Epidemiology, risk factors, and prevention of colorectal cancer

Background: Colorectal cancer remains the fourth most common malignancy in Korea, and has been ranked as the third leading cause of cancer deaths in 2020. This study aims to describe the epidemiologic status of colorectal cancer in Korea, and provide basic data for effective primary and secondary prevention methods by summarizing risk factors and screening tools. Current Concepts: Although colorectal cancer incidence and mortality have decreased in recent years in Korea, it still poses a significant public health burden. From the early 1990s until the mid-2000s, the 5-year relative survival of patients with colorectal cancer in Korea continuously increased. This can be attributed to the successful introduction of the government-led screening program;development of improved surgical techniques, anticancer drugs, and adjuvant treatment;and advances medical resources and infrastructure along with economic growth. However, since the late 2000s, the improvement in survival has stagnated. The coronavirus disease 2019 outbreak has reduced hospital visits and screenings, which is assumed to cause delays in diagnosis, leading to a worse prognosis in the patients. To overcome these obstacles, it is essential to explore modifiable environmental risk factors and appropriate screening test methods in Korea. Discussion and Conclusion: Primary prevention through risk factor modification and secondary prevention using suitable screening programs can reduce the incidence and mortality rates of colorectal cancer.

The impact of COVID-19 on screening for colorectal, gastric, breast, and cervical cancer in Korea.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has affected the utilization of healthcare services, including participation in cancer screening programs. We compared cancer screening participation rates for colorectal, gastric, breast, and cervical cancers among participants in the National Cancer Screening Program (NCSP) in 2019 and 2020 to address the potential distraction effect of COVID-19 on cancer screening. METHODS: Data from the NCSP for 4 cancer types (stomach, colorectal, breast, and cervical) in 2019 and 2020 were used to calculate cancer screening participation rates by calendar month, gender, age group, and geographical region. Monthly participation rates were analyzed per 1,000 eligible individuals. RESULTS: The screening participation rate decreased in 2020 compared to 2019 for all 4 cancers: colorectal (40.5 vs. 35.3%), gastric (61.9 vs. 54.6%), breast (63.8 vs. 55.8%), and cervical (57.8 vs. 52.2%) cancers. Following 2 major COVID-19 waves in March and December 2020, the participation rates in the 4 types of cancer screening dropped compared with those in 2019. The highest decline was observed in the elderly population aged 80 years and older (percentage change: -21% for colorectal cancer; -20% for gastric cancer; -26% for breast cancer; -20% for cervical cancer). CONCLUSIONS: After the 2 major COVID-19 waves, the screening participation rate for 4 types of cancer declined compared with 2019. Further studies are needed to identify the indirect effects of the COVID-19 pandemic on cancer patients, such as delayed diagnoses of cancer or excess cancer deaths.

News

This section offers gastrointestinal nursing-related news briefs as of April 2023 including constipation, bloating and diarrhoea in long Covid-19, role of urine test in reducing surveillance for bowel cancer, and information on the Great British Poo Taboo.

COVID-19 Pandemisinin Kanser Erken Teşhis Tarama ve Eğitim Merkezleri Hizmetlerinin Kullanımına Etkisi

Objective: This study was conducted to evaluate the impact of the COVID-19 pandemic on the use of Cancer Early Diagnosis, Screening, and Education Centers (KETEM) services. Materials and Methods: In this study, which was conducted as a descriptive retrospective cohort type, a total of 52.955 patient application records made to KETEM between January 1st and December 31st, 2017-2020 and January 1st-1 October 2021 were examined. The data obtained within the scope of the study were expressed as frequency and percentage. Results: In the study, it was determined that the numbers decreased as compared to previous three years (2017, 2018 and 2019) 70.4%, 59.1%, 68.8% for mammography screenings, 75.8%, 68.8%, 65.8% for HPV-Pap smear scans and 46.1%, 81.9%, and 72.2% for colorectal scans, respectively. Conclusion: It was detected that mammography, HPV-Pap, smear, and colorectal screenings offered within the scope of KETEM services decreased significantly in 2020 and 2021 which includes the pandemic process, compared to the previous years. It is estimated that cancers that cannot be detected in the early period due to the decrease in the number of applications will cause a significant increase in cancer mortality in the following years. Accordingly, it is recommended that the society, especially the individuals in the risk group, not delay their applications to cancer screening services, to take the necessary pandemic measures to inform them about making their applications without delay, and to improve their awareness about this issue. Amaç: Bu çalışma COVID-19 pandemisinin Kanser Erken Teşhis, Tarama ve Eğitim Merkezleri (KETEM) hizmetlerinin kullanımı üzerindeki etkisini değerlendirmek amacıyla yapılmıştır. Gereç ve Yöntem: Retrospektif kohort tipinde betimleyici olarak yürütülen bu araştırmada, 2017-2020 yıllarında 1 Ocak-31 Aralık tarihleri ile 1 Ocak-1 Ekim 2021 tarihleri arasında bir ilin Kanser Erken Teşhis, Tarama ve Eğitim Merkezleri'ne yapılan toplam 52.955 hasta başvuru kaydı incelenmiştir. Çalışma kapsamında elde edilen veriler frekans ve yüzde ile ifade edilmiştir. Bulgular: Çalışmada 2020 yılındaki mamografi tarama sayısının önceki üç yıla kıyasla (2017, 2018, 2019) sırasıyla %70.4, %59.1, %68.8 oranında;HPV-Pap smear tarama sayısının %75.8, %68.8, %65.8 oranında;kolorektal tarama sayısının ise sırasıyla %46.1, %81.9 ve %72.2 oranında düştüğü saptanmıştır. Sonuç: Bu araştırmada KETEM hizmetleri kapsamında sunulan mamografi, HPV-Pap smear ve kolorektal taramalarının pandemi sürecini kapsayan 2020 ve 2021 yıllarında önceki yıllara nazaran önemli düzeylerde azaldığı belirlenmiştir. Başvuru sayısındaki azalmaya bağlı olarak erken dönemde tespit edilemeyen kanserlerin ilerleyen yıllarda kanser mortalitesinde önemli bir artışa neden olacağı ön görülmektedir. Bu doğrultuda özellikle risk grubunda yer alan bireyler başta olmak üzere toplumun kanser tarama hizmetlerine başvurularını ertelememeleri, gerekli pandemi tedbirlerini alarak vakit kaybetmeden başvurularını gerçekleştirmeleri konusunda bilgilendirilmesi ve bu duruma yönelik farkındalıklarının geliştirilmesi önerilmektedir.

News

This section offers gastrointestinal health-related news briefs as of February 1, 2023, including a study which found that plant-based diet could reduce bowel cancer risk in men, a study which showed that the COVID-19 virus may have a profound effect on the gut microbiome balance, and the call by Coeliac UK for manufacturers to sign up for its labelling scheme in support of research which found that 76% of gluten-free consumers want to be labelled with the Crossed Grain trademark.

Epidemiology, risk factors, and prevention of colorectal cancer.

Background: Colorectal cancer remains the fourth most common malignancy in Korea, and has been ranked as the third leading cause of cancer deaths in 2020. This study aims to describe the epidemiologic status of colorectal cancer in Korea, and provide basic data for effective primary and secondary prevention methods by summarizing risk factors and screening tools. Current Concepts: Although colorectal cancer incidence and mortality have decreased in recent years in Korea, it still poses a significant public health burden. From the early 1990s until the mid-2000s, the 5-year relative survival of patients with colorectal cancer in Korea continuously increased. This can be attributed to the successful introduction of the government-led screening program;development of improved surgical techniques, anticancer drugs, and adjuvant treatment;and advances medical resources and infrastructure along with economic growth. However, since the late 2000s, the improvement in survival has stagnated. The coronavirus disease 2019 outbreak has reduced hospital visits and screenings, which is assumed to cause delays in diagnosis, leading to a worse prognosis in the patients. To overcome these obstacles, it is essential to explore modifiable environmental risk factors and appropriate screening test methods in Korea. Discussion and Conclusion(s): Primary prevention through risk factor modification and secondary prevention using suitable screening programs can reduce the incidence and mortality rates of colorectal cancer.Copyright © Korean Medical Association.

Overall management strategies for colorectal cancer patients during the COVID-19 outbreak.

The Corona Virus Disease 2019 (COVID-19) since December, 2019 has a wide range of infection due to the strong infectious characteristics. Both medical staff and patients are at increased risk of infection. It is an urgent clinical problem for specialist doctors to work with diagnosis and treatment of cancer patients during the epidemic situation. Based on the colorectal cancer diagnosis and treatment guidelines (2019 CSCO guideline), combined with their own experience, the authors propose the overall management strategies for colorectal cancer patients. This strategies cover the key diagnosis and treatment of colorectal cancer, and provide targeted clinical practice. These work will be helpful for colorectal cancer specialists to carry out the diagnosis and treatment of colorectal cancer effectively under the epidemic of COVID-19.Copyright © 2020 by the Chinese Medical Association.

Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement.

Colorectal cancer (CRC) screening reduces morbidity and mortality, but screening rates in the USA remain suboptimal. The Colorectal Cancer Control Program (CRCCP) was established in 2009 to increase screening among groups disproportionately affected. The CRCCP utilizes implementation science to support health system change as a strategy to reduce disparities in CRC screening by directing resources to primary care clinics to implement evidence-based interventions (EBIs) proven to increase CRC screening. As COVID-19 continues to impede in-person healthcare visits and compel the unpredictable redirection of clinic priorities, understanding clinics' adoption and implementation of EBIs into routine care is crucial. Mailed fecal testing is an evidence-based screening approach that offers an alternative to in-person screening tests and represents a promising approach to reduce CRC screening disparities. However, little is known about how mailed fecal testing is implemented in real-world settings. In this retrospective, cross-sectional analysis, we assessed practices around mailed fecal testing implementation in 185 clinics across 62 US health systems. We sought to (1) determine whether clinics that do and do not implement mailed fecal testing differ with respect to characteristics (e.g., type, location, and proportion of uninsured patients) and (2) identify implementation practices among clinics that offer mailed fecal testing. Our findings revealed that over half (58%) of clinics implemented mailed fecal testing. These clinics were more likely to have a CRC screening policy than clinics that did not implement mailed fecal testing (p = 0.007) and to serve a larger patient population (p = 0.004), but less likely to have a large proportion of uninsured patients (p = 0.01). Clinics that implemented mailed fecal testing offered it in combination with EBIs, including patient reminders (92%), provider reminders (94%), and other activities to reduce structural barriers (95%). However, fewer clinics reported having the leadership support (58%) or funding stability (29%) to sustain mailed fecal testing. Mailed fecal testing was widely implemented alongside other EBIs in primary care clinics participating in the CRCCP, but multiple opportunities for enhancing its implementation exist. These include increasing the proportion of community health centers/federally qualified health centers offering mailed screening; increasing the proportion that provide pre-paid return mail supplies with the screening kit; increasing the proportion of clinics monitoring both screening kit distribution and return; ensuring patients with abnormal tests can obtain colonoscopy; and increasing sustainability planning and support.

No evidence of delay in colorectal cancer diagnosis during the COVID-19 pandemic in Gwangju and Jeonnam, unclosed areas in Korea.

Objectives: We evaluated whether the coronavirus-2019 (COVID-19) pandemic caused delays in diagnosis and treatment of colorectal cancer (CRC) in Korea, where there have been no regional or hospital lockdowns during the pandemic period. Methods: Data on CRC patients (n = 1,445) diagnosed in the Gwangju metropolitan city and Jeonnam province between January 2019 and December 2021 were assessed. Stage at the time of CRC diagnosis, route to diagnosis, time to initial cancer treatment, and length of hospital admission were compared before and during the COVID-19 pandemic. Logistic regression was also performed to identify the factors associated with the risk for diagnosis in an advanced stage. Results: No negative effects indicating a down-shifting of CRC stage at diagnosis and delayed treatment during the pandemic were observed. Instead, the risk for advanced stage at diagnosis (TNM stage III/IV) was reduced in CRC patients diagnosed during the pandemic (odds ratio 0.768, 95% confidence interval 0.647-0.911). No significant differences in the interval from diagnosis to operation or chemotherapy were observed. Conclusion: No negative effects on CRC diagnosis and treatment were found until the of the 2021, which may be related to the small magnitude of the COVID-19 epidemic, absence of a lockdown policy in Korea, and rebounding increase of diagnostic colonoscopy in 2021.

Development of a colorectal cancer screening intervention for Alaska Native people during a pandemic year.

Objectives: Alaska Native (AN) people experience twice the rate of colorectal cancer (CRC) as US Whites. There is a need for increased screening and early detection. We describe the development and implementation of a randomized controlled trial of the multi-target stool DNA test (mt-sDNA; Cologuard® Exact Sciences, Madison WI) to increase CRC screening among AN people. Methods: A total of 32 rural/remote AN communities were randomized to a varied intensity intervention (patient navigation vs mailed health education) compared to 14 communities receiving usual opportunistic care. Outcome measures include screening completion and method used (mt-sDNA vs colonoscopy). Health care provider interviews and AN patient focus groups will be used to assess patient-, provider-, and system-level CRC screening promoters and barriers. Results: The study began in April 2020 during the COVID-19 pandemic, resulting in a number of challenges and study adaptations. These included difficulty finding laboratory space, lack of timely mail service due to flight reductions across the state, and travel restrictions that led to postponement of in-person focus groups. Videoconferencing platforms for Tribal engagement replaced face-to-face interactions. After an extensive search, a laboratory with space available was identified and the preprocessing laboratory established. Study staff will work closely with patients to monitor mail service to get mt-sDNA kits sent on time. We are also exploring the use of videoconferencing platforms as alternatives to in-person focus groups. Conclusions: Despite the challenges encountered during the COVID-19 pandemic, we successfully initiated the intervention and established the first mt-sDNA preprocessing laboratory in Alaska.

Colonoscopy screening and surveillance disparities during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has increased barriers to accessing preventive healthcare. This study identifies populations disproportionately underrepresented in screening and surveillance colonoscopies during the COVID-19 pandemic. METHODS: In this single-center cohort study, colonoscopy procedures were reviewed during 6-month intervals before the pandemic (July 1, 2019 - December 31, 2019) and during the pandemic (July 1, 2020 - December 31, 2020 and January 1, 2021 - June 30, 2021). 7095 patients were categorized based on procedure indication, demographics, Charlson Comorbidity Index and Social Vulnerability Index (SVI). Statistics performed using VassarStats. RESULTS: 2387 (2019) colonoscopies pre-pandemic and 2585 (2020) and 2123 (2021) during the pandemic were identified. There was a decrease in colonoscopies performed during months when COVID-19 cases peaked. The total number of average CRC risk patients presenting for first colonoscopy declined during the pandemic: 232 (10 %) pre-pandemic to 190 (7 %) in 2020, 145 (7 %) in 2021 (p < 0.001). Fewer of these patients presented from highly vulnerable communities, SVI > 0.8, during the pandemic, 39 in 2019 vs 16 in 2020 and 22 in 2021. Of all screening and surveillance patients, fewer presented from communities with SVI > 0.8 during the pandemic, 106 in 2019 versus 67 in 2020 and 77 in 2021. CONCLUSION: It is important to address the decline in CRC preventive care during this pandemic among average CRC risk first-time screeners and vulnerable community patients. An emphasis on addressing social determinants of health and establishing patients in gastroenterology clinics is imperative to promote future health in these populations.

Postoperative histology discussion in the colorectal multidisciplinary team: requirement for the colorectal nurse specialist

Background: COVID-19-related workforce absences have led to shortages of frontline healthcare staff. The colorectal nursing unit at Lincoln County Hospital was short-staffed for a few months due to the pandemic. This led to a change in the system of flagging postoperative histology results to the colorectal cancer multidisciplinary team (MDT) meeting. Data for patients during this period were studied to assess if this led to delays in MDT discussion. Methods: Data were extracted from a prospectively maintained database for all colorectal cancer patients undergoing resection surgery from 1 April 2021 to 31 July 2021. Data collected included: date of surgery, operation notes, histology results and date of postoperative MDT discussion. The time interval between date of surgery and date of MDT discussion was tabulated from this data. Results: Out of 98 patients identified on the database, 76 were included in this study. Eight (11%) of these patients did not have their histology results discussed in a timely fashion in the colorectal MDT. Four out of these eight subsequently required adjuvant therapy (chemotherapy or radiotherapy). Conclusion: There was a delay in discussion of postoperative histology in the colorectal MDT due to the change of pathway. This highlights the important role of the colorectal nurse specialists (CNSs) in the overall management of colorectal cancer patients. This article highlights the need to avoid burdening the CNS with tasks that can easily be completed by implementing advanced electronic MDT reporting systems.

Impact of two waves of Sars-Cov2 outbreak on the number, clinical presentation, care trajectories and survival of patients newly referred for a colorectal cancer: A French multicentric cohort study from a large group of university hospitals.

The SARS-Cov2 may have impaired care trajectories, patient overall survival (OS), tumor stage at initial presentation for new colorectal cancer (CRC) cases. This study aimed at assessing those indicators before and after the beginning of the pandemic in France. In this retrospective cohort study, we collected prospectively the clinical data of the 11.4 million of patients referred to the Greater Paris University Hospitals (AP-HP). We identified new CRC cases between 1 January 2018 and 31 December 2020, and compared indicators for 2018-2019 to 2020. pTNM tumor stage was extracted from postoperative pathology reports for localized colon cancer, and metastatic status was extracted from CT-scan baseline text reports. Between 2018 and 2020, 3602 and 1083 new colon and rectal cancers were referred to the AP-HP, respectively. The 1-year OS rates reached 94%, 93% and 76% for new CRC patients undergoing a resection of the primary tumor, in 2018-2019, in 2020 without any Sars-Cov2 infection and in 2020 with a Sars-Cov2 infection, respectively (HR 3.78, 95% CI 2.1-7.1). For patients undergoing other kind of anticancer treatment, the percentages are 64%, 66% and 27% (HR 2.1, 95% CI 1.4-3.3). Tumor stage at initial presentation, emergency level of primary tumor resection, delays between the first multidisciplinary meeting and the first anticancer treatment did not differ over time. The SARS-Cov2 pandemic has been associated with less newly diagnosed CRC patients and worse 1-year OS rates attributable to the infection itself rather than to its impact on hospital care delivery or tumor stage at initial presentation.

Management of colorectal cancer during the COVID-19 pandemic: Recommendations from a statewide multidisciplinary cancer collaborative.

COVID-19 has resulted in significant disruptions in cancer care. The Illinois Cancer Collaborative (ILCC), a statewide multidisciplinary cancer collaborative, has developed expert recommendations for triage and management of colorectal cancer when disruptions occur in usual care. Such recommendations would be applicable to future outbreaks of COVID-19 or other large-scale disruptions in cancer care.

Autophagy: The Potential Link between SARS-CoV-2 and Cancer.

COVID-19 infection survivors suffer from a constellation of symptoms referred to as post-acute COVID-19 syndrome. However, in the wake of recent evidence highlighting the long-term persistence of SARS-CoV-2 antigens in tissues and emerging information regarding the interaction between SARS-CoV-2 proteins and various components of the host cell macroautophagy/autophagy machinery, the unforeseen long-term consequences of this infection, such as increased risk of malignancies, should be explored. Although SARS-CoV-2 is not considered an oncogenic virus, the possibility of increased risk of cancer among COVID-19 survivors cannot be ruled out. Herein, we provide an overview of the possible mechanisms leading to cancer development, particularly obesity-related cancers (e.g., colorectal cancer), resulting from defects in autophagy and the blockade of the autophagic flux, and also immune escape in COVID-19 survivors. We also highlight the potential long-term implications of COVID-19 infection in the prognosis of patients with cancer and their response to different cancer treatments. Finally, we consider future directions for further investigations on this matter.

Has the COVID-19 Pandemic Caused Upshifting in Colorectal Cancer Stage?

PURPOSE: Coronavirus disease 2019 (COVID-19) has affected many parts of daily life and healthcare, including cancer screening and diagnosis. The purpose of this study was to determine whether there was an upshift in the colorectal cancer stage at diagnosis due to delays related to the COVID-19 outbreak. METHODS: From January to June of each year from 2017 to 2020, a total of 3,229 patients who were first diagnosed with colorectal cancer were retrospectively reviewed. Those enrolled from 2017 to 2019 were classified as the 'pre-COVID' group, and those enrolled in 2020 were classified as the 'COVID' group. The primary outcome was the rate of stage IV disease at the time of diagnosis. RESULTS: There was no statistically significant difference in the proportion of stage IV patients between the pre-COVID and COVID groups (P = 0.19). The median preoperative carcinoembryonic antigen level in the COVID group was higher than in the pre-COVID group in all stages (all P < 0.05). In stage I, II patients who underwent radical surgery, the lymphatic invasion was more presented in COVID patients (P = 0.009). CONCLUSION: We did not find significant stage upshifting in colorectal cancer during the COVID-19 outbreak. However, there were more initially unresectable stage IV colorectal cancer patients with a low conversion rate to resectable status, and more patients had factors related to poor prognosis. These results may become more apparent over time, so it is vital not to neglect cancer screening to not delay the diagnosis during the COVID-19 epidemic.

Network Pharmacology and bioinformatics analyses identify intersection genes of niacin and COVID-19 as potential therapeutic targets.

OBJECTIVES: Patients with colorectal cancer (CRC) may be susceptible to the coronavirus disease-2019 (COVID-19). However, anti-CRC/COVID-19 treatment options are currently unavailable. Since niacin is a vitamin with cytoprotective and anti-inflammatory functions, this study aimed to evaluate the possible functional roles and underlying mechanisms of action of niacin as an anti-COVID-19 and -CRC therapy. INTERVENTIONS: We used a series of network pharmacology-based and computational analyses to understand and characterize the binding capacity, biological functions, pharmacological targets and therapeutic mechanisms of niacin in CRC/COVID-19. MEASUREMENTS AND MAIN RESULTS: We revealed the clinical characteristics of CRC patients and COVID-19 patients, including predisposing genes, survival rate and prognosis. Moreover, the results of molecular docking analysis indicated that niacin exerted effective binding capacity in COVID-19. Further, we disclosed the targets, biological functions and signaling pathways of niacin in CRC/COVID-19. The analysis indicated that niacin could help in treating CRC/COVID-19 through cytoprotection, enhancement of immunologic functions, inhibition of inflammatory reactions and regulation of cellular microenvironment. Furthermore, five core pharmacological targets of niacin in CRC/COVID-19 were also identified, including BCL2L1, PTGS2, IL1B, IFNG and SERPINE1. CONCLUSIONS: This study, for the first time, revealed the niacin-associated molecular functions and pharmacological targets for treating CRC/COVID-19, as COVID-19 remains a serious pandemic. But the findings were not validated in actual CRC patients infected with COVID-19, so further investigation is needed to confirm the potential use of niacin for treating CRC/COVID-19.

The impact of coronavirus disease 2019 on surveillance colonoscopies in South Australia.

BACKGROUND AND AIM: The coronavirus disease 2019 (COVID-19) global pandemic has affected elective procedures, including colonoscopy, worldwide. Delayed colorectal cancer surveillance may increase cancer risk. This study aimed to determine the impact of COVID-19 on the proportion of surveillance colonoscopies booked and completed and the extent to which that surveillance was delayed. METHODS: This was a retrospective analysis of colonoscopy data during the 3 months (April-June 2020) when clinical services were most affected by COVID-19 in South Australia compared to the same period in 2019. Data on colonoscopies and responses to surveillance recall letters were reviewed to determine the numbers and proportions of colonoscopies that were delayed. RESULTS: During 2020, the total number of colonoscopies decreased by 51.1% (n = 569) compared to 2019 (n = 1164). In 2019, 45.5% (n = 530) of colonoscopies were completed for surveillance, but this proportion decreased to 32.0% (n = 182) during 2020, an overall decrease in the number of surveillance colonoscopies of 65.6%. Of surveillance colonoscopies that were due in 2020, 46.1% (134/291) were delayed >6 months, a significant increase compared to 2019 (19.3%; 59/306, P < 0.001). A decrease in response to surveillance recall letters was only observed in patients ≥75 years, with more nonresponders (51.6%) in 2020 compared to that observed in 2019 (25.6%, P = 0.03). CONCLUSIONS: Significant delays in surveillance colonoscopies occurred during the COVID-19 pandemic in South Australia. These effects are likely to be in areas more severely affected by the pandemic. Planning for post-COVID-19 colonoscopy capacity is required to avoid cancer progression due to delays in surveillance colonoscopies.