Sweden has been slow to introduce screening; this spring, Skåne will become the third region to offer screening widely in a scheme to be rolled out nationally in the future. Many other European countries already have screening programmes with good results.
“Skåne has been very forward-looking in its decision to launch a summons system, despite the pandemic. Many people have worked to enable this to happen,” says Marie-Louise Lydrup, consultant surgeon and associate professor at Skåne University Hospital in Malmö.
Cancer in the colon and rectum is the third most common form of cancer after prostate and breast cancer. This screening will help healthcare providers to detect colorectal cancer at an early stage, when it does not yet cause any symptoms. In the early stages of the disease, colorectal cancer often causes no symptoms at all, or only vague ones. The most common signs are changes in bowel function, which can take the form of abdominal pain, constipation, diarrhoea, difficult bowel movements and blood in the faeces.
The chances of being cured of the disease increase significantly with early detection. In the early stages, a tumour in the intestine may bleed only a little, making it difficult to discover. A test for colorectal cancer can reveal such hidden traces of blood in the faeces at an early stage.
“The obvious benefit is finding tumours before they cause symptoms and finding precursors to cancer so that they can be removed,” explains Lydrup, continuing:
“This enables us to remove polyps with less advanced surgery, which does not have such a heavy impact on the patient”.
The research team at Lund University’s Department of Clinical Sciences in Malmö conducts patient-centred research into bowel diseases, eg risk factors for recurrence of colorectal cancer as well as functional results after cancer surgery. Some patients suffer complications such as bowel leakage, after removing a segment of the bowel,, which affects bowel function.
The research team led by Marie-Louise Lydrup and Pamela Buchwald has studied the long-term outcomes of complications in colorectal cancer requiring major surgery.
“It is important to examine the complications that can arise after major surgery. The patient survives, but because the tumour has grown over other organs in the pelvis, it is necessary to remove the bladder, prostate or uterus. How does this affect quality of life? Here at Skåne University Hospital in Malmö, we are very interested in these patients whose treatment is centralised here from Southern Sweden, to perform longterm follow up and study complications and survival rates”, explains Lydrup.
Research has also shown that many people affected by colorectal cancer become acutely ill and then have a much poorer survival prognosis.
“If we screen our population, we will have fewer emergency operations. Currently, the disease starts with an emergency operation for 20 - 25 % of patients and the most common presentation is intestinal blockage”, says Pamela Buchwald, consultant surgeon and associate professor at Skåne University Hospital.
Challenges in the screening programme
Testing is free, but also voluntary. In order for the screening programme to have an impact, most of those summoned need to choose to take part. A letter arrives home with instructions, a sample container and a return envelope; the patient collects a stool sample and sends it to the laboratory for analysis. If traces of blood are found in the faeces, the patient is summoned for a colonoscopy. However, researchers fear that many people will balk at such an examination.
“I don’t think it is so difficult for people to take a stool sample, but the subsequent step to undergo a colonoscopy could be trickier. Particularly in the absence of any symptoms”, says Pamela Buchwald. “There will always be patient groups that decline to attend, as we have observed for mammography and prostate examinations”.
Another set of problems that could jeopardise the full potential of the screening programme is the shortage of colonoscopy experts among both physicians and nursing staff. According to Lydrup and Buchwald, the colonoscopies must maintain high quality; hopefully there is now a stronger incentive to invest in training.
“We cannot avoid a cost increase at the beginning, but the long-term estimates show that costs will decline as we reduce the need for surgery and chemotherapy”, says Lydrup.
This also means that fewer patients will be seriously ill, which entails less personal suffering. The prognosis is also that once the entire screening programme has been developed in Sweden, around 300 lives will be saved per year.
Young people also affected
This form of cancer has increased over the years, affecting relatively young people under the age of 50. Being overweight or not exercising enough increases the risk of several types of cancer, not only colorectal cancer.
Buchwald and Lydrup are in agreement. They would like to see screening offered to Swedes under the age of 50 as well. Their research team is investigating whether colorectal cancers differ in patients under 50 compared to older patients. They are also studying whether genetics determine who is affected by this form of cancer. As this younger group is not covered by the screening programme, it is important to reach out to general practitioners with information concerning the importance of proper investigations when young people present with symptoms , as doctors already do with older patients. Public healthcare needs to be better prepared.
“In younger patients, it is difficult to distinguish between colorectal cancer and inflammation. Also, when an x-ray shows a perforation in a diverticula in the colon, physicians should be on their guard”, says Buchwald.
Public healthcare has become better and better at treating this type of cancer and Sweden currently has a survival rate of 70 %. For those who do not have metastatic disease at the time of diagnosis, the survival rate is even higher, at 90 %.
“This is why screening is so important. 25 % of patients have a metastatic tumour when the cancer is detected, which makes the outcome much worse. We need to detect the cancer before any metastatic tumours appear. For many people, rectal issues are still a taboo subject, but I hope that the screening will help to open up a good atmosphere for discussion which gets us to check our bodily functions”, says Buchwald.
March is the awareness month for colorectal cancer when one can join in activities that will increase awareness and prevention of colorectal cancer