Colorectal cancer screening and early diagnosis: Are expansion and partnership feasible?

MOH’s Disease Control Division (DCD) collaborated with the Digestive Health Malaysia (DHM) and Clinical Research Centre Hospital Sultanah Bahiyah (CRCHSB), Alor Star, Kedah, to organize a virtual Colorectal Cancer Screening Symposium recently.

The symposium, held in conjunction with the Colorectal Cancer Awareness Month and World Digestive Day, aimed to raise awareness on the importance and challenges in implementing the Colorectal Cancer Screening and Early Detection Programme in Malaysia and advocate for the involvement of external stakeholders.

Over 600 healthcare providers from MOH, private healthcare facilities and NGOs participated in this symposium, which was divided into three main sessions, namely overview of colorectal cancer (CRC) in Malaysia, and challenges and expanding the horizon in CRC screening.

While highlighting the local CRC burden based on the data from the National Cancer Registry in the officiating address, Datuk Dr Norhayati Rusli, director, DCD, MOH, emphasized on the importance of joint participation, partnerships, and commitment of various stakeholders to achieve the objectives of the National CRC Screening Programme.

Overview of CRC screening
Data from GLOBOCAN 2020 showed that CRC was the third most common cancer and the second most common cause of cancer deaths worldwide, said Dr Nor Saleha Ibrahim Tamin, public health physician, Cancer Prevention and Control Unit, DCD, MOH. [CA Cancer J Clin. 2021;71(3):209–249]

The Malaysia National Cancer Registry (MNCR) Report 2012–2016 showed CRC is the second most common cancer in the general population (13.5 percent)—most common among males (16.9 percent) and second most common among females (10.7 percent)—with an age-standardized rate (ASR) of 14.8/100,000 in males and 11.1/100,000 in females (Figure 1). The incidence rate is also higher among those of Chinese ethnicity compared to those of Malay and Indian ethnicity, she added. [https://www2.moh.gov.my/moh/resources/Penerbitan/Laporan/Umum/2012-2016%20(MNCRR)/MNCR_2012-2016_FINAL_(PUBLISHED_2019).pdf]

More than 70 percent of Malaysians (male: 72.4 percent; female: 73.1 percent) are diagnosed at stages III and IV. According to the Malaysian Study on Cancer Survival (MySCan), the 5-year relative survival for CRC is 51.1 percent. [https://www2.moh.gov.my/moh/resources/Penerbitan/Laporan/Umum/Malaysian_Study_on_Cancer_Survival_MySCan_2018.pdf]

Nor Saleha emphasized CRC screening is important because CRC is a costly disease to treat and manage, particularly in the advanced stages. CRC can be detected early through screening while premature death can be prevented with early diagnosis and prompt treatment.

She said the CRC Screening Programme, which utilizes immunochemical faecal occult blood test (iFOBT), started with a feasibility study conducted in Negeri Sembilan in 2008–2009, followed by a series of pilot projects in Perak, Pulau Pinang, Terengganu, Pahang, Kuala Lumpur, Putrajaya, and Negeri Sembilan in 2013. The national rollout was started in a stepwise approach with 262 MOH health clinics in 2014 and expanded to over 600 clinics in 2021. Implementation of the screening programme is based on the Clinical Practice Guidelines (CPG) on Management of Colorectal Carcinoma published in 2017. [https://www.moh.gov.my/moh/resources/penerbitan/CPG/CPG%20Management%20of%20Colorectal%20%20Carcinoma.pdf]

Although the screening coverage in MOH healthcare facilities is <1 percent of eligible population since the start of the screening programme, the uptake of iFOBT continues to significantly increase year-on-year. Of those tested, nearly 10 percent had positive results. Of these patients, 10 percent refused referral for colonoscopy. Of those who agreed to be referred, 40 percent defaulted. Of those who underwent colonoscopy, about 4 percent were diagnosed with malignant lesions while about 14.5 percent had polyps, said Nor Saleha.

MOH together with all the related stakeholders developed the National Strategic Plan for CRC (NSP-CRC) 2021–2025, a subset of the National Strategic Plan for Cancer Control Programme (NSP-CCP) 2021–2025, with selected objectives to be achieved by 2030 (Table 1).

“MOH will continue to increase the screening coverage in MOH facilities, work with multiple stakeholders, including private healthcare facilities, academia, NGOs, etc, to participate in the screening programme and initiate a patient navigation pathway to link CRC patients in the community to healthcare services,” said Nor Saleha.

In her concluding remarks, Nor Saleha emphasized the increasing CRC burden affects not just the patient but also the family and society. “Challenges faced such as test uptake and defaulters should be addressed. Within MOH, the decision to increase the number of health clinics providing screening services should grow in parallel with capacity improvement at MOH hospitals,” she said.

Dr Hamdan Mohamad, senior dietitian, DCD, MOH, described many studies that have shown high body mass index (BMI) and abdominal obesity are associated with increased CRC risk. “Obesity may also play a role in cancer recurrence, treatment outcomes and survival. The pathophysiological processes include chronic inflammation, insulin resistance, altered levels of growth hormones, and increased steroid hormones. Other risk factors for CRC include alcohol intake, consumption of red and processed meat, smoking, sedentary lifestyle, and inflammatory bowel disease.”

Challenges in CRC screening
In the session on challenges in CRC screening, Dr Nur Nadiatul Asyikin Bujang, a DrPH candidate of Universiti Malaya, presented her research on factors associated with CRC screening via iFOBT in an average-risk population from a multi-ethnic, middle-income setting. Her research was performed in several health clinics in Hulu Langat and involved administering a dual-language questionnaire based on the Health Belief Model on a sample of healthy Malaysians aged ≥50.

Although half of the respondents indicated their willingness to be screened, only 7.5 percent underwent iFOBT. Knowledge of risk factors, perceived susceptibility, and doctors’ recommendations positively influenced their willingness to undergo screening. Overall, 74 percent did not perceive themselves to be susceptible to CRC, as they had low awareness that CRC is asymptomatic in early stages. A significant barrier to iFOBT uptake was negative perception towards the test, specifically unwillingness to handle stool.

Based on her research findings, Nur Nadiatul recommended all doctors in primary care clinics routinely advise patients to take iFOBT; health education is strengthened; lay health advocates are trained to support patients; CRC screening is incorporated into existing community-based noncommunicable disease-related programmes; and home-based stool self-testing with an organized system is set up.

Dr Sharifah Saffinas Syed Soffian, a DrPH candidate of Universiti Kebangsaan Malaysia, presented her research titled ‘Prevalence and associated factors of refusal to perform stool-based CRC screening in public health clinics across Kedah state, Malaysia.’ In her cross-sectional study of 920 interviewees, 32.2 percent refused iFOBT. While most were unable to specify a reason (47.3 percent), others were not ready (21.6 percent), felt healthy (14.9 percent), had logistical issues (7.1 percent), were busy (5.4 percent), and were inconvenienced (3.7 percent).

Sharifah explained active smokers, asymptomatic patients, and healthy people were more likely to refuse iFOBT. Patients are also more likely to refuse iFOBT when offered by nurses and medical assistants. She recommended strategies targeting smokers may be helpful, and further training on the use of iFOBT may help nurses and medical assistants promote it more convincingly, thus reducing the burden on doctors and expanding the reach of CRC screening.

Dr Mohd. Azri Mohd Suan, a medical officer at the CRCHSB, presented his research titled ‘Perceived deterrence towards colonoscopy for CRC screening among northern Malaysia population: A qualitative study.’ Although colonoscopy is the gold standard diagnostic and therapeutic tool for CRC, participation was lower compared to iFOBT, and adherence to colonoscopy following a positive iFOBT is also suboptimal, he said.

Mohd. Azri’s qualitative study involved in-depth phone interview with patients who had positive iFOBT but refused colonoscopy between April and December 2016 in Kedah. These interviews produced five main themes for refusal:
1.    Patients had misperceptions on the necessity of colonoscopy and 69 percent had perceived it as unnecessary due to asymptomatic status or negative family history.
2.    Many patients, mostly female, expressed anxiety, fear, and embarrassment about the procedure.
3.    Patients experienced logistical obstacles such as busy with work or being dependent on their children to accompany them.
4.    Influences from friends and family affected the respondents’ decision. For example, one of the patients’ children did not agree for the parent to undergo colonoscopy.
5.    Patients presented with other competing health priorities as an obstacle to colonoscopy screening.

Based on the research, Mohd. Azri recommended several strategies to improve the uptake of colonoscopy ie, creating awareness on the importance of colonoscopy, involving the patient’s family during counselling and referral process, using attentive educational aids, and providing alternative appointment methods.

Expanding the horizon in CRC screening
The session on expanding the horizon in CRC screening focused on the perspectives of key opinion leaders from different backgrounds. Dato’ Dr Meheshinder Singh, consultant general and colorectal surgeon, Pantai Hospital Kuala Lumpur, said about 20 percent of his CRC patients presented in late stages with large bowel obstruction despite the widespread availability of screening tools.

“Nip the buds, save the guts,” is Meheshinder’s tagline for the fight against CRC, which he highlighted during the Blue Star campaign launch in March 2015. He also advocated for the Colorectal Cancer Survivorship Society Malaysia (CORUM), acknowledging that solidarity in patient survivorship journey plays an important psychosocial support role, often with greater weight than a surgeon can provide.

Treating cancer in the private sector has huge financial implications. Statistics showed that in 2013, 53 percent of an insurance company’s total payouts was spent on cancer alone, superseding all other diseases. This leads to the question of how CRC screening uptake can be improved in Malaysia. In the US, patients are intentionally engaged in shared decision making to improve compliance to CRC screening which led to a decline in CRC mortality—this can be a model for Malaysia.

“In Malaysia, further studies should be conducted on the disparities in CRC screening uptake between ethnic backgrounds, insurance coverage, and level of education. It is worth confirming if the better 5-year relative survival of CRC patients in urban Kuala Lumpur compared to rural areas can be attributed to better access to care and treatment, due to private-public infrastructure and insurance coverage,” he said.

Meheshinder emphasized on the role of primary care physicians and public-private partnership in this cause. He ended with a quote from Thomas Reed: “It is troubling that so much energy and expense is devoted to the cure of advanced CRC, but so little time and money spent on screening.”

Dato’ Dr Lee Cheng Yew, a GP and president-elect, Academy of Family Physicians of Malaysia (AFPM), revealed a sizeable proportion of GPs are unable to clearly differentiate between the role of a screening and a diagnostic test. “They are frequently concerned and consequentially wrongly claimed that iFOBT is unreliable,” he said.

A study on private GPs in northeast Peninsular Malaysia showed while 21.3 percent of GPs had good knowledge of CRC screening, only 3.9 percent had good practice. The study also showed 78 percent of GPs did not think diabetes is a risk factor for CRC; less than a quarter of GPs asked about family history of CRC; almost 60 percent were aware of the current recommendation on CRC screening but only 4 percent followed the recommended guidelines; and most GPs would refer patients for a colonoscopy but screening of average-risk patients with iFOBT was still at low rates. [https://eduimed.usm.my/EIMJ20211301/EIMJ20211301_05.pdf]

“Maslow’s Hierarchy of Needs theory can be applied. Discourse opportunities among peers and continued medical training and education followed by recognition and reward for those who do well can tap into their social and esteem needs,” said Lee.

A risk-stratifying questionnaire, checklists, digital systems, which can flag patients eligible for screening; special focused clinic sessions, and engagement of patients for self-risk assessment in the waiting room may hugely benefit, he said.

Dr Murallitharan Munisamy, medical director, National Cancer Society Malaysia (NCSM), speaking on an NGO perspective of CRC screening said there is an invisible barrier between healthcare professionals (HCPs) and their patients; HCPs can advise but cannot coerce patients to take up CRC screening. Intensive behavioral interventions cannot be adequately fulfilled by healthcare systems alone due to the maintenance of this professional distance combined with the lack of specific resources—this is where the role of a strong civil society comes into play.

“There are three key drivers that dictates our behaviour towards an intervention. One, the patient must perceive that it will benefit; two, that in doing so, it will prevent harm; and three, they will gain satisfaction from the process. One can have health education, awareness, and literacy, and yet may not act on it. The provision of external cues to action and the disablement of barriers to action is missing in the current cancer screening landscape.”

He added, “… much of what we have learned through breast cancer can be applied. One example here is the hugely successful programme that NCSM runs with Etiqa, which aims to remove the usual barriers for the B40 women in getting their mammograms – by providing childcare, shopping trips, travel vouchers. This program currently runs across 11 states in Malaysia.”

Murallitharan shared a pilot study that was performed in Malacca. Communities in seven districts were mapped out and the existing governance structure was leveraged on, through which they organized a CRC awareness campaign in the local community hall at a time and place of their choosing. The pilot study was well supported by the state of Melaka as well as the public and private healthcare sector. The multilingual campaign included a health awareness talk, a workshop on risk reduction strategies, and an individual CRC risk assessment using the Asia Pacific Colorectal Screening Tool, followed by appropriate screening tests. Of the 265 individuals who took up risk assessment scoring, 43.0 percent took iFOBT and 2.6 percent underwent a colonoscopy.

Some interesting barriers that were discovered included: patients were uncomfortable passing motion outside of their homes, not being able to pass motion on demand, and some reluctance on transporting their stools from home to the community hall. NCSM went the extra mile and set up tent the next morning to collect these extra samples. A hotline was also set up and active tracking of these individuals for adequate follow up.

Due to the current COVID-19 pandemic, NCSM shifted to virtual and online resources. NCSM also embarked on another pilot test, where a RM10 self-testing kit has been made available at community pharmacies and clinics. By penetrating everyone’s daily routines, they intend to normalize the presence of colorectal screening, “to make a shitty situation less shitty.”

Lastly, Murallitharan provided a final perspective on funding. He believes that a universal funding mechanism will be hard to achieve. “Instead, we need to use the tools and levers we have available using a risk and resource stratification system, where people who are willing to pay out of pocket or are adequately covered by insurance are shuttled towards the private sector, freeing up space in the public sector for those who cannot afford it.”

In the closing remarks, Datuk Dr Muhammad Radzi Abu Hassan, consultant gastroenterologist and hepatologist, Hospital Sultanah Bahiyah, and DHM’s president, emphasized CRC can be prevented and early detection and screening is important. He wants to see screening placed as top priority based on current scientific evidence. Radzi acknowledged there are many challenges in screening, but he believed that by working together in a collaborative manner, all these challenges can be overcome.

Key Takeaways
1. Colorectal cancer is the second most common cancer in Malaysia.
2. Colorectal cancer screening is offered as an opportunistic screening for close to no cost in Malaysia, yet the coverage is still low.
3. To further strengthen the prevention and control of colorectal cancer, MOH has published the National Strategic Plan for Colorectal Cancer Program 2021–2025.
4. Several studies have been conducted in Malaysia to explore the various barriers to screening and understanding the behaviour of Malaysians, providing evidence to develop more effective interventions.
5. The private healthcare sector and NGOs have very important roles to play, and collaboration will be crucial moving forward.