Colorectal cancer in Malaysia: Its burden and implications for a multiethnic country

Insights into the molecular mechanisms and signalling pathways of epithelial to mesenchymal transition (EMT) in colorectal cancer: A systematic review and bioinformatic analysis of gene expression

Colorectal cancer (CRC) is ranked as the second leading cause of mortality worldwide, mainly due to metastasis. Epithelial to mesenchymal transition (EMT) is a complex cellular process that drives CRC metastasis, regulated by changes in EMT-associated gene expression. However, while numerous genes have been identified as EMT regulators through various in vivo and in vitro studies, little is known about the genes that are differentially expressed in CRC tumour tissue and their signalling pathway in regulating EMT. Using an integration of systematic search and bioinformatic analysis, gene expression profiles of CRC tumour tissues were compared to non-tumour adjacent tissues to identify differentially expressed genes (DEGs), followed by performing systematic review on common identified DEGs. Fifty-eight common DEGs were identified from the analysis of 82 tumour tissue samples obtained from four gene expression datasets (NCBI GEO). These DEGS were then systematically searched for their roles in modulating EMT in CRC based on previously published studies. Following this, 10 common DEGs (CXCL1, CXCL8, MMP1, MMP3, MMP7, TACSTD2, VIP, HPGD, ABCG2, CLCA4) were included in this study and subsequently subjected to further bioinformatic analysis. Their roles and functions in modulating EMT in CRC were discussed in this review. This study enhances our understanding of the molecular mechanisms underlying EMT and uncovers potential candidate genes and pathways that could be targeted in CRC.

Dietary Patterns and Lifestyle Factors Associated with the Risk of Colorectal Cancer: A Hospital-Based Case-Control Study among Malaysians

Background

This study aimed to examine the association between dietary patterns, lifestyle factors, and colorectal cancer (CRC) risk among the Malaysian population.

Methods

We recruited 100 patients and 100 controls from two selected government hospitals. Principal component analysis was used to identify dietary patterns using a 123-item semiquantitative food frequency questionnaire. Tobacco smoking and alcohol consumption questionnaires were modified from the WHO STEPS Survey questionnaire. Physical activity levels were assessed using the revised Global Physical Activity questionnaire. Associations between dietary patterns, lifestyle factors and CRC risk were assessed using logistic regression with SPSS version 24.0.

Results

Three dietary patterns were derived from factor analysis: i) vegetables; ii) meat, seafood and processed food; and iii) grains and legumes. High vegetable diet intake was independently and significantly associated with an 81% decreased risk of CRC (odds ratio [OR]: 0.19; 95% confidence interval [CI]: 0.08, 0.46). Both recreational-related physical activity (OR: 2.04; 95% CI: 1.14, 3.64) and vigorous physical activity (OR: 2.06; 95% CI: 1.13, 3.74) are significantly associated with decreased risk of CRC. Increasing the number of cigarettes smoked (≥ 16 cigarettes) per day significantly increased the odds of developing CRC (OR: 2.58; 95% CI: 1.95, 6.75). The duration of alcohol consumption cessation was inversely associated with CRC risk (OR: 2.52; 95% CI: 2.30, 10.57).

Conclusion

The protective effects of a fruit and vegetable diet, and a healthy lifestyle can be used to develop interventions that help reduce the risk of CRC in the Malaysian population.

Genoprotective potential of Macaranga species phytochemical compounds on HT-29 human colorectal adenocarcinoma cell line

BACKGROUND

The species of genus Macaranga are widely found in Malaysian secondary forests and has been used as an alternative for treating varieties of illness. Studies have shown that the medicinal properties of this genus contain anti-inflammatory, antioxidant, and anti-cancer effects. This study aimed to determine the cytotoxicity of six isolated phytochemicals from Macaranga heynei (M. heynei), Macaranga lowii and Shorea leprosula on HT-29 human colorectal adenocarcinoma cell lines.

RESULTS

One out of six isolated phytochemical compounds, identified as "Laevifolin A", showed a cytotoxicity with an IC50 value of 21.2 µM following 48 h treatment as detected using Sulforhodamine B (SRB) assay. Additionally, no induction of apoptosis and oxidative stress were observed on Laevifolin A treated HT-29 cells as determined using Annexin V-FITC/PI assay and dihydroethidine (HE) staining, respectively. Additionally, no damage to the DNA were observed as measured using the Alkaline Comet assay. Further investigation on menadione-induced oxidative DNA damage showed the genoprotective potential of Laevifolin A on HT-29 cells.

CONCLUSIONS

In conclusion, this study indicated that only one compound (Laevifolin A) that extracted from M. heynei has the cytotoxicity potential to be developed as an anticancer agent in human colorectal adenocarcinoma. However, besides exhibiting cytotoxic effect, the compound also exhibits genoprotective capability that warrant further investigation.

Testing the validity of a new scale designed to assess beliefs and perceptions about colorectal cancer and colorectal cancer screening in Malaysia: a principal component analysis

OBJECTIVE

To conduct a cultural adaptation and validation of the Champion Health Belief Model Scale (CHBMS) for colorectal cancer (CRC) screening (CHBMS-CRC-M) in order to assess and investigate perceptions and beliefs about CRC screening in Malaysia.

DESIGNS AND PARTICIPANTS

The results from an evidence synthesis and the outcomes from an expert panel discussion were used to shape CHBMS scale content into an assessment of beliefs about CRC screening (CHBMS-CRC). This questionnaire assessment was translated into the official language of Malaysia. An initial study tested the face validity of the new scale or questionnaire with 30 men and women from various ethnic groups. Factorial or structural validity was investigated in a community sample of 954 multiethnic Malaysians.

SETTING

Selangor state, Malaysia.

RESULTS

The new scale was culturally acceptable to the three main ethnic groups in Malaysia and achieved good face validity. Cronbach's alpha coefficients ranged from 0.66 to 0.93, indicating moderate to good internal consistency. Items relating to perceived susceptibility to CRC 'loaded' on Factor 1 (with loadings scoring above 0.90); perceived benefits of CRC screening items loaded on factor 2 and were correlated strongly (loadings ranged between 0.63 and 0.83) and perceived barriers (PBA) to CRC screening (PBA) items loaded on factor 3 (range 0.30-0.72).

CONCLUSION

The newly developed CHBMS-CRC-M fills an important gap by providing a robust scale with which to investigate and assess CRC screening beliefs and contribute to efforts to enhance CRC screening uptake and early detection of CRC in Malaysia and in other Malay-speaking communities in the region.

Cancer incidence and mortality in Brunei Darussalam, 2011 to 2020

This study presents the trends of age-standardised incidence and mortality rates of common cancers in Brunei Darussalam from 2011 to 2020. All cancer cases diagnosed among Brunei Darussalam citizens and permanent residents in the period 2011 to 2020 were included in the study. De-identified data were provided by the CanReg5 based BDCR, Ministry of Health Brunei Darussalam. The annual age-standardised incidence and mortality rates per 100,000 persons were standardised by the direct method using the World Health Organization (WHO) world standard population distribution. Joinpoint regression analyses were used to study the incidence and mortality trends of cancer in Brunei Darussalam over the 2011-2020 period. Trends were expressed as average annual percent change (AAPC) over 2011 to 2020, or annual percent change (APC) for a given time period. There were a total of 6,495 new cancer cases diagnosed and 3,359 death cases recorded from 2011 to 2020, in Brunei Darussalam. The five common cancers for males were colorectal, lung and bronchus, prostate, liver, and non-Hodgkin lymphoma. Among females, the five most common cancers were breast, colorectal, lung and bronchus, corpus uteri and cervix uteri. The five leading cancer deaths for males were lung and bronchus, colorectal, liver, prostate, and stomach, while for females, the five leading cancer deaths were breast, lung and bronchus, colorectal, ovary, and cervix uteri. There was a significant increase in the incidence trend of corpus uteri (AAPC[Formula: see text]) and a significant decline in the incidence trend for cervical cancer (AAPC[Formula: see text]) from 2011 to 2020. There was a significant increase in the mortality trend of female breast cancer from 2011 to 2015 (APC[Formula: see text]), but the trend significantly declined from 2015 to 2020 (APC[Formula: see text]). We also found a significant decrease in mortality trends for stomach cancer (AAPC[Formula: see text]) from 2011 to 2020 for both genders combined. The burden of common cancers is expected to continue to grow with ageing population, effective public health interventions targeting high burden cancers and high-risk groups, and control of modifiable risk factors will continue to be the essential approaches in reducing cancer burden.

Budget impact analysis of a home-based colorectal cancer screening programme in Malaysia

OBJECTIVES

The 2020-2022 research project 'Colorectal Cancer Screening Intervention for Malaysia' (CRC-SIM) evaluated the implementation of a home-based CRC screening pilot in Segamat District. This budget impact analysis (BIA) assessed the expected changes in health expenditure of the Malaysian Ministry of Health budget in the scenario where the pilot programme was implemented nationwide vs current opportunistic screening.

DESIGN

Budget impact analysis. Assumptions and costs in the opportunistic and novel CRC screening scenarios were derived from a previous evaluation of opportunistic CRC screening in community health clinics across Malaysia and the CRC-SIM research project, respectively.

SETTING

National level (with supplement analysis for district level). The BIA was conducted from the viewpoint of the federal government and estimated the annual financial impact over a period of 5 years.

RESULTS

The total annual cost of the current practice of opportunistic screening was RM1 584 321 (~I$1 099 460) of which 80% (RM1 274 690 or ~I$884 587) was expended on the provision of opportunistic CRC to adults who availed of the service. Regarding the implementation of national CRC screening programme, the net budget impact in the first year was estimated to be RM107 631 959 (~I$74 692 546) and to reach RM148 485 812 (~I$103 043 589) in the fifth year based on an assumed increased uptake of 5% annually. The costs were calculated to be sensitive to the probability of adults who were contactable, eligible and agreeable to participating in the programme.

CONCLUSIONS

Results from the BIA provided direct and explicit estimates of the budget changes to when implementing a population-based national CRC screening programme to aid decision making by health services planners and commissioners in Malaysia about whether such programme is affordable within given their budget constraint. The study also illustrates the use and value of the BIA approach in low-income and middle-income countries and resource-constrained settings.

Survival outcomes among colorectal cancer patients at Kenyatta National Hospital: A retrospective cohort study

BACKGROUND

Colorectal cancer is a growing burden in Africa. However, survival for patients with colorectal cancer remains low in sub-Saharan African countries, with the poorest survival, particularly at a late stage at diagnosis. Despite this, there is a paucity of sufficient data about the survival outcomes of colorectal cancer patients in Kenya.

AIMS

This study aimed to determine the survival outcomes among colorectal cancer patients at Kenyatta National Hospital.

METHODS AND RESULTS

A retrospective cohort study was employed among 232 eligible medical records of colorectal cancer patients. Simple random sampling was used to select the medical records of the patients. The included medical records of the study participants were followed up retrospectively from the date of primary cancer diagnosis until the last visit to the hospital. All relevant data, such as sociodemographics, clinical characteristics, and outcome-measuring parameters, were recorded in the predesigned data abstraction tool by reviewing the documented clinical records of the patients. The data were entered and analyzed using International Business Machines (IBM) Statistical Package for the Social Sciences (SPSS) version 26 software. Mean, median, standard deviation, frequency tables, and figures were used to present the data. Kaplan Meier analyses were employed to determine survival outcomes. The mean age of the study participants was 54.1 ± 13.3 years, and the majority were males (126, 54.3%). Almost a third (34.1%) of patients had evidence of disease progression despite treatment in the follow-up period, with 7.8% showing no response to therapy and 23.6% experiencing new distant metastasis. The survival rate dwindled from the first year (87.9%) to the fifth year (45.4%), and the mortality rate was 22.8% CONCLUSION: There was a high mortality rate, disease progression, and distant metastasis in the last follow-up period suggesting the need to strengthen the healthcare system by ensuring access to prevention, early diagnosis, and optimal treatment of colorectal cancer.

Dietary Inflammatory Index, Obesity, and the Incidence of Colorectal Cancer: Findings from a Hospital-Based Case-Control Study in Malaysia

Obesity-mediated inflammation represents a key connection between the intake of foods with high inflammatory potential and colorectal cancer (CRC) risk. We aimed to explore the association between energy-adjusted dietary inflammatory index (E-DII) in relation to CRC risk in both obese and non-obese subjects. This study included 99 histopathologically confirmed CRC cases, 73 colonic polyps cases, and 141 healthy controls from tertiary medical centres in both urban and suburban areas in Peninsular Malaysia. The subjects were categorised into body mass index (BMI) < 25 kg/m² and BMI ≥ 25 kg/m² groups. E-DII scores were computed based on dietary intake assessed using a validated food frequency questionnaire (FFQ). Logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs), adjusted for potential cofounders. The mean dietary energy intake and mean BMI values of the subjects tended to increase as the E-DII scores increased (p for trend < 0.001). E-DII was significantly related to CRC risk only in obese subjects (OR = 1.45; 95% CI = 1.30-1.77; p < 0.001 for trend). Stratified analyses of risk factors showed significant associations between E-DII and CRC risk by age group (p for interaction = 0.030), smoking status (p for interaction = 0.043), and anthropometric indices for both males and females (p for interaction < 0.001) in the most pro-inflammatory E-DII quartile vs. the lowest E-DII quartile. Overall, pro-inflammatory diets were associated with an increased incidence of CRC in the Malaysian population, particularly in obese subjects.

Exploration of Malaysian Stakeholders View on Barriers to and Facilitators of Colorectal Cancer Screening Among Older Population

According to the Malaysian National Cancer Registry (MNCR), more than 70% of colorectal cancer (CRC) cases in Malaysia are presented in the advanced stages of the disease, leading to poor survival rates while taxing the health care system. This study aims to explore the barriers to and facilitators of CRC screening uptake in the perspectives of the general population, health care providers, and policymakers. In-depth, semi-structured interviews were conducted with 25 purposively sampled respondents comprising general population above the age of 40, health care providers, and policymakers. Commonly reported barriers to CRC screening included psychological, poor knowledge and awareness, lack of physicians' recommendation, and inadequate implementation of CRC-related campaigns at systemic level. Facilitating factors for CRC screening included family support and family history of CRC. A comprehensive understanding of barriers and facilitators is relevant for designing an effective intervention and policy to increase CRC screening rates in Malaysia.

The role of artificial intelligence based systems for cost optimization in colorectal cancer prevention programs

Colorectal Cancer (CRC) has seen a dramatic increase in incidence globally. In 2019, colorectal cancer accounted for 1.15 million deaths and 24.28 million disability-adjusted life-years (DALYs) worldwide. In India, the annual incidence rates (AARs) for colon cancer was 4.4 per 100,000. There has been a steady rise in the prevalence of CRC in India which may be attributed to urbanization, mass migration of population, westernization of diet and lifestyle practices and a rise of obesity and metabolic risk factors that place the population at a higher risk of CRC. Moreoever, CRC in India differs from that described in the Western countries, with a higher proportion of young patients and more patients presenting with an advanced stage. This may be due to poor access to specialized healthcare and socio-economic factors. Early identification of adenomatous colonic polyps, which are well-recognized pre-cancerous lesions, at the time of screening colonoscopy has been shown to be the most effective measure used for CRC prevention. However, colonic polyps are frequently missed during colonoscopy and moreover, these screening programs necessitate man-power, time and resources for processing resected polyps, that may hamper penetration and efficacy in mid- to low-income countries. In the last decade, there has been significant progress made in the automatic detection of colonic polyps by multiple AI-based systems. With the advent of better AI methodology, the focus has shifted from mere detection to accurate discrimination and diagnosis of colonic polyps. These systems, once validated, could usher in a new era in Colorectal Cancer (CRC) prevention programs which would center around “Leave in-situ” and “Resect and discard” strategies. These new strategies hinge around the specificity and accuracy of AI based systems in correctly identifying the pathological diagnosis of the polyps, thereby providing the endoscopist with real-time information in order to make a clinical decision of either leaving the lesion in-situ (mucosal polyps) or resecting and discarding the polyp (hyperplastic polyps). The major advantage of employing these strategies would be in cost optimization of CRC prevention programs while ensuring good clinical outcomes. The adoption of these AI-based systems in the national cancer prevention program of India in accordance with the mandate to increase technology integration could prove to be cost-effective and enable implementation of CRC prevention programs at the population level. This level of penetration could potentially reduce the incidence of CRC and improve patient survival by enabling early diagnosis and treatment. In this review, we will highlight key advancements made in the field of AI in the identification of polyps during colonoscopy and explore the role of AI based systems in cost optimization during the universal implementation of CRC prevention programs in the context of mid-income countries like India.

Implementation of a colorectal cancer screening intervention in Malaysia (CRC-SIM) in the context of a pandemic: study protocol

INTRODUCTION

Colorectal cancer (CRC) is the second most common cancer in Malaysia and cases are often detected late. Improving screening uptake is key in down-staging cancer and improving patient outcomes. The aim of this study is to develop, implement and evaluate an intervention to improve CRC screening uptake in Malaysia in the context of the COVID-19 pandemic. The evaluation will include ascertaining the budgetary impact of implementing and delivering the intervention.

METHODS AND ANALYSIS

The implementation research logic model guided the development of the study and implementation outcome measures were informed by the 'Reach, Effectiveness, Adoption, Implementation and Maintenance' (RE-AIM) framework. This CRC screening intervention for Malaysia uses home-testing and digital, small media, communication to improve CRC screening uptake. A sample of 780 people aged 50-75 years living in Segamat district, Malaysia, will be selected randomly from the South East Asia Community Observatory (SEACO) database. Participants will receive a screening pack as well as a WhatsApp video of a local doctor to undertake a stool test safely and to send a photo of the test result to a confidential mobile number. SEACO staff will inform participants of their result. Quantitative data about follow-up clinic attendance, subsequent hospital tests and outcomes will be collected. Logistic regression will be used to investigate variables that influence screening completion and we will conduct a budget impact-analysis of the intervention and its implementation. Qualitative data about intervention implementation from the perspective of participants and stakeholders will be analysed thematically.

ETHICS AND DISSEMINATION

Ethics approval has been granted by Monash University Human Research Ethics Committee (MUHREC ID: 29107) and the Medical Review and Ethics Committee (Reference: 21-02045-O7G(2)). Results will be disseminated through publications, conferences and community engagement activities.

TRIAL REGISTRATION NUMBER

National Medical Research Register Malaysia: 21-02045-O7G(2).

Colorectal cancer survival rates in Makassar, Eastern Indonesia: A retrospective Cohort Study

Background

Materials and methods

Results

Conclusion

•

Colorectal cancer is relatively common in Indonesia, and its incidence is slowly increasing.

•

Most Indonesian cases are detected at an advanced stage owing to educational, cultural, social, and economic factors.

•

Histopathology, tumor stage and history of definitive surgery significantly affected recurrence-free survival.

•

Chemotherapy and radiotherapy treatments had significantly different recurrence-free survival rates.

Effects of Perioperative Oral Nutrition Supplementation in Malaysian Patients Undergoing Elective Surgery for Breast and Colorectal Cancers-A Randomised Controlled Trial

This study aimed to investigate the effectiveness of preoperative and an extended 90-days postoperative use of ONS among patients undergoing elective surgery for breast and colorectal cancers. Ninety-one patients were randomised into (i) Group SS received ONS up to 14 days preoperatively and postoperatively up to discharge, (ii) Group SS-E received ONS up to 14 days preoperatively, postoperatively up to discharge and for an extended 90-days after discharge and (iii) Group DS received ONS postoperatively up to discharge. Preoperatively, SS had significantly higher body weight (66.1 ± 15.3 kg vs. 62.5 ± 12.0 kg, p = 0.010) and BMI (26.8 ± 6.8 kg/m2 vs. 26.1 ± 6.7 kg/m2, p = 0.022) than DS when adjusted for baseline values. Postoperatively, SS-E had significantly higher handgrip strength (26 ± 9 kgF vs. 24 ± 6 kgF, p = 0.044) than DS at 90-days post-discharge after adjusted for preoperative values. At 90-days post-discharge, the proportions of patients in SS with albumin < 35 g/d, CAR ≥ 0.1, mPINI ≥ 0.4, mGPS score 1 or 2 were significantly reduced while in SS-E, the reduction in proportions of patients with high hsCRP and mPINI ≥ 0.4 was significant compared to upon discharge. Preoperative ONS had modest benefits in attenuating weight loss whilst postoperative supplementation up to 90-days post-discharge improved handgrip strength and inflammatory prognostic markers.

Dietary Risk Factors and Odds of Colorectal Adenoma in Malaysia: A Case Control Study

Current evidence suggests that dietary and lifestyle factors may play an important role in colorectal cancer risk but there are only a few studies that investigated their relationship with colorectal adenomas (CRA), the precursors for colorectal cancer. A case-control study was conducted to determine the relationship between dietary and lifestyle factors associated with CRA risk among 125 subjects with CRA and 150 subjects without CRA at Hospital Canselor Tuanku Muhriz UKM (HCTM), Malaysia. We used dietary history questionnaire (DHQ) and International Physical Activity Questionnaire-Short Form (IPAQ) to estimate the diet and physical activity. The findings of this study showed that male gender [OR = 2.71 (95% CI= 1.01-7.27)], smoking [OR = 6.39 (95% CI= 1.04-39.30)], family history of cancer [OR = 6.39 (95% CI= 1.04-39.30)], high body fat percentage [OR = 1.25 (95% CI= 1.04-1.51)], high calorie and fat intake [OR = 1.03 (95% CI= 1.01-1.06)], [OR = 1.01 (95% CI= 0.95-1.09)] and red meat intake more than 100 g per day [OR = 1.02 (95% CI= 1.01-1.04)] increased CRA risk. High fiber [OR = 0.78 (95% CI= 0.64-0.95)] and calcium intake [OR = 0.78 (95% CI= 0.98-1.00)] was found to decrease CRA risk. Some of these modifiable risk factors could be advocated as lifestyle interventions to reduce risk of CRA.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis treatment and follow-up of patients with localised colon cancer

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of localised colon cancer was published in 2020. It was decided by both the ESMO and the Japanese Society of Medical Oncology (JSMO) to convene a special virtual guidelines meeting in March 2021 to adapt the ESMO 2020 guidelines to take into account the ethnic differences associated with the treatment of localised colon cancer in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with localised colon cancer representing the oncological societies of Japan (JSMO), China (CSCO), India (ISMPO), Korea (KSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence and was independent of the current treatment practices and drug availability and reimbursement situations in the different Asian countries.

Incidence and clinicopathological features of colorectal cancer among multi-ethnic patients in Kuala Lumpur, Malaysia: a hospital-based retrospective analysis over two decades

Background

The incidence rate of colorectal cancer (CRC) in Asian countries is increasing. Furthermore, recent studies have shown a concerning rise in the incidence of CRC among younger patients aged less than 50 years. This study aimed to analyze the incidence trends and clinicopathological features in patients with early-onset CRC (EOCRC) and later-onset CRC (at age ≥ 50 years).

Methods

A retrospective analysis was performed on 946 patients with CRC diagnosed from 1997 to 2017 at Universiti Kebangsaan Malaysia Medical Centre. The time trend was assessed by dividing the two decades into four 5-year periods. The mean age-standardized and age-specific incidence rates were calculated by using the 5-year cumulative population of Kuala Lumpur and World Health Organization standard population. The mean incidence was expressed per 100,000 person-years.

Results

After a stable (all age groups) CRC incidence rate during the first decade (3.00 per 100,000 and 3.85 per 100,000), it sharply increased to 6.12 per 100,000 in the 2008-2012 period before decreasing to 4.54 per 100,000 in the 2013-2017 period. The CRC incidence trend in later-onset CRC showed a decrease in the 2013-2017 period. Contrariwise, for age groups of 40-44 and 45-49 years, the trends showed an increase in the latter 15 years of the study period (40-44 years: 1.44 to 1.92 to 2.3 per 100,000; 45-49 years: 2.87 to 2.94 to 4.01 per 100,000). Malays' EOCRC incidence rate increased from 2008-2012 to 2013-2017 for both the age groups 40-44 years (1.46 to 2.89 per 100,000) and 45-49 years (2.73 to 6.51 per 100,000). Nearly one-fifth of EOCRC cases were diagnosed at an advanced stage (Dukes D: 19.9%), and the majority of them had rectal cancer (72.8%).

Conclusion

The incidence of EOCRC increased over the period 1997-2017; the patients were predominantly Malays, diagnosed at a later stage, and with cancer commonly localized in the rectal region. All the relevant stakeholders need to work on the management and prevention of CRC in Malaysia.

Study protocol for an open labelled randomised controlled trial of perioperative oral nutrition supplement in breast and colorectal cancer patients undergoing elective surgery

Background

While it is well established that perioperative use of oral nutrition supplement (ONS) improves nutrition status among severely malnourished surgical cancer patients, the evidence requires further substantiation for non-severely malnourished patients with cancer. This protocol paper presents the rationale and design of a randomised controlled trial to evaluate the effectiveness of preoperative as well as an extended 90-day postoperative use of ONS on nutritional and clinical outcomes among patients undergoing elective surgery for breast and colorectal cancer.

Methods

Patients with primary breast and colorectal cancer undergoing elective surgery are recruited from two tertiary hospitals. Eligible patients are assigned into one of the three intervention arms: (i) Group SS will receive ONS in addition to their normal diet up to 14 days preoperatively and postoperatively up to discharge; (ii) Group SS-E will receive ONS in addition to their normal diet up to 14 days preoperatively, postoperatively up to discharge and for an extended 90 days after discharge; and (iii) Group DS will receive ONS in addition to their normal diet postoperatively up to discharge from the hospital. The ONS is a standard formula fortified with lactium to aid in sleep for recovery. The primary endpoints include changes in weight, body mass index (BMI), serum albumin and prealbumin levels, while secondary endpoints are body composition (muscle and fat mass), muscle strength (handgrip strength), energy and protein intake, sleep quality, haemoglobin, inflammatory markers (transferrin, high sensitivity C-reactive protein, interleukin-6), stress marker (saliva cortisol), length of hospital stay and postoperative complication rate.

Discussion

This trial is expected to provide evidence on whether perioperative supplementation in breast and colorectal cancer patients presenting with high BMI and not severely malnourished but undergoing the stress of surgery would be beneficial in terms of nutritional and clinical outcomes.

Trial registration

ClinicalTrial.gov NCT04400552. Registered on 22 May 2020, retrospectively registered

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05716-5.

Rate and associated factors of refusal to perform immunochemical Faecal Occult Blood Test (iFOBT) among semi-urban communities

The uptake of the immunochemical faecal occult blood test (iFOBT) in many countries with an opportunistic colorectal cancer (CRC) screening programme remains suboptimal. This study aimed to determine the rate, associated factors and reasons of refusal to perform the iFOBT test offered under an opportunistic CRC screening programme in semi-urban communities. This cross-sectional study was conducted among the average-risk individuals living in semi-urban areas, who sought care from public primary care centres across Kedah state, Malaysia. The information regarding the sociodemographic and clinical characteristics of individuals who were offered the iFOBT between January and April 2019, along with their willingness to perform the test, was gathered. The factors associated with the refusal were further explored using the logistic regression analysis. The individuals offered the iFOBT (n = 920) were mainly female (52.4%) and had a mean age of 58.7±10.6 years. The refusal rate of the iFOBT was 32.2%. Patients who did not have hypertension (adjusted OR: 3.33; 95% CI: 2.44, 4.54), did not have CRC symptoms (adjusted OR: 3.15; 95% CI:1.26, 7.89), had the test offered by either medical assistants (adjusted OR: 2.44; 95% CI: 1.71, 3.49) or nurses (adjusted OR: 2.41; 95% CI 1.65, 3.51), did not have diabetes (adjusted OR: 1.99; 95% CI: 1.42, 2.77),and were not active smokers (adjusted OR: 1.74; 95% CI: 1.22, 2.47), were more likely to refuse the iFOBT. The common reasons of refusing the test included "feeling not ready for the test" (21.6%) and "feeling healthy" (14.9%). The iFOBT was refused by one-third of the average-risk individuals from semi-urban communities. The associated factors and reasons of refusal found in this study could guide policymakers in developing targeted interventions to boost the uptake of CRC screening in Malaysia.

Whole-Genome Profiles of Malay Colorectal Cancer Patients with Intact MMR Proteins

Background: This study aimed to identify new genes associated with CRC in patients with normal mismatch repair (MMR) protein expression. Method: Whole-genome sequencing (WGS) was performed in seven early-age-onset Malay CRC patients. Potential germline genetic variants, including single-nucleotide variations and insertions and deletions (indels), were prioritized using functional and predictive algorithms. Results: An average of 3.2 million single-nucleotide variations (SNVs) and over 800 indels were identified. Three potential candidate variants in three genes—IFNE, PTCH2 and SEMA3D—which were predicted to affect protein function, were identified in three Malay CRC patients. In addition, 19 candidate genes—ANKDD1B, CENPM, CLDN5, MAGEB16, MAP3K14, MOB3C, MS4A12, MUC19, OR2L8, OR51Q1, OR51AR1, PDE4DIP, PKD1L3, PRIM2, PRM3, SEC22B, TPTE, USP29 and ZNF117—harbouring nonsense variants were prioritised. These genes are suggested to play a role in cancer predisposition and to be associated with cancer risk. Pathway enrichment analysis indicated significant enrichment in the olfactory signalling pathway. Conclusion: This study provides a new spectrum of insights into the potential genes, variants and pathways associated with CRC in Malay patients.

Cost-Effectiveness of Colorectal Cancer Genetic Testing

Colorectal cancer (CRC) remains the second leading cause of cancer-related deaths worldwide. Approximately 3–5% of CRCs are associated with hereditary cancer syndromes. Individuals who harbor germline mutations are at an increased risk of developing early onset CRC, as well as extracolonic tumors. Genetic testing can identify genes that cause these syndromes. Early detection could facilitate the initiation of targeted prevention strategies and surveillance for CRC patients and their families. The aim of this study was to determine the cost-effectiveness of CRC genetic testing. We utilized a cross-sectional design to determine the cost-effectiveness of CRC genetic testing as compared to the usual screening method (iFOBT) from the provider’s perspective. Data on costs and health-related quality of life (HRQoL) of 200 CRC patients from three specialist general hospitals were collected. A mixed-methods approach of activity-based costing, top-down costing, and extracted information from a clinical pathway was used to estimate provider costs. Patients and family members’ HRQoL were measured using the EQ-5D-5L questionnaire. Data from the Malaysian Study on Cancer Survival (MySCan) were used to calculate patient survival. Cost-effectiveness was measured as cost per life-year (LY) and cost per quality-adjusted life-year (QALY). The provider cost for CRC genetic testing was high as compared to that for the current screening method. The current practice for screening is cost-saving as compared to genetic testing. Using a 10-year survival analysis, the estimated number of LYs gained for CRC patients through genetic testing was 0.92 years, and the number of QALYs gained was 1.53 years. The cost per LY gained and cost per QALY gained were calculated. The incremental cost-effectiveness ratio (ICER) showed that genetic testing dominates iFOBT testing. CRC genetic testing is cost-effective and could be considered as routine CRC screening for clinical practice.

Clinicopathological patterns and survival outcomes of colorectal cancer among young adults in Malaysia: an institutional cohort study

INTRODUCTION

This study aimed to investigate the clinicopathological patterns and survival outcomes of young-onset colorectal cancer (CRC) in Malaysia.

METHODS

The study consisted of 206 patients with young-onset CRC (age < 50 years at diagnosis) and 1,921 patients with late-onset CRC (age ≥ 50 years at diagnosis) diagnosed during 2002-2016. The clinicopathological characteristics of patients with young-onset CRC were compared with those of patients with late-onset CRC during 2009-2013. Kaplan-Meier survival analysis was performed to determine the overall survival (OS) and disease-specific survival (DSS) in these patients.

RESULTS

The overall proportion of young-onset CRC was 10.7%. Mean age for young-onset CRC was 39.5 ± 7.4 years, with male-to-female ratio of 1.2:1.0. There were more Malay patients with young-onset CRC than late-onset CRC (44.0% vs. 19.9%, p = 0.004). Most CRC were diagnosed at advanced stage in both groups. However, young-onset CRC showed more aggressive tumour characteristics, such as poorer differentiation and mucinous subtype. Despite such differences, OS and DSS in both groups were similar (five-year OS for young-onset CRC vs. late-onset CRC: 44.2% vs. 49.0%, p = 0.40; five-year DSS for young-onset CRC vs. late-onset CRC: 48.8% vs. 57.6%, p = 0.53; mean survival of young-onset CRC vs. late-onset CRC: 4.9 years vs. 5.4 years, p = 0.15). Advanced stage at diagnosis and treatment modality were independent prognostic factors.

CONCLUSION

The unique ethnic and histological differences between patients with young- and late-onset CRC suggest that young-onset CRC may represent a distinct entity. However, despite such differences, prognosis between both groups were equivalent.

Survival of colorectal cancer patients in Brunei Darussalam: comparison between 2002-09 and 2010-17

Background

Colorectal cancer (CRC) is a major cause of cancer-related mortality worldwide. It is the second leading cause of cancer death in men and women in Brunei Darussalam in 2017, posing a major burden on society.

Methods

This retrospective cohort study (n = 1035 patients diagnosed with CRC in Brunei Darussalam from 1st January 2002 until 31st December 2017) aims to compare the overall survival rates of CRC patients (2002–2017), to compare survival rates between two study periods (2002–2009 and 2010–2017) and to identify prognostic factors of CRC. Kaplan-Meier estimator and log-rank tests were performed to analyse the overall survival rates of CRC patients. Multiple Cox regression was performed to determine the prognostic factors of CRC with adjusted hazard ratios (Adj. HRs) reported.

Results

The 1-, 3- and 5-year survival rates of CRC patients are 78.6, 62.5, and 56.0% respectively from 2002 to 2017. The 1-, 3-, and 5-year survival rates of CRC patients for 2002–2009 are 82.2, 69.6, and 64.7%; 77.0, 59.1, and 51.3% for 2010–2017 respectively. A significant difference in CRC patients’ survival rate was observed between the two study periods, age groups, ethnic groups, cancer stages, and sites of cancer (p < 0.05). The Adjusted Hazard Ratios (Adj. HRs) were significantly higher in the 2010–17 period (Adj. HR = 1.78, p < 0.001), older age group ( ≥ 60 years) (Adj. HR = 1.93, p = 0.005), distant cancer (Adj. HR = 4.69, p < 0.010), tumor at transverse colon and splenic flexure of colon (Adj. HR = 2.44, p = 0.009), and lower in the Chinese(Adj. HR = 0.63, p = 0.003).

Conclusion

This study highlights the lower survival rates of CRC patients in 2010–2017, Malays, older patients, distant cancer, and tumors located at the latter half of the proximal colon (transverse colon), and predominantly LCRC (splenic flexure, descending colon, sigmoid colon, overlapping lesion colon and colon (NOS), as well as the rectosigmoid junction and rectum (NOS)). Age, ethnicity, cancer stage, and tumor location are significant prognostic factors for CRC. These findings underscore the importance of public health policies and programmes to enhance awareness on CRC from screening to developing strategies for early detection and management, to reduce CRC-associated mortality.

SOX-17 is involved in invasion and apoptosis of colorectal cancer cells through regulating miR-302b-3p expression

The prognosis of advanced colorectal cancer (CRC) is currently still very poor, which suggests that the biological mechanisms of CRC oncogenesis are not fully understood. This study was conducted to explore the regulatory effect of SOX-17 on the expression of microRNA (miR)-302b-3p, and the involvement of SOX-17 in the invasion and apoptosis of CRC cells. The expression of SOX-17 and miR-302a,b,c,d-3p in colorectal cancer and normal colon epithelial cell lines was measured by real-time polymerase chain reaction and/or western blot. The regulatory effects of SOX-17 on miR-302b-3p gene in HT29 and LoVo cells were tested using the ChiP assay. The biological activities of SOX-17 and miR-302b-3p were evaluated by invasion and apoptosis assay. Results showed that transfection of SOX-17 small interfering RNA (siSOX-17) significantly increased, whereas transfection of SOX-17 overexpression vector (oeSOX-17) significantly decreased, miR-302b expression in HT29 and LoVo cells. Cotransfection of oeSOX-17 and miR-302b-3p inhibitor (INmiR-302b) significantly blocked the effects of SOX-17 in HT29 and LoVo cells. ChIP experiments showed that SOX-17 bonded to the miR-302b-3p promoter in HT29 and LoVo cells. Transfection of oeSOX-17 and miR-302b-3p mimics (MImiR-302b) significantly decreased, whereas transfection of siSOX-17 and INmiR-302b significantly increased, the invasion of HT29 and LoVo cells. In contrast, transfection of oeSOX-17 and MImiR-302b significantly increased, while transfection of siSOX-17 and INmiR-302b significantly decreased, apoptosis in HT29 and LoVo cells. Cotransfection of oeSOX-17 and INmiR-302b significantly blocked the effects of oeSOX-17 on cell invasion and apoptosis in HT29 and LoVo cells. These results suggested that SOX-17 can bind to the promoter of miR-302b-3p gene to regulate its expression, while both SOX-17 and miR-302b regulate the invasion and apoptosis in colorectal cancer cells.

Very-low-dose aspirin and surveillance colonoscopy is cost-effective in secondary prevention of colorectal cancer in individuals with advanced adenomas: network meta-analysis and cost-effectiveness analysis

BACKGROUND

Individuals with advanced colorectal adenomas (ACAs) are at high risk for colorectal cancer (CRC), and it is unclear which chemopreventive agent (CPA) is safe and cost-effective for secondary prevention. We aimed to determine, firstly, the most suitable CPA using network meta-analysis (NMA) and secondly, cost-effectiveness of CPA with or without surveillance colonoscopy (SC).

METHODS

Systematic review and NMA of randomised controlled trials were performed, and the most suitable CPA was chosen based on efficacy and the most favourable risk-benefit profile. The economic benefits of CPA alone, 3 yearly SC alone, and a combination of CPA and SC were determined using the cost-effectiveness analysis (CEA) in the Malaysian health-care perspective. Outcomes were reported as incremental cost-effectiveness ratios (ICERs) in 2018 US Dollars ($) per quality-adjusted life-year (QALY), and life-years (LYs) gained.

RESULTS

According to NMA, the risk-benefit profile favours the use of aspirin at very-low-dose (ASAVLD, ≤ 100 mg/day) for secondary prevention in individuals with previous ACAs. Celecoxib is the most effective CPA but the cardiovascular adverse events are of concern. According to CEA, the combination strategy (ASAVLD with 3-yearly SC) was cost-saving and dominates its competitors as the best buy option. The probability of being cost-effective for ASAVLD alone, 3-yearly SC alone, and combination strategy were 22%, 26%, and 53%, respectively. Extending the SC interval to five years in combination strategy was more cost-effective when compared to 3-yearly SC alone (ICER of $484/LY gain and $1875/QALY). However, extending to ten years in combination strategy was not cost-effective.

CONCLUSION

ASAVLD combined with 3-yearly SC in individuals with ACAs may be a cost-effective strategy for CRC prevention. An extension of SC intervals to five years can be considered in resource-limited countries.

Factors Associated With Colorectal Cancer Screening Via Immunochemical Fecal Occult Blood Test in an Average-Risk Population From a Multiethnic, Middle-Income Setting

PURPOSE

The Malaysian Ministry of Health had launched free opportunistic screening for colorectal cancer using immunochemical fecal occult blood test (iFOBT) targeting the average-risk individuals since 2014. This study aims to determine factors associated with colorectal cancer screening using iFOBT among the average-risk Malaysian population.

METHODS

A cross-sectional study was conducted at five government-run health clinics in the state of Selangor. Adults with an average risk of colorectal cancer (age > 50 years, asymptomatic, and no family history of colorectal cancer) were recruited using systematic random sampling. An interviewer-administered questionnaire adapted from the Cancer Awareness Measure and Health Belief Model was used.

RESULTS

The median age of participants was 61 years (interquartile range, 56 to 66). Almost 60% of participants indicated their willingness to be screened. However, only 7.5% had undergone iFOBT. Good knowledge of risk factors of colorectal cancer, perceived susceptibility to the disease, and the doctor's recommendation were associated with increased willingness to be screened: adjusted odds ratio (aOR), 1.66 (95% CI, 1.12 to 2.46); aOR, 1.70 (95% CI, 1.08 to 2.70); and aOR, 5.76 (95% CI, 2.13 to 15.57), respectively. Nevertheless, being elderly (aOR, 0.67; 95% CI, 0.45 to 0.99) and high negative perception toward the testing method (iFOBT) (aOR, 0.12; 95% CI, 0.05 to 0.30) were independently associated with lower willingness to be screened. Multivariable analysis within the average-risk individuals who were willing to be screened for colorectal cancer showed that the doctor’s recommendations remained as an important cue for positive action, whereas negative perception toward the test was a significant barrier to the actual uptake of iFOBT.

CONCLUSION

The present findings must be factored in when tailoring colorectal cancer screening promotion activities in multiethnic, middle-income settings.

LncRNA EWSAT1 Promotes Colorectal Cancer Progression Through Sponging miR-326 to Modulate FBXL20 Expression

BACKGROUND

Ewing sarcoma-associated transcript 1 (EWSAT1) has been reported to be a pivotal modulator in a series of cancers. However, the function of EWSAT1 in colorectal cancer (CRC) has not been elaborated. This study aimed to explore the role of EWSAT1 in CRC progression and the underlying mechanisms.

METHODS

The expression patterns of EWSAT1, miR-326 and FBXL20 were examined by qCRCR. Si-EWSAT1 was transfected to study the effects of EWSAT1 on cell proliferation and metastasis. Rescue experiments were performed to investigate the underlying mechanisms in vitro. Xenograft models were used to evaluate the role of EWSAT1 in vivo.

RESULTS

We found that EWSAT1 was highly expressed in CRC tissues and cell lines and associated with poor overall survival. In vitro, knockdown of EWSAT1 suppressed the cell proliferation, migration and invasion. Moreover, miR-326 was found to be a target of EWSAT1, and miR-326 inhibitor could partially reverse the effects on CRC cell progression induced by si-EWSAT1. Subsequently, we validated FBXL20 as a vital downstream target for miR-326, and EWSAT1 positively regulated FBXL20 via miR-326 in vitro. In addition, these findings were confirmed by in vivo experiments.

CONCLUSION

Taken together, the data showed that EWSAT1 promoted CRC progression via targeting miR-326/FBXL20 pathway, which might provide a novel therapeutic target for CRC treatment.

Factors of Never Screened with Faecal Occult Blood Test in Public Primary Care Facilities

BACKGROUND

Colorectal cancer (CRC) is still a major public health threat. In the effort to reduce CRC incidence and mortality, faecal occult blood test (FOBT) is currently the screening tools used for early detection of CRC. However, the uptake of FOBT screening is less than promising. This study aims to identify the prevalence and predictors of Never Screened with FOBT (NS-FOBT).

METHODS

A cross sectional study was conducted in five health clinics under Kota Kinabalu district, Sabah, Malaysia Borneo involving 162 attendees with age of 50 years old and above. A validated self-administered questionnaire was used to collect the data. Multiple logistic regression analysis was used to determine the predictors of NS-FOBT.

RESULTS

The prevalence of NS-FOBT was 85.8% (n=139). Important predictors of NS-FOBT were age (aOR: 0.922; 95% CI: 0.855, 0.995; p=0.035), Bumiputera ethnicity (vs Non Bumiputera; aOR: 4.285; 95% CI: 1.384, 13.263; p=0.012), knowledge score (aOR: 0.921; 95% CI: 0.856, 0.99; p=0.027), and attitude score (aOR: 0.801; 95% CI: 0.702, 0.913; p=0.001).

CONCLUSION

There is high prevalence of NS-FOBT. Age, ethnicity, knowledge, and attitude were important predictors of NS-FOBT. Strategies are needed to improve FOBT screening rate among the public. Socio-culturally tailored health promotion strategies as well as strengthening the communication, collaboration, and education to enhance the role of family physician is vital in improving the CRC prevention and care.

A 5-year evaluation of using stool-based test for opportunistic colorectal cancer screening in primary health institutions across Malaysia

INTRODUCTION

The immunochemical fecal occult blood test (iFOBT) has been widely used for opportunistic colorectal cancer (CRC) screening in average-risk individuals seeking care from public health clinics in Malaysia. This study provides a 5-year outcome evaluation of such a practice.

METHODS

The findings for a few outcome indicators, ranging from the iFOBT uptake to the CRC and polyp detection rates, were generated from the data contributed by 583 public health clinics between 2014 and 2018. The trends in their changes were also evaluated.

RESULTS

The iFOBT uptake constantly increased over the years (p < 0.001), totaling 2.29 % (n = 127,957) as at 2018. Nearly 10 % (n = 11,872) of the individuals screened had a positive test result. Of those who underwent colonoscopy (n = 6,491), 4.04 % (n = 262) and 13.93 % (n = 904) were found to have CRC and polyps, respectively.

CONCLUSION

An uptrend in the CRC screening uptake was witnessed following the introduction of the iFOBT in public health clinics.

Association between MDR1 polymorphisms and XELIRI and XELOX chemoresistance in Saudi patients with colorectal cancer

Multidrug resistance member 1 (MDR1) is located on chromosome 7 and encodes P-glycoprotein, which is universally accepted as a drug resistance biomarker. MDR1 polymorphisms can alter protein expression or function, which has been previously reported to associate with various types of malignancies, such as colorectal cancer (CRC). Therefore, the present study aimed to determine the effects of MDR1 polymorphisms on drug responses of Saudi patients with CRC. DNA samples were obtained from 62 patients with CRC and 100 healthy controls. Genotypes and allele frequencies of MDR1 single nucleotide polymorphisms (SNPs) G2677T and T1236C were determined using the PCR-restriction fragment length polymorphism procedure. The results showed no significant differences in the genotype distribution and allele frequency of T1236C between patients with CRC and controls. However, G2677T was found to serve a highly significant role in protecting against the progression of CRC. In addition, none of the genotypes in SNPs T1236C and G2677T was found to affect chemoresistance to XELIRI and XELOX. In conclusion, although T1236C in the MDR1 gene is not associated with CRC risk, G2677T protects against the development of CRC. Neither of the MDR1 SNPs tested were associated with the risk of chemoresistance. Therefore, these two SNPs cannot be used as molecular markers for predicting drug response in patients with CRC.

Incidence, Clinico-demographic Profiles and Survival Rates of Colorectal Cancer in Northern Malaysia: Comparing Patients Above and Below 50 Years of Age

Background:

While the world witnesses an increasing trend of young-onset colorectal cancer (CRC), the information regarding the impact of age on CRC is limited in Malaysia. This study aimed to compare the incidence, clinic-demographic profiles and survival rates of CRC between patients above and under 50 years of age in northern Malaysia.

Methods:

This was a registry-based, cross-sectional study. All the CRC cases reported by 18 hospitals to the National Cancer Patient Registry - Colorectal Cancer (NCPR-CC) between January 2007 and December 2017 were included in the analysis. The patients were categorized by age into the above-50 and under-50 groups. The changes in the age-standardized incidence and mortality rates of both the age groups were determined using the time-series analysis, and the impact of age on the mortality risk was assessed using the Cox regression analysis.

Results:

Of the 6,172 CRC patients enrolled in the NCPR-CC, 893 (14.5%) were in the under-50 group. As compared with their older counterparts, the patients in the under-50 group were more likely to be female, be of Malay ethnicity, be non-smokers, have a family history of CRC, and present late for treatment. The age-standardized incidence and mortality rates of CRC in the under-50 group remained stable over the years, while a decreasing trend was clearly seen in the mortality rates of CRC in the above-50 group (p=0.003). Nevertheless, the two age groups also did not differ in the mortality risk (adjusted hazards ratio: 1.10; 95% CI: 0.90, 1.36).

Conclusion:

Young-onset CRC constituted a considerable proportion of CRC cases in Malaysia. However, in contrast with the findings of most studies, it demonstrated neither an uptrend in age-standardized incidence rates nor a higher mortality risk. Our findings suggest the need to upscale and lower the recommended age for CRC screening in Malaysia.

Clinical characteristics and predictors of 5-year survival among colorectal cancer patients in a tertiary hospital in Malaysia

Background

Colorectal cancer is the second most common cancer in Malaysia. Its disease burden is likely to increase over time owing to its current trends in this region. This study was undertaken to determine the 5-year survival rate and prognostic factors for survival in colorectal cancer patients treated in a tertiary hospital, in Malaysia.

Methods

We reviewed the records of colorectal cancer patients treated in Hospital Tuanku Ja'afar Seremban, Malaysia from 2008 to 2012. Survival analysis at five years was performed using the Kaplan-Meier method. Cox proportional hazard regression analysis was carried out to determine the predictors of 5-year colorectal cancer survival.

Results

Of the 275 patients, 43.3% were colon cancers, 51.8% were rectal cancers. Only 2.2% were diagnosed in Stage I. 28.7%, 33.1%, and 16.7% were in Stage II, III and IV respectively; 62/79 (78%) of Stage II patients were in Stage IIb; 15.7% of patients were below the age of 50 and fewer of them presented early (P=0.002). The overall 5-year survival was 46.5%. It was 67.9%, 50.5% and 12.8% for Stage I&II, III and IV patients respectively. Early stage of cancer (P<0.001) and age below the mean (P=0.01) were the most significant factor in predicting better survival. Gender and ethnic group were not associated with late presentation nor survival. Neither was there a difference between colon and rectum cancers nor patients who received elective surgical treatment compared to patients receiving other treatment first (P=0.085).

Conclusions

Late presentation is the most important predictor for poor outcome for colorectal cancer in Seremban. Patients under the age of 50 years present late more often, but do not have poorer survival.

Survival Rates and Associated Factors of Colorectal Cancer Patients in Brunei Darussalam

Background:

Colorectal cancer (CRC) is the third most common cancer in both men and women. In most Asian countries, both the incidence and mortality rates of CRC are gradually increasing. In Brunei Darussalam, CRC ranks first and second in lifetime risk among men and women respectively. This study aims to report the overall survival rates and associated factors of CRC in Brunei Darussalam.

Methods:

This is a retrospective study examining CRC data for the period 2007 to 2017 retrieved from a population based cancer registry in Brunei Darussalam. A total of 728 patients were included in the analysis. Kaplan Meier method was used to estimate survival rates. Univariate analysis using log-rank test was used to examine the differences in survival between groups. Multivariate analysis using Cox PH regression was used to estimate hazard of death and obtain significant predictors that influence CRC patients’ survival.

Results:

The median survival time for colorectal, colon and rectal cancer patients were 57.0, 85.8 and 40.0 months respectively. The overall 1-, 3- and 5- year survival rates for CRC patients were 78.0%, 57.7% and 49.6% respectively. In univariate analysis, age at diagnosis, ethnicity, cancer stage, tumour location and histology were found to have significant difference in CRC patients’ survival. In the Cox PH analysis, older age (≥70 years), cancer stage, ethnicity and other histological type were determined as associated factors of CRC patients’ survival.

Conclusion:

This study found the overall 5-year survival rate of CRC in Brunei Darussalam is similar to that in some Asian countries such as Singapore and Malaysia. However, more efforts need to be carried out in order to raise awareness of CRC and improve the survival of CRC patients.

Colorectal Cancer in Brunei Darussalam: An Overview and Rationale for National Screening Programme

Colorectal cancer (CRC) is the third most common cancer worldwide after lung and breast cancers, and ranks second in terms of cancer mortality globally. Brunei Darussalam reports high incidence of CRC in the Southeast Asian region and has no formal national screening programme for CRC. Screening for CRC in Brunei Darussalam is offered in an opportunistic fashion for individuals with average or above average risks for CRC, that is, the individual has a positive family history of CRC or neoplasms and is more than 50 years old. Opportunistic screening is widely practiced but this is not standardised. The Ministry of Health in Brunei Darussalam is currently in the process of implementing a CRC screening programme as part of a larger national health screening based on the increasing incidence of non-communicable diseases (NCDs). This review article assesses the situation of CRC in Brunei Darussalam from the 1980s to present day, including incidence of CRC in different age groups, ethnicities and genders; relevant non-modifiable and modifiable risk factors of CRC in Brunei Darussalam setting; and common CRC screening techniques used in Brunei Darussalam as well as other Asia-Pacific countries. The review also discusses the merits of a national CRC screening programme. With the increasing incidence of CRC worldwide and in Brunei Darussalam, national screening for CRC in Brunei Darussalam is an important strategy to lower morbidity and mortality rates. A review of the progress and outcome of the national screening programme will be available a few years after rollout.

Genomics and metagenomics of colorectal cancer

Colorectal cancer (CRC) is a common cancer globally. It is a complex disease influenced by genetic and environmental factors. Early studies on familial cases have identified major genes involved in CRC, such as proto-oncogenes KRAS, PIK3CA and BRAF, and tumour-suppressor genes APC and TP53. These genes have provided valuable insight into the molecular pathogenesis of CRC, and some have made ways to clinical utility to help diagnose cancer syndromes, prognosticate oncological outcomes and predict treatment responses. While these genetic factors are important, recent studies have suggested contribution of microorganisms to colorectal carcinogenesis. Observational studies, animal experiments and translational works have identified several microorganisms as potential carcinogenic bacteria, such as Fusobacterium nucleatum and Peptostreptococcus anaerobius. With the advent of sequencing technology and bioinformatics, more genomic and metagenomic factors are being uncovered as important players in CRC carcinogenesis. This article aims to review recent genomic and metagenomic discoveries relating to CRC.

Extracellular Vesicle-derived circular RNAs confers chemoresistance in Colorectal cancer

Chemo-resistance is associated with poor prognosis in colorectal cancer (CRC), with the absence of early biomarker. Exosomes are microvesicles released by body cells for intercellular communication. Circular RNAs (circRNAs) are non-coding RNAs with covalently closed loops and enriched in exosomes. Crosstalk between circRNAs in exosomes and chemo-resistance in CRC remains unknown. This research aims to identify exosomal circRNAs associated with FOLFOX-resistance in CRC. FOLFOX-resistant HCT116 CRC cells (HCT116-R) were generated from parental HCT116 cells (HCT116-P) using periodic drug induction. Exosomes were characterized using transmission electron microscopy (TEM), Zetasizer and Western blot. Our exosomes were translucent cup-shaped structures under TEM with differential expression of TSG101, CD9, and CD63. We performed circRNAs microarray using exosomal RNAs from HCT116-R and HCT116-P cells. We validated our microarray data using serum samples. We performed drug sensitivity assay and cell cycle analysis to characterize selected circRNA after siRNA-knockdown. Using fold change >2 and p < 0.05, we identified 105 significantly upregulated and 34 downregulated circRNAs in HCT116-R exosomes. Knockdown of circ_0000338 improved the chemo-resistance of CRC cells. We have proposed that circ_0000338 may have dual regulatory roles in chemo-resistant CRC. Exosomal circ_0000338 could be a potential biomarker for further validation in CRC.

LncRNA CCAT1 Promotes Colorectal Cancer Tumorigenesis Via A miR-181b-5p/TUSC3 Axis

AIM

The aim was to determine the function and molecular mechanism of long non-coding RNA colon cancer associated transcript-1(lncRNA CCAT1) in the development of colorectal cancer (CRC).

METHODS

CCAT1 mRNA expression levels were determined in CRC tissues and cells using reverse transcription-quantitative polymerase chain reaction. Cell Counting Kit-8 and colony formation assays were used to examine the effects of CCAT1 on the proliferation of CRC cells. Luciferase reporter gene analysis was used to confirm the target gene of microRNA-181b-5p (miR-181b-5p) in CRC cells. Tumor xenografts were subsequently used to investigate the role of CCAT1 in CRC growth in vivo.

RESULTS

The relative mRNA expression levels of CCAT1 were significantly higher in CRC tissues and cell lines compared with the normal tissues or cells. CCAT1 knockdown significantly inhibited CRC cell proliferation in vitro and in vivo. Bioinformatics and luciferase reporter assays showed that miR-181b-5p was a direct target of CCAT1, and the expression of miR-181b-5p was negatively correlated with the expression of CCAT1 in CRC tissues. Furthermore, CCAT1 positively regulated the level of tumor suppressor candidate 3 (TUSC3) by competing with miR-181b-5p in CRC cells.

CONCLUSION

These data suggested that lncRNA CCAT1 promoted colorectal cancer tumorigenesis via a miR-181b-5p/TUSC3 axis.

The Rise of Colorectal Cancer in Asia: Epidemiology, Screening, and Management

PURPOSE OF REVIEW

Colorectal cancer (CRC) remains the third most commonly diagnosed cancer globally, and its incidence and mortality rates have been on the rise in Asia. In this paper, we summarize the recent trends and screening challenges of CRC in this region.

RECENT FINDINGS

In 2018, Asia had the highest proportions of both incident (51.8%) and mortality (52.4%) CRC cases (all genders and ages) per 100,000 population in the world. In addition, there has been a rising trend of this disease across Asia with some regional geographic variations. This rise in CRC can be attributed to westernized dietary lifestyle, increasing population aging, smoking, physical inactivity, and other risk factors. In curbing the rising trend, Japan, South Korea, Singapore, and Taiwan have launched nationwide population-based screening programs. CRC screening across this region has been found to be effective and cost-effective compared with no screening at all. The emergence of new therapies has caused a reduction in case fatality; however, these new options have had a limited impact on cure rates and long-term survival due to the great disparity in treatment capacity/resources and screening infrastructures among Asian countries with different degrees of economic development. CRC is still rising in Asia, and implementation of screening is necessary for moderate- to high-incidence countries and construction of treatment capacity is the priority task in low-incidence and low-income countries. Unless countries in Asia implement CRC screening, the incidence and mortality rates of this disease will continue to rise especially with the rapidly rising population growth, economic development, westernized lifestyle, and increasing aging.

Usable Mobile App for Community Education on Colorectal Cancer: Development Process and Usability Study

Background

Participation in colorectal cancer screening is still low among Malaysians despite the increasing trend of incidence, with more than half of the new cases being detected in the advanced stages. Knowledge improvement might increase screening participation and thus improve the chances of disease detection. With the advancement of communication technology, people nowadays prefer to read from their mobile phone using a Web browser or mobile apps compared with the traditional printed material. Therefore, health education and promotion should adapt this behavior change in educating the community.

Objective

This study aimed to document the process of designing and developing a mobile app for community education on colorectal cancer and assess the usability of the prototype.

Methods

The nominal group technique (NGT) was used for the content development of the mobile app. NGT involving community educationists and clinicians combined with community representatives as the target users identified relevant health information and communication strategies including features for a user-friendly mobile app. The prototype was developed using framework Ionic 1, based on the Apache Cordova and Angular JS (Google). It was published in the Google Play store. In total, 50 mobile phone users aged 50 years and above and who had never been diagnosed with any type of cancer were invited to download and use the app. They were asked to assess the usability of the app using the validated Malay version of System Usability Scale Questionnaire for the Assessment of Mobile Apps questionnaire. The One-sample t test was used to assess the usability score with a cut-off value of 68 for the usable mobile app.

Results

The Colorectal Cancer Awareness Application (ColorApp) was successfully developed in the local Malay language. The NGT discussion had suggested 6 main menus in the ColorApp prototype, which are Introduction, Sign and Symptoms, Risk Factors, Preventive Measures, Colorectal Cancer Screening Program, and immunochemical fecal occult blood test kit. A total of 2 additional artificial intelligence properties menus were added to allow user-ColorApp interaction: Analyze Your Status and ColorApp Calculator. The prototype has been published in the Google Play store. The mean usability score was 72 (SD 11.52), which indicates that ColorApp is a usable mobile app, and it can be used as a tool for community education on colorectal cancer.

Conclusions

ColorApp mobile app can be used as a user-friendly tool for community education on colorectal cancer.

The Complex Puzzle of Interactions Among Functional Food, Gut Microbiota, and Colorectal Cancer

Colorectal cancer exerts a strong influence on the epidemiological panorama worldwide, and it is directly correlated to etiologic factors that are substantiated by genetic and environmental elements. This complex mixture of factors also has a relationship involving the structural dependence and composition of the gut microbiome, leading to a dysbacteriosis process that may evolve to serious modifications in the intestinal lining, eventually causing the development of a neoplasm. The gastrointestinal tract presents defense strategies and immunological properties that interfere in intestinal permeability, inhibiting the bacterial translocation, thus maintaining the integrity of intestinal homeostasis. The modulation of the intestinal microbiome and the extinction of risk factors associated with intestinal balance losses, especially of environmental factors, make cell and defense alterations impossible. This modulation may be conducted by means of functional foods in the diet, especially soluble fibers, polyunsaturated fatty acids, antioxidants and prebiotics that signal immunomodulatory effects in the intestinal microbiota, with preventive and therapeutic action for colorectal cancer. In summary, this review focuses on the importance of dietary modulation of the intestinal microbiota as an instrument for dysbacteriosis and, consequently, for the prevention of colorectal cancer, suggesting anticarcinogenic, and antiangiogenic properties. Among the intestinal modulating agents considered here are functional foods, especially flaxseed, oat and soy, composing a Bioactive Food Compound.

miRNAs and lncRNAs as Predictive Biomarkers of Response to FOLFOX Therapy in Colorectal Cancer

Chemotherapy is one of the options for cancer treatment. FOLFOX is one of the widely used chemotherapeutic regimens used to treat primarily colorectal cancer and other cancers as well. However, the emergence of chemo-resistance clones during cancer treatment has become a critical challenge in the clinical setting. It is crucial to identify the potential biomarkers and therapeutics targets which could lead to an improvement in the success rate of the proposed therapies. Since non-coding RNAs have been known to be important players in the cellular system, the interest in their functional roles has intensified. Non-coding RNAs (ncRNAs) as regulators at the post-transcriptional level could be very promising to provide insights in overcoming chemo-resistance to FOLFOX. Hence, this mini review attempts to summarize the potential of ncRNAs correlating with chemo-sensitivity/resistance to FOLFOX.

Cytotoxic, Anti-Proliferative and Apoptosis Activity of l-Amino Acid Oxidase from Malaysian Cryptelytrops purpureomaculatus (CP-LAAO) Venom on Human Colon Cancer Cells

The aim of this study is to investigate the potential anti-cancer activity of l-amino acid oxidase (CP-LAAO) purified from the venom of Cryptelytrops purpureomaculatus on SW480 and SW620 human colon cancer cells. Mass spectrometry guided purification was able to identify and purify CP-LAAO. Amino acid variations identified from the partial protein sequence of CP-LAAO may suggest novel variants of these proteins. The activity of the purified CP-LAAO was confirmed with o-phenyldiamine (OPD)-based spectrophotometric assay. CP-LAAO demonstrated time- and dose-dependent cytotoxic activity and the EC₅₀ value was determined at 13 µg/mL for both SW480 and SW620 cells. Significant increase of caspase-3 activity, reduction of Bcl-2 levels, as well as morphological changes consistent with apoptosis were demonstrated by CP-LAAO. Overall, these data provide evidence on the potential anti-cancer activity of CP-LAAO from the venom of Malaysian C. purpureomaculatus for therapeutic intervention of human colon cancer.

Effects of chemopreventive agents on the incidence of recurrent colorectal adenomas: a systematic review with network meta-analysis of randomized controlled trials

BACKGROUND

Protective effects of several chemopreventive agents (CPAs) against colorectal adenomas have been well documented in randomized controlled trials (RCTs); however, there is uncertainty regarding which agents are the most effective.

METHODS

We searched for RCTs published up until September 2016. Retrieved trials were evaluated using risk of bias. We performed both pairwise analysis and network meta-analysis (NMA) of RCTs to compare the effects of CPAs on the recurrence of colorectal adenomas (primary outcome). Using NMA, we ranked CPAs based on efficacy.

RESULTS

We identified 20 eligible RCTs enrolling 12,625 participants with a history of colorectal cancer or adenomas who were randomly assigned to receive either a placebo or one of 12 interventions. NMA using all trials demonstrated that celecoxib 800 mg/day (relative risk [RR] 0.61, 95% confidence interval [CI] 0.45-0.83), celecoxib 400 mg/day (RR 0.70, 95% CI 0.55-0.87), low-dose aspirin (RR 0.75, 95% CI 0.59-0.96) and calcium (RR 0.81, 95% CI 0.69-0.96) were significantly associated with a reduction in the recurrence of any adenomas. NMA results were consistent with those from pairwise meta-analysis. The evidence indicated a high (celecoxib), moderate (low-dose aspirin) and low (calcium) Grading of Recommendations, Assessment, Development and Evaluation (GRADE) quality. NMA ranking showed that celecoxib 800 mg/day and celecoxib 400 mg/day were the best CPAs, followed by low-dose aspirin and calcium. Considering advanced adenoma recurrence, only celecoxib 800 mg/day and celecoxib 400 mg/day were demonstrated to have a protective effect (RR 0.37, 95% CI 0.27-0.52 vs RR 0.48, 95% CI 0.38-0.60, respectively).

CONCLUSION

The available evidence from NMA suggests that celecoxib is more effective in reducing the risk of recurrence of colorectal adenomas, followed by low-dose aspirin and calcium. Since cyclooxygenase-2 (COX-2) inhibitors (eg, celecoxib) are associated with important cardiovascular events and gastrointestinal harms, more attention is warranted toward CPAs with a favorable benefit-to-risk ratio, such as low-dose aspirin and calcium.

Survival rates and predictors of survival among colorectal cancer patients in a Malaysian tertiary hospital

Background

Colorectal cancer is the third most commonly diagnosed malignancy and the fourth leading cause of cancer-related death globally. It is the second most common cancer among both males and females in Malaysia. The economic burden of colorectal cancer is likely to increase over time owing to its current trend and aging population. Cancer survival analysis is an essential indicator for early detection and improvement in cancer treatment. However, there was a scarcity of studies concerning survival of colorectal cancer patients as well as its predictors. Therefore, we aimed to determine the 1-, 3- and 5-year survival rates, compare survival rates among ethnic groups and determine the predictors of survival among colorectal cancer patients.

Methods

This was an ambidirectional cohort study conducted at the University Malaya Medical Centre (UMMC) in Kuala Lumpur, Malaysia. All Malaysian citizens or permanent residents with histologically confirmed diagnosis of colorectal cancer seen at UMMC from 1 January 2001 to 31 December 2010 were included in the study. Demographic and clinical characteristics were extracted from the medical records. Patients were followed-up until death or censored at the end of the study (31st December 2010). Censored patients’ vital status (whether alive or dead) were cross checked with the National Registration Department. Survival analyses at 1-, 3- and 5-year intervals were performed using the Kaplan-Meier method. Log-rank test was used to compare the survival rates, while Cox proportional hazard regression analysis was carried out to determine the predictors of 5-year colorectal cancer survival.

Results

Among 1212 patients, the median survival for colorectal, colon and rectal cancers were 42.0, 42.0 and 41.0 months respectively; while the 1-, 3-, and 5-year relative survival rates ranged from 73.8 to 76.0%, 52.1 to 53.7% and 40.4 to 45.4% respectively. The Chinese patients had the lowest 5-year survival compared to Malay and Indian patients. Based on the 814 patients with data on their Duke’s staging, independent predictors of poor colorectal cancer (5-year) survival were male sex (Hazard Ratio [HR]: 1.41; 95% CI: 1.12, 1.76), Chinese ethnicity (HR: 1.41; 95% CI: 1.07,1.85), elevated (≥ 5.1 ng/ml) pre-operative carcino-embryonic antigen (CEA) level (HR: 2.13; 95% CI: 1.60, 2.83), Duke’s stage C (HR: 1.68; 95% CI: 1.28, 2.21), Duke’s stage D (HR: 4.61; 95% CI: 3.39, 6.28) and emergency surgery (HR: 1.52; 95% CI: 1.07, 2.15).

Conclusions

The survival rates of colorectal cancer among our patients were comparable with those of some Asian countries but lower than those found in more developed countries. Males and patients from the Chinese ethnic group had lower survival rates compared to their counterparts. More advanced staging and late presentation were important predictors of colorectal cancer survival. Health education programs targeting high risk groups and emphasizing the importance of screening and early diagnosis, as well as the recognition of symptoms and risk factors should be implemented. A nationwide colorectal cancer screening program should be designed and implemented to increase early detection and improve survival outcomes.