Colorectal cancer (CCR) is a common malignancy, both in the world, where there are about 1.5 million new cases per year, and in Portugal, where there are about 7000 new cases of CCR per year, being the 2nd most frequent cancer in both sexes. In addition, CCR is the leading cause of cancer death in Portugal, the second in Europe and the third worldwide.
Screening for CCR is essential for two main reasons: first, because it allows detection of CCR at an early stage, which is associated with a cure rate of over 90%.
On the other hand, and not least, because it allows the removal of pre-malignant lesions – the colon polyps – through colonoscopy with polypectomy. Thus, CCR screening is a unique opportunity in Oncology, in the sense that it is really possible to prevent its occurrence. In fact, it is widely demonstrated that CCR screening leads to a reduction in mortality and incidence of this neoplasm.
Due to the impact that screening programs have on reducing the incidence and mortality of CRC, the Directorate General of Health (DGS) recognizes the need and importance of population-based CCR screening under the National Program for Oncological Diseases.
Thus, in 2014 the DGS implemented an opportunistic CCR screening program, based on the annual fecal occult blood test (PSOF), using the fecal immunochemical test (FIT) in all individuals aged between 50 and 74 years. of age, asymptomatic and without other risk factors (personal or family history of colon polyps or RCC; hereditary syndromes of RCC; inflammatory bowel disease).
In this strategy, when the stool test is negative, it must be repeated after 1 year. When the result is positive, the user is asked to perform a total colonoscopy, which should ideally take place within 8 weeks.
If the total colonoscopy is performed under optimal conditions and the result is normal, it should only be repeated after 10 years (provided that no intestinal symptoms appear during this period).
In line with the national CCR screening strategy of the DGS, an opportunistic screening program organized between the ACES of the Sotavento Algarvio and the Gastroenterology Service of the Hospital de Faro of CHUA during the years 2018 to 2020 which, despite some difficulties, demonstrated the feasibility of carrying out this strategy using the installed capacity in the NHS.
There are other alternative methods for carrying out the CCR screening, all with advantages and disadvantages compared to the national strategy proposed by the DGS.
In particular, it is legal to perform a primary test with endoscopic exams (rectosigmoidoscopy or colonoscopy). In this context, some pilot experiences have already been carried out at national level, which found as major limiting factors the adhesion of users and the responsiveness of the Gastroenterology services of the National Health Service (SNS).
Due to these limitations, the DGS recognizes the inability to implement a screening strategy primarily based on performing a colonoscopy for all users included in the target groups.
Other screening strategies include: annual PSOF and sigmoidoscopy every 5 years; or performing colonography by computed tomography (aka CT scan) or endoscopic colonic videocapsule every 5 years. If, in one of these alternatives, at least one colonic polyp is found, subsequent colonoscopy with polypectomy is mandatory.
What is important to emphasize, however, is that, whatever the strategy used, what is essential is TRACK. Only by screening CCR can we aim to prevent CCR and reduce the number of new cases. For these results to be achieved it is therefore necessary to TRACK.
And for screening to be successfully implemented in the community, a strategy of commitment and motivation at three levels is needed:
1 - Population - it is important to increase the health literacy of the population, through education, motivation and promotion of adherence to screening campaigns with clarification and demystification of fears and fears, particularly about colonoscopy and polypectomy - which is a safe test, provided that carried out in reputable centers and by experienced professionals.
2 - Primary Health Care – it is important that Family Doctors propose to the user to carry out the CCR screening and have the necessary training to allow them to clarify the user about the available modalities, relative advantages and disadvantages and answer the doubts raised by the user.
3 - STATUS – It is important to invest in population-based CCR screening as a strategy to prevent the occurrence of new cases of cancer and, in this way, achieve a reduction in costs inherent to the treatment of patients with cancer.
It is essential to provide the NHS with high-resolution endoscopy equipment, in accordance with international recommendations for CCR screening.
Additionally, as warned by the Portuguese Society of Gastroenterology in February 2021, it is essential to implement a specific screening program for the recovery of exams not performed during 2020 due to the SARS-CoV2 pandemic.
In conclusion, CCR screening offers not only the possibility of early detection of this neoplasm but also, and more importantly, the prevention of the occurrence of CCR.
Therefore, it is essential to implement and adhere the population to CCR screening. Whichever tracking modality is chosen, the important thing is to TRACK.
Author: Helena Tavares de Sousa is a Gastroenterologist at the Rectal Cancer Reference Center – Algarve University Hospital Center (CHUA)
Note: This is the first in a series of articles that the Sul Informação will publish in the coming months, in partnership with the CHUA Rectal Cancer Reference Center, in order to contribute to increasing health literacy, specifically on issues related to CCR.
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