Exploring the challenges of colorectal cancer in the Philippines

One of the most common malignancies worldwide that is gradually increasing is colorectal cancer (CRC). Patients with CRC are treated with emergency surgery due to large bowel obstruction, which occurs in 7% to 29% of them.1 In the Philippines, CRC is the third most common cancer among Filipinos. The battle against CRC has faced several challenges over the years. Despite the government’s campaign to control it, several barriers hinder its success, such as the potential out-of-pocket costs or heavy financial burden of CRC screening; fatalistic beliefs; a reactive approach to health; and the lack of awareness in the community on CRC screening.2 Lastly, aside from the screening, the treatment procedure itself for patients with CRC is expensive and not affordable for ordinary locals who mostly live within and even below the poverty level.

CRC’s incidence and impact can be significantly reduced by implementing prevention strategies, which include living by practicing early detection through screening, having a healthy lifestyle, and avoiding risk factors. Screening can reduce CRC incidence and mortality through early detection and the removal of precancerous growths. Non-invasive screening techniques, such as stool-based tests, like the fecal occult blood test, are used to detect CRC or precancerous polyps in the stool.3 Other CRC screening modalities are also available, including fecal immunochemical test (FIT), CT colonography, sigmoidoscopy, multitargeted stool DNA testing (FIT-DNA), and colonoscopy, which is more reliable and has high sensitivity, among other tests.

Despite the benefits of various early detection modalities, there is currently no standardized CRC screening program in the country. Most health facilities with a colonoscopy service are situated in the cities. The unavailability of a standardized program results in low CRC screening participation and higher mortality and morbidity of CRC in the country.4 The cost of a colonoscopy varies for CRC screening, depending on whether it will be done in a government or private hospital. Private hospitals usually offer packages ranging from 10,500 Philippine Peso (PHP) to 16,000 PHP, with some facilities providing packages up to 18,000 PHP. It is cheaper in government hospitals since a significant portion of the cost is shouldered by PhilHealth, a government-owned corporation.5 However, the problem is that not all Filipinos are PhilHealth members, and for those members, they prefer to spend their money on other priorities like food rather than their medical needs. It is important to note that a Filipino worker's current average monthly salary is only 19,436 PHP, meaning they have a budget of only 647 PHP per day for all their basic needs. It is possible to prioritize the CRC screening test over the basic needs.

The lack of awareness among the primary health providers of the screening guidelines for CRC screening is another challenge. This means that there are fewer recommendations for CRC screening tests from physicians. Some factors for this barrier include the physician’s lack of knowledge and training, forgetfulness, time and opportunity, and a cost assessment by the physician that they think is beyond the patient’s capacity. Likewise, inconsistencies in guideline recommendations may make doctors reluctant to advise their patients.6

Lastly, aside from the costly colonoscopy screening test for CRC, the treatment for patients with CRC is all the more expensive, making it unaffordable for most average-income Filipino earners. Treatment expenses in the Philippines range from 120,000 PHP (2,000 United States dollars [USD]) to exceeding 1 million PHP (17,000 USD). For instance, the cost per chemotherapy session starts at 20,000 PHP (340 USD) and can soar beyond 120,000 PHP (2,000 USD).7 However, as mentioned previously, not all Filipinos are PhilHealth members and thus are not eligible for government benefits. At the same time, a significant out-of-the-pocket amount inpatient spending continues to be a burden for many locals, leading to financial toxicity. Patients visiting public hospitals typically shoulder around 29% of direct expenses, encompassing treatment, hospital fees, laboratory tests, and medications. Conversely, those seeking care in private hospitals bear a more significant load, covering approximately 64% of outpatient expenses. The wide gap between average monthly income and treatment costs remains evident.

These challenges need to be addressed for a successful campaign against CRC. There should be a regular endoscopy practice accessible and affordable to the public, regardless of their economic status. The different CRC screening modalities must be a top priority for the country’s healthcare program. Actionable endoscopy-focused recommendations, such as FIT-first pathways, colonoscopy capacity building, and quality assurance, must be the main content of these interventions. In the same way, there should be a collaborative effort among different institutions spearheaded by the government and actively participated in by lawmakers, health institutions, and medical schools. If everyone is involved in this noble cause, a higher chance of winning the fight against CRC is possible.