A call to intensify colorectal cancer (CRC) screening campaigns

In 2025, it is anticipated that Colorectal Cancer (CRC) incidence in Lebanon will witness an increase to 28.8 and 26.1 per 100,000 for males and females, respectively. This is a notable rise from the 2016 rates of 23.2 and 20.2 per 100,000 (1). Lebanon ranks the second among the Middle East and North Africa (MENA) region for CRC incidence, with CRC being the fifth most prevalent cancer in the country (2). Between 2005 and 2016, there were 10,284 incident cases of CRC, with 77.4% occurring in individuals aged 50 years and above (1). The severity of the disease was reported at advanced stage (T3 and T4) in more than 80% of diagnosed cases (3).

Building on the alarming statistics, the low level of CRC screening is a major health issue that puts individuals at risk of reaching advanced stages of untreatable cancer when it could be managed if detected early. More than 59% of the Lebanese population lacks awareness and knowledge about CRC, and around 83% are unaware of its risk factors (4). Additionally, 67% were not familiar with its warning signs (5).

Unfortunately, CRC is overlooked and not prioritized in the Ministry of Public Health (MoPH) agenda. This was evident when the National CRC campaign shortly stopped after its launching in 2019. Accordingly, the cost of treatment increased to USD 64,805 per patient, with 67% of the MoPH oncology drug budget from 2008-2013 allocated to CRC (6, 7). Despite compelling evidence on the effectiveness of screening programs in reducing CRC incidence and mortality, such programs are inactive and screening test uptake remain very low in Lebanon (7).

What is CRC?

CRC is a disease commonly developed from precursor lesions known as polyps, specifically classified as adenomatous polyps. An adenomatous polyp is an abnormal growth that arises in the colon or rectum. The majority of adenomatous polyps are benign (not cancerous) and do not cause any symptoms. However, a subset of polyps may undergo malignant transformation, progressing to carcinoma and eventually evolving into aggressive metastatic cancer (8). Adenomatous polyps that transform into cancer undergo a slow transition process, typically over several years. This slow growth of precancerous lesions makes early detection a fundamental step for fighting the disease (9).

The signs and symptoms of CRC include anal bleeding, abdominal pain, bowel habit changes, anemia, and unexplained weight loss. CRC is associated with multiple risk factors such as age, inflammatory bowel disease, obesity, physical inactivity, smoking, alcohol, poor dietary intake, and most importantly, family history (2).

What is CRC screening?

CRC screening is recommended for individuals aged between 45 and 75 years and for patients with colorectal bleeding symptoms (10). The two most effective screening and detection tests of polyps include non-invasive tests such as fecal tests- Fecal Immunochemical Test (FIT) and invasive tests such as colonoscopy (11). The FIT uses antibodies to detect blood in the stool and is done once a year. If FIT is tested positive, a colonoscopy is done which uses a thin, flexible, lighted tube to check for polyps or cancer inside the rectum and the entire colon.

The removal of polyps by colonoscopy has proven to reduce the risk of developing CRC by 90% (12). Evidence from a systematic review has shown the potential of invasive tests to reduce the incidence and mortality of CRC by 20- 30% in randomized trials and 40-60% in case-control studies (13). The annual use of fecal tests reduced CRC mortality by 32% (11).

Relaunching the national CRC campaign is an important and crucial step to prevent and early detect CRC. This would increase the population’s knowledge about CRC, its symptoms, warning signs, and encourage preventive actions. Moreover, the MoPH must ensure the availability, accessibility, and affordability of screening tests, hence enhancing the willingness to perform screening. This could be addressed by integrating CRC screening into primary care settings and laboratories and sensitizing healthcare providers on CRC education and available screening tests.