Japanese Journal of Clinical Oncology Advance Access published online on March 20, 2008
Japanese Journal of Clinical Oncology, doi:10.1093/jjco/hyn020
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© The Author (2008). Published by Oxford University Press. All rights reserved
Colon and Rectum Cancer in Thailand: An Overview
National Cancer Institute, Bangkok, Thailand
For reprints and all correspondence: Petcharin Srivatanakul, National Cancer Institute, Rama VI Road, Ratchathewi, Bangkok 10400, Thailand. E-mail: petcharin_sri{at}hotmail.com
Received February 6, 2008; accepted February 20, 2008
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Abstract |
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 TOP Abstract INTRODUCTIONEPIDEMIOLOGYINCIDENCE OF COLON AND...SCREENING FOR COLON AND...SCREENING METHODSCONCLUSIONReferences |
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Cancers of the colon and rectum are rare in developing countries, in contrast to the high incidence rates in countries of Europe, North America, Australia and Japan. Significant differences also exist within continents. Colorectal cancer mortality and incidence rates have decreased in the USA. However, the incidence in Japan and Thailand is rising, probably due to the acquisition of Western lifestyle. Incidence also increases with age: carcinomas are rare before the age of 40 years except in individuals with genetic predisposition or predisposing conditions. The incidence rate of colorectal cancer in Thailand is low when compared with other countries. It is the third in frequency in males after liver and bile duct and lung cancers, and the fifth after cancers of the cervix, breast, liver and bile duct and lung for females. The highest incidence for both sexes is seen in Bangkok. The number of cases of colorectal cancer in both sexes is increasing and will probably exceed that of lung cancer in the next decade. Thus, we are planning to have colorectal cancer screening programme. We should pay more attention on primary and secondary prevention to control colorectal cancer in Asian countries.
Key Words: colon and rectum cancer • Thailand • incidence • risk-factors • screening programme
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INTRODUCTION |
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TOPAbstractINTRODUCTIONEPIDEMIOLOGYINCIDENCE OF COLON AND...SCREENING FOR COLON AND...SCREENING METHODSCONCLUSIONReferences |
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Colorectal cancer is one of the cancers that can be prevented by secondary prevention. The precursor of advanced colorectal cancer is either an adenomatous polyp or a flat neoplastic lesion. The majority of cancers arising in the colon and rectum is adenocarcinomas that account for more than 90% of all large bowel tumours. Colorectal cancer fulfils the conditions required for mass screening: it is a major cause of morbidity and mortality in industrialized countries; at the same time, however, it can be cured by the detection at earlier stage and even prevented by the removal of adenomas. Cancer registries have been of great importance in planning and evaluating population-based studies.
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EPIDEMIOLOGY |
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TOPAbstractINTRODUCTIONEPIDEMIOLOGYINCIDENCE OF COLON AND...SCREENING FOR COLON AND...SCREENING METHODSCONCLUSIONReferences |
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A Worldwide Pattern
Cancers of the colon and rectum are rare in developing countries, while it occurs in high incidence rates in countries of Europe, North America, Australia and Japan. It was estimated that 1 023 152 new cases of colorectal cancer occur annually worldwide and is responsible for 528 980 deaths (1). The highest incidence rates of colon cancer for males (age-standardized incidence rates (ASR) = 59.2) were in Japan, Hiroshima and for females (ASR = 28.6) in New Zealand. The highest incidence rates of rectal cancer for males (ASR = 27.4) were in Japan, Hiroshima and for females (ASR = 12.1) in Chinese Singaporeans (2). Significant differences also exist within continents, e.g. with higher incidences in western and northern than in central and southern Europe (3). Incidence rates in the 1973–87 USA SEER data for colorectal adenocarcinoma for males were higher than those for females; Caucasians had higher rates than African Americans for rectal adenocarcinomas, but the latter had slightly higher rates for rectal mucinous carcinomas and colonic adenocarcinoma (4). During 1975–94 in the USA, a decrease in incidence rates in Caucasians was evident, whereas the incidence rates of proximal colon cancers in African Americans still increased (5). The decline in the incidence rates among the former has been primarily attributed to the more widespread colorectal carcinoma screening. Among immigrants and their descendants, incidence rates rapidly reach those of the adopted country, indicating that environmental factors are important. During 1973–96, colorectal cancer mortality and incidence rates have decreased concomitant with age-adjusted rates, dropping to 16.8 and 42.7 per 100 000 population, respectively, in 1996 (6). In contrast, the incidence rate in Japan is rising rapidly (7), probably due to the acquisition of Western lifestyle. Incidence rate increases with age: carcinomas are rare before the age of 40 years except in individuals with genetic predisposition or predisposing conditions like chronic inflammatory bowel diseases.
Aetiology
A high incidence of colorectal carcinomas is consistently observed in populations with a Western type diet, i.e. highly caloric food rich in animal fats, most often as red meat and combined with low physical activity and vegetable consumption. Epidemiological studies have indicated that a positive family history, meat consumption, smoking and alcohol consumption are risk factors (8,9). The risk of alcohol consumption can be enhanced in ALDH2 heterozygotes (10). Inverse associations include vegetable consumption, prolonged use of non-steroidal anti-inflammatory drugs, oestrogen replacement therapy and physical activity. Fibres may have a protective role, but this has been questioned recently. In a study in Bangkok, nitrite-treated meat increased colorectal cancer risk, while dietary fibre decreased risk; there was an elevated risk of colorectal cancer in those with a history of bowel polyps (OR = 14.69, 95% CI = 2.01–301.46) (11). Chronic inflammatory bowel diseases, i.e. ulcerative colitis, Crohn's disease, are aetiological factors in the development of colorectal adenocarcinomas (12–17). Sequential genetic alterations mediate development of colon cancer, the earliest of such change being mutation of the APC gene. Familial clustering usually has a genetic basis. Typical genetic syndromes associated with colorectal cancer include familial adenomatosis polyposis and hereditary non-polyposis colon cancer (18).
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INCIDENCE OF COLON AND RECTUM CANCER IN THAILAND |
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TOPAbstractINTRODUCTIONEPIDEMIOLOGYINCIDENCE OF COLON AND...SCREENING FOR COLON AND...SCREENING METHODSCONCLUSIONReferences |
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Thailand is located in Southeast Asia, with Laos and Cambodia to its east, the Gulf of Thailand and Malaysia to its south, and the Andaman Sea and Myanmar to its west. The total area is 513 155 km2. Thailand is divided into 76 provinces, within four geographical regions: the Northern, Northeastern, Southern and Central. The geographical area covered by the nine population-based cancer registries is shown in Fig. 1 and the estimated population in each province by sex are shown in Table 1. The ASR of cancer at all sites in 1999 (1998–2000) ranged from 104.5 per 100 000 (M) and 77.6 per 100 000 (F) in Prachuap Khiri Khan to 242.0 per 100 000 (M) and 158.4 per 100 000 (F) in Udon Thani (Table 2) (19).
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In Chiang Mai, lung cancer (ASR = 29.6) is the most important site in men, followed by cancers of liver and bile duct, and then colon and rectum. Cervix cancer (ASR = 29.4) is the leading cancer in women, followed by cancers of lung, breast and colon and rectum.
In Lampang, the profile of leading cancer in men is similar to that in Chiang Mai. Lung cancer in men (ASR = 53) is even higher than in Chiang Mai. Lung cancer is also the most common cancer in women, followed by cancers of cervix, breast, liver and bile duct and colon and rectum.
In the northeastern regions, Nakhon Phanom, Udon Thani and Khon Kaen, the picture is dominated by liver cancer, by far the most common cancer in men (45–59% of all cancers) and women (24.2–32.4% of all cancers). Cervix cancer is second in frequency in women.
In Bangkok, lung cancer (ASR = 18.4) is the most important cancer of men, followed by cancers of the liver and bile duct, and then the colon and rectum. In women, breast cancer (ASR = 24.3) is the leading cancer, ahead of cervix cancer (in contrast to the other eight registries), and colon and rectum cancer is third in frequency.
In Rayong, lung cancer (ASR = 25.1) is the most important cancer in men, followed by liver and bile duct cancer, esophagus cancer (ASR = 10.3 is highest incidence in the nine registries). Cervix cancer is also very high incidence (ASR = 28.5) and followed by cancers of breast, lung and colon and rectum.
In Prachuap Khiri Khan, lung cancer (ASR = 12.1) is the most common cancer in men, followed by cancers of colon and rectum and liver and bile duct. Cervix cancer (ASR = 21.2) is the leading cancer in women, followed by breast cancer and colon and rectum cancer.
In Songkhla, the leading site in men is lung (ASR = 13.5), followed by cancers of colon and rectum, oral cavity and esophagus. In women, cervix and breast cancers predominate, with colon and rectum in third place.
The estimated numbers of new cancer cases in Thailand from the nine population based cancer registries in 1999 were 31 582 in men and 33 678 in women. These correspond to ASR of 127.7 per 100 000 for men and 125.5 per 100 000 in women. The national estimates of the 10 leading cancers in men and women are shown as ASR in Fig. 2. Liver and bile duct cancer is the most common cancer in men (ASR = 33.4), followed by lung cancer (ASR = 20.6), colon and rectum cancer (ASR = 8.8) and oral cancer (ASR = 5.2). In women, cervix cancer is the most common (ASR = 24.7), followed by breast cancer (ASR = 20.5), liver and bile duct cancer (ASR = 12.3) and lung cancer (ASR = 9.3) and colon and rectum (ASR = 7.6).
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The incidence rate of colorectal cancer in Thailand is low when compared with other countries. It is the third in frequency in males after the cancers of liver and lung, and the fifth after cancers of the cervix, breast, liver and lung for females (Fig. 2). The highest incidence rate for both sexes is in Bangkok (ASR = 12.4 for males and 9.6 for females) and the lowest incidence rate is seen in Nakhon Phanom (ASR = 5.5 for males and 4.8 for females) (20). The estimated incidence rate in Thailand is 8.8 for males and 7.6 for females (Fig. 3). The number of cases of colorectal cancer in both sexes is rapidly increasing (Table 3). Thus, over 8000 new cases are expected in 2008 (21). Most cases of colorectal cancer were diagnosed at an advanced stage. For example, of cases with known stage in Chiang Mai, only 10.4% were diagnosed with localized disease, whereas 29.2% had metastatic disease. The sex ratio (male: female) varied from 1:1 to 1.24:1. Age-specific incidence rates of colorectal cancer are shown in Fig. 4. The percentage of cases registered with histological verification of diagnosis ranged 27.1–93.2% for males and 31.3–93.1% for females. Adenocarcinoma is the most common histological type.
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SCREENING FOR COLON AND RECTUM CANCER |
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TOPAbstractINTRODUCTIONEPIDEMIOLOGYINCIDENCE OF COLON AND...SCREENING FOR COLON AND...SCREENING METHODSCONCLUSIONReferences |
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Colorectal cancer fulfils the conditions required for mass screening: it is a major public health problem; and also it can be cured by the detection at early stage and even prevented by the removal of adenomas. Descriptive epidemiological data provided by cancer registries proved useful in designing screening programmes for colorectal cancer (22). Colorectal cancer is uncommon before the age of 50. Incidence rate increases rapidly from this age onwards. Thus, the average risk population was defined as subjects over age 50. The cumulative risk of colorectal cancer in first degree relatives of a patient having a colorectal cancer before 50, or having two first-degree relatives affected, has been estimated to be over 10%. A small proportion of colorectal cancers occur among those with a family history of the disease. The main aim of screening is to detect 90% of cases of colorectal cancer that occurs sporadically, most of these in patients above the age of 50. The precursor of advanced colorectal cancer is either an adenomatous polyp or a flat neoplastic lesion. Considering these data and the results of screening trials, it was recommended to implement screening in asymptomatic adults aged 50 and over by the European Group for Colorectal Cancer Screening (23).
In Thailand, the number of cases of colorectal cancer in both sexes is increasing and will probably exceed that of lung cancer in the next decade (21). Thus, we are planning to have colorectal cancer screening programme. Mass screening protocols are generally recommended to be initiated in people of age 50 and above.
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SCREENING METHODS |
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TOPAbstractINTRODUCTIONEPIDEMIOLOGYINCIDENCE OF COLON AND...SCREENING FOR COLON AND...SCREENING METHODSCONCLUSIONReferences |
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Several tests and procedures have been proposed for the screening of colorectal cancer. The most commonly used is the faecal occult blood test (FOBT). FOBT is the most cost-effective and comprehensively applicable screening method available, but its specificity and sensitivity are limited (24–30). Most of these tests are guaiac-based tests, which are intended to detect the peroxidase-like activity of haemoglobin. This test is easy to perform, without great inconvenience to the individual, and is inexpensive. If any of the slides are positive, a complete colonoscopy is recommended. Sensitivity in detecting cancer with a non-rehydrated test and biennial screening in populations over 50 is situated between 50 and 60% for cancers (31) and between 20 and 30% for adenomas larger than 1 cm of diameter (32,33). The true positive rate is between 40 and 50%. Rehydration increases sensitivity but also decreases specificity, so that the predictive accuracy of a positive test becomes very low (31). FOBT require special dietary restrictions which may be difficult for the patients. More complex FOBTs, particularly immunochemical tests specific for human haemoglobin, have been developed. They are more sensitive and no need for dietary restrictions, but more expensive and their specificity at a population level is not well established. The role of immunochemical tests for a mass screening programme are currently being examined. We are planning to investigate the new immunochemical test for colorectal cancer screening programme in Thailand.
Endoscopy provides the best method to detect colorectal cancer and its precursor lesions, e.g. polyps (34–37). The theoretical advantages of endoscopic screening include its high diagnostic sensitivity and specificity. However, its application to population-based screening is limited by cost and availability of qualified specialists. Periodic sigmoidoscopy has been recommended by some organizations, whereas colonoscopy is rarely considered for individuals at average risk. Evidence to suggest that sigmoidoscopy may be effective for colorectal cancer screening, with benefits lasting for up to ten years, has come from two case-controlled studies (38,39). Trials are now underway to evaluate flexible sigmoidoscopy and colonoscopy for screening.
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CONCLUSION |
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TOPAbstractINTRODUCTIONEPIDEMIOLOGYINCIDENCE OF COLON AND...SCREENING FOR COLON AND...SCREENING METHODSCONCLUSIONReferences |
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The incidence rates of cancers of colon and rectum are increasing in Asia including Japan and Thailand. The highest incidence rates of colon cancer for males were seen in Japan and for females in New Zealand. The highest incidence rates of rectal cancer for males were also seen in Japan and for females in Chinese Singaporeans. Colorectal cancer mortality and incidence rates have decreased in the USA. In contrast, the incidence in Japan, as well as in Thailand, is rising rapidly, probably due to the acquisition of Western lifestyle. We should pay more attention to primary and secondary preventions for colorectal cancer control in Asian countries. Cancer registries have been of great importance in the planning, evaluation and monitoring of screening programmes for colorectal cancer.
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Acknowledgments |
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The authors thank Mrs. Adisorn Jedpiyawongse, Ms. Pavena Kladbaimai and Mr. Wainawin Pengchata for their help in preparing this manuscript.
Conflict of interest statement
None declared.
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References |
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