Doing things right and doing the right things: Colorectal cancer screening in Saudi Arabia

Saudi Arabia has witnessed a decrease in all-cause age-standardized mortality, which is mainly derived from a reduction in communicable diseases. But some of the major causes of death from non-communicable disease remain high including cardiovascular disease, cancer, chronic respiratory diseases, and diabetes.^[1] In fact, deaths from cancer are on the rise.^[1] Colorectal cancer (CRC) prevention and early detection through population-based screening is one of the interventions in medicine that had a very favorable narrative in settings with high burden of the disease. The importance of screening programs is augmented given the steady increase in age standardized incidence rate (ASIR) for colorectal cancer globally.^[2] Though CRC incidence and mortality in the West Asia region is still slightly lower than the global average, the rapid socio-economic transition and changing lifestyle in the region are likely to change the scenario soon. For example, in the Middle East and North Africa the ASIR increased by 40% between 1990 and 2017, while in Saudi Arabia it was estimated to have increased by 150% during the same period.^[2] In a modeling study, CRC screening was demonstrated to be cost-effective even in a relatively low incidence area like Saudi Arabia.^[3] However, realization of benefits of screening is dependent on achieving high participation rates, timely referral of the screen positives, optimal therapeutic interventions and maintaining disease registries, and quality processes that would ensure optimal resource utilization and removing redundancies [Figure 1]. All Gulf Cooperative Council (GCC) countries have CRC screening programs that are either in a pilot stage or established, apart from Oman.^[4]

Figure 1: Some of the elements that should be accounted for in a colorectal cancer screening program

In this issue of the Saudi Journal of Gastroenterology, Zacharakis et al.^[5] report on the outcomes of a CRC screening demonstration program that was implemented over a 5-year period in the central area of Riyadh. There are several key issues that this study sheds light upon, which need to be considered while scaling up the national CRC screening program in Saudi Arabia. In this stool-based screening strategy, the participation rate was reasonably high (73%). Usually, screening programs need time to achieve such a high level of uptake; for example, screening participation increased from 38.9% in 2000 to 82.7% in 2015 in a cohort from Kaiser Permanente Northern California when the program was shifted from an opportunistic approach to an organized direct-to-patient annual FIT outreach program.^[6] The participation rate reported by Zacharakis et al. was also higher than that achieved by a pilot study by the Saudi Ministry of Health (MoH)^[7] and a retrospective study by Almoneef et al.^[8] [Table 1]. It is important to further study the community mobilization and invitation processes of these studies to explain the variability in participation rates.

In the report from the Saudi MoH on the pilot, stool-based colorectal cancer screening program that was rolled out in 2017 and involved 417 centers across the country, 82,500 individuals were targeted and the outcomes of that pilot were sub-optimum^[7] [Table 1 and Figure 2]. The report of the pilot exposed several barriers to CRC screening including the gap between knowledge and action.^[10] There were several operational challenges, including supply-demand mismatch in FIT testing, manpower and facility limitations, lack of an information technology platform to monitor the program, lack of feedback to the referring center, and system design issues in the patient journey through the healthcare system.^[7] A robust quality assurance mechanism supported by appropriate performance indicators and standards is the key to success of any screening program.

Table 1: Results of selected stool-based and colonoscopy-based colorectal screening initiatives in Saudi Arabia

Figure 2: Saudi Ministry of Health pilot program for colorectal cancer screening from 2017-2021

There was a lot of variability in the outcomes of some of the reported stool-based screening programs that have been conducted in Saudi Arabia [Table 1]. This variability is an opportunity to explore the various factors that might optimize the patient journey through a screening program. While some of these pertain to the population, others are related to the system.

Access to high-quality colonoscopy can make a significant impact on compliance to further assessment and the detection rates. It might be that the time interval between a positive test result and a colonoscopy might play a role, as it was 13.4 workdays in the study by Zacharakis et al.,^[5] while the median time was 5 months in the study by Almoneef et al.,^[8] and it was not reported in the pilot project by the MoH. Colonoscopy participation rate of 76% and adequate bowel preparation rate of 77% reported by the study by Zacharakis et al. shows that there is a significant scope for improvement.^[11]

When implementing a screening program, we should look at the system as a whole. A study from Riyadh demonstrated that surveillance colonoscopies after colon cancer detection and treatment also requires improvement; out of 280 patients who had colon cancer only 55.7% had a surveillance colonoscopy^[12] and there were incident cancers after the initial CRC was treated. Furthermore, the time between a positive stool-based test and a colonoscopy should be kept to a reasonable duration as a delay of more than a year has been associated with an increased risk of colon cancer,^[13] which defeats the purpose of screening. These patients who had a positive stool based result might have sought getting a colonoscopy in other centers given the prolonged wait times, thus highlighting the importance of having national registries and quality programs that assess various elements of these system-related issues in a screening program.

These issues are not unique to the region and have been realized in the recently published Nordic-European Initiative on Colorectal Cancer (NordICC) controlled trial, where 84,585 average risk individuals were randomly invited in a 2:1 fashion to usual care with no screening or a single screening colonoscopy, respectively.^[14] This trial although demonstrated a modest reduction in CRC incidence at 10-years (relative risk (RR) 0.82; 95% confidence interval (CI) 0.70 to 0.93) and the number needed to invite was 455 persons to prevent one case of CRC, it failed to show a decrease in CRC-related mortality (RR 0.90; 95% CI 0.64 to 1.16) or overall mortality (RR 0.99; 95% CI 0.96 to 1.04).^[14] The NordICC trial was severely criticized for the low response rate and the short study duration as it might have needed a longer follow-up time to realize the benefits of screening, and the possibility that Europeans had a lower CRC risk given their diet and lifestyle. Despite these points, this trial sheds light that the act of providing a screening test is only a small part of the story and there are numerous factors that need to be considered and that real world practice, doing things right (efficiency), might be different from doing the right things (effectiveness) in clinical trials [Figure 2].

As Peter Drucker, who is thought of as the founder of modern management stated “Efficiency is concerned with doing things right. Effectiveness is doing the right things.” These elements are embodied in healthcare systems and in their designs and delivery; we should choose the right interventions in the right context and timing. That is not enough, as it must be done the right way with reducing waste and redundancies and delivering value-based health care, otherwise we would be wasting time and money as well as doing a disservice to the people we care for.