Colorectal carcinoma (CRC) is the second most common cancer in Malaysia at a prevalence of 13.2% as reported in Malaysian National Cancer Registry Report 2007-2011. According to National Cancer Patient Registry on Colorectal Cancer 2008-2013, the overall incidence rate for CRC was 21.3 cases per 100,000 population. Age-adjusted incidence rate was 1.33 times higher among male than female. The incidence was highest in Chinese followed by Malay and Indian. Overall mortality rate was 9.8 cases per 100,000 population and age-adjusted mortality rate was 1.42 times higher in male than female.
The most common presenting symptoms of CRC are altered bowel habit (41.7%) followed by blood in stool (35.5%), abdominal pain (31.5%), weight loss (31.0%), anaemia (9.8%) and intestinal obstruction (9.3%).
Left-sided carcinoma is the commonest form and constitutes 81.8% of all notified cases. Unfortunately, majority of patients are at stage III and IV (54.36%) while only 8.4% are diagnosed at stage I according to the tumour-node-metastasis (TNM) staging.
Management of patients with CRC consists of a comprehensive strategy of screening, diagnosis, staging, treatment and follow-up. Hence, this first national CPG on CRC is developed to assist healthcare providers in the management of CRC. One of the objectives of this CPG is to assist Family Medicine Specialists and other primary care providers in providing structured screening and referral programme according to the symptoms and risk stratification. In addition, it is hoped that this CPG will help to reduce the variation in clinical practice in management of patients with CRC namely in diagnosis, staging, treatment and follow-up.
The mainstay of treatment for CRC is surgical resection, which offers the best curative outcome. Chemotherapy and radiotherapy are used to downstage, as adjuvant therapy and for palliative purposes. With the advancement of technologies, evidence has shown their effectiveness and safety in different stages of CRC. This evidence-based Clinical Practice Guidelines on Management of Colorectal Carcinoma addresses these issues for best clinical practice in managing CRC in Malaysia.
The estimated societal cost of CRC management in government hospitals in Malaysia using conventional chemotherapy ranges between RM13,622 to RM27,163 based on different stages, with an average of RM21,377 per patient. The cost of treatment is higher when combined conventional chemotherapy and monoclonal antibody is used. With increasing number of new cases detected every year, the economic burden of CRC management is escalating especially if the patients present in advanced stage. Introduction of organised screening programmes should be undertaken in a phased manner for the early detection of cancer, which can ultimately reduce the economic burden of colorectal cancer.
Thus, it is timely that this CPG is developed for those who are directly or indirectly involved in the management of colorectal carcinoma. This will ultimately help to improve the care of colorectal carcinoma patients in Malaysia. Various algorithms, tables, figures and appendices are featured for better understanding of the target users of the document.
DATUK DR. NOOR HISHAM ABDULLAH
Director General of Health Malaysia
27th June 2018