March 5, 2009
March: Colorectal Cancer Awareness Month - Get Screened - Cover story
Stop No. 1 cancer
Colorectal cancer, the most common cancer in Singapore, is highly curable and preventable. It's a matter of catching it at an early stage
By Poon Chian Hui
Are you over 50 years old? If you are, get screened for colorectal cancer.
This is because people above that age are at higher risk of getting the cancer, said Dr Francis Seow-Choen, a colorectal surgeon at Mount Elizabeth Hospital.
More importantly, colorectal cancer - which affects the large intestine and the rectum - tops the list of the most common cancers affecting Singaporeans. Every year, about 1,400 Singaporeans are diagnosed with it.
However, it is highly curable. Last year, 123 lives were saved through the Singapore Cancer Society's (SCS) colorectal screening programme.
One reason for this is that colorectal cancer can be easily detected during screening, said Dr Seow-Choen.
This is because the tumours occur on the surface of the intestines and are therefore highly visible, he said.
'If nothing is observed, you can be almost completely sure that you don't have colorectal cancer,' he added.
This is unlike other kinds of cancer, such as breast cancer, where deep-set or tiny growths may sometimes go undetected in a mammogram.
In addition, colorectal cancer develops very slowly. Polyps, which are benign abnormal growths in the colon, can take two to 10 years to turn cancerous, said Dr Seow-Choen.
'Early screening allows ample time for these polyps to be removed and reduces the chances of one getting cancer in the future,' he said.
It is also never too late to get screened.
Even advanced colorectal cancer is curable if the cancerous cells have not spread to other parts of the body, said Professor John Zalcberg, a visiting medical oncologist from the Peter MacCallum Cancer Centre in Melbourne, Australia.
Colorectal cancer is currently the third most common cancer worldwide, according to the World Health Organization. However, it is the most prevalent one in Singapore.
In males, it is the most common, while in females, it ranks second, behind breast cancer.
However, this was not always the case. Less than a decade ago, colorectal cancer was ranked second for Singaporean males, behind lung cancer.
The reason for its rise? Affluence.
'Colorectal cancer is becoming more frequent because our lifestyle has changed,' said Prof Zalcberg.
'Nowadays, people are eating more but are less active,' he said. 'We are also eating less fruits and vegetables, which is said to help reduce the risk of the cancer.'
What makes screening vital for colorectal cancer is that its symptoms are often either hard to detect or do not appear till the later stages.
Warning signs include blood in the stools or a change in bowel habits, said Prof Zalcberg. However, they are easy to miss.
'The bleeding could be very slight and you can't really detect it,' he said. 'Or people might think it's because of haemorrhoids.'
A haemorrhoid is an inflammation of blood vessels in the rectum or anus that can cause bloody stools.
Worldwide statistics also seem to suggest that Singaporeans could do with better awareness of this disease. That is why the emphasis on screening from the age of 50.
About one in every 3,000 Singaporeans had colorectal cancer in 2002, placing the country ninth in the world, according to Globocan, a database of cancer statistics worldwide.
The alarming fact was that a larger fraction of Singaporean patients died from colorectal cancer. In 2002, there were about 1,500 recorded cases and 800 deaths, which translates to a death to incidence ratio of more than 50 per cent - the second highest worldwide.
In contrast, Australia had more cases - about 12,000 - but relatively fewer deaths at 4,800.
While this phenomenon could be a result of numerous factors like lifestyle preferences, Prof Zalcberg suggested that a national screening programme could go a long way in improving this statistic.
Australia has had a national colorectal cancer screening programme since 2002 and this could be why more Australians survive colon cancer.
Fortunately, there are signs that Singaporeans are gradually moving in this direction.
In recent years, public institutions and voluntary welfare organisations like the SCS have stepped up efforts in providing free colorectal screening kits. This year, SCS is doubling its target to reach 30,000 people.
Now, the private sector is also weighing in. Parkway Cancer Centre (PCC) will be holding its first public screening exercise for colorectal cancer this month.
Mind Your Body columnist Dr Ang Peng Tiam, medical director of PCC, said that many people do not go for colorectal cancer screening despite its status as the most common cancer.
Those above 50 years should get screened every three years, said Dr Ang.
The screening process involves testing for blood traces in the stools. If results are positive, the person would have to go for a colonoscopy, where the doctor inserts a tube, with a tiny video camera at its tip, through the anus to check for any abnormal growths.
'If everyone were to go for a colonoscopy once every three years, almost no one would die of colorectal cancer,' Dr Ang said.
WARNING SIGNS
Colorectal cancer, which occurs in the large intestine and the rectum, is the most common cancer affecting Singaporeans.
Symptoms:
§ Blood in the stools, as tumours tend to bleed.
§ Altered bowel habits, such as decreased frequency of bowel movements.
§ Narrow or ribbon-like stools, as this may indicate there are blockages in the large intestine or rectum.
§ Constipation, abdominal pains or cramps, and a feeling of bloatedness may signal there are blockages in the form of tumours.
§ Feeling of incomplete bowel emptying.
§ Persistent nausea and vomiting.
§ Unexplained weight loss.
At 7, he had cancer
Colorectal surgeon Francis Seow-Choen tells POON CHIAN HUI his traumatic experience with cancer has moulded him into a more compassionate doctor
It started with an unbearable pain in his abdomen while the Primary 1 pupil's mother was helping him with his homework one afternoon.
Then, seven-year-old Francis Seow-Choen had no idea that he had a rare and deadly form of cancer called Burkitt's lymphoma.
The flurry of events that followed left an indelible mark on Dr Seow-Choen, 52, now a colorectal surgeon at Mount Elizabeth Hospital.
'It was 1964... a long time ago, but I still remember everything as if it was yesterday,' he said.
After the pain started, he was quickly taken to the family doctor who told his mother to take him to the hospital.
At Mount Alvernia Hospital, doctors gave the child's parents solemn news - the condition was so serious that an operation was required immediately.
'A portion of my intestines was totally blocked by cancerous cells,' he said.
'The doctors had to remove two to three feet of my intestines.'
While the doctors' quick action saved 'xiao didi', which means 'little boy' in Mandarin - their nickname for Dr Seow-Choen - the case was a confounding one.
Then, Burkitt's lymphoma was almost unheard of, as the cancer was first described only a few years earlier in 1956 by a British surgeon, Dr Dennis Burkitt, in faraway Africa.
While the doctors mulled over the first recorded case of Burkitt's lymphoma in Singapore, the young boy was slowly recovering from the operation upstairs in StFrancis Ward.
Other than having fond memories of the nurses who looked after him, Dr Seow-Choen had another lasting souvenir from his month-long stay at Mount Alvernia hospital.
'That was where my Christian name, Francis, came from,' he said. 'I named myself after the hospital ward.'
However, that was not the end of his journey.
Every day for the next six months, he had to go to Singapore General Hospital for radiotherapy and chemotherapy.
Looking back, Dr Seow-Choen felt that his traumatic experience with cancer has moulded him into a more compassionate doctor.
'The experience has helped me to understand my patients' anxieties and fears, because I had been there myself.
'I remember how nauseous I felt after every radiotherapy session,' he said.
'And how I could not eat barbecued and roast meat for a few years because radiotherapy had the exact same smell.'
The encounter has also instilled in him a fierce determination.
'My motto in life is, whatever you want to do, do it properly and do it well,' he said, citing the example of how he learnt Bahasa Indonesia by relentlessly reading and watching television shows in the language.
Although his decision to be a colorectal specialist was not a direct result of his experience with cancer, it might have had a subconscious influence.
'It's ironic that I'm also dealing with intestines now,' said Dr Seow-Choen, who admitted that his childhood ambition was to be a zoologist - which is why he has a stick insect 'farm' in his home that boasts thousands of creatures.
Married to a teacher, and with three children - two sons and a daughter aged 24, 21 and 18 respectively - Dr Seow-Choen sees himself as someone who has beaten the odds.
He recalled what his radiotherapist, the late Dr Chia Kim Boon, said when they met again years after Dr Seow-Choen survived the cancer. 'He said to me, 'You're still alive? I thought you'd be dead by now.' '
Rare and aggressive
Burkitt's lymphoma is a rare and aggressive form of lymphoma - a cancer that affects a class of white blood cells called B-lymphocytes.
'It is one of the most aggressive cancers around,' said Dr Benjamin Mow, a consultant haematologist and oncologist in private practice. 'Every day, the cancerous cells can double in number.'
Worldwide, this cancer occurs in one person out of every 100,000, Dr Mow said.
First discovered in 1956 by British surgeon Dennis Burkitt in Africa, the cancer is caused by the Epstein-Barr virus, which transforms normal white blood cells into cancerous cells at an impressive rate.
'Burkitt's lymphoma tends to occur in people with low immunity, as it makes them more vulnerable to the virus,' said DrMow.
Thus, people suffering from or just recovering from an illness might be more susceptible to this cancer - for instance, people with HIV, which weakens one's immune system.
Jaw and intestines affected
There are two forms of Burkitt's lymphoma - endemic and sporadic.
The endemic strain is native to Africa and occurs mostly in children. Usually, the affected children also suffer from malaria, thus decreasing their resistance to the virus.
For endemic Burkitt's lymphoma, tumours usually grow along the jawbone.
The sporadic strain on the other hand, which Dr Francis Seow-Choen suffered from, tends to take root in the intestines.
Its usual symptoms are swelling or tumour growths in the abdominal area, said Dr Mow.
This is because there are numerous lymph nodes in the intestines, he added.
Other symptoms may include enlarged lymph glands and night sweats.
The cancer can spread quickly to other parts of the body through the lymphatic system, which is linked to many parts of the body.
However, extensive research over the years has increased the chances of surviving this disease.
According to eMedicine.com, Burkitt's lymphoma is highly curable, with at least 60per cent of patients surviving with intensive treatment.
Treatment for Burkitt's lymphoma usually involves a short-term but intensive period of chemotherapy, said Dr Mow, adding that the usual period is about six months.
Surgery is seldom needed unless there is, for example, an obstruction in the intestines.
Although the survival rate is high, however, as in all cancers, there is always a chance that it might resurface again, said Dr Mow.
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