Colorectal diseases, which impose a significant global burden, have been growing daily throughout the world, and low-income countries like Nepal are not immune to them1. A relatively low burden of colorectal carcinoma (CRC) seems to be reported from low and middle-income countries (LMIC), which could be due to underdiagnosis and there is a dearth of publications related to CRC from LMICs2. The age-standardized incidence rates of CRC reported in LMICs such as India are 7.2 and 5.1 per 100,000 population for men and women in comparison with global CRC incidence rates of 20.6 and 14.3 per 100,000 population, respectively3. But, the mortality rates reported have been higher compared with global north nations, which can be attributed to limited access to health care facilities, cancer screenings, and advanced illness4. The similar lifestyles, cultural beliefs, and geographical similarities between Nepal and India imply similar incidences, as no data-driven research has come to light regarding colorectal lesions from our country.
The changing lifestyles, westernization of the population groups, and dietary modifications prevalent today have contributed to the increase in disease conditions related to the colon and rectum5. Screening for colorectal cancers is the most effective way to catch the lesions in the early stage, which might be deemed curable after necessary surgical intervention. However, the lack of adequate screening facilities in low-income countries has contributed to the excessive burden of the disease, being diagnosed at late stages. The available screening programs can be characterized by a lack of a qualified, robust workforce, a few well-trained, specialized surgeons, a backlog in screening centers and cancer registries, and limited access to care outside of the capital6. Some factors that challenge the already compromised system include constraints in the availability of well-furnished operation tables, appropriate retractors, adjuvant chemotherapy centers/units, or colonoscopy facilities; limited training in minimally invasive surgery, pelvic floor repairs, laparoscopic colorectal surgeries, or treatment pursued at local levels as hemorrhoids for rectal malignancies; and less awareness among consumer groups and even health care professionals at the peripheries7.
The global incidences of young-onset colorectal cancers are rising. The transition of disease prevalence from elderly populations to the younger generation has been overlooked, albeit a change in behaviors related to obesity, physical activity, and smoking can be speculated as potential factors3. The other possibilities remain the 3 intercalated factors: diet, bacteria in the gut, and inflammation. Diets high in processed meat and fats while being low in fruits and vegetables generally deteriorate gut health; chiefly, some gut bacteria strains intensify inflammation by recruiting immune cells that help cancer grow and block the defensive immune cells that fight cancer. Further, inflammation has been attributed to chronic diseases like irritable bowel syndrome, diabetes, and Crohn disease5.
Colorectal screening modalities ought to be enacted in low and LMICs, and if feasible, the screening age can be reduced from 50 to 45 with a screening interval of every 10 years or more frequently depending on the patient’s history. Tailoring or precision CRC screening should be especially adopted for younger high-risk patients8. In addition to strategizing national guidelines for the general population, subsidizing noninvasive screening modalities like fecal occult blood test (FOBT) and fecal immunochemical test will ameliorate access-to-care disparities among high-risk groups. The fecal immunochemical test is better and more specific than FOBT, uses antibodies to detect blood in the stool, and has high sensitivity and specificity for lower colorectal lesions whereas FOBT consumes guaiac chemical for blood detection in stool determines the bleed from upper and lower gastrointestinal tract requiring restricted diet before the procedure6. Increasing access to invasive sigmoidoscopy/colonoscopy among suspected groups would be the subsequent goal, which would have to be approached cognizant of the predominant logistic issues in countries like Nepal1. Holistically, the formula for decreasing the incidence of CRC in LMICs would not be complete without enhancing public awareness: awareness campaigns can address knowledge deficiencies among the population regarding risk factors, symptomatology, warning signs, and treatment modalities6. To shift the focus towards primordial prevention, patients and physicians alike need to retire the notion of CRC as an “old man’s disease.” A data-driven, evidence-based approach should be done in collaboration with high-income countries from the southeast. The BLUE MARCH should be the defining ideal year-round in the fight to conquer this gruesome disease, such that no portion of this earth is left behind. Let us ask ourselves: Are we all truly aware? Are we truly “marching,” collectively?
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Author contributions
S.B.: Wrote the article, conducted literature search and finalised the manuscript. B.P., S.B. and V.N.: Copyedited and reviewed the manuscript.
Conflict of interest disclosures
The authors declare that they have no financial conflict of interest with regard to the content of this report.
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Guarantor
Suman Baral.
References
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2. Pathy S, Lambert R, Sauvaget C, et al. The incidence and survival rates of colorectal cancer in India remain low compared with rising rates in East Asia. Dis Colon Rectum 2012;55:900–6.
3. Sarkar S, Mukherjee R, Paira SK, et al. Profile of colorectal cancer in Eastern India. J Indian Med Assoc 2012;110:901–3.
4. Arnold M, Abnet CC, Neale RE, et al. Global Burden of 5 Major Types of Gastrointestinal Cancer. Gastroenterology 2020;159:335–49. e315.
5. Bishehsari F, Mahdavinia M, Vacca M, et al. Epidemiological transition of colorectal cancer in developing countries: environmental factors, molecular pathways, and opportunities for prevention. World J Gastroenterol 2014;20:6055–72.
6. Schliemann D, Matovu N, Ramanathan K, et al. Implementation of colorectal cancer screening interventions in low-income and middle-income countries: a scoping review protocol. BMJ Open 2020;10:e037520.
7. Unger-Saldaña K, Saldaña-Tellez M, Potter MB, et al. Barriers and facilitators for colorectal cancer screening in a low-income urban community in Mexico City. Implementation Science Communications 2020;1:64.
8. Imperiale TF, Glowinski EA, Lin-Cooper C, et al. Tailoring colorectal cancer screening by considering risk of advanced proximal neoplasia. Am J Med 2012;125:1181–7.
