Lack of screening program 'very short-sighted'
Colorectal cancer will kill thousands of Canadians this year. So why isn't more being done to prevent it?
LISA PRIEST
From Friday's Globe and Mail
Marc St. Coeur was doubled over in pain, passing blood. With no family physician, he went to an Ottawa hospital emergency department, where doctors detected the source of his problem: His rectum was blocked with cancer.
On the East Coast, Linda McAlpine had been ill for a week, suffering flu-like symptoms. She was barely able to stand when a friend's doctor stopped by her Halifax home, noticed her grey pallor and whisked her to the emergency room. Surgeons removed a large tumour that was obstructing her colon.
Mr. St. Coeur and Ms. McAlpine don't know each other, but they share a diagnosis of advanced colorectal cancer, in 2005 and 2003, respectively, and neither of them had family doctors.
Given that Ms. McAlpine, 59, is a woman and Mr. St. Coeur, 48, worked in a low-income job, they also represent the two groups of patients most likely to present with serious complications at the time of diagnosis.
"Cancer has a funny way of creeping up on people," Mr. St. Coeur said. Especially when there's no colorectal screening program in Canada, offering the chance to detect cancers in an early stage -- or even before they begin.
An estimated
20,000 Canadians are expected to be diagnosed with colorectal cancer this year; some 8,500 will die of the disease, making it the second biggest cause of cancer death, the Canadian Cancer Society says. Given that organized, colorectal cancer screening programs can reduce death rates by 15 to 33 per cent, the question arises: Why doesn't Canada have one?
Barry Stein, president of the Colorectal Cancer Association of Canada, has long been pushing for such a program. "It's very short-sighted to not have a program like this," Mr. Stein said in a telephone interview from Montreal. "We will be paying the costs, whether it's human costs or financial costs, loss of productivity, those things we don't actually calculate or think about."
Ontario said in April that it wants to be the first in Canada to start a colorectal screening program -- but so far, no program has been announced. British Columbia is studying a proposal by the BC Cancer Agency to start such a program. Alberta plans to have a program up and running some time next year. Manitoba expects to make recommendations in six to 12 months on resources required. Quebec is studying the feasibility.
So what's the holdup?
For one thing, doctors warn that screening programs would create a crush of patients who, having tested positive in fecal occult blood tests -- finding blood in the stool -- would require colonoscopies.
"Clearly, there is no way we have the resources [in Canada] that would be directed to colonoscopy," said William Paterson, president of the Canadian Association of Gastroenterologists, a national group of specialists that specialize in diseases of the digestive system. He said gastroenterologists do roughly half of all colonoscopies, a procedure in which a thin, flexible viewing instrument looks at the interior lining of the rectum and colon. General surgeons do the other half.
As it is, only 41 per cent of patients across Canada who test positive in fecal occult blood tests are able to obtain a colonoscopy within two months -- the association's maximum recommended waiting time. In Ontario, where a screening program seems closest to becoming reality, doctors are meeting that two-month maximum only 31 per cent of the time, he said.
Although Dr. Paterson stressed the importance of screening programs, he wonders how doctors will be able to meet the increased demand.
"One of my concerns is that if everybody is going off to do screening on patients, who is going to look after the sick people?" he asked.
Those people, he said, include chronic diarrhea sufferers, who may have ulcerative colitis. They should have a colonoscopy within two months, but 10 per cent of them are waiting one year and still have not seen a gastroenterologist or undergone the procedure, he said.
Dhali Dhaliwal, president and chief executive officer of CancerCare Manitoba, said the resources required for a screening program will be massive. Unlike similar programs for breast and cervical cancer, colorectal cancer screening would include both genders.
"The limitation will be the capacity of gastroenterologists and surgeons," Dr. Dhaliwal said. ". . . Everybody has plans in the pipeline."
Heather Logan, director of cancer control policy for the Canadian Cancer Society's national office, said before a screening program can be undertaken, there have to be enough resources to ensure prompt investigation after a positive test result. "It's really important that this is done right," she said.
Without prompt follow-up, doctors say patients could be left worrying for months about whether a positive test spells cancer. Of those whose feces tests positive for hidden blood, 30 per cent will have polyps and 2.2 per cent will have colorectal cancer. The remaining cases could be attributed to hemorrhoids, colitis or other non-cancerous conditions, said Derek Jonker, a medical oncologist at the Ottawa Hospital Regional Cancer Centre.
"I would certainly recommend that the province certainly use the fecal occult blood testing, preferably on a yearly basis on everyone aged 50 to 74," said Dr. Jonker, who specializes in gastrointestinal cancer.
At least one dozen European countries have some form of colorectal cancer screening program. Of those, Finland has the highest compliance rate, with 70 per cent of the target population participating. Australia has a compliance rate of 45 per cent. In Canada, the test is recommended for those aged 50 and older. But, according to Canadian Cancer Statistics 2006, participation is low, ranging from 13 to 14 per cent of men in British Columbia, Saskatchewan and Ontario -- down to 4 per cent of women in Newfoundland and Labrador.
With a fecal occult blood test, a patient is an active (if not exactly enthusiastic) participant, having to take a small sample of feces every day, for three days, then house it in a special cardboard box to which a chemical solution is later added.
The sample should be taken before it has hit the water of the toilet bowel, leaving some puzzled at precisely how to complete this task. An Internet search reveals a sure-fire method: placing plastic wrap over the toilet seat.
In some cases, colorectal cancer can be stopped before it begins. Found in the colon -- a hollow, muscular tube some five feet long -- a polyp can be flat or hang like a cherry from a stem. Polyps can exist for five to 10 years before causing cancer and, while not all polyps necessarily cause cancer, their surgical removal is recommended.
According to Canadian Cancer Statistics for 2006, if 70 per cent of the target population aged 50 to 74 had the fecal occult blood test every two years, the death rate for the disease would drop by 17 per cent.
"There's good evidence it reduces the risk of developing extensive cancer and certainly, if you have a polyp, it's removed," said Brent Schacter, chief executive officer of the Canadian Association of Provincial Cancer Agencies.
But Linda Rabeneck, regional vice-president for Cancer Care Ontario and lead author on a study published in the May issue of American Journal of Gastroenterology, found a telling 19 per cent of Ontario patients were diagnosed because they experienced dangerous complications, including bowel obstruction, perforation at the site of the tumour or emergency admission to hospital.
Her study identified more than 41,000 cases of colorectal cancer in Ontario through health-record databases between 1996 and 2001. It found women and low-income Ontarians are more likely to have serious complications at the time they are diagnosed.
Overall, the study suggests that women and low-income Canadians are not being sent as often as men and financially better-off patients for tests to detect colorectal cancer at a point where it could be more easily treated.
"These clearly represent failures in access to screening and access to diagnostic tests," said Dr. Rabeneck, vice-president of Toronto Sunnybrook Regional Cancer Centre. "The system, if you will, has failed these patients in an important way."
Dr. Rabeneck's study used census data from Statistics Canada to define high and low income. In Ottawa, low-income neighbourhoods were defined as having an average income, adjusted for family size, of less than $29,626 -- which certainly includes Mr. St. Coeur, who, until the time of his diagnosis, operated a skidder (a four-wheel tractor used to haul logs).
Mr. St. Coeur also has cancer in the family: His brother died of colorectal cancer five years ago, and another brother was diagnosed with the disease in 2003, two years before Mr. St. Coeur showed up in a hospital emergency with a case of it himself. Two older brothers do not have the disease. Had Mr. St. Coeur been able to find a family doctor, the physician would likely have recommended a colonoscopy when he experienced symptoms or even before then. Instead, his cancer was caught so late that the tumour had invaded his bladder.
"Once I went into hospital that was it, they had to do something right away or I probably would have died," Mr. St. Coeur said.
As for Ms. McAlpine, just being a woman meant she was more likely to present with a complicated, advanced case of colorectal cancer.
Dr. Rabeneck speculated that women may tend to be averse to colonoscopy out of a reluctance to undergo procedures performed by a male physician -- in short, they're embarrassed. But Ms. McAlpine said that wasn't the case.
"I ate all the right things, I exercised, I didn't smoke -- the whole bit," said Ms. McAlpine, who, until her diagnosis, was a psychologist who worked with visually impaired, blind and hearing impaired.
She first attributed her symptoms of bloating, diarrhea and vomiting to a bout of the flu. Other times, difficulty tolerating food was ascribed to menopause or indigestion.
"If there was a screening program, I would have done it," Ms. McAlpine said. "These symptoms are too easy to ignore."
Screening and symptoms of colon cancer
Colorectal cancer is a slow-growing, malignant tumour that develops on the bowel wall before invading it and moving on to other organs. Because it usually takes at least a decade to develop from polyps ( raised clumps of noncancerous cells) to a cancer, regular screening is vital to diagnosing the disease early, when it is more treatable.
Symptoms of colorectal cancer include fatigue and weakness, a change in bowel habits that alternates between constipation and increased stool frequency, stool streaked or mixed with blood, and discomfort or pain in the lower abdomen.
