Colorectal cancer: Awareness in people and policymakers is the key

Diagnosis of cancer is emotionally and financially challenging for patients and their relatives.[1-3] Colorectal cancer (CRC), earlier considered a disease of the West, now has an increasing prevalence in many low- and middle-income countries (LMICs) due to the westernization of the diet.[4] This includes a diet comprising red meat, refined sugars, grains, and proportionally more low-residue processed foods.[5,6] When this is associated with a lack of physical exercise, obesity, and smoking, the incidence of CRC further increases. These lifestyle changes are slowly being adopted in countries such as India and other LMICs, leading to an increase in the incidence of CRC.[7] Because the incidence of CRC was previously low in these countries, organized screening programs for CRC have not yet been established LMICs as in Western countries. Hence, it is imperative to increase awareness about this disease, as early diagnosis of CRC can result in a better prognosis. Survival rates can go up to 90% if diagnosed early, however, they can drastically fall to as low as 10% when diagnosed late.[8] Studies have documented that healthy lifestyle choices can reduce the incidence of CRC by 20–40% and mortality by 50%.[9] For CRC, the focus must be on disease awareness, specifically focusing on risk factors and warning symptoms. Thomas et al.,[10] conducted a study to determine the awareness of risk factors and warning signals in a rural and semi-urban population in South India. In their questionnaire-based study, they found a low level of awareness of risk factors and warning signs of CRC and identified that a low-fiber diet (fast food), alcohol consumption, cigarette smoking, and a family history of CRC were the most frequently recognized risk factors. Symptoms such as abdominal pain, bleeding per rectum, change in bowel habits, and loss of appetite were commonly identified as warning signs.[10] Of note, some well-known factors that needed prompting, were not elaborated in the study. We request the authors to provide the details, preferably in a diagrammatic form, of the questions that needed prompting, and those that did not. The scores reported showed that people were unaware of most of the CRC risk factors and needed prompting to even identify them. The authors have described the rationale of the study quite well and the need for such regional data. There are limited studies reported from India on this subject, as highlighted by the authors.[10] The primary determinants of survival among patients with CRC include advanced stage and late presentation, and it is important that the population at risk is aware of this fact as well as the preventive measures. Noronha et al.[11] reported in their study on 151 patients that 41.8% of the patients presented with stage IV disease, and 27% presented with stage III, thus stressing that the majority presented in the late stages of CRC. Thomas et al.,[10] have also highlighted the same fact of late diagnosis of CRC and the factors that led to the delayed presentation. However, a larger sample size would have been preferable, as 75 is too small a number for a population-based study. The reference study used for sample size calculation also had approximately 350 patients.[12] It would have been good to carry out a posthoc analysis between the determinants of the awareness of the risk factors and warning signals and the socio-demographic characteristics such as residence, education, and occupation. The socio-demographic standards reported in this study should also have some reference scale.[10] A report from a tertiary care hospital on 800 patients showed that the rectum (42%), followed by rectosigmoid (21%), colon (20%), and anorectum (13%) were the common sites of CRC, and a majority of the patients presented at advanced stages, thus making the outcomes worse.[13] This combination of delayed presentation and poor prognosis is largely preventable, and larger population-based awareness studies from different zones of India can help in developing a good database. This database can guide policymakers and create more regional and national cancer control programs. Studies on the knowledge, attitudes, and practice of people toward CRC and other types of cancers[14] can help improve outcomes. This will be the key to the effective implementation and execution of optimal oncological therapy, policy-making, and addressing the challenges caused by limited economic resources and the increased burden of cancer. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.