Colonoscopy, Barriers, and Challenges for Colorectal Cancer Screening in Developing Countries

Abstract

Colorectal cancer (CRC) is the third most common cancer worldwide. The incidence of CRC is rising in developing countries but decreasing in developed countries due to the widespread use of screening and surveillance colonoscopy. The implementation of screening and surveillance programs remains a challenge in developing countries, especially Indonesia. Increasing screening rates among underserved populations in Indonesia, the world’s fourth most populous country, will reduce the global burden of colorectal cancer. The need for an integrated screening program in its healthcare system will provide a successful screening program. The purpose of a screening colonoscopy is to reveal the asymptomatic population with a certain disease through the use of an effective investigation to detect and treat the disease before it advances. Screening improves the prognosis of patients and the mortality rate. Removal of neoplastic polyps such as adenomas, the precancerous lesions during colonoscopy, is the cornerstone of screening colonoscopy. The detection rate is a measure of screening colonoscopy performance quality. Technology has been used to improve detection, such as mechanical technology (Endocuff) and optical, such as magnification, endocytoscopy, virtual chromoendoscopy, and recently artificial intelligence. Indonesia is a nation that is significantly affected by CRC and will benefit from screening colonoscopy.

1. Introduction

Colorectal cancer is the most common type of gastrointestinal malignancy, the third most diagnosed cancer worldwide, and the second most common cause of cancer death. Among other continents, according to GLOBOCAN 2020 reports, Asia has the highest prevalence of 50%. Of these, 75% of cases are reported in East Asia. Indonesia has the highest estimated number of new cases (32%; 34.189 cases), followed by Thailand. The incidence of colorectal cancer in Indonesia is 12.8 per 100,000 citizens, with a mortality rate of 9.5% from all malignancies. This high incidence ranked Indonesia, the top third in the world [1].

Identification of the population at risk and screening of asymptomatic patients is therefore crucial imperatives. Most colorectal cancer is slow-growing, arising from precancerous lesions such as adenomatous polyps or sessile serrated lesions. This slow growth gives a window of time to screen for both early cancer and precancer lesions. If colorectal cancer is diagnosed at an early stage, however, it is one of the most curable malignancies.

Considering the increasing number of locally advanced and advanced cases of colorectal cancer in developing countries, there is an urgent need to implement screening strategies. Screening programs are aimed at early detection, recognizing early signs and symptoms of the presence of the disease, and treating patients with curative intent. Colonoscopy, as step two of screening, has been proven to improve the prognosis and lower the mortality rate. Therefore, in order to maximize the benefits of cancer prevention programs, it is worth identifying, and defining investment opportunities for colonoscopy in the healthcare system, especially in populous developing countries like Indonesia.

Global differences are reported in colonoscopy implementation in developing countries. It is likely due to differences and limitations in access to diagnostic and treatment facilities in most developing countries, a lack of resources for the health care system and cancer care is commonly seen. There are social, cultural, and structural ranging from poverty, limited access, the misbelief of the incurability of any tumor, the fear of stigma, and sociodemographic barriers related to proper health facility accessibility due to long distances or unaffordable cancer services not covered by national health insurance [2].

Colonoscopy is highly sensitive and specific for colorectal cancer detection and polyp removal. This invasive and resourceful procedure is performed in more developed countries in organized mass screening protocols in persons with a positive response to a filter fecal occult blood test (FOBT). However, compliance is still limited, cost is high, and complications can occur. In recent years, colonoscopy tends to be performed more often as a primary test in opportunistic nonorganized screening for asymptomatic persons asking for prevention.

In developing countries, the risk of colorectal cancer may increase, contrasting with a persistent weakness in organized mass screening under the control of Health Authorities. The discrepancy should encourage the growth of opportunistic indications for primary colonoscopy in spite of its high cost. However, this is not a population-based strategy of prevention. Hence, the prognosis, mortality rate, and burden of disease have improved through the implementation of effective screening.

The advantages of colonoscopy are both its benefit of simultaneous diagnostic and therapeutic procedures. Its direct visualization and marking site option are very useful in the era of multimodality optimal cancer care via personalized medicine. It assists surgeons in deciding on a tailored surgery approach and the possibility of the option of chemoradiation modalities.

Disadvantages of colonoscopy are its invasiveness, risk of complications (such as perforation and hemorrhage), the need for bowel preparation, and its burden on resources and associated costs. Colonoscopy detects and visualizes directly the structural identification of many diminutive small adenomatous and sessile serrated polyps.

2. The role of the essential triangle factor in screening colonoscopy

Colonoscopy is the gold standard procedure for the early detection of colorectal cancer and premalignant adenomatous polyps. Screening procedures can be indicated in two conditions: a primary colonoscopy or a secondary colonoscopy. The primary colonoscopy was conducted without a filter test in nonorganized or opportunistic screening of the average risk person group, aged 50 years or more. The secondary colonoscopy was the stage two program after a positive first stage filter of fecal occult blood test (FOBT) in an organized mass screening protocol by Health Authorities in a population of asymptomatic persons of both sexes in age 50 to 70 years.

The colonoscopy screening program will be effective and successful through a solid collaboration between the essential triangle factors that consist of the role of Health Authorities, compliance of population or patient adherence, and lastly, the provider side (Figure 1).

Figure 1.

Essential triangle factors in screening colonoscopy.

2.1 National Health Policy

The policy of prevention deserves to be generalized in developing countries. Government support, public health campaigns, and nationwide strategies must be formulated as the authority’s priority. In each country, cancer prevention is under the control of a National Health Service of the Ministry of Health, like in Indonesia [3]. The National Authorities actively encourage the control of environmental carcinogenic factors linked to diet with excess calories and lack of vegetables and physical activity. The organization of a screening policy of secondary prevention depends on the Colorectal Cancer National Guideline. Developing countries with low resources tend to concentrate resources on treatment services in their National Health Care System. Emerging countries with higher resources have already built better healthcare structures [4]. In Indonesia, colonoscopy as a step two screening procedure has been established in the national colorectal cancer control guideline, but heterogeneity persists in rural and urban areas. An integrated national registry will help to scale up and enable the identification of discrepancies, false-negative cases, and interval cancers. National reporting systems of screening activate better monitoring consistency as well as continuous quality assurance and further cancer control planning. Information technology can assist coverage of screening tests by a model of mobile application based on the Asia Pacific Colorectal Screening (APCS) score.

2.2 Health literacy and patient participation

Public education and general practitioner insight into the risk factors of colorectal cancer and referral indication need to be pursued. Health promotion increases public and physician awareness and strengthens the compliance of the screened population and patient adherence to cancer surveillance. Physicians in primary health services should not ignore the presence of blood in the stool of patients older than 50 years old as simply hemorrhoids. Investigation into the risk factor must be highlighted, particularly for patients with genetic predispositions in the first degree. Asymptomatic patients at average risk should also be promoted.

Patient selection is still based on primary and secondary procedures. An educated and well-informed population with risk factors for colorectal cancer tends to get the primary colonoscopy as an opportunistic screening. Hence, the secondary procedure is the follow-up intervention after a positive noninvasive screening option, like FOBT screening, has been established in many developing countries [5].

Discrepancy must be avoided as rural areas have more population with a lower education level than urban areas. Geographical issues still exist in many developing countries, such as Indonesia, due to colonoscopy services are commonly in the sub or urban areas, in tertiary hospitals. Some patients need to put more effort into accommodation. Social and community support sometimes helps in some local conditions, especially for those who live in archipelago areas.

The urban area also has its own problem with screening procedures. The change in sedentary lifestyle, smoking, alcohol consumption, “westernized” food, and lack of physical activity resulting in obesity, make the risk of colorectal cancer become higher. The incidence and prevalence of young colorectal cancer patient in developing countries tends to increase recently, projected to continue over the next decade. Screening consideration for the working-class population, in productive age, is getting important. Diagnosing colorectal cancer early is cheaper than treating advanced malignancy. The short and long-term term-productivity loss also could be minimized.

Social media impact by health volunteers, influencers, or public figures promotion will provide an insight that colonoscopy as an invasive procedure is more culturally and psychosocially acceptable.

Successful participant recruitment through the repeating multifactorial cycle results in strong fundamental patient adherence and compliance with colonoscopy screening (Figure 2). Each of the cycle factors could be explored particularly in many creative and innovative ways. Continuous activities that engage the public, patients, and primary care physicians should be encouraged, like cancer awareness month, social campaigns, and sports events.

Figure 2.

Patient participation and compliance.

2.3 Provider factors

Financial reimbursement and human resources are the keys on the provider side. Financial limitations in many developing countries are still problematic and require a defining concern and model to fill the gap [6]. Reimbursement from national health insurance or private insurance must promptly accept the need for screening colonoscopy. Delayed procedures due to multilevel administrative referral systems and hierarchical insurance approval may limit compliance and coverage.

Gastroenterologists and digestive surgeons both can perform the procedure effectively. The aim is the patient-oriented goal to achieve early detection of colorectal cancer. Complete colonoscopy units for performing full colonoscopy equipment including endoscopes with biopsy puncture facilities and polypectomy snares need to be standardized in every hospital. Personalized colonoscopy plans and additional technology in colonoscopy can be established through partnership training between the developed world and developing countries to build better capacity levels. Advanced technology such as mechanical technology (Endocuff) and optical, such as magnification, endocytoscopy, and virtual chromoendoscopy could be introduced to invite investors. Information technology like artificial intelligence is also required in the near future to assist well-trained operators and junior staff in training in order to improve coverage, safety level, performance quality, detection rate, and treatment rate [7].

Epidemiological research in developing countries and cancer registries helps to picture the landscape of colorectal cancer in a particular area and build patient navigation. The ratio between patient and provider needs to be calculated to avoid a long waiting list for the procedure. A national cost-effective study must be conducted in the developing world in order to analyze the cost-effective colonoscopy screening model and to integrate the research component into the national cancer control plan.

3. Conclusion

Overcoming barriers in the implementation of colonoscopy remains a challenge in developing countries, especially Indonesia. Indonesia, the world’s fourth most populous country, is significantly affected by colorectal cancer and will benefit from colonoscopy. Increasing screening uptake among underserved populations in Indonesia should be supported.

As a part of optimal cancer care in developing countries with increasing resources, colonoscopy procedures should be developed its feasibility as a screening measure and integrated policy for colorectal cancer prevention and surveillance. Health Authorities, compliance of the population, and provider resources are the essential triangle factors in colonoscopy sustainability.

In current practice, the opportunities for collaborative service and future research between developing countries and developed countries are widely open and will enhance the availability and detection rate of colonoscopy as the gold standard screening procedure in reducing the global burden of colorectal cancer, with an impact on mortality and survival.

Acknowledgments

The authors gratefully acknowledge the colonoscopy facilities provided by Dr. Suhardi Hardjolukito Central Air Force National Hospital and all its staff in Public Health Services. The authors would specifically like to thank all the faculties and staff of the Digestive Surgery Division of RSUP Dr. Sardjito Hospital Yogyakarta-Indonesia, Digestive Surgery Division of RSUP Dr. Kariadi Hospital Semarang-Indonesia, and the Advanced Surgery Training Center of National University Hospital Singapore for the coordination and opportunity in the context of the advanced colonoscopy training.

Conflict of interest

The authors declare no conflict of interest.