Shaheeda Jamal’s initial reaction was not of fear. She was a tad apprehensive, but the overriding emotion was concern.

The Dubai-based Indian expat had been experiencing acute abdominal pain for a few days but on a Sunday morning she was taken aback to see traces of blood in her stool.

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The 42-year-old immediately remembered reading a health feature where it was mentioned that blood in stools could be a symptom of a serious medical issue and should not be ignored.

Staring at her reflection in the mirror, Shaheeda* considered her next course of action, before deciding to monitor her bowel movements the next day. She promised herself that if she noticed blood traces again, she would consult a gastroenterologist.

The next morning, as soon as she exited the washroom, Shaheeda picked up the phone to schedule an appointment with Dr Rahul Nathwani.

A while later, in Dubai’s Mediclinic City Hospital, Dr Nathwani, the consultant gastroenterologist, conducted a detailed examination of Shaheeda. ‘Her symptoms were suggestive of a possible colon cancer,’ says the doctor, who immediately suggested that she undergo a colonoscopy.

‘Colonoscopy is the gold standard test to be done to check for polyps in the colon and to determine if they are cancerous or not,’ he says.

The results confirmed his diagnosis: she had colon cancer.

Shaheeda’s case is a stark indicator that highlights several factors regarding colorectal cancer.

According to a report published in Gulf News, 30 per cent of all cancers diagnosed in the UAE are colorectal cancers. It is the second most recorded cancer in the country and second highest cause of mortality due to cancer in the emirates.

Screening is invaluable in the early detection of colon cancer, says Dr Nathwani
Anas Thacharpadikkal

A 2018 Cleveland Clinic Abu Dhabi report highlighted an alarming lack of awareness of the risk of colorectal cancer in the UAE, adding not enough people are being screened for the disease that is completely preventable and treatable if detected early.

But all is not gloomy – a simple stool test may show traces of blood that might suggest underlying sinister pathology.

Disturbing statistics

Worldwide, at 10.2 per cent, colorectal cancer is the third most common cancer (after lung and breast) detected last year, according to a report by the International Agency for Research on Cancer. The incidence of this type of cancer is also the highest in Asia with nearly every second person detected living on this continent.

Another report says colorectal cancer is the third leading cause of cancer deaths and the MD Anderson Cancer in Houston, Texas, predicts that by 2030, one in 10 colon cancer and one in four rectal cancer will be diagnosed in people under 50.

That figure regarding age is important.

Unlike earlier where colorectal patients were usually in the 50-plus age group, a disturbing factor – and which reflects Shaheeda’s case – is that of late a large number of people, both men and women, detected with this cancer are in their 40s.

‘We are noticing a sizeable number of patients – many of them in their early 40s – being diagnosed with colon cancer. In fact, we detect on average around two new cases every month,’ says Dr Nathwani, who is also an adjunct clinical associate professor of gastroenterology at the Mohammed Bin Rashid University in Dubai’s Healthcare City.

He attributes a reason for the spike in the number of cases detected to increased awareness about the cancer, and the fact that more and more young people are opting for a colon check up to ensure that in case something alarming is detected, it can be tackled in the initial stages itself. ‘But there is still a lack of awareness in this part of the world on colorectal cancer screening,’ he says.

Medical experts insist that both men and women need to get their colons checked regularly after a certain age. While earlier, age 50 was the chronological marker when a person was expected to get their first colon check-up done, new health guidelines mandate doing the test at age 45.

‘And contrary to what many believe, men and women are equally predisposed to developing this cancer; there is no gender bias,’ says Dr Nathwani.

Westerners are particular about screening because they are well aware that prevention is better than cure, says the doctor. Just as there are specific guidelines regarding ages when women need to get mammograms and pap smears done, and men get their prostates tested, both men and women should get their colons first checked preferably at around age 45, say experts.

Dr Nathwani agrees. ‘To that I must add that there are strict guidelines on when a colonoscopy needs to be done if there is a history of colon cancer in the family,’ he says. ‘If it was detected in your first degree family member – either parents or siblings – you should undergo a colonoscopy 10 years before the age at which it was diagnosed in the family member, or at age 40, whichever is earlier.

‘For instance, if a parent was diagnosed with colon cancer at age 40, you should take the test at age 30.’

Symptoms

One of the first symptoms that all is not right with your colon is if you notice traces of blood in the stools. ‘Some patients might mistakenly believe that it’s a symptom of haemorrhoids. But my advice is to not ignore; inform your doctor immediately,’ says Dr Nathwani.

Other symptoms include irregular bowel movements, very narrow, pencil-like stools; severe, unexplained abdominal pain that continues to worsen, with an associated loss of appetite and an unexplained loss of weight.

Anaemia is also an associated symptom. A sudden drop in haemoglobin levels is a red flag sign that warrants further investigation.

Colorectal cancer, nevertheless, is considered to be the number one most curable cancer if detected early, says the doctor.

‘If picked up at an early stage, it can be treated and the patient can continue having a normal life expectancy. But a lot of cancers, particularly those related to the gastro-intestinal tract, often begin to exhibit symptoms only when the disease stage is quite advanced.

‘Once the disease has advanced to a later stage and has spread to other organs, the chances of the patient’s survival drops significantly.’

Once a patient reports symptoms of an unhealthy colon, one of the first invasive procedures conducted after a detailed examination is the colonoscopy.

The goal of a colonoscopy is to detect and identify certain types of lesions, or polyps, in the colon, says the doctor. ‘Polyps are actually little growths of tissue, much like a pimple, and it is common for the colon to develop some kinds of polyps after a certain age. However, while some polyps are benign, others could be precursors of cancer. Once such polyps are identified via a colonoscopy, they should be removed.’

Early detection

In Shaheeda’s case, surgery was the best option, he says. ‘Because it was an early pick up, the cancer had not spread beyond the colon; it often spreads to the regional lymph nodes and liver. In that case, apart from surgery, the patient would have also had to undergo chemotherapy. This is why experts insist that you consult a doctor as soon as you notice any red flags.

‘If picked up early, only one surgery is generally curative,’ he says. Thanks to advances in the medical field, laparoscopic and robotic surgery is possible where the part of the colon that has a tumour can be resected and the colon reconnected.

Post surgery, the patient needs to be on a surveillance protocol with recommendations to repeat a colonoscopy a year after surgery to ensure no recurrence, and then one each after three and five years.

Are there any risks associated with a colonoscopy?

Very minimal, says Dr Nathwani. The benefits clearly outweigh any risk of complications from the procedure. If the patient has had previous abdominal surgery – particularly women who have had hysterectomies – scar tissue can develop and make the procedure technically challenging, but this is where the expertise of the gastroenterologist can prove valuable, he says.

Causative factors

Medical experts point to a definite genetic disposition to developing colon cancer. ‘We send biopsies from the cancerous tissue to look for gene mutations in every patient diagnosed with colon cancer whether they have a family history or not,’ Dr Nathwani says. Another major factor is diet, he says. ‘Certain diets can predispose a person to this cancer.’

The best diet for colon health in general, is one that is high in fibre. ‘Including more fruits, salads and green leafy vegetables in your diet can help prevent or reduce the incidence of this cancer.

‘Red meats and fatty, junk food are usually blamed for increasing the risks.’

He suggests reducing consumption of red meats, increasing water intake – at least 2 litres a day – and eating healthy.

Lack of exercsie is another causative factor. An epidemiologist at Alberta Health Services-Cancer Care in Canada, Christine Friedenreich has been quoted as saying that in the US, physical inactivity is linked to around 43,000 cases of colon cancer annually.

To encourage people to be more physically active in office environments, the American Institute for Cancer Research offers a few tips to break up your sitting sessions:

- Set an alarm on your computer reminding you every hour to stand up, stretch and take a short walk.

- If possible, instead of emailing a colleague, walk over and chat with him or her.

- If you can, walk around during phone calls and avoid sit-down meetings.

Screening helps

According to Dr Nathwani, screening is invaluable in the early detection of colon cancer. He mentions how during a free-of-cost screening campaign as part of the hospital’s community initiative, a woman was diagnosed with the cancer, being completely asymptomatic. ‘She had traces of blood in her stool that was picked up on her stool analysis although she herself had not noticed any bleeding in her stool. A subsequent colonoscopy was done and she was detected with colon cancer. Luckily for her, it was early stage, so surgery helped her.

While screening is one of the easiest ways to detect potential colon cancer-causing polyps, many insurance companies do not cover the costs for a screening colonoscopy, says Dr Nathwani. ‘They do not cover screening unless the patient has a family history of the disease or has exhibited any of the symptoms of the condition.’

He believes it makes more sense for insurance companies to sign off on the screening because it could be a win-win situation for the company as well as the patient.

‘A barely 20-minute procedure, colonoscopy may be able to detect a tumour in the early stages following which the patient can undergo a surgery and the disease can be nipped in the bud,’ he says. ‘Compare this with a patient who is not screened, but whose cancer is detected in an advanced stage and then has to undergo a colonoscopy, surgery, chemotherapy, follow-ups… all of which would cost probably five times what it would for the initial colonoscopy.’

He says a section of the medical fraternity is in talks with insurance providers and is raising awareness on this aspect.

Meanwhile, Shaheeda has undergone surgery to remove the cancer and is doing well, reports Dr Nathwani. ‘She does need to come in for follow-up check-ups but clearly, thanks to awareness and prompt action, her quality of life has improved and she is back to her usual healthy self.’

What’s a colonoscopy?

A thin, flexible tube that has a tiny camera at one end and is connected to a monitor is inserted into the rectum to examine the colon.

Before conducting this procedure, the bowel and colon is prepared – a strong laxative is administered and the system flushed out and cleaned so the camera will be able to clearly pick up any abnormalities in the colon.

Once a polyp or a tumour is detected, the colonoscope can take a sample of it for a biopsy and if proved cancerous, a multidisciplinary team of surgeons, gastroenterologist and oncologists is on hand to take a call on how to proceed with the case.

‘Surgery is the gold standard to treat colon cancerous tumours provided they are resectable,’ says Dr Nathwani.

A CT scan is done of the chest, abdomen and pelvis to see if the cancer has spread. ‘Treatment options vary depending on the location of the cancers. If there is an obstruction of the colon due to the tumour and the patient is unable to have bowel movements or has vomiting, then emergency surgery is often required.’

*Name changed