Colorectal cancer prevention in Brazil - where are we?

Prevenção do câncer colorretal no Brasil - onde estamos?

Colorectal cancer (CRC) has high incidence and mortality in our country. According to estimates of incidence for 2012 from the National Cancer Institute (INCA), ^{( 1 )} 14,180 new cases of cancer of the colon and rectum are expected in men and 15,960 in women, corresponding to an estimated risk of 15 new cases per 100,000 men and 16 per 100,000 women. Excluding the non-melanoma skin tumors, cancer of the colon and rectum is the third most frequent in both genders in Brazil and the second in the Southeast region, surpassing lung cancer in men and cervical cancer in women.

Although it originates from benign lesions in most cases and the fact that it has a biological behavior characterized by slow growth, it has a high mortality rate. Thus, CRC has characteristics that justify performing preventive campaigns: high incidence and mortality, as well as favorable prognosis in the early stages.

The incidence has increased in recent years, which becomes evident in our daily clinical activities. Patients receive the diagnosis with great surprise and total unawareness about the disease, some with evident risk factors. We continue to identify a worsening situation, which fills our outpatient clinics and operating rooms, consumes millions of reais in treatment and follow-up and brings great suffering for the patients and their families.

Prevention is effective and can reduce mortality by 60%.^{( 2 ), ( 3 )} Strategies of CRC prevention and early diagnosis were introduced in the 1970s and 1980s, after finding that the use of fecal tests was feasible and effective. Randomized trials showed a reduction in the incidence of mortality, supporting their recommendation as an effective method for early diagnosis. ^{( 4 ), ( 5 )} Considering this situation, we must ask ourselves why governmental public health measures to fight colorectal cancer are not present in Brazil, unlike other countries.

In the United States, Societies and Institutes responsible for cancer treatment, prevention and registry show epidemiological data, and also the impact from interventions such as screening and treatment. They have identified, for instance, that the slight decline in the incidence of colorectal cancer in the country can be attributed to the large number of colonoscopies performed, around 40 million/year, and to a lesser extent, to behavioral changes or more effective therapies. In Great Britain, in the last 30 years, the estimated incidence for the development of colorectal cancer increased from 3.5% to 6.9%.^{( 6 )} Thus, since 2006, they have implemented a prevention program to test occult blood every two years, intended for individuals older than 60 years, aiming to reduce mortality by 16%.

However, even in developed countries, there are difficulties in implementing effective and permanent campaigns at population level, which can be attributed to the complex logistics, lack of access to endoscopic tests and high costs.

In Brazil, in recent years, we have identified a growing demand for preventive screening in colonoscopy services, whether by medical indication or spontaneous request, demonstrating awareness of the patients on the subject, albeit on a small scale. However, it can be assumed that only a small portion of the population benefits from this type of prevention. One should also consider that the poor access to high quality medical care in the public system, as well as the existence of conditions that negatively impact on public health, such as poor sanitation, makes the implementation of systematic campaigns by the government to prevent the most common malignancies a very difficult task.

Thus, campaigns arising from the private sector have emerged in recent years with the intention of filling this gap, with the creation of the Brazilian Association of Intestinal Cancer Prevention (ABRAPRECI) and the Colorectal Cancer Prevention and Screening Program carried out at the Hospital Alemão Oswaldo Cruz in São Paulo.

In UNICAMP, a CRC screening and prevention program was implemented in 2011 in the Zeferino Vaz Campus, aiming to include employees, students and faculty aged > 50 years, with an estimated population of 5,000 people. Conceived by the Coloproctology Unit and implemented by the Community Health Center (CECOM), the program is based on guidance lectures, providing occult blood testing, colonoscopy and surgery when necessary and monitoring of participants. Initial results showed adherence of 50% in 2012 and provided information to the general public as a secondary outcome, which extrapolated the limits of the campus. The acquired experience has enabled adjustments that allowed the identification of reasons for non-compliance, as well as the implemention of measures that enabled effective monitoring and guidance in positive cases.

The continental size of Brazil, with its vast regional differences and structural deficiencies, makes it impossible, at least currently, to establish a national campaign, but experience from the private sector or government agencies such as UNICAMP has shown that these programs are feasible in our country and should encourage similar regional campaigns.

Claudio Saddy Rodrigues Coy Co-editor Journal of Coloproctology

REFERENCES

• ¹
  http://www.inca.gov.br/estimativa/2012
  » http://www.inca.gov.br/estimativa/2012
• ²
  Whitlock EP, Lin JS, Liles E, Beil TL, Fu R. Screening for colorectal cancer: a targeted, updated systematic review for the U.S. Preventive Services Task Force. Ann. Intern. Med. 2008;149:638-658.
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  Laiyemo AO, Doubeni C, Pinsky PF, Doria-Rose VP, Bresalier R, Lamerato LE, et al. Race and colorectal cancer disparities: health-care utilization vs different cancer susceptibilities. J. Natl. Cancer Inst. 2010;102:538-546.
• ⁴
  Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med. 1993;328:1365-1371.
• ⁵
  Mandel JS, Church TR, Bond JH, et al. The effect of fecal occult-blood screening on the incidence of colorectal cancer. N Engl J Med. 2000;343:1603-1607.
• ⁶
  UK CR. http://info.cancerresearchuk.org/cancerstats/incidence/risk/; 2011.
  » http://info.cancerresearchuk.org/cancerstats/incidence/risk/;

Publication Dates

• Publication in this collection
  Sept 2013