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Saturday 17 February 2018

People are dying from a very treatable disease

There are 2,000 new cases of colon cancer every year in Ireland, but too few specialists, writes John Crown

The recent announcement that a limited colorectal cancer screening programme will be introduced in Ireland is welcome. We have one of the highest rates of the disease in the world, with 2,000 Irish people diagnosed annually. Tragically, 900 die.

It is no respecter of rank or fame. Pope John Paul II, President Ronald Reagan and Sharon Osbourne all had it and recovered. It killed Ian Dury, Audrey Hepburn, Bobby Moore and Neville Chamberlain.

We are what we eat, and it is no surprise that the digestive tract, which extracts the nutrients from our food and then expels the waste, is complex. The oesophagus is a long muscular tube which propels food from the mouth (no, it doesn't just fall, you can swallow upside down) to the stomach, where the process of breaking it down into its component parts is begun.

It then enters the small intestine, which consists of approximately 30ft feet of tube (the 'guts') where the actual business of absorption takes place. The residual waste matter is then passed onto the 8ft-long colon or large intestine ('large' because it's thicker), where the bulk of the fluid is reabsorbed. The last part of the colon is called the rectum, and it is from here that waste faeces are discharged via the anus, or back passage.

Cancers of the colon and rectum (colorectal cancer) are the most common of the digestive malignancies.

Luckily, they is very amenable to prevention and early diagnosis. Why is this? Most colorectal cancers develop from pre-existing non-cancerous growths called polyps. Polyps are, in most cases, fairly silent, but they can cause bleeding or other complaints. Crucially they are visible to doctors via an instrument called a colonoscope, a long flexible tube which is inserted through the anus. It is carried out under light anaesthesia as an outpatient. It contains a light, and a telescope so that the entire length of the colon can be inspected. It can also be used to take small samples, and has a device for removing polyps.

Samples and polyps that are removed are studied in the laboratory, and it can be determined if there is a cancer, or some other condition. In theory the great majority of colorectal cancers should either be preventable (by removing polyps before they turn into cancer) or diagnosed at an early curable stage.

The treatment for colon cancer has improved dramatically. The operations are smaller, often done by key-hole, and very few patients require a 'colostomy' or 'bag' to collect waste. The use of chemotherapy, radiotherapy and newer 'magic bullet' cancer drugs have resulted in improved outcomes. Even patients with advanced incurable disease live much longer and much better than before.

This is the reason why there has been such concern at the long waiting lists in Ireland for colonoscopy. Over recent years, widely fluctuating figures (provided by the HSE) have suggested that the wait for public patients who have symptoms that might be colon cancer (including bleeding, constipation, diarrhoea, pain) can be as long as six months or longer.

Department of Health attempts to justify this by saying that high-risk patients can be prioritised fall in the face of the argument that any bowel symptom might indicate an underlying cancer, although in most cases they will thankfully have a more trivial explanation.

The waiting lists are partly due to our public policy to limit specialist numbers, which has resulted in Ireland being desperately short of gastroenterologists, the doctors who perform colonoscopy. It also results from our system of paying hospitals, which are given a fixed budget at the start of the year and told to make it last 12 months. If 10 patients or 100 patients need colonoscopy, the payment is the same. Patients on waiting lists are free; colonoscopies eat into your budget.

The new national screening programme, which is being partially underwritten by the Irish Cancer Society is, for reasons of cost effectiveness being aimed initially at the elderly. It will not involve colonoscopy, but rather will involve testing faeces for the presence of blood. The small minority who have a positive test will be called for colonoscopy. This is a less satisfactory way to rule out cancer in an individual, but is reasonable as a population screen.

It will almost certainly result in a modest but important reduction in colon cancer mortality. On a population basis it makes sense.

However, it is difficult to know how a health system that is so short of specialists that patients with worrying symptoms already have to wait up to six months for colonoscopy will cope with the added demands of screened patients.

If you have symptoms, see your GP.

Professor John Crown is a consultant oncologist

Sunday Independent

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