines, despite the big difference in genetics, environmental factors, and national government resources?
Prof. Sollano analyzed the data on whether to lower CRC screening age to 45. However, there is no data available yet in the Philippines to support this unlike in Western medical literature. The screening guidelines of other Asia-Pacific countries are still recommending the start of screening at the age of 50. Moreover, some of these developed countries have already established colorectal cancer screening programs. The cost-effectivity of lowering the age to 45 has not yet been demonstrated in the East.
In building a colorectal cancer screening program, the government needs data, infrastructure, personnel, and funds. An efficient system of screening millions of Filipinos and the needed recall of those who tested positive in their Fecal Immunochemical Test (FIT) must be in place in order for the program to be successful. Prof. Sollano also underscored that “there are only more than 500 board-certified gastroenterologists for 104 million Filipinos in the whole country.” Expanding the screening to lower-aged patients will likely overwhelm the program and medical professionals.
Without any data, infrastructure or funds from the national government, lowering the age of screening average-risk Filipinos for colorectal cancer may not yet be feasible in the Philippines.
CDC screening program
It has been three years since the successful passage of the Universal Health Care Act and the National Integrated Cancer Control Act (NICCA). The good news about NICCA is that PhilHealth is expanding its benefit packages to include primary care screening, detection, diagnosis, treatment, supportive care, and end-of-life care for all types and stages of cancer in both adults and children.
Dr. Clarito Cairo Jr. of the Department of Health (DOH) said his office will be launching the National Organized Colorectal Cancer Screening this year by using the automated and quantitative FIT and colonoscopy in selected access sites or hospitals nationwide. The Cancer Assistance Fund will be used to procure the initial 50,000 FIT test kits to be given away for free to the eligible population.
This annual DOH initiative is good news to Filipinos as it will help address the preventable and treatable aspect of colorectal cancer as a public health problem. Healthy lifestyle and appropriate screening will help us beat colorectal cancer.
Dr. Jun R. Ruiz is a Philippine and American board certified gastroenterologist at The Medical City. He is also the Lead for Colorectal Cancer Screening Program and the Programs and Advocacy of the APSCI of The Medical City.
