The Patient Safety Group (PSG) of the Royal College of Surgeons of Edinburgh (Ƶ) are delighted to lend our enthusiastic support to the sixth World Patient Safety Day (WPSD). This event, established by the World Health Organisation (WHO) in 2019, takes place on 17 September every year. It helps to raise global awareness amongst all stakeholders about key Patient Safety issues and foster collaboration between patients, health care workers, health care leaders and policy makers to improve patient safety. Each year a new theme is selected to highlight a priority patient safety area for action.
The theme set by the WHO for this year’s WPSD is “Improving diagnosis for patient safety”, recognising the vital importance of correct and timely diagnosis in ensuring patient safety and improving health outcomes.
Colorectal cancer is the second leading preventable cause of death from cancer(1). If detected early, it can be cured!This is the purpose of cancer screening programs,toidentifycancers early or at the premalignantstage(2). Colonoscopy can detect cancer or cancer-forming polyps in theirearly stagesand is the gold standard in detecting colorectal cancer.This isbased on the fact thatmost colorectal cancers develop inpreexistingpolypsand it takes seriesofgenetic changesover a decadebefore becoming cancerouslesions (3).It is also an excellent screening modality, and most developed countries recommend screening above 50years of age.However, it is resource-intensive, has associated risks such as bleeding and perforation, and can be technically challenging to provide to everyone, even in developed countries, let alone on a global scale.Theneed for training,anda capacity-demand mismatchin mostcountries,hindersthe use of colonoscopy as a screening tool.
But what about our poo? Testing stool for blood is one way to detect colorectal cancer. It started with the guaiac faecal occult blood test (gFOBT),where the stool was tested for blood by applying a chemical that changed colour to detect thepresence ofiron in the bloodif present in the stool. This involved collecting a person's stool and smearing it on test cards for further laboratory testing. The test usually needed to be done three times to increase sensitivity. Additionally, there were food and medication restrictions before these tests, and these testscould also detect blood from sources above the large intestine, which decreases their usefulness as a screening modality for large bowelcancers(4).
Then came the FIT (faecal immunochemical test), which detects human blood usingspecific antibodies. The FIT needs to be done only once and does not require the food and dietary restrictions associated withgFOBT. The test results provide specificvalues, allowingus to set cut-off points based on local population data and the desired sensitivity and specificity. It is also more targeted for blood from the largeintestine(5).
FIT andgFOBTneed to be doneat regularintervalsifwe are screening for colorectal cancer, as bleeding from a tumour issporadic. But what if we could detect DNA from developing pre-cancerous lesions as well? This is addressed by the faecal DNAtest(6). As expected, it is more expensive but has higher sensitivity than theprevioustwo tests. It can detect lesions that could develop into cancer in the future; thus, it needs to berepeatedevery three yearsas a screening test.
FIT and faecal DNA tests involve a home kit.The stoolcan be collected using a small stick provided in the kit and placed into a small solution-filled vial. The kit is designed to make collecting stool for testingless cumbersomeand non-repulsive for some as possible.
It is proven that public health cannot be improved through isolated, advanced medical procedures alone but rather throughengagingpublichealth measures like education, a healthy lifestyle, early screening, and awareness of its utility. It is the right direction to use advancements in biotechnology to basic screening procedures to provide a test that is accessible, safe,affordableandeffective,bringing it closerto an ideal screening test(7).It is also importantto appreciatethat stool tests shouldnot becumbersomeandmessyandrathereasyto dowhichincreasesadherence to screening programmes.Such tests can ease the burden on colonoscopy lists and provide screening possibilities worldwide,especially for resource-deprivedeconomies. These kits have reached the market asover-the-counter self-detection kits,although their efficacy is doubtful.
All these screening tests are followed by colonoscopy to assess the colon toidentify,andremove polyps and toidentifycancers.
Our call toaction?Colorectal cancer is a preventablediseasewith awell-recognisedpremalignantlesion. In the NHS, there is a quality assured bowel cancer screening program that was initially started between the ages of 60-74 with FOBT, which now is replaced with a user-friendly FIT test, and there is also an age extension to 50 yearsin the next fewyears(4). This, along with early referral of common bowel symptoms, will ensurethe majority ofbowel cancers areidentifiedat an early stage,which can be cured with less detrimental effect to quality of life.
Written by:
PrateekArora.MS, MRCS,DNB,DrNBSurgical Gastro,Senior ClinicalFellow,Colorectal and PeritonealOncology Unit,Christie NHS
Co-author:CRSelvasekarMD.FƵ(Gen),MFSTEd, MA (Clin Ed), MBA (Health Executive)
Consultant General, Colorectal and Robotic Surgeon,Divisional Medical Director, Clinical Services & Specialist Surgery,The Christie NHS Foundation Trust, Manchester
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- SiegelRL et al. Cancerstatistics, 2024.CA Cancer J Clin. 2024
- Shekleton FE, Okocha M. UK Screening and SurveillanceForBowel Cancers. [Updated 2024 Jan 7].
- Testa U, Pelosi E, Castelli G. Colorectal cancer: genetic abnormalities,tumorprogression,tumorheterogeneity, clonalevolutionandtumor-initiating cells. Med Sci (Basel). 2018 Apr 13;6(2):31.doi: 10.3390/medsci6020031. PMID: 29652830; PMCID: PMC6024750.
- NCI (national cancer institute)- Colorectal Cancer Screening (PDQ®)–Patient Version 2024
- - Bowel cancer screening: programme overview 2024
- Carethers JM.FecalDNA Testing for Colorectal Cancer Screening. Annu Rev Med. 2020
- Maxim LD,NieboR,UtellMJ. Screening tests: a review with examples.InhalToxicol. 2014 Nov;26(13):811-28