Colorectal Cancer Health Advisory

The risk of a person getting colorectal cancer during his or her lifetime is 5.6%, about 1 in 20. There are about 1500 new colorectal cancers cases diagnosed every year. If diagnosed early, there is chance for cure. Rectal cancers account for around 30% of the total number of colorectal cancers seen here.

Colorectal Cancer

​In Singapore, colorectal cancer is the second most common cancer in men and the 2nd most common cancer in women. Combined it would be the most common cancer.

The risk of a person getting colorectal cancer during his or her lifetime is 5.6%, about 1 in 20. There are about 1500 new colorectal cancers cases diagnosed every year. If diagnosed early, there is chance for cure.

Rectal cancers account for around 30% of the total number of colorectal cancers seen here.

What is colorectal cancer

​It is cancer arising from the colon or rectum. Usually it arises from the epithelium (inner lining) of the gut wall.

Who can get colorectal cancer

​Colorectal cancer can affect any age, any race and both sexes. It is more common after the age of 50 years, more common among the Chinese. For colon cancer, the incidence is the same between males and females, whereas rectal cancer is more common among males.

How do we know we have colorectal cancer?

​These are the warning symptoms that would alert us to look out for colorectal cancer.

• Blood in the stools
• Change in bowel habits
• Unexplained Anaemia
• Unexplained abdominal pain
• Abdominal mass

But bear in mind that especially in the early stages, colorectal cancer can be a silent disease and not have any symptoms at all.

How do you make the diagnosis?

​Usually the doctor will be suspicious if you have some of the warning symptoms or if he feels a mass in your belly or rectum during examination. Oftentimes the diagnosis is confirmed during the colonoscopy(when the tumour is visualized) and when a biopsy will be taken. Sometimes the diagnosis can be made on barium enema, CT colonography or CT scan findings as well.

What is the cause of colorectal cancer?

​No one really knows. But it is a combination of genetic causes and environmental causes. About 15% of colorectal cancers have a strong genetic basis. There have been certain well-defined genetic syndromes, namely, the Familial Adenomatous Polyposis (FAP) and Hereditary Non-Polyposis Colorectal Cancer (HNPCC).

Dietary causes account for about 90% of environmental causes. There is some link between colorectal cancer and certain factors, ie obesity, high caloric intake, alcohol intake and tobacco smoking, just to name a few.

What can I do to prevent colorectal cancer?

​The best known way to decrease the likelihood of colorectal cancer at this point in time is colorectal screening. There is no guaranteed formula to prevent colorectal cancer. But certain general measures can be helpful. Like exercise, taking fibre, having moderate caloric intake, eating lean meat and fish, moderate carbohydrate intake and reducing refined sugars and starches. There is no evidence that ‘antioxidants’, colonic irrigation or herbal remedies help lower the risk of colorectal cancer.

What is special about rectal cancer?

​The special thing about the rectum is that it is located within the pelvis, which is a limited space, about the volume of a jam jar. For men, the rectum, the bladder and the prostate are all within that area and for women, the rectum, uterus and bladder. This plays a role because of the limited space; it is easy for the cancer to grow from the rectum into the prostate or bladder, or for women, the uterus and bladder.

The rectum is near anus (the end of the gastrointestinal tract).  The anal muscles are the structures responsible for faecal continence, that is, it is closed when a person is moving around so that stool doesn’t leak out and it is also able to relax and open to let stool out during a bowel movement. For the rectal cancers which are very close to the anal sphincter (anal muscles), there is a possibility that cancer cells have invaded the anal sphincter and have to be removed as well. The implication of that is after surgery, the patient would have to ‘wear a bag’ and have his bowel movements through an ostomy. Not all rectal tumours would need that; it is only those which are very close to the anal sphincter.

Why is colorectal cancer screening important?

The majority of colorectal cancers arise from adenomatous polyps. Malignant transformation of adenomatous polyps (adenoma-carcinoma sequence) takes 5 to 10 years via multiple gene mutations. Adenomatous polyps are relatively asymptomatic. They are present in up to 25% of individuals at age 50 and the prevalence increases with age. Most polyps (90%) can be removed at colonoscopy, thereby precluding the need for surgery.

Thus, colorectal cancer has a detectable premalignant phase (adenoma) and a relatively long duration of malignant transformation. Mortality from colorectal cancer can be reduced by screening asymptomatic individuals for the presence of adenomas and early cancers. Adenomatous polyps are largely asymptomatic. The process of malignant transformation takes a relatively long time.

Screening for colorectal cancer:

• prevents cancer by removing polyps during colonoscopy
• detects early cancers with a good chance of a cure

Who should be screened for colorectal cancer?

​Screening should begin at age 50 years for individuals without any risk factors. In individuals with an increased risk, screening should begin earlier, before the age of 50, depending on the risk factor(s) present.

Why is Colorectal Cancer So Common in Singapore?

There are several reasons why colorectal cancer is becoming more common, not just in Singapore but around the world. People who are overweight, smoke, drink alcohol regularly, consume a high-fat diet, or don't exercise are all at a higher risk of developing the condition

How is colorectal cancer screening performed?

For a screening test to be widely applicable, it must be inexpensive, reliable and acceptable. Various screening tests for colorectal cancer have been reported. Faecal occult blood testing (FOBT) is the only screening modality that has been shown in 3 large randomised trials to show a 33% reduction in colorectal cancer mortality. In light of this, it would be almost medically negligent not to offer FOBT screening for average-risk individuals age 50 and above. The other commonly employed screening test is colonoscopy.

Other screening alternatives include barium enema, sigmoidoscopy and CT colonography (virtual colonoscopy). However, current evidence suggests that these alternatives may not be as effective and reliable as FOBT or colonoscopy in large-scale population screening.

Faecal Occult Blood Tests (FOBT)

Immunochemical FOBTs detect human haemoglobin from partially digested blood in the stool. They are more sensitive and more specific than guaiac-based tests that were used in the past. Another advantage is that dietary restriction is not required in immunochemical testing.

Further evaluation will be recommended if any of the two stool samples provided by the patient is positive. In a large UK study, 12% and 23% of FOBT-positive individuals had cancer and adenomatous polyps respectively on colonoscopy. Cancers detected at screening were of an earlier stage than symptomatic ones (Duke's A: 26% screened vs 11% in controls).

Immunochemical FOBT

The main disadvantage of FOBT screening is its low sensitivity. An estimated 50% of cancers will be missed on each screening round. To enhance the pick-up rate, FOBT must be done annually.

How to collect a stool sample for FOBT:

Lay toilet paper in toilet bowl 

Reverse sitting position as shown below need be adopted to allow for stool to collect on the toilet paper to simplify collection of the stool sample for the FOBT test.

Immunochemical FOBTs do not need dietary restriction. Individuals with positive FOBT require colonoscopy. Individuals with negative FOBT are tested annually.

Colonoscopy

Colonoscopy is the gold standard for complete large bowel evaluation. The main disadvantages are its higher cost, the need for full bowel preparation and sedation. There is also a small risk of bowel preparation. For high-risk patients e.g., individuals at risk of hereditary non-polyposis colorectal cancer, colonoscopy is the screening investigation of choice.

The main advantages are its high sensitivity and specificity and the long recommended screening interval of 10 years. The protective effect of colonoscopy is attributed to the ability to remove asymptomatic polyps before malignant transformation occurs.

Usually, bowel preparation takes 1 of 2 forms: high-volume (3-4 litres) polyethene glycol (PEG) or low-volume (90 ml) oral fleet. Oral fleet is contraindicated in patients with renal impairment due to its high phosphate content. For suitable patients, it is a more palatable option as it can be mixed with sweetened fluids. Patients taking oral fleet must be encouraged to drink plenty of water to decrease the likelihood of phosphate toxicity.

General advice to patients on bowel preparation for patients undergoing colonoscopy:

Oral medications which need to be stopped before colonoscopy:

• iron supplements (1 week before appointment)
• anticoagulation medications e.g. aspirin, ticlid, warfarin (5 days before the appointment)

Patients should go on a low fibre diet 3 days before colonoscopy, and avoid:

• fruits and vegetables including fresh fruit and vegetable juices

    vegetable soup

• red meat
• milk products
• Cereals and grains e.g. oats, bran, wheat, muesli, barley, nuts and beans

Foods allowed include:

• Simple carbohydrates (white rice, white bread, mee sua, bee hoon, kway teow, potatoes)
• Fish
• Plain coffee, tea, glucose, honey or clear soup

Colonoscopy is the gold standard for large bowel evaluation. The screening interval for colonoscopy is 10 years. Bowel preparation with low-volume oral fleet is feasible in the absence of contraindications.

Barium enema

A barium enema is an alternative to colonoscopy for large bowel evaluation. However, bowel preparation is still needed and in some studies, the false negative rate is as high as 50%. Furthermore, colonoscopy may still be needed to rule out suspicious lesions on the enema. There are currently no population screening studies using barium enema.

CT Colonography/Virtual Colonoscopy

Virtual colonoscopy is a new radiologic technique used to generate images of the colon and rectal wall. Bowel preparation is still needed and like barium enema, colonoscopy may be needed for ruling out suspicious lesions and for therapeutic polypectomy.

A recent meta-analysis suggests that overall polyp detection rate is woefully inadequate, making this new technique unsuitable for population screening.

To learn more check out NUH Website on Colorectal Cancer