Colorectal Cancer Screening - A Huge Gap in Asia

Colorectal cancer (CRC) almost always begins as a precancerous growth which can remain undetected for almost 10-15 years before causing noticeable symptoms in the patient¹. Early screening tests are most beneficial during this period as they can find these growths before they progress to a more invasive stage.

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The longer a growth is able to remain undetected, the more deadly it becomes, as shown in the rapidly plummeting 5-year survival rate percentage for each cancer stage² in the figure below:

Colorectal cancer is the second most common cancer in Hong Kong³, accounting for 15.8% of all new cancer diagnoses in 2019. This figure has continued to trend upwards in recent years - since 1983, the age-standardized incidence rate for both males and females has been steadily increasing⁴, despite the city-wide screening program implemented since 2016. Regular and timely screening is an integral part for effective prevention and treatment.

The Hong Kong Government recommends regular screening every two years for those individuals between the ages of 50 and 75 with average risk of colorectal cancer³. Other health authorities such as the United States Preventive Task Force⁵, American Cancer Society⁶, and National Comprehensive Cancer Network⁷ even suggest lowering the age requirement to 45 years rather than 50 to account for the recent trend of younger onset colorectal cancer incidence in both western and Asian regions⁸.

According to the Hong Kong Department of Health, roughly 2.9 million residents (39% of the Hong Kong population) are eligible for this testing scheme. However, only 209,000 residents completed the test in 2019³, leaving 93% of the eligible population untested and unaware of their colorectal health.

Screening in SEA

This discrepancy between the screened population and the eligible-to-be-screened population is not just limited to Hong Kong, either. Many regions have also issued regular testing guidelines for individuals at risk of developing precancerous growths. Countries such as Singapore, Malaysia, Thailand, and Macau recommend that all individuals between the ages of 50-75 complete a routine screening test every few years^9-12. While most of these governments have created subsidized screening programs to incentivize their citizens to participate, the adoption rate remains low. Notable screening barriers in these SEA regions include a lack of referrals and recommendations from health care providers, concerns regarding the hygiene and privacy of stool sample collection, limited screening resources and infrastructure, and poor awareness of personal CRC health risk^9-12.

Hong Kong

Thailand

Malaysia

Singapore

Macau

Top barriers to CRC screening reported by unscreened patients (pre-COVID)

% of patients reporting
(n=80)

As reported by unscreened patient (pre-COVID), the extremely low adoption rate within the eligible screening population in Hong Kong specifically comes as a result of very similar factors. Three of the most common self-reported patient-level barriers to regular screening include the lack of recommendation and referral by healthcare providers, a general attitude of fear towards the screening process, and the financial burden of the procedure¹³. Furthermore, many individuals who fail to adhere to CRC screening guidelines do so because they feel their likelihood of developing CRC is low, despite the fact that CRC is the third most common cancer worldwide¹³.

Hong Kong Subsidized CRC Screening Program

The Hong Kong government Colorectal Cancer Screening Programme (CRCSP) provides subsidized testing for asymptomatic Hong Kong residents between the ages of 50-75 to undergo screening for the prevention of colorectal cancer¹. The programme provides an initial FIT test conducted by a primary care doctor. If the FIT test results are positive, the patient will be given a referral to an enrolled colonoscopy specialist for a diagnostic colonoscopy. If the FIT test results are negative, the patient is advised to repeat the screening in two years time. Though FIT tests remains the standard screening methodology under the Hong Kong CRCSP, sDNA-FIT has previously been identified as a potential emerging technology by the Hong Kong Anti-Cancer Society¹⁴ and its effectiveness is supported by its recent recommendation for screening use in the United States by the United States Preventive Services Task Force⁵.

References

What Can I Do to Reduce My Risk of Colorectal Cancer?” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 17 Feb. 2022, https://www.cdc.gov/cancer/colorectal/basic_info/prevention.htm.
United States of America. National Cancer Institute. (2022). Cancer Stat Facts: Colorectal Cancer.
“Eligibility of Colorectal Cancer Screening Programme Updated.” GovHK, 30 Dec. 2021, https://www.info.gov.hk/gia/general/202012/30/P2020123000566.htm. Accessed 17 May 2022.
“Centre for Health Protection, Department of Health - Colorectal Cancer.” Centre for Health Protection, 4 Jan. 2022, https://www.chp.gov.hk/en/healthtopics/content/25/51.html.
Davidson, Karina W., et al. “Screening for Colorectal Cancer.” JAMA, vol. 325, no. 19, 2021, p. 1965., https://doi.org/10.1001/jama.2021.6238.
“Colorectal Cancer Guideline: How Often to Have Screening Tests.” American Cancer Society, 17 Nov. 2020, https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/acs-recommendations.html.
Shead, Dorothy A, et al. “For Patients Colorectal Cancer Screening - Nccn.org.” National Comprehensive Cancer Network, 13 Apr. 2021, https://www.nccn.org/patients/guidelines/content/PDF/colorectal-screening-patient.pdf.
Sung, Joseph J.Y., et al. “Increasing Trend in Young-Onset Colorectal Cancer in Asia: More Cancers in Men and More Rectal Cancers.” American Journal of Gastroenterology, vol. 114, no. 2, 2019, pp. 322–329., https://doi.org/10.14309 /ajg.0000000000000133.
Lohsiriwat, Varut, et al. “Current Colorectal Cancer in Thailand.” Annals of Coloproctology, vol. 36, no. 2, 2020, pp. 78–82., https://doi.org/10.3393/ac.2020.01.07.
Arunah, C et al. “Overview of colorectal cancer screening programme in Malaysia.” The Medical journal of Malaysia vol. 75,3 (2020): 235-239.
Tan,C (2021, March 18).Many shying away from screening for colorectal cancer:study. The Straits Times. PB5. https://nus.edu.sg/newshub/news/2021/2021-03/2021-03-18/man-st-18mar-pB5.pdf
“Health Bureau Launches New Round of Colorectal Cancer Screening.” TDM, TDM - Teledifusao De Macao, S.A., 24 Feb. 2022, https://www.tdm.com.mo/en/news-detail/661481?isvideo=false&lang=en&category=all.
Muthukrishnan M, Arnold LD, James AS. Patients' self-reported barriers to colon cancer screening in federally qualified health center settings. Prev Med Rep. doi:10.1016/j.pmedr.2019.100896.
Ying, Anthony C.H. “Guidelines for Cancer Prevention, Early Detection & Screening: Colorectal Cancers (CRC) Recommendation.” The Hong Kong Anti-Cancer Society, Mar. 2009.