Disparities Persist in CRC Screening, Management Between High-, Low-Income Countries

Limited access to screening and treatment remains a primary reason behind screening disparities for colorectal cancer (CRC) in low- and middle-income countries (LMICs) compared with high-income countries (HICs), according to a review published in Cureus.¹ Investment in infrastructure and global collaboration could help to mitigate these disparities.

CRC is the second-leading cause cancer-related death globally,² with new cases expected to increase by 2030. Survival rates have improved in patients 65 years and older, but they have declined in patients 50 years and younger due to low screening. Differences in the health systems of different countries could play a part in screening but is ultimately secondary to lifestyle of the patient and how they grew up, which could affect prognosis for CRC. This review aimed to compare screening and management of CRC in different LMICs and HICs to identify the disparities that exist.

Overall, incidence of CRC is 3 to 4 times higher in HICs compared with LMICs, with the highest incidences of CRC in Australia and New Zealand (35.3 per 100,000 individuals), Northern Europe (32.0 per 100,000), and Southern Europe (31.5 per 100,000) compared with the lowest incidences in Western Africa (6.5 per 100,000), Middle Africa (5.5 per 100,000), and South-Central Asia (5.5 per 100,000). HICs, however, have a lower mortality rate compared with LMICs. Countries with a low human development index (HDI) had incidence of approximately 6 per 100,000 and mortality of approximately 4 per 100,000 compared with countries with a very high HDI, who had an incidence of nearly 30 per 100,000 but a mortality rate of approximately 10 per 100,000.

Total CRC cases are expected to increase by 2040 due to the increaing incidence and mortality rates in LMICs, whereas the rates are stabilizing or decreasing in HICs due to population-level shifts in lifestyle changes and the availability of screening and prevention methods, including colonoscopies. Compared with HICs, lifestyles and demographic aging could be the cause of increased incidence in CRC.

Disparities persist in screening and treatment of CRC between low- and high-income countries | Image credit: mi_viri - stock.adobe.com

Screening for CRC usually involves a colonoscopy, which remains the gold standard for preventive care and the most commonly used method of screening. Fecal tests are also methods of screening gaining in popularity, including fecal immunochemical tests (FITs), that can encourage noninvasive methods of screening in patients unwilling to get a colonoscopy. Screening has been a primary factor in reducing incidence in HICs and could be used to reduce the incidence in LMICs. However, cultural and socioeconomic challenges and inadequate infrastructure and limited resources could make this a hard task. The authors suggest that either low-cost screening options, such as FIT, or opportunistic screening, where screening is done during regular visits to the doctor, could help to increase in these countries.

When it comes to managing CRC, there are various methods of treating the cancer. These can include resection, chemotherapy, radiation therapy, and targeted therapy depending on the severity of the cancer when first treated and the specific patient. Although HICs have access to more personalized treatment strategies, LMICs have limited availability of these treatments and advanced technologies, such as minimally invasive resection methods. As a result, patients in LMICs are more likely to present with advanced forms of cancer at the time of initial treatment vs those in HICs. Limited resource settings, the authors said, should instead focus on basic imaging and essential diagnostic tests rather than more advanced technologies in order to maximize resources. LMICs can also use more traditional open surgeries and cost-effective drug regimens.

Disparities between HICs and LMICs exist in other ways, including in the limitations of resources such as access to water or sanitation products and unreliable power. HICs have some communities of lower-income populations that also have similar disparities as LMICs, including individuals avoiding health care due to fear of deportation or because they have communication issues from not understanding the language. These individuals can also be uninsured, which might discourage them from seeking treatment. The authors recommend catering strategies to improve health care access that focus on different communities and customizing strategies around them, which can include different subsidized services.

The researchers suggest that telemedicine can also help to bridge the disparity gaps in LMICs with less infrastructure, as it can help with follow-ups and consultations. This can help to reduce the number of visits that a patient will need to attend in person. Artificial intelligence can help to identify prognostic markers in image analysis, which can help in areas with less advanced imaging technologies. Equitable access to care for CRC can also be achieved through government and international organization interventions. This can include making sure that primary health care systems have cancer prevention integrated into their care, which can include increased funding to prevention, research, and infrastructure.

Overall, disparities between HICs and LMICs still persist in the world when it comes to screening for CRC. Using more tailored strategies to encourage screening for CRC and maximizing the resources available can help to mitigate these disparities outside of more targeted interventions from government and global collaboration through telemedicine and personalized medicine. Assuring cancer prevention is included in primary health care can help to alleviate incidence in both LMICs and globally.

References

1. Abreu Lopez BA, Pinto-Colmenarez R, Caliwag FMC, et al. Colorectal cancer screening and management in low- and middle-income countries and high-income countries: a narrative review. Cureus. 2024;16(10):e70933. doi:10.7759/cureus.70933

2Colorectal cancer: key facts. World Health Organization. July 11, 2023. Accessed November 7, 2024. https://www.who.int/news-room/fact-sheets/detail/colorectal-cancer