Colorectal cancer (CRC) is a malignancy with a relatively long preclinical phase which provides a unique opportunity for screening and early detection. Many developed countries have either established programmatic CRC screening endeavors or use healthcare systems that can facilitate early detection and treatment of CRC. The story is quite different in continental Africa.
Although the burden of CRC is relatively lower in most countries in Africa when compared to developed countries, there is very little investment in CRC control. There is a general lack of CRC screening programs and poor access to standard treatment for this disease. Under the auspices of the African Organization for Research and Training in Cancer (AORTIC), the challenges and possible solutions to enhance CRC control were discussed at the 9th scientific meeting of the organization in Durban, South Africa in November 2013.
The major challenges to CRC control include patient factors such low socioeconomic status and health literacy which lead to patronage of unstandardized alternative medical care including traditional practices and religious (faith) healing; and health system factors such as lack of effective health insurance systems which promotes cash-based healthcare delivery. There is a lack of adequate manpower of cancer control experts from prevention to treatment of diseases. Furthermore, there is a constant inadequate budget for health by various governments in Africa. Therefore, increasing available resources, equipment, facilities and healthcare providers such as gastroenterologists, surgeons, radiation oncologists and oncology nurses will be essential.
Although inadequate research opportunities and data collection systems raise concerns of possible under-reporting, available data suggest a lower burden of CRC in Africa (1). While the overwhelming majority of the population in Africa is of indigenous African origin (black), countries with substantial other racial groups, such as in South Africa, report significant population (racial) differences in CRC burden. The lowest burden of disease have been noted among blacks, and especially those who have maintained their traditional lifestyle including diet, an intermediate burden among Indians and those of mixed ancestry (coloreds), and the highest burden among persons of European origin (whites) (1). This contrasts the findings in the United States where African Americans suffer a disproportionally higher burden of CRC when compared to other population groups (2).
Of note, there is no organized population-based CRC screening in any African country. Characterization of familial and genetic predisposition to CRC has not been carried out at the population level in Africa. This highlights the need to improve education and access to genetic testing in Africa. In rural communities in South Africa, mobile colonoscopic screening of high risk patients with mismatch repair gene defects has been shown to improve survival (3). In this mobile screening endeavor, once patients are diagnosed with a cancer, they are referred to a dedicated colorectal unit.
Primary prevention of CRC is needed to mitigate expected rise in the burden of the disease in Africa as more people adopt Western lifestyle and dietary patterns. This will involve stellar health promotion on a national scale in every African country to improve awareness and reduce the stigma and taboo associated with cancer. Primary prevention strategies including healthy living, avoiding cigarette smoking, maintaining healthy weight and CRC screening should be encouraged. Given the cost and lack of adequate capacity for colonoscopy in virtually all African countries, an initial targeted CRC screening may be instituted. This will involve screening of family members of an index patient with CRC diagnosis, especially focusing on those diagnosed under the age of 50 years. They should be screened with colonoscopy or fecal immunochemical tests as resources permit. Of note, Quintero et al. (4) reported, in a recent study, that yearly fecal immunochemical tests over the three-year duration of the study was not inferior to colonoscopy in detecting advanced colorectal neoplasia among first degree relatives of patients with CRC. The initial modality for opportunistic and programmatic screening for the general, average risk population should be with stool based tests with follow up colonoscopy for abnormal results. This is due to the proven efficacy, relatively lower cost, and lack of adequate capacity for endoscopy-based screening modalities. It will be important to conduct population based research to establish the most cost effective and culturally acceptable approach to population based screening in Africa. Mathematical modeling may also be informative with reasonable assumptions based on the unique characteristics of the population.
Given the projection that Africa will have an 85% increase in cancer burden in the next 15 years (by 2030), it is imperative that certain steps be undertaken to reduce the burden of CRC or at least slow down the expected rise in the disease burden (5). The suggested steps include:
Build a strong private-public relationship to ensure optimal allocation of resources devoted to cancer control and establish cancer registries to ensure adequate cataloging of disease burden.
Increase health literacy campaign to engage the population on the signs and symptoms suggestive of CRC and encourage discussions about cancer in the community.
Identify high-risk groups (those with predisposing genetic diseases such as Familial Adenomatous Polyposis (FAP), Lynch syndrome, those with first degree relatives with CRC and those with inflammatory bowel disease); and encourage family discussions about CRC and screening for the disease.
Establish regional cancer centers to serve the population and maximize the reach of limited resources, and
Begin CRC screening and early detection targeting family members of patients with CRC diagnosis.
In conclusion, there is a need to improve communal education and awareness about cancers in general, and CRC in particular in Africa. Private-Public-Partnership investments would be essential to address known barriers to establishing durable CRC screening programs in Africa. Further discussions and strategic planning to improve CRC control will continue at the 10th scientific meeting of AORTIC scheduled to take place in Marrakech, Morocco from November 18 to 22, 2015. The theme of AORTIC 2015 is “Roadmap to Cancer Control in Africa” and this international conference on cancer will focus on all aspects of cancer management from prevention and early diagnosis, to treatment and palliation.
Acknowledgments
Grant support: Dr Laiyemo is supported by grant awards from the National Center for Advancing Translational Science, (Grant: KL2TR000102-04 and UL1RT000101) and from the National Institute for Diabetes, Digestive Diseases and Kidney (Grant: R21DK100875), National Institutes of Health.
Footnotes
Conflict of interest: None.
References
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