THE coronavirus disease 2019 (COVID-19) pandemic has been an unprecedented global health crisis that has severely challenged the provision of routine healthcare, including screening for colorectal cancer (CRC).

These screening programs throughout the world ceased operating primarily due to fear of transmission of SARS-CoV-2, the virus that causes COVID-19, and from decreasing healthcare resources. There is a real risk of spreading and being infected during an endoscopy examination, due to the potential aerosol-producing nature of these procedures. The professional societies initially recommended only emergent endoscopic procedures for symptomatic patients. Screening and surveillance procedures have not been performed regularly during the pandemic period.

The interruption of CRC screening and surveillance in many countries during the pandemic has resulted in a delayed diagnosis of CRC, possibly in a more advanced stage. Published articles have shown that delaying colonoscopy by more than nine months after a positive Fecal Immunochemical Test (FIT) can lead to an increased risk of CRC.

There is an apparent lack of awareness of the preventability of this disease among our patients. Not all primary health providers are updated on the current screening guidelines for this cancer. There is no national population-based CRC screening program in the country, but it is not surprising as only a few Asian countries have one, like Japan, Hongkong, Taiwan, and Singapore. The Department of Health has recently announced its plans on prevention and early detection initiatives of colorectal cancer in the next few years in line with the implementation of the National Integrated Cancer Control Act (NICCA), signed into law in 2019.

March is Colorectal Cancer Awareness Month. The massive worldwide campaign for colorectal cancer screening has its beginnings in the United States in 2000. In the Philippines, The Medical City and its doctors have been among the leading advocates for this cause since 2010.

The big financial burden of CRC screening on the patient presents another very significant barrier to this campaign. The most commonly used method of CRC screening in the Philippines, the colonoscopy, can cost between P15,000 to P30,000 depending on the hospital. Many may not know that FIT is a less expensive screening test, which only costs less than P500. What makes things worse is that several local health maintenance organizations (HMOs) refuse to pay for CRC screening strategies. I sympathize with my patients who were encouraged to undergo screening for their health, but had to pay out of pocket since the test was disapproved by their health card.

RISK FACTORS FOR COLORECTAL CANCER
Despite these challenges, we need to continue educating our primary healthcare providers, our patients, and the general public on the importance of CRC screening.

Almost all of these CRCs start as abnormal growths in the lining of the colon and rectum called polyps. These polyps grow slowly and it may take around 10 years for some polyps to develop into cancer. However, not all polyps progress to cancer. The removal of these polyps reduces the risk of developing cancer.

An important fact is that these polyps and early cancer may not cause complaints. Signs and symptoms, like rectal bleeding, constipation, anemia, weight loss, and abdominal pain may be experienced by patients only in later stages of cancer.

The most common individual-specific factors that increase risk for cancer in the colon and rectum are: 1) age greater than 50; 2) personal history of colorectal cancer or advanced polyps; 3) family history of cancer in the colon and rectum; 4) certain diseases, like Inflammatory Bowel Disease.

Being over 50 is the most common risk factor for this cancer, as 90% of new cases of CRC occur after the age of 50. A family history of a first-degree relative with CRC increases risk by two- to three-fold.

There are also lifestyle habits that can be modified that likely contribute to the formation of this cancer: 1) cigarette smoking; 2) alcohol consumption; 3) obesity; 4) lack of exercise; 5) a diet that has high saturated fat, low fiber, and high red meat consumption.

Living a healthy lifestyle by avoiding smoking, not consuming excessive alcohol, regular exercise, and eating the right food all can lower your risk of cancer in the colon and rectum.

COLORECTAL CANCER SCREENING
In several countries, CRC screening is recommended for average-risk people starting the age of 50. Screening at an earlier age, usually at 40, is advocated in first-degree relatives of patients with CRC, and in those with other additional risk factors. The death of Black Panther star Chadwick Boseman last year, at the age of 43, turned the spotlight on CRC.

The gold standard for CRC screening is a colonoscopy as it can detect and remove pre-cancerous polyps. The procedure involves a flexible fiber-optic scope with a camera that is inserted through the rectum and is carefully advanced to visualize the colon under mild anesthesia.

Some patients may not want to have an invasive test. A stool test called FIT is a good screening alternative. It detects only human blood and is specific for bleeding in the colon. The test is repeated every year if the initial test is negative. If the test is positive, a colonoscopy is needed to rule out the presence of cancer. In pandemic times, the FIT test may be used to stratify patients as to who need the colonoscopy more urgently than others, given the more limited health resources of our country during these times.

When the Department of Health plans a population-based screening program in the Philippines, this can result in diagnosing cancers in the earlier stages when these can be effectively treated and lead to an eventual decrease in mortality. We can hope that once this COVID-19 pandemic is over, screening measures to prevent colorectal cancer can be finally realized as envisioned by NICCA.

Dr. Jun R. Ruiz is a Philippine and American board-certified gastroenterologist and the lead advocate for colorectal cancer screening of the Augusto P. Sarmiento Cancer Institute of The Medical City. He finished his Gastroenterology Fellowship at the George Washington University Medical Center in DC. He was part of the staff of the Gastroenterology Department in Kaiser Santa Clara in their successful colorectal cancer screening program of the Kaiser Permanente in Northern California from 2005 to 2013.