Colorectal Cancer Screening - Is it of any Use in India?

The only other cancer left in our list for screening in a non-high-risk general population is colorectal cancer, i.e. cancer of the colon and rectum. The USPSTF recommends screening for all adults in the US between the ages of 50 and 75 with definite benefit and likely benefit for those between 45 and 50 years of age. This is because colorectal cancer (CRC) is the third commonest cancer in the US, most frequently diagnosed in the age group of 65 to 74 years with an incidence of 10.1% in those below the age of 50 years [1].

In India, colorectal cancer in 2020 accounted for 5% of all new cancers and 4.2% of all cancer deaths. It is the 6^th commonest cancer by incidence and the 7^th commonest causing deaths [2].

So would screening be of help?

Unlike in the Western World, CRC occurs in a younger population in India with a median age of  47 years [3], most likely because the number of elderly people is low (10% of the population). In this setting, population screening mandated by the Government has no role because the resources needed to pick up CRC would not justify the lives saved due to early pick-up.

That brings us to opportunistic screening. If you have the means to do a screening test (fecal blood, colonoscopy, etc), should you go ahead and do it? Like with prostate cancer screening, you should be careful what you wish for. The only modality that has been proven to save lives in the context of CRC screening in the Western world is flexible colonoscopy and it is not a modality without complications [4]. In the Indian setting, with the low incidence of CRC in our population, unless you are at high-risk for getting CRC (family history, specific syndromes), there is no rationale for any form of CRC screening in India. There is no data and there are no guidelines to support CRC screening, even if you have all the resources at your disposal.

What does this mean for you and I when it comes to colorectal cancer screening.

The only cancers worth screening for at this stage of human development are breast cancer (mammography) and cervical cancer (HPV DNA) in women and lung cancer screening in smokers. Screening for prostate cancer is a challenge in India and unless there is a specific reason to screen, you should not. The same applies to CRC. It is just not worth the effort and there is no data that suggests that early pick-up in the Indian setting would make any difference to your healthspan or lifespan.

Footnotes

1. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening
2. https://gco.iarc.fr/today/data/factsheets/populations/356-india-fact-sheets.pdf
3. 3. Patil PS et al. Colorectal Cancer in India: An Audit from a Tertiary Center in a Low Prevalence Area. Indian J Surg Oncol. 2017 Dec;8(4):484-490.
4. 4. Powell K, Prasad V. Colorectal cancer screening at a younger age: pitfalls in the model-based recommendation of the USPSTF. BMJ Evid Based Med. 2022 Aug;27(4):206-208.