Colorectal Cancer in Malaysia: Its Burden and Implications for a Multiethnic Country Sajesh K

+ MODEL Asian Journal of Surgery (2016) xx,1e9

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ORIGINAL ARTICLE Colorectal cancer in Malaysia: Its burden and implications for a multiethnic country Sajesh K. Veettil a, Kean Ghee Lim b,*, Nathorn Chaiyakunapruk c,d,e,f, Siew Mooi Ching g, Muhammad Radzi Abu Hassan h,i a School of Pharmacy/School of Postgraduate Studies, International Medical University, Kuala Lumpur, Malaysia b Clinical School, Department of Surgery, International Medical University, Jalan Rasah, Seremban, Negeri Sembilan, Malaysia c School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia d Centre of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand e School of Population Health, University of Queensland, Brisbane, Australia f School of Pharmacy, University of WisconsindMadison, Madison, WI, USA g Department of Family Medicine, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia h Gastroenterology Service, Ministry of Health, Malaysia i Department of Internal Medicine, Hospital Sultanah Bahiyah, Kedah, Malaysia

Received 21 January 2016; received in revised form 18 March 2016; accepted 21 March 2016

KEYWORDS Summary Background: This study aims to provide an analytical overview of the changing burden; burden of colorectal cancer and highlight the implementable control measures that can help cancer prevention; reduce the future burden of colorectal cancer in Malaysia. colorectal neoplasms; Methods: We performed a MEDLINE search via OVID with the Medical Subject Headings (MeSH) Malaysia; terms “Colorectal Neoplasms”[Mesh] and “Malaysia”[Mesh], and PubMed with the key words review; “colorectal cancer” and “Malaysia” from 1990 to 2015 for studies reporting any clinical, soci- screening etal, and economical ﬁndings associated with colorectal cancer in Malaysia. Incidence and mortality data were retrieved from population-based cancer registries/databases. Results: In Malaysia, colorectal cancer is the second most common cancer in males and the third most common cancer in females. The economic burden of colorectal cancer is substantial and is likely to increase over time in Malaysia owing to the current trend in colorectal cancer incidence. In Malaysia, most patients with colorectal cancer have been diagnosed at a late

Conﬂicts of interest: The authors have no conﬂicts of interest to declare. * Corresponding author. Clinical School, Department of Surgery, International Medical University, Jalan Rasah, Seremban 70300, Negeri Sembilan, Malaysia. E-mail address: [email protected] (K.G. Lim). http://dx.doi.org/10.1016/j.asjsur.2016.07.005 1015-9584/Copyright ª 2016, Asian Surgical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY- NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

stage, with the 5-year relative survival by stage being lower than that in developed Asian countries. Public awareness of the rising incidence of colorectal cancer and the participation rates for colorectal cancer screening are low. Conclusion: The efﬁciency of different screening approaches must be assessed, and an organized national screening program should be developed in a phased manner. It is essential to maintain a balanced investment in awareness programs targeting general population and primary care providers, focused on increasing the knowledge on symptoms and risk factors of colorectal cancer, awareness on beneﬁts of screening, and promotion of healthy life styles to prevent this important disease. Copyright ª 2016, Asian Surgical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc- nd/4.0/).

1. Introduction 2. Methods

Colorectal cancer is the third and second most common We searched MEDLINE via OVID with the MESH terms cancer, respectively, in men and women worldwide,1,2 and is “Colorectal Neoplasms”[Mesh] and “Malaysia”[Mesh], and a major cause of morbidity and mortality.1 Mortality due to PubMed with the key words “colorectal cancer” and colorectal cancer is increasing, and it is the fourth leading “Malaysia.” Additional articles were identified by reviewing cause of cancer death in the world.1 There is wide the bibliographies of retrieved articles and hand searching geographical variation in the incidence of colorectal cancer of journals. Publications were limited to human studies across the world, and there has been a rapid rise in its published between 1990 and 2015. Only full papers and incidence in many Asian countries during the past few de- abstracts published in English were included. For this re- cades.1,3 The reported incidence of colorectal cancer is view, we included studies that reported any clinical, soci- higher in developed Asian countries such as Japan, South etal, and economical findings associated with colorectal Korea, and Singapore than in Malaysia and other developing cancer in Malaysia. Incidence and mortality data were Asian countries.4,5 However, the incidence and mortality retrieved from population-based cancer registries/data- rates for colorectal cancer in Japan, South Korea, and bases. We also searched the available national cancer Singapore have been stable and are even declining, which is registries of individual Asian countries to make a compari- similar to the pattern seen in the USA and the UK.1,2,4,6 This son on cancer statistics. trend may be attributed to colorectal cancer screening programs, reduced prevalence of risk factors, and/or improved treatments in these countries.2 The improving 3. Results and Discussion socioeconomic status and increasingly westernized life style in developing countries in Asia, including Malaysia, could be 3.1. Burden of colorectal cancer in Malaysia expected to be associated with an increasing incidence of 7 colorectal cancer. Malaysia is undergoing an aging of its Malaysia, with a population of w30 million in 2014, is a 8 population, with increasing affluence and an increased multiethnic country, with the Malays being the majority, prevalence of risk factors for colorectal cancer, such as followed by Chinese, Indians, and other indigenous 5,9 westernized diet, obesity, and smoking. As about 80% groups.18 The development of colorectal cancer registry in colorectal cancer cases in Malaysia are diagnosed in people Malaysia is still not mature. Hence, the assessment of the 10 older than 50 years, the aging trend may further increase epidemiology of colorectal cancer in this review is primarily the prevalence. The majority of colorectal cancer patients based on the data from GLOBOCAN 2012, existing cancer 11,12 in Malaysia present at a late stage with a poor prognosis, registries from Malaysia, and publications on colorectal which can obviously increase the health burden due to the cancer in Malaysia. A total of 67,792 new cancer cases were higher treatment cost and poor quality of life in the late diagnosed in Peninsular Malaysia in 2003e2005, of which 13,14 stages. At present, there is no formal/structured na- 12% were colorectal cases, giving a total of 8135 colorectal 15 tional colorectal cancer screening program in Malaysia. cancers in 3 years and an average of 2712 cases per year.10 Presently, surgical resection provides the best hope of cure Colorectal cancer is the second and third most commonly 15 for colorectal cancer patients. Despite its growing burden, diagnosed cancer in males and females, respectively, with colorectal cancer remains a low priority in healthcare an age-standardized rate of 20.9 (male) and 16.8 (female) 16,17 planning and expenditure in Malaysia. This review aims per 100,000 persons per year in 2003e2005.10 According to to provide an analytical overview of the changing burden of GLOBOCAN 2012 estimates,1,4 colorectal cancer is the colorectal cancer in Malaysia by compiling published data on second most common cancer in Malaysia in both males and the clinical, societal, and economic findings associated with females, with an age-standardized rate of 18.3 per 100,000 the disease. Moreover, this review highlights the imple- persons per year in 2012 (Table 1), similar to what was seen mentable control measures that can help reduce the future in the National Cancer Registry in 2003e2005.10 Although burden of colorectal cancer in Malaysia. the overall incidence and mortality of colorectal cancer are

Singapore and Malaysia in 2012 may forecast the continuous Table 1 Estimated incidence and mortality rates of three upsurge of deaths due to colorectal cancer in Malaysia most common cancers in Malaysia. (Table 1).4 The societal burden of colorectal cancer is sig- Sex Types of Incidence Mortality niﬁcant and is likely to increase over time in Malaysia owing cancer Cases % ASRa Deaths % ASRa to the current incidence trend. Colorectal cancer accounts (N ) (N ) for 13% of the total disability-adjusted life years attribut- able to cancer in Malaysia. It is the third highest attribut- Men Lung 3240 17.9 26.9 2783 24.7 23.4 able burden of cancer among males and second highest Colorectal 2563 14.1 21.1 1274 11.3 10.6 among females in 2000.20 Nasopharynx 1487 8.2 10.6 533 4.7 3.9 Women Breast 5410 28.0 38.7 2572 24.7 18.9 Cervix uteri 2145 11.1 15.6 621 6.0 4.7 3.2. Economic burden of colorectal cancer Colorectal 1976 10.2 15.7 1026 9.9 8.3 Both sexes Breast 5410 14.5 38.7 2572 11.9 18.9 Important economic components of economic burden Colorectal 4539 12.1 18.3 2300 10.6 9.4 include direct medical care and nonmedical costs, and Lung 4403 11.8 17.9 4134 19.1 17.0 productivity losses among patients and caregivers.21 A 2012 ASR Z age-standardized rate. study13,22 in the central region of Malaysia demonstrated Note. Adapted from “Estimated cancer incidence, Mortality and the cost of colorectal cancer management using conven- Prevalence Worldwide,” by GLOBOCAN, 2012, International tional chemotherapy for different stages. The mean cost Agency for Research on Cancer. 2012. Available at: http:// (direct medical costs and nonmedical costs) of treating globocan.iarc.fr/Default.aspx. a colorectal cancer per year in Malaysian Ringgit (RM) was ASR is the number of new cases or deaths per 100,000 RM13,622 for Stage 1, RM19,752 for Stage 2, RM24,972 for persons per year. A population would have an ASR if it had a Stage 3, and RM27,377 for Stage 4.13 An estimate of new standard age structure. cases of colorectal cancer each year in Malaysia was 4539 in 2012.4 Therefore, by using the stage distribution of colorectal cancer at presentation in Malaysian patients23 and correlating with costs from the study by Ezat et al,13 the growing in the Southeast Asian countries, there is a wide economic burden of colorectal cancer management of new disparity in the country-speciﬁc incidence, with the highest cases alone is estimated to be around RM108 million per incidence being reported in Singapore (33.7 per 100,000 year (Table 2). This estimate, however, excludes new persons, about twice the incidence rate of Malaysia in therapies with targeted agents such as monoclonal anti- 4,6 2012). However, trends for both the incidence and the bodies, e.g., cetuximab and bevacizumab, which may add mortality rates for Singapore have been stable and even RM20,438e36,666 for selected patients. It also excludes 6,19 declining since 2000. Other Southeast Asian countries, costs for nonincident cases, such as detection and man- such as Indonesia, Thailand, Vietnam, and Myanmar, have agement of recurrences, and ongoing palliative care of comparatively lower incidence rates of colorectal cancer Stage 4 patients who survive more than a year. 1 than Malaysia. Meanwhile, private expenditure on health is growing, Information on the mortality rate of colorectal cancer in with around 50% of the total healthcare expenditure in Malaysia is not available. A comparison of GLOBOCAN esti- Malaysia coming from private resources in 2009.24 It is mates of age-standardized rates of colorectal cancer inci- estimated that around 30% of the Malaysian population are dence (33.7 vs. 18.3) and mortality (11.8 vs. 10.6) between served by private hospitals.25 The cost of care for

Table 2 Estimated cost of colorectal cancer management of new cases in 2012 in Malaysia. Stage distribution Expected number of The mean cost Total cost of treatment per at presentation colorectal cancer of treatment per yearc (Stages 1e4) in Malaysia23 cases in 2012a person per yearb (Stages 1e4) (in RM) (Stages 1e4)13 Stage 1 6.7% 304 13,622 4,141,088 Stage 2 24% 1090 19,752 21,529,680 Stage 3 37.3% 1693 24,972 42,277,596 Stage 4 32% 1452 27,377 39,751,404 Total cost of colorectal cancer management of new cases in 2012 107,699,768 RM Z Malaysian Ringgit. Note. Adapted from GLOBOCAN 2012: Estimated cancer incidence, Mortality and Prevalence Worldwide in 2012 (GLOBOCAN, 2012). a Source: GLOBOCAN 2012destimate of new cases of colorectal cancer in Malaysia is 4539 cases in 2012.4 b This cost would therefore cover the incident cases for the year. It can be assumed that diagnosis, surgery, and chemotherapy/ radiotherapy would, in most cases, be completed in 1 year. c The cost would therefore not include follow-up care after detection and treatment of recurrences and palliative care for Stage 4 patients who survive more than 1 year.

Table 3 Colorectal cancer stage distribution at presentation in Malaysian patients from different settings. Dukes’ classiﬁcation 62 Stage A Stage B Stage C Stage D Unstaged Ghazali et al41 (1996e2005; Kelantan) 0 43.5 33 23.5 Nil (n Z 115) Goh et al12 (1999e2003; Kuala Lumpur) 5 42 15 39 74 (excluded) (n Z 228) Rashid et al11 (1997e2000; Kuala Lumpur) 2.8 35.5 40.2 21.5 Nil (n Z 107) Penang Cancer Registry (2004e2008; Penang)42 12 30.5 28 29.5 721 (excluded) (n Z 1363) TNM classiﬁcation62 Stage 1 Stage 2 Stage 3 Stage 4 Unstaged Shah et al23 (1995e2011; Kuala Lumpur) 6.7 24 37.3 32 Nil (n Z 75) Data are presented as %.

colorectal cancer in the private healthcare setting is ex- Malaysian population, or in what combination or sequence, pected to be higher than that calculated for public tertiary in order to maximize cost effectiveness. Hence, the cost hospitals. If their cost was double that for public tertiary effectiveness of nationwide screening approaches and their hospitals, the higher cost incurred by this 30% of colorectal financial consequences must be assessed to inform the cancer patients might be expected to add 30% to the esti- policy makers on which screening approach should be mated direct medical and nonmedical costs of RM108 implemented in Malaysia. million calculated for colorectal cancer care. When exam- ining the costs of managing breast and lung cancer, two other common cancers in Malaysia, the economic burden 3.3. Influence of age due to colorectal cancer can be considered the second highest after breast cancer.26 The expected increase in the More than 90% of the colorectal cancer cases in Malaysia aging population and healthcare costs in Malaysia will in- initially occur in people over the age of 40 years10,15; this crease the competition for healthcare expenditure was observed for all ethnic groups.10 Patients aged 60e69 currently available; this may also affect cancer health years accounted for the highest proportion of cases10;a services. In the case of colorectal cancer, striking a balance similar trend was seen in Singapore.19,28 Western guidelines between investment in preventive and treatment services recommended colorectal cancer screening at the age of 50 and allocation of resources effectively for improving facil- years for individuals with average risk.29e32 The most ities for screening, early detection, diagnosis, and subse- recent findings showed that the incidence increased by quent treatment will be an additional challenge in > 2% each year in younger adults33; moreover, a high pro- Malaysia. Early detection and treatment of colorectal portion of the younger population diagnosed with colo- cancer result in substantial saving in treatment costs. It is rectal cancer has a poor prognosis.34,35 The age estimated that diagnosis of advanced stage of colon cancer characteristics of colorectal cancer patients enrolled in the was associated with 1.8e2.5-fold higher cost than that of cancer registry (n Z 8077; 2003e2005) in Malaysia10 early-stage cancer in South Korea.27 The provision of colo- showed an occurrence of 14.6% of cases among patients rectal cancer screening may shift the current stage distri- younger than 50 years, while only 7% of cases were among bution pattern in Malaysia toward the Western figures patients younger than 40 years. A similar distribution of (Tables 3 and 4); thus, a reduction in the overall cost of colorectal cancer cases was shown by Qureshi et al36 in colorectal cancer management can be expected. Although 1998. The consensus on screening for colorectal cancer in there are several strategies for colorectal cancer screening, Malaysia suggested that the entry age for a colorectal it is uncertain which is most cost effective in the local cancer-screening program in Malaysia should be earlier context. Although there is evidence to support the than that of the developed nations.36 Further research on different strategies for screening and reducing the inci- the epidemiology and characteristics of colorectal cancer dence and mortality of colorectal cancer, it is vital to know and adenomas by age group in the population is necessary which strategy/strategies should be considered in the to identify the entry age of Malaysians for the screening

Table 4 Colorectal cancer stage distribution at presentation in the USA, the UK, and Singapore. Dukes’ classiﬁcation Stage A Stage B Stage C Stage D Unstaged United States (1996e1998)43 17 (14e23) 28 (24e36) 38 (29e46) 10 (7e18) 7 (3e10) Europe (1996e1998)43 17 (11e28) 30 (25e37) 21 (24e30) 21 (11e33) 10 (4e24) Singapore (2007e2011)44 14.7 27 35.1 23.2 Unknown Data are presented as % or % (range).

Please cite this article in press as: Veettil SK, et al., Colorectal cancer in Malaysia: Its burden and implications for a multiethnic country, Asian Journal of Surgery (2016), http://dx.doi.org/10.1016/j.asjsur.2016.07.005 + MODEL Burden of colorectal cancer in Malaysia 5 program. Simultaneously, the efficiency of considering an late. The Penang Cancer Registry from 2004 to 200842 has age of 40 years for average-risk individuals for colorectal provided the largest data set among these studies in terms cancer screening program in Malaysia should be of patient number (n Z 1363); however, more than half of investigated. the patients’ data for stages of their cancer (n Z 721) were missing. This was probably due to incomplete information 40 3.4. Influence of ethnicity on distant metastasis. Hence, a higher percentage of patients among those who were excluded from the Penang Cancer Registry42 and from the study by Goh et al12 were Among ethnic groups in Malaysia, the Chinese population e most probably with late-stage cancer. Thus, the number of has the highest rate of colorectal cancer cases.10 12,23 The colorectal cancer cases in Dukes’ stages C and D is expected annual incidence of colorectal cancer per 100,000 is about to be greater than the figure shown in Table 3. Compared 28.8 in Chinese, which is significantly higher than that in with the United States (48%) and Europe (42%), a higher other ethnic groups (Malay: 11, Indian: 14.3).10 A similar percentage of colorectal cancers are diagnosed at late pattern has been observed in Singapore, where the colo- stages (Dukes’ stages C and D) in Malaysia,42,43 but the rectal cancer incidence is significantly lower among the percentage is similar to that in Singapore (Tables 3 and 4). Indian (16.1) and Malay (26.1) populations compared with However, in view of the large number of unstaged cases in that in the Chinese population (34.1).37 The ethnic simi- the Penang registry, the number of late-stage cancer cases larity in the incidence of colorectal cancer was previously is expected to be more. Moreover, in Europe,43 the United reviewed by Sung et al,38 who compared the incidence of States,43 and Singapore,44 a much higher percentage of colorectal cancer in Chinese and Indians in Malaysia, patients present at an early stage (Dukes’ stage A; Tables 3 Singapore, China, and India. It is evident that the higher and 4). This likely reflects the outcome of the ongoing incidence among Chinese and the lower incidence among effective colorectal cancer screening in the mentioned Indians living in Southeast Asia are similar to those in the countries. As mentioned previously, the expected increase countries of origin, although both ethnic groups migrated in mortality rate due to colorectal cancer in Malaysia could more than three generations ago.38 Similar to the Chinese, be correlated to the findings on the stages of colorectal Japanese and Koreans also have higher colorectal cancer cancer at presentation, which emphasizes the need for incidence than other ethnic groups such as Indians, Malays, developing a colorectal cancer screening program at a na- and Indonesians.5,38 These ethnic differences may suggest tional level. As colorectal cancer screening programs ach- an etiological role of the genetic factors in colorectal ieve progressively higher uptakes, we can anticipate a cancer.38 The cumulative life time risks of colorectal cancer reduction in the incidence of colorectal cancers diagnosed for Chinese in Malaysia were 1:27 for men and 1:33 for at late stages in Malaysia, thus improving survival, as seen women, which are significantly higher than those in other in the USA and Europe.1 ethnic groups.10,23 An updated Asia Pacific Consensus rec- The socioeconomic class may have an impact on colo- ommended the use of a risk-stratified scoring system to rectal cancer stage distribution at presentation.45 A study select high-risk individuals for early colonoscopy, especially by Kong et al46 showed that Kuala Lumpur, an affluent re- in Asia where the burden to the healthcare system is high.5 gion in Malaysia with an improved socioeconomic status, A recent study39 demonstrated a risk score to prioritize has a lower rate of late-stage colorectal cancers compared colonoscopy referrals in symptomatic patients from with Kuching, Malaysia. Factors that contribute to this Malaysia; this included ethnicity as one of the components disparity may include poor awareness of colorectal cancer to predict the risk of colorectal neoplasia and cancer. Thus, and a lack of access to cancer awareness programs, Malaysia, which has a diverse multiethnic population, screening tests, skilled healthcare workers, and referral where Chinese have the highest risk of getting colorectal systems in rural compared with metropolitan areas. cancer, should consider these ethnic differences in framing Awareness of colorectal cancer among the general popu- its screening policy. Pertaining to the Asia-Pacific colorectal lation and preventive activities among primary care pro- screening score, the opportunity to further develop the viders are conspicuously limited in rural areas.17,47e50 More scoring system for asymptomatic individuals in the Malay- public health attention should be paid to promoting sian setting should be considered by incorporating the knowledge and awareness of colorectal cancer screening ethnic risk difference. among the general population nationwide. The role of primary care providers in colorectal cancer prevention should 3.5. Colorectal cancer stage distribution at be well defined, and policy makers need to take initiatives presentation in Malaysian patients to improve colorectal cancer screening services in primary clinics. The survival rate for patients with colorectal cancer is closely correlated with the stage of the disease at diagnosis; the earlier the stage at diagnosis, the higher the 3.6. Colorectal cancer survival in Malaysia chance of survival. Staging information on Malaysians diagnosed with colorectal cancer is not yet available Information on cancer survival is an important indicator of nationwide.40 Table 3 presents the available stage distri- the cancer system’s effectiveness in detecting and treating bution of colorectal cancer at presentation in Malaysian cancer. Colorectal cancer survival is highly dependent on patients from different settings. Studies,11,12,41,42 using the stage of disease at diagnosis, and typically 5-year sur- Dukes’ classification for staging of colorectal cancer, vival rates are 90% and 80%, respectively, for Stages 1 and revealed that most patients were presenting themselves 2, 30e60% for Stage 3, and around 5e10% for Stage 4.16,51 In

Table 5 Five-year relative survival (%) by stage62 in CRC patients: Malaysia, Singapore, the UK, and the USA. Country Year Stage 1 Stage 2 Stage 3 Stage 4 Kuala Lumpur, Malaysia46 2000e2004 78.6 52.9 44.3 9.3 Kuching, Malaysia46 2000e2004 74.5 65 36.4 5.2 Singapore44 2007e2011 82.2 72.2 55.3 8.7 United Kingdom 63 2002e2006 97.4 84.7 62.7 7.5 United States 64 1991e2000 93.2 82.5 59.5 8.1 Data are presented as %. CRC Z colorectal cancer.

lower/higheremiddle-income Asian countries such as India, colorectal cancer screening in Malaysia, no uniform stra- China, the Philippines, and Thailand, the 5-year overall tegies, and no general consensus from professional bodies colorectal survival rates are much lower (6e40%) than the based on the colorectal cancer data to inform the policy high-income Asian countries, such as Singapore and South makers on resources for screening. Additional challenges Korea (about 60% and 73%, respectively).16,52 Malaysia, for an organized colorectal cancer screening program are which is considered a higheremiddle-income country, the requirements of a considerable number of organizations showed an overall 5-year survival rate of 40% in the period to be involved in awareness programs, resources including 1997e2000.11 While, a more recent study (2000e2004) skilled healthcare workers for screening within routine demonstrated an improved overall 5-year survival rate of health services, as well as diagnostic and treatment in- 53%.46 Five-year relative survival by stage for colorectal frastructures; these require additional investment for cancer in Malaysia was comparatively lower than that in health services. Singapore, United Kingdom, and United States (Table 5). The screening behavior of the Malaysian population re- Disparities in the survival rates probably reflect the dif- mains largely unknown. Public awareness of the rising ference in the management practices among these coun- incidence of colorectal cancer and the participation rates tries. A lack of cohesive practice guidelines for colorectal for colorectal cancer screening are low.49 A multicentre management and inadequate development to deal with the study49 in Asia-Pacific regions revealed poor knowledge of increasing demand of diagnostic, therapeutic, and follow- colorectal cancer symptoms, risk factors, and screening up care interventions could be reasons for the lower sur- tests among Malaysians compared with that in other pop- vival rate in Malaysia. ulations from Southeast regions. This study showed that Kong et al,46 showed an overall 5-year relative survival Malaysians had a significantly more negative response to rate for cases diagnosed in 2000e2004 of 60.5% in Kuala the intention to undergo screening for colorectal cancer.49 Lumpur, compared with about 45.7% in Kuching. This A similarly negative perception among Malaysians con- disparity in the survival rate from two settings probably cerning screening was described by Hilmi et al,56 who found reflects the differences in access to early detection tests, that only 38% of the participants were willing to undergo receipt of timely and high-quality treatment, and the colorectal cancer screening. Among the ethnic groups in prevalence of other illnesses among patients. Kuala Lum- Malaysia, Chinese were paradoxically the least willing pur, a highly developed region in the country, has an overall group to undergo screening, despite having the greatest risk 5-year relative survival rate similar to that in the developed compared with other ethnic groups.56 This disparity in the countries.44,51,53 The improvement in survival rate in Kuala negative perception among ethnic groups has not been Lumpur may be due to early detection and better access to clearly defined. Similarly, a recent study conducted in a treatment, as a result of well-developed health services semiurban area in Malaysia57 showed the awareness of and organized healthcare infrastructures within the region. screening tests to be meager, although the knowledge on The relatively poor prognosis in some regions in Malaysia colorectal cancer symptoms and risk factors was better underscores the need of improvement in public healthcare among Malaysians in the semiurban area, compared with infrastructures to support screening, staging, and colo- the level of knowledge and awareness on colorectal cancer rectal cancer management throughout the country.54 symptoms, risk factors, and screening tests in the rural population of Malaysia, which remains very low.17 These 3.7. Colorectal cancer screening in Malaysia disparities demonstrate substantial deficiencies in the awareness programs for rural areas and disadvantaged There is no nationwide, population-based screening for populations, as evidenced by the late colorectal cancer colorectal cancer in Malaysia, where there is a high reliance stage distribution at presentation in hospitals for patients on opportunistic screening.15,55 The rate of change in the living in nonmetropolitan areas. The behavior of the par- epidemiology of colorectal cancer in Malaysia demands a ticipants toward the screening recommendations and reg- prompt action to prevent colorectal cancer and diagnose ular follow-up has not been reported in Malaysia. Since it is difficult to achieve the requisite compliance rate with the disease at an early stage through screening. To achieve 38 this goal, high-quality interventions and approaches should screening recommendations and regular follow-up, future be delivered to a large proportion of the target population. studies are needed to explore the attitude and behavior of However, there are no up-to-date national guidelines on the population toward different strategies for screening.

The role of primary care physicians is crucial in the knowledge on symptoms and risk factors of colorectal implementation of screening programs. It is obvious that cancer, awareness on benefits of screening, and promotion inadequate counseling by physicians appears to be one of of healthy life styles to prevent this important disease. the barriers for patient acceptance for colorectal cancer Empowering primary care providers by providing them with screening.58 Colorectal cancer preventive activities among resources to undertake preliminary screening, or devel- primary care providers are still poor in Malaysia.47 A recent oping a referral strategy for early clinical diagnosis of pa- survey49 in the Asia-Pacific region demonstrated that tients who are symptomatic, is an important approach that significantly fewer Malaysian participants received physi- requires to be promoted. Introduction of organized cian recommendations for colorectal cancer screening, screening programs should be undertaken in a phased compared with other regions. Although these participants manner for the early detection of cancer, which can ulti- were aged 50 years and older, which is considered an mately reduce the economic burden of colorectal cancer. average risk for getting colorectal cancer, relatively few of The financial consequences and benefits of different them were recommended by their physicians for screening. screening approaches must be assessed prior to the Professional bodies in Malaysia need to produce a uniform implementation. A set of screening guidelines that suit the strategy to define the role of physicians in colorectal cancer present needs of Malaysia should be promulgated, based on prevention, starting from the primary health service level. the recommendations from international organizations and Furthermore, financial constraints, access to screening, local professional bodies, and the data from the local time constraints, and cultural and emotional elements research and cancer registries. Further research on the appear to be barriers to colorectal cancer screening in epidemiology and characteristics of colorectal cancer in Malaysia.17,47e49 Despite the increasing incidence of colo- the Malaysian population, and public perception and pro- rectal cancer, health promotion regarding this disease is fessional attitude on screening and screening behavior of not highlighted by the Ministry of Health compared with the population are required. Further development of a other cancers such as lung, cervical, and breast cancers.17 colorectal cancer registry comprising data from public and Therefore, extensive health education and awareness pro- private sectors is required to observe trends relating to grams on colorectal cancer should be initiated nationwide. colorectal cancer, and to evaluate the performance of Another concern still to be addressed is the best strategy health systems and patterns of care in the country. for colorectal cancer screening in Malaysia. Although colo- Healthcare infrastructures, accessible treatment services, noscopy is the precise and effective screening tool,29 the and the number of healthcare specialists for colorectal decision on which colorectal cancer screening program cancer screening and treatment need to be increased in a should be implemented in the first place is based on the phased manner, and must be consistently accessible in both availability of resources, including skilled healthcare pro- rural and urban areas of the country. Treatment of colo- fessionals, costs, and population preferences.5 Hence, co- rectal cancer is resource intensive and often multidimen- lonoscopy, one of the more expensive and invasive methods sional, involving surgery, chemotherapy, radiotherapy, for colorectal cancer screening, might not be appropriate in palliative care, and rehabilitation. Development and a country like Malaysia, where there are limited resources implementation of evidence-based management guidelines and insufficient specialists to tackle the expected number and follow-up care for colorectal cancer should be of individuals undergoing screening.24,59 This could explain strengthened for effective and optimum use of resources why many countries have initiated preliminary colorectal throughout the nation. The above initiatives require com- cancer screening using fecal occult blood tests, either mitments from political and professional bodies and the opportunistic or population based.55,60 Although not supe- recognition of the fact that colorectal cancer will be an rior to colonoscopy, the effectiveness of fecal occult blood increasing public health problem in Malaysia. tests in detecting colorectal cancer and reducing colorectal cancer-related mortality is well established.5,29 Hence, prioritizing colonoscopy for individuals with a greater risk Acknowledgments of colorectal cancer may be a worthwhile approach to reduce the burden of colorectal cancer in Malaysia. The authors wish to thank Mr Razman Shah Mohd Razali, Average-risk individuals with a positive result on noninva- reference librarian, International Medical University, Kuala sive fecal occult blood tests, along with individuals having a Lumpur, Malaysia, for providing full-text articles whenever family history of colorectal cancer and other risk factors needed. can be prioritized for early colonoscopy.5 The use of a risk- based algorithm can direct screening of high-risk individuals by colonoscopy, which permits a more efficient allocation of limited healthcare resources.5,39,61 References

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