Colorectal Cancer

Adenocarcinoma of the colon and rectum (colorectal cancer, CRC) is the third most common cancer, the fourth most common cause of cancer death, and the second most common cancer in terms of the number of individuals living with cancer five years after diagnosis worldwide. An estimated 1,361,000 people are diagnosed with CRC annually; approximately 694,000 people die from CRC annually; and 3,544,000 individuals are living with CRC (Ferlay and others 2013). Randomized controlled trials (RCT) have shown that screening is associated with a reduction in CRC mortality; in several high-income countries (HICs), organized, population-based screening programs have been introduced, starting in 2006. Some screening tests detect cancer at an early stage when treatment is less arduous and more often results in cure. Other screening tests have the ability to detect adenomas as well as cancer. Screening provides the opportunity to identify and remove adenomas and thereby to prevent the development of the disease (Lieberman and others 2012). In general, the burden of disease, as measured by incidence and mortality rates, tracks the World Bank grouping of countries into low-, lower-middle, upper-middle, and high-income: the lowest-income countries have the lowest burden of disease. The ability to intervene to introduce screening and offer access to high-quality treatment is a function of resource availability, which is associated with income level. The ability of countries to develop interventions increases with income, suggesting a progression in policy options as country income increases. The focus of this chapter is on those who are at average risk for CRC. In our discussion of policy options, we use a slightly different typology than income for resource availability, following chapter 3 in this volume (Anderson and others 2015). The resources available at a health facility can be described as basic, limited, enhanced, and maximal. The basic level corresponds approximately to the situation in low-income countries (LICs), the limited level to the situation in rural areas of lower-middle-income countries and upper-middle-income countries, the enhanced level to the situation in urban areas of lower-middle-income and upper-middle-income countries, and the maximal level to the situation in HICs. We provide suggestions for appropriate screening and treatment strategies that correspond to these resource levels for policy makers to consider.