The Role of Pathology and Laboratory Services in Global Colorectal Cancer Prevention

Globally, colorectal cancer (CRC) is the third most common cancer in men and the second in women.1 It is the fourth main cause of cancer death in the world, with nearly 1.8 million new cases and 881,000 deaths in 2018.2 As alarming as these numbers, some progress has been made in terms of disease occurrence and outcome in many developed countries through the design and implementation of effective screening programs. With better access to healthcare services and overall improvements in treatment of CRC, patients in developed countries can have their pre-malignant, in-situ and minimally invasive polyps detected and removed in time through effective colonoscopy screens and disease interpretation by pathologists. Unfortunately, this progress is not uniform across the globe. Many developing countries across Latin America, Africa and Asia are experiencing increases in their CRC cases.3-5 A number of factors are responsible for this disparate reality.

With limited healthcare resources, many developing countries still struggle with efficient and effective health services. Several studies have shown the significant role of effective screening programs in detecting early colorectal adenomas. However, channeling scarce resources to support preventative health services is still a luxury many of these countries cannot afford. In addition, making sure these services actually work, would require effective laboratory services, laboratory professionals and pathologists. Unfortunately, due to limited resources and ambiguous priorities, laboratory services in some areas are not equipped to prioritize preventive health services, with direct impacts on CRC incidence and survival.

Image 1. Hematoxylin and Eosin-stained composite image of Medullary Colon Cancer. Left side (4x magnification) shows colonic mucosa with a well-demarcated solid nest of tumor cells with conspicuous lymphoplasmacytic infiltrates. Right side (20x magnification) shows a higher magnification of the pleomorphic tumor cells with irregular nuclear membranes, vesicular chromatin, prominent nucleoli and multiple mitotic figures. Medullary colon cancers are usually right-sided and have a better prognosis compared with poorly-differentiated or undifferentiated adenocarcinoma of the colon.6 

Even though the majority of CRC occur through somatic events, some however, do progress through well-defined germline mutations including inherited cancer syndromes including Lynch syndrome (Hereditary Non-Polyposis colon cancer/HNPCC), Peutz-Jeghers syndrome and the Familial Adenomatous Polyposis (APC mutations) pathway. Unfortunately, cancer genetics and molecular diagnostics is still not mainstream in healthcare institutions in many developing countries. Therefore, patients and their families with affected mutations may find it extremely difficult getting access to the care they need in terms of diagnosis and treatment.

The rising incidence of CRC in developing countries may also be explained by the rising trends in Westernized practices which leads to several modifiable risk factors including the consumption of diets rich in saturated fats, lack of physical activity, diabetes, obesity, alcohol consumption and smoking. Preventive health services through effective public health education on the dangers and risks of these environmental practices may play a role in disease prevention and outcomes.

At the crux of CRC prevention and early detection is effective screening programs. As March marks colorectal cancer awareness month, it is imperative to emphasize that any sustainable health policy program must consider the unique role that effective pathology and laboratory services has to play. We must be invited to stakeholder discussions as the value we bring to such discussions cannot be overstated. A failure to recognize our position as central to improving patient outcomes has made many healthcare systems less effective in addressing public health challenges.

References

  1. GLOBOCAN. Estimated cancer incidence, mortality and prevalence worldwide in 2012. 2012. http://globocan.iarc.fr/Default.aspx
  2. Bray F, Ferlay J, Soerjomataram I, et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394–424.
  3. Bosetti C, Malvezzi M, Chatenoud L, et al. Trends in colorectal cancer mortality in Japan, 1970‐2000. Int J Cancer 2005;113:339–41.
  4. Center MM, Jemal A, Ward E. International trends in colorectal cancer incidence rates. Cancer Epidemiol Biomarkers Prev 2009;18:1688–94.
  5. Souza DL, Jerez‐Roig J, Cabral FJ, et al. Colorectal cancer mortality in Brazil: predictions until the year 2025 and cancer control implications. Dis Colon Rectum 2014;57:1082–9.
  6. Cunningham J, Kantekure K, Saif MW. Medullary carcinoma of the colon: a case series and review of the literature. In Vivo. 2014;28(3):311-314.

-Evi Abada, MD, MS is a Resident Physician in anatomic and clinical pathology at the Wayne State University School of Medicine/Detroit Medical Center in Michigan. She earned her Masters of Science in International Health Policy and Management from Brandeis University in Massachusetts, and is a global health advocate. Dr. Abada has been appointed to serve on the ASCP’s Resident’s Council and was named one of ASCP’S 40 under Forty honorees for the year 2020. You can follow her on twitter @EviAbadaMD.

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