Colorectal cancer – can an emergency be avoided?

Dr Simbarashe Chinyowa, one of the AWACAN-ED Scholars at the University of Zimbabwe, attempts to understand why many colorectal cancer patients in Zimbabwe present first as emergencies and whether opportunities for earlier diagnosis are missed.

Colorectal cancer (CRC) is the third most common cancer worldwide and the third most common cause of cancer deaths. Historically, CRC has not been common in Zimbabwe and Sub-Saharan Africa. Still, in the past 10-20 years, the incidence has been increasing, ostensibly due to the Westernisation of diet and lifestyle (1).  In our experience in Harare, many cases of CRC in the public sector present as an emergency admission, with the patient in critical condition.  The disease is often advanced, resulting in poor treatment outcomes (2). Personal, societal, and health-system factors probably contribute to this emergency presentation of CRC.  Understanding these factors will help identify intervention points that could lead to earlier diagnosis, down-staging of disease at diagnosis, and improved treatment outcomes.

Challenges

The decision to seek help for CRC is complex and multi-layered.  Some challenges are outlined below.

• Lack of Screening – There are no screening facilities for CRC in the public sector in Zimbabwe since the cost of screening is currently beyond the capacity of the health system.
• Symptom recognition and evaluation – The colon and rectum (large bowels) are located within the abdomen. Early CRC is symptomatically silent. Even when symptoms develop, it is difficult for the patient and/or health care worker to appreciate when an abdominal complaint indicates a severe condition because the same symptoms may be attributed to other non-cancer conditions such as haemorrhoids/piles. Often, symptoms such as bleeding, constipation, or pain are initially dismissed as trivial until they become severe or persistent.
• Cost of evaluation and treatment – The diagnosis of CRC ultimately requires that a tissue biopsy be obtained at colonoscopy. Colonoscopy is expensive and available only at specialist centres. The patient may have to pay for this test out of pocket. Unfortunately, this is only one of many patient expenses – others include travel and accommodation, ancillary tests, cancer staging, and treatment.
• Referral pathway – The specialized nature of testing and treatment for CRC requires that a patient with suspected cancer is referred to a tertiary facility. There are several logistical challenges that may complicate this journey.
• Perceived futility – An emerging challenge seen among some cancer patients in Zimbabwe is a perception that treatment by conventional medicine is futile. Upon diagnosis, a growing number of patients prefer alternative means of relief e.g. spiritual, herbal or traditional. Some of these patients eventually return to the point of diagnosis after several months with worse disease. The magnitude of this challenge is not yet known and requires further study.

Research outline

I will focus on the emergency presentation of CRC in Zimbabwe and examine the pathway leading up to diagnosis, asking whether this emergency could have been averted?

My research will:

• Explore the journey to diagnosis of CRC from the perspective of the patient or a significant caregiver.
• Identify barriers and missed opportunities to earlier diagnosis of CRC in patients currently presenting as an emergency.
• Compare CRC features and treatment outcomes for emergency patients vs. non-emergency CRC patients.

Outcomes & Impact

The results of this research are potentially valuable for clinicians, hospital administrators, and policy leaders in the Ministry of Health and Childcare in Zimbabwe.  I hope to prompt discussion on improved access to care and more efficient distribution of resources around CRC management.

References

1. Katsidzira L, Gangaidzo I, Thomson S, Rusakaniko S, Matenga J, Ramesar R. The shifting epidemiology of colorectal cancer in sub-Saharan Africa. lancet Gastroenterol Hepatol. 2017 May;2(5):377–83.
2. Golder AM, McMillan DC, Horgan PG, Roxburgh CSD. Determinants of emergency presentation in patients with colorectal cancer: a systematic review and meta-analysis. Sci Rep. 2022;12(1):1–13.

Simbarashe is a general surgeon at the University of Zimbabwe. His research interest lies in earlier diagnosis and treatment of cancer in low-income settings. Previous work includes anal HPV and anal cancer precursor lesions. He is currently pursuing a PhD at the University of Zimbabwe funded by the AWACAN-ED programme.