Asian Journal of Surgery (2017) 40, 481e489

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ORIGINAL ARTICLE

Colorectal cancer in Malaysia: Its burden and

implications for a multiethnic country
Sajesh K. Veettil a, Kean Ghee Lim b,*,
Nathorn Chaiyakunapruk c,d,e,f, Siew Mooi Ching g,
Muhammad Radzi Abu Hassan h,i

a
School of Pharmacy/School of Postgraduate Studies, International Medical University, Kuala Lumpur,
Malaysia
b
Clinical School, Department of Surgery, International Medical University, Jalan Rasah, Seremban,
Negeri Sembilan, Malaysia
c
School of Pharmacy, Monash University, Bandar Sunway, Selangor, Malaysia
d
Centre of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of
Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
e
School of Population Health, University of Queensland, Brisbane, Australia
f
School of Pharmacy, University of WisconsindMadison, Madison, WI, USA
g
Department of Family Medicine, Faculty of Medicine and Health Sciences, University Putra Malaysia,
Serdang, Malaysia
h
Gastroenterology Service, Ministry of Health, Malaysia
i
Department of Internal Medicine, Hospital Sultanah Bahiyah, Kedah, Malaysia

Received 21 January 2016; received in revised form 18 March 2016; accepted 21 March 2016
Available online 2 August 2016

KEYWORDS Summary Background: This study aims to provide an analytical overview of the changing
burden; burden of colorectal cancer and highlight the implementable control measures that can help
cancer prevention; reduce the future burden of colorectal cancer in Malaysia.
colorectal neoplasms; Methods: We performed a MEDLINE search via OVID with the Medical Subject Headings (MeSH)
Malaysia; terms “Colorectal Neoplasms”[Mesh] and “Malaysia”[Mesh], and PubMed with the key words
review; “colorectal cancer” and “Malaysia” from 1990 to 2015 for studies reporting any clinical, soci-
screening etal, and economical findings associated with colorectal cancer in Malaysia. Incidence and
mortality data were retrieved from population-based cancer registries/databases.
Results: In Malaysia, colorectal cancer is the second most common cancer in males and the
third most common cancer in females. The economic burden of colorectal cancer is substantial
and is likely to increase over time in Malaysia owing to the current trend in colorectal cancer
incidence. In Malaysia, most patients with colorectal cancer have been diagnosed at a late

Conflicts of interest: The authors have no conflicts of interest to declare.

* Corresponding author. Clinical School, Department of Surgery, International Medical University, Jalan Rasah, Seremban 70300, Negeri
Sembilan, Malaysia.
E-mail address: keanghee_lim@imu.edu.my (K.G. Lim).

http://dx.doi.org/10.1016/j.asjsur.2016.07.005
1015-9584/ª 2016 Asian Surgical Association and Taiwan Robotic Surgical Association. Publishing services by Elsevier B.V. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
482 S.K. Veettil et al.

stage, with the 5-year relative survival by stage being lower than that in developed Asian coun-
tries. Public awareness of the rising incidence of colorectal cancer and the participation rates
for colorectal cancer screening are low.
Conclusion: The efficiency of different screening approaches must be assessed, and an orga-
nized national screening program should be developed in a phased manner. It is essential to
maintain a balanced investment in awareness programs targeting general population and pri-
mary care providers, focused on increasing the knowledge on symptoms and risk factors of
colorectal cancer, awareness on benefits of screening, and promotion of healthy life styles
to prevent this important disease.
ª 2016 Asian Surgical Association and Taiwan Robotic Surgical Association. Publishing services
by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction 2. Methods

Colorectal cancer is the third and second most common
cancer, respectively, in men and women worldwide,1,2 and is
a major cause of morbidity and mortality.1 Mortality due to
colorectal cancer is increasing, and it is the fourth leading
cause of cancer death in the world.1 There is wide
geographical variation in the incidence of colorectal cancer
across the world, and there has been a rapid rise in its
incidence in many Asian countries during the past few de-
cades.1,3 The reported incidence of colorectal cancer is
higher in developed Asian countries such as Japan, South
Korea, and Singapore than in Malaysia and other developing
Asian countries.4,5 However, the incidence and mortality
rates for colorectal cancer in Japan, South Korea, and
Singapore have been stable and are even declining, which is
similar to the pattern seen in the USA and the UK.1,2,4,6 This
trend may be attributed to colorectal cancer screening
programs, reduced prevalence of risk factors, and/or
improved treatments in these countries.2 The improving
socioeconomic status and increasingly westernized life style
in developing countries in Asia, including Malaysia, could be
expected to be associated with an increasing incidence of
colorectal cancer.7 Malaysia is undergoing an aging of its
population,8 with increasing affluence and an increased
prevalence of risk factors for colorectal cancer, such as
westernized diet, obesity, and smoking.5,9 As about 80%
colorectal cancer cases in Malaysia are diagnosed in people
older than 50 years,10 the aging trend may further increase
the prevalence. The majority of colorectal cancer patients
in Malaysia present at a late stage with a poor prognosis,11,12
which can obviously increase the health burden due to the
higher treatment cost and poor quality of life in the late
stages.13,14 At present, there is no formal/structured na-
tional colorectal cancer screening program in Malaysia.15
Presently, surgical resection provides the best hope of cure
for colorectal cancer patients.15 Despite its growing burden,
colorectal cancer remains a low priority in healthcare
planning and expenditure in Malaysia.16,17 This review aims
to provide an analytical overview of the changing burden of
colorectal cancer in Malaysia by compiling published data on
the clinical, societal, and economic findings associated with
the disease. Moreover, this review highlights the imple-
mentable control measures that can help reduce the future
burden of colorectal cancer in Malaysia.
We searched MEDLINE via OVID with the MESH terms
“Colorectal Neoplasms”[Mesh] and “Malaysia”[Mesh], and
PubMed with the key words “colorectal cancer” and
“Malaysia.” Additional articles were identified by reviewing
the bibliographies of retrieved articles and hand searching
of journals. Publications were limited to human studies
published between 1990 and 2015. Only full papers and
abstracts published in English were included. For this re-
view, we included studies that reported any clinical, soci-
etal, and economical findings associated with colorectal
cancer in Malaysia. Incidence and mortality data were
retrieved from population-based cancer registries/data-
bases. We also searched the available national cancer
registries of individual Asian countries to make a compari-
son on cancer statistics.
3. Results and Discussion
3.1. Burden of colorectal cancer in Malaysia
Malaysia, with a population of w30 million in 2014, is a
multiethnic country, with the Malays being the majority,
followed by Chinese, Indians, and other indigenous
groups.18 The development of colorectal cancer registry in
Malaysia is still not mature. Hence, the assessment of the
epidemiology of colorectal cancer in this review is primarily
based on the data from GLOBOCAN 2012, existing cancer
registries from Malaysia, and publications on colorectal
cancer in Malaysia. A total of 67,792 new cancer cases were
diagnosed in Peninsular Malaysia in 2003e2005, of which
12% were colorectal cases, giving a total of 8135 colorectal
cancers in 3 years and an average of 2712 cases per year.10
Colorectal cancer is the second and third most commonly
diagnosed cancer in males and females, respectively, with
an age-standardized rate of 20.9 (male) and 16.8 (female)
per 100,000 persons per year in 2003e2005.10 According to
GLOBOCAN 2012 estimates,1,4 colorectal cancer is the
second most common cancer in Malaysia in both males and
females, with an age-standardized rate of 18.3 per 100,000
persons per year in 2012 (Table 1), similar to what was seen
in the National Cancer Registry in 2003e2005.10 Although
the overall incidence and mortality of colorectal cancer are
Burden of colorectal cancer in Malaysia 483

Singapore and Malaysia in 2012 may forecast the continuous

Table 1 Estimated incidence and mortality rates of three
upsurge of deaths due to colorectal cancer in Malaysia
most common cancers in Malaysia.
(Table 1).4 The societal burden of colorectal cancer is sig-
Sex Types of Incidence Mortality nificant and is likely to increase over time in Malaysia owing
cancer Cases % a
ASR Deaths % ASRa to the current incidence trend. Colorectal cancer accounts
(N ) (N ) for 13% of the total disability-adjusted life years attribut-
able to cancer in Malaysia. It is the third highest attribut-
Men Lung 3240 17.9 26.9 2783 24.7 23.4
able burden of cancer among males and second highest
Colorectal 2563 14.1 21.1 1274 11.3 10.6
among females in 2000.20
Nasopharynx 1487 8.2 10.6 533 4.7 3.9
Women Breast 5410 28.0 38.7 2572 24.7 18.9
Cervix uteri 2145 11.1 15.6 621 6.0 4.7 3.2. Economic burden of colorectal cancer
Colorectal 1976 10.2 15.7 1026 9.9 8.3
Both sexes Breast 5410 14.5 38.7 2572 11.9 18.9 Important economic components of economic burden
Colorectal 4539 12.1 18.3 2300 10.6 9.4 include direct medical care and nonmedical costs, and
Lung 4403 11.8 17.9 4134 19.1 17.0 productivity losses among patients and caregivers.21 A 2012
ASR Z age-standardized rate. study13,22 in the central region of Malaysia demonstrated
Note. Adapted from “Estimated cancer incidence, Mortality and the cost of colorectal cancer management using conven-
Prevalence Worldwide,” by GLOBOCAN, 2012, International tional chemotherapy for different stages. The mean cost
Agency for Research on Cancer. 2012. Available at: http:// (direct medical costs and nonmedical costs) of treating
globocan.iarc.fr/Default.aspx. colorectal cancer per year in Malaysian Ringgit (RM) was
a
ASR is the number of new cases or deaths per 100,000
RM13,622 for Stage 1, RM19,752 for Stage 2, RM24,972 for
persons per year. A population would have an ASR if it had a
Stage 3, and RM27,377 for Stage 4.13 An estimate of new
standard age structure.
cases of colorectal cancer each year in Malaysia was 4539 in
2012.4 Therefore, by using the stage distribution of colo-
rectal cancer at presentation in Malaysian patients23 and
correlating with costs from the study by Ezat et al,13 the
growing in the Southeast Asian countries, there is a wide economic burden of colorectal cancer management of new
disparity in the country-specific incidence, with the highest cases alone is estimated to be around RM108 million per
incidence being reported in Singapore (33.7 per 100,000 year (Table 2). This estimate, however, excludes new
persons, about twice the incidence rate of Malaysia in therapies with targeted agents such as monoclonal anti-
2012).4,6 However, trends for both the incidence and the bodies, e.g., cetuximab and bevacizumab, which may add
mortality rates for Singapore have been stable and even RM20,438e36,666 for selected patients. It also excludes
declining since 2000.6,19 Other Southeast Asian countries, costs for nonincident cases, such as detection and man-
such as Indonesia, Thailand, Vietnam, and Myanmar, have agement of recurrences, and ongoing palliative care of
comparatively lower incidence rates of colorectal cancer Stage 4 patients who survive more than a year.
than Malaysia.1 Meanwhile, private expenditure on health is growing,
Information on the mortality rate of colorectal cancer in with around 50% of the total healthcare expenditure in
Malaysia is not available. A comparison of GLOBOCAN esti- Malaysia coming from private resources in 2009.24 It is
mates of age-standardized rates of colorectal cancer inci- estimated that around 30% of the Malaysian population are
dence (33.7 vs. 18.3) and mortality (11.8 vs. 10.6) between served by private hospitals.25 The cost of care for

Table 2 Estimated cost of colorectal cancer management of new cases in 2012 in Malaysia.
Stage distribution Expected number of The mean cost Total cost of treatment per
at presentation colorectal cancer of treatment per yearc (Stages 1e4)
in Malaysia23 cases in 2012a person per yearb
(Stages 1e4) (in RM)
(Stages 1e4)13
Stage 1 6.7% 304 13,622 4,141,088
Stage 2 24% 1090 19,752 21,529,680
Stage 3 37.3% 1693 24,972 42,277,596
Stage 4 32% 1452 27,377 39,751,404
Total cost of colorectal cancer management of new cases in 2012 107,699,768
RM Z Malaysian Ringgit.
Note. Adapted from GLOBOCAN 2012: Estimated cancer incidence, Mortality and Prevalence Worldwide in 2012 (GLOBOCAN, 2012).
a
Source: GLOBOCAN 2012destimate of new cases of colorectal cancer in Malaysia is 4539 cases in 2012.4
b
This cost would therefore cover the incident cases for the year. It can be assumed that diagnosis, surgery, and chemotherapy/
radiotherapy would, in most cases, be completed in 1 year.
c
The cost would therefore not include follow-up care after detection and treatment of recurrences and palliative care for Stage 4
patients who survive more than 1 year.
484 S.K. Veettil et al.

Table 3 Colorectal cancer stage distribution at presentation in Malaysian patients from different settings.
62
Dukes’ classification Stage A Stage B Stage C Stage D Unstaged
41
Ghazali et al (1996e2005; Kelantan) 0 43.5 33 23.5 Nil
(n Z 115)
Goh et al12 (1999e2003; Kuala Lumpur) 5 42 15 39 74 (excluded)
(n Z 228)
Rashid et al11 (1997e2000; Kuala Lumpur) 2.8 35.5 40.2 21.5 Nil
(n Z 107)
Penang Cancer Registry (2004e2008; Penang)42 12 30.5 28 29.5 721 (excluded)
(n Z 1363)
TNM classification62 Stage 1 Stage 2 Stage 3 Stage 4 Unstaged
Shah et al23 (1995e2011; Kuala Lumpur) 6.7 24 37.3 32 Nil
(n Z 75)
Data are presented as %.

colorectal cancer in the private healthcare setting is ex-
pected to be higher than that calculated for public tertiary
hospitals. If their cost was double that for public tertiary
hospitals, the higher cost incurred by this 30% of colorectal
cancer patients might be expected to add 30% to the esti-
mated direct medical and nonmedical costs of RM108
million calculated for colorectal cancer care. When exam-
ining the costs of managing breast and lung cancer, two
other common cancers in Malaysia, the economic burden
due to colorectal cancer can be considered the second
highest after breast cancer.26 The expected increase in the
aging population and healthcare costs in Malaysia will in-
crease the competition for healthcare expenditure
currently available; this may also affect cancer health
services. In the case of colorectal cancer, striking a balance
between investment in preventive and treatment services
and allocation of resources effectively for improving facil-
ities for screening, early detection, diagnosis, and subse-
quent treatment will be an additional challenge in
Malaysia. Early detection and treatment of colorectal
cancer result in substantial saving in treatment costs. It is
estimated that diagnosis of advanced stage of colon cancer
was associated with 1.8e2.5-fold higher cost than that of
early-stage cancer in South Korea.27 The provision of colo-
rectal cancer screening may shift the current stage distri-
bution pattern in Malaysia toward the Western figures
(Tables 3 and 4); thus, a reduction in the overall cost of
colorectal cancer management can be expected. Although
there are several strategies for colorectal cancer screening,
it is uncertain which is most cost effective in the local
context. Although there is evidence to support the
different strategies for screening and reducing the inci-
dence and mortality of colorectal cancer, it is vital to know
which strategy/strategies should be considered in the
Malaysian population, or in what combination or sequence,
in order to maximize cost effectiveness. Hence, the cost
effectiveness of nationwide screening approaches and their
financial consequences must be assessed to inform the
policy makers on which screening approach should be
implemented in Malaysia.
3.3. Influence of age
More than 90% of the colorectal cancer cases in Malaysia
initially occur in people over the age of 40 years10,15; this
was observed for all ethnic groups.10 Patients aged 60e69
years accounted for the highest proportion of cases10; a
similar trend was seen in Singapore.19,28 Western guidelines
recommended colorectal cancer screening at the age of 50
years for individuals with average risk.29e32 The most
recent findings showed that the incidence increased by
> 2% each year in younger adults33; moreover, a high pro-
portion of the younger population diagnosed with colo-
rectal cancer has a poor prognosis.34,35 The age
characteristics of colorectal cancer patients enrolled in the
cancer registry (n Z 8077; 2003e2005) in Malaysia10
showed an occurrence of 14.6% of cases among patients
younger than 50 years, while only 7% of cases were among
patients younger than 40 years. A similar distribution of
colorectal cancer cases was shown by Qureshi et al36 in
1998. The consensus on screening for colorectal cancer in
Malaysia suggested that the entry age for a colorectal
cancer-screening program in Malaysia should be earlier
than that of the developed nations.36 Further research on
the epidemiology and characteristics of colorectal cancer
and adenomas by age group in the population is necessary
to identify the entry age of Malaysians for the screening

Table 4 Colorectal cancer stage distribution at presentation in the USA, the UK, and Singapore.
Dukes’ classification Stage A Stage B Stage C Stage D Unstaged
43
United States (1996e1998) 17 (14e23) 28 (24e36) 38 (29e46) 10 (7e18) 7 (3e10)
Europe (1996e1998)43 17 (11e28) 30 (25e37) 21 (24e30) 21 (11e33) 10 (4e24)
Singapore (2007e2011)44 14.7 27 35.1 23.2 Unknown
Data are presented as % or % (range).
Burden of colorectal cancer in Malaysia 485

program. Simultaneously, the efficiency of considering an late. The Penang Cancer Registry from 2004 to 200842 has
age of 40 years for average-risk individuals for colorectal provided the largest data set among these studies in terms
cancer screening program in Malaysia should be of patient number (n Z 1363); however, more than half of
investigated. the patients’ data for stages of their cancer (n Z 721) were
missing. This was probably due to incomplete information
3.4. Influence of ethnicity on distant metastasis.40 Hence, a higher percentage of
patients among those who were excluded from the Penang
Cancer Registry42 and from the study by Goh et al12 were
Among ethnic groups in Malaysia, the Chinese population
most probably with late-stage cancer. Thus, the number of
has the highest rate of colorectal cancer cases.10e12,23 The
colorectal cancer cases in Dukes’ stages C and D is expected
annual incidence of colorectal cancer per 100,000 is about
to be greater than the figure shown in Table 3. Compared
28.8 in Chinese, which is significantly higher than that in
with the United States (48%) and Europe (42%), a higher
other ethnic groups (Malay: 11, Indian: 14.3).10 A similar
percentage of colorectal cancers are diagnosed at late
pattern has been observed in Singapore, where the colo-
stages (Dukes’ stages C and D) in Malaysia,42,43 but the
rectal cancer incidence is significantly lower among the
percentage is similar to that in Singapore (Tables 3 and 4).
Indian (16.1) and Malay (26.1) populations compared with
However, in view of the large number of unstaged cases in
that in the Chinese population (34.1).37 The ethnic simi-
the Penang registry, the number of late-stage cancer cases
larity in the incidence of colorectal cancer was previously
is expected to be more. Moreover, in Europe,43 the United
reviewed by Sung et al,38 who compared the incidence of
States,43 and Singapore,44 a much higher percentage of
colorectal cancer in Chinese and Indians in Malaysia,
patients present at an early stage (Dukes’ stage A; Tables 3
Singapore, China, and India. It is evident that the higher
and 4). This likely reflects the outcome of the ongoing
incidence among Chinese and the lower incidence among
effective colorectal cancer screening in the mentioned
Indians living in Southeast Asia are similar to those in the
countries. As mentioned previously, the expected increase
countries of origin, although both ethnic groups migrated
in mortality rate due to colorectal cancer in Malaysia could
more than three generations ago.38 Similar to the Chinese,
be correlated to the findings on the stages of colorectal
Japanese and Koreans also have higher colorectal cancer
cancer at presentation, which emphasizes the need for
incidence than other ethnic groups such as Indians, Malays,
developing a colorectal cancer screening program at a na-
and Indonesians.5,38 These ethnic differences may suggest
tional level. As colorectal cancer screening programs ach-
an etiological role of the genetic factors in colorectal
ieve progressively higher uptakes, we can anticipate a
cancer.38 The cumulative life time risks of colorectal cancer
reduction in the incidence of colorectal cancers diagnosed
for Chinese in Malaysia were 1:27 for men and 1:33 for
at late stages in Malaysia, thus improving survival, as seen
women, which are significantly higher than those in other
in the USA and Europe.1
ethnic groups.10,23 An updated Asia Pacific Consensus rec-
The socioeconomic class may have an impact on colo-
ommended the use of a risk-stratified scoring system to
rectal cancer stage distribution at presentation.45 A study
select high-risk individuals for early colonoscopy, especially
by Kong et al46 showed that Kuala Lumpur, an affluent re-
in Asia where the burden to the healthcare system is high.5
gion in Malaysia with an improved socioeconomic status,
A recent study39 demonstrated a risk score to prioritize
has a lower rate of late-stage colorectal cancers compared
colonoscopy referrals in symptomatic patients from
with Kuching, Malaysia. Factors that contribute to this
Malaysia; this included ethnicity as one of the components
disparity may include poor awareness of colorectal cancer
to predict the risk of colorectal neoplasia and cancer. Thus,
and a lack of access to cancer awareness programs,
Malaysia, which has a diverse multiethnic population,
screening tests, skilled healthcare workers, and referral
where Chinese have the highest risk of getting colorectal
systems in rural compared with metropolitan areas.
cancer, should consider these ethnic differences in framing
Awareness of colorectal cancer among the general popu-
its screening policy. Pertaining to the Asia-Pacific colorectal
lation and preventive activities among primary care pro-
screening score, the opportunity to further develop the
viders are conspicuously limited in rural areas.17,47e50 More
scoring system for asymptomatic individuals in the Malay-
public health attention should be paid to promoting
sian setting should be considered by incorporating the
knowledge and awareness of colorectal cancer screening
ethnic risk difference.
among the general population nationwide. The role of pri-
mary care providers in colorectal cancer prevention should
3.5. Colorectal cancer stage distribution at be well defined, and policy makers need to take initiatives
presentation in Malaysian patients to improve colorectal cancer screening services in primary
clinics.
The survival rate for patients with colorectal cancer is
closely correlated with the stage of the disease at diag-
nosis; the earlier the stage at diagnosis, the higher the 3.6. Colorectal cancer survival in Malaysia
chance of survival. Staging information on Malaysians
diagnosed with colorectal cancer is not yet available Information on cancer survival is an important indicator of
nationwide.40 Table 3 presents the available stage distri- the cancer system’s effectiveness in detecting and treating
bution of colorectal cancer at presentation in Malaysian cancer. Colorectal cancer survival is highly dependent on
patients from different settings. Studies,11,12,41,42 using the stage of disease at diagnosis, and typically 5-year sur-
Dukes’ classification for staging of colorectal cancer, vival rates are 90% and 80%, respectively, for Stages 1 and
revealed that most patients were presenting themselves 2, 30e60% for Stage 3, and around 5e10% for Stage 4.16,51 In
486
Table 5 Five-year relative survival (%) by stage62 in CRC patients: Malaysia, Singapore, the UK, and the USA.
Country Year Stage 1
46
Kuala Lumpur, Malaysia 2000e2004 78.6
Kuching, Malaysia46 2000e2004 74.5
Singapore44 2007e2011 82.2
United Kingdom 63 2002e2006 97.4
United States 64 1991e2000 93.2
Data are presented as %.
CRC Z colorectal cancer.
lower/higheremiddle-income Asian countries such as India,
China, the Philippines, and Thailand, the 5-year overall
colorectal survival rates are much lower (6e40%) than the
high-income Asian countries, such as Singapore and South
Korea (about 60% and 73%, respectively).16,52 Malaysia,
which is considered a higheremiddle-income country,
showed an overall 5-year survival rate of 40% in the period
1997e2000.11 While, a more recent study (2000e2004)
demonstrated an improved overall 5-year survival rate of
53%.46 Five-year relative survival by stage for colorectal
cancer in Malaysia was comparatively lower than that in
Singapore, United Kingdom, and United States (Table 5).
Disparities in the survival rates probably reflect the dif-
ference in the management practices among these coun-
tries. A lack of cohesive practice guidelines for colorectal
management and inadequate development to deal with the
increasing demand of diagnostic, therapeutic, and follow-
up care interventions could be reasons for the lower sur-
vival rate in Malaysia.
Kong et al,46 showed an overall 5-year relative survival
rate for cases diagnosed in 2000e2004 of 60.5% in Kuala
Lumpur, compared with about 45.7% in Kuching. This
disparity in the survival rate from two settings probably
reflects the differences in access to early detection tests,
receipt of timely and high-quality treatment, and the
prevalence of other illnesses among patients. Kuala Lum-
pur, a highly developed region in the country, has an overall
5-year relative survival rate similar to that in the developed
countries.44,51,53 The improvement in survival rate in Kuala
Lumpur may be due to early detection and better access to
treatment, as a result of well-developed health services
and organized healthcare infrastructures within the region.
The relatively poor prognosis in some regions in Malaysia
underscores the need of improvement in public healthcare
infrastructures to support screening, staging, and colo-
rectal cancer management throughout the country.54
3.7. Colorectal cancer screening in Malaysia
There is no nationwide, population-based screening for
colorectal cancer in Malaysia, where there is a high reliance
on opportunistic screening.15,55 The rate of change in the
epidemiology of colorectal cancer in Malaysia demands a
prompt action to prevent colorectal cancer and diagnose
the disease at an early stage through screening. To achieve
this goal, high-quality interventions and approaches should
be delivered to a large proportion of the target population.
However, there are no up-to-date national guidelines on
S.K. Veettil et al.
Stage 2 Stage 3 Stage 4
52.9 44.3 9.3
65 36.4 5.2
72.2 55.3 8.7
84.7 62.7 7.5
82.5 59.5 8.1
colorectal cancer screening in Malaysia, no uniform stra-
tegies, and no general consensus from professional bodies
based on the colorectal cancer data to inform the policy
makers on resources for screening. Additional challenges
for an organized colorectal cancer screening program are
the requirements of a considerable number of organizations
to be involved in awareness programs, resources including
skilled healthcare workers for screening within routine
health services, as well as diagnostic and treatment in-
frastructures; these require additional investment for
health services.
The screening behavior of the Malaysian population re-
mains largely unknown. Public awareness of the rising
incidence of colorectal cancer and the participation rates
for colorectal cancer screening are low.49 A multicentre
study49 in Asia-Pacific regions revealed poor knowledge of
colorectal cancer symptoms, risk factors, and screening
tests among Malaysians compared with that in other pop-
ulations from Southeast regions. This study showed that
Malaysians had a significantly more negative response to
the intention to undergo screening for colorectal cancer.49
A similarly negative perception among Malaysians con-
cerning screening was described by Hilmi et al,56 who found
that only 38% of the participants were willing to undergo
colorectal cancer screening. Among the ethnic groups in
Malaysia, Chinese were paradoxically the least willing
group to undergo screening, despite having the greatest risk
compared with other ethnic groups.56 This disparity in the
negative perception among ethnic groups has not been
clearly defined. Similarly, a recent study conducted in a
semiurban area in Malaysia57 showed the awareness of
screening tests to be meager, although the knowledge on
colorectal cancer symptoms and risk factors was better
among Malaysians in the semiurban area, compared with
the level of knowledge and awareness on colorectal cancer
symptoms, risk factors, and screening tests in the rural
population of Malaysia, which remains very low.17 These
disparities demonstrate substantial deficiencies in the
awareness programs for rural areas and disadvantaged
populations, as evidenced by the late colorectal cancer
stage distribution at presentation in hospitals for patients
living in nonmetropolitan areas. The behavior of the par-
ticipants toward the screening recommendations and reg-
ular follow-up has not been reported in Malaysia. Since it is
difficult to achieve the requisite compliance rate with
screening recommendations and regular follow-up,38 future
studies are needed to explore the attitude and behavior of
the population toward different strategies for screening.
Burden of colorectal cancer in Malaysia
The role of primary care physicians is crucial in the
implementation of screening programs. It is obvious that
inadequate counseling by physicians appears to be one of
the barriers for patient acceptance for colorectal cancer
screening.58 Colorectal cancer preventive activities among
primary care providers are still poor in Malaysia.47 A recent
survey49 in the Asia-Pacific region demonstrated that
significantly fewer Malaysian participants received physi-
cian recommendations for colorectal cancer screening,
compared with other regions. Although these participants
were aged 50 years and older, which is considered an
average risk for getting colorectal cancer, relatively few of
them were recommended by their physicians for screening.
Professional bodies in Malaysia need to produce a uniform
strategy to define the role of physicians in colorectal cancer
prevention, starting from the primary health service level.
Furthermore, financial constraints, access to screening,
time constraints, and cultural and emotional elements
appear to be barriers to colorectal cancer screening in
Malaysia.17,47e49 Despite the increasing incidence of colo-
rectal cancer, health promotion regarding this disease is
not highlighted by the Ministry of Health compared with
other cancers such as lung, cervical, and breast cancers.17
Therefore, extensive health education and awareness pro-
grams on colorectal cancer should be initiated nationwide.
Another concern still to be addressed is the best strategy
for colorectal cancer screening in Malaysia. Although colo-
noscopy is the precise and effective screening tool,29 the
decision on which colorectal cancer screening program
should be implemented in the first place is based on the
availability of resources, including skilled healthcare pro-
fessionals, costs, and population preferences.5 Hence, co-
lonoscopy, one of the more expensive and invasive methods
for colorectal cancer screening, might not be appropriate in
a country like Malaysia, where there are limited resources
and insufficient specialists to tackle the expected number
of individuals undergoing screening.24,59 This could explain
why many countries have initiated preliminary colorectal
cancer screening using fecal occult blood tests, either
opportunistic or population based.55,60 Although not supe-
rior to colonoscopy, the effectiveness of fecal occult blood
tests in detecting colorectal cancer and reducing colorectal
cancer-related mortality is well established.5,29 Hence,
prioritizing colonoscopy for individuals with a greater risk
of colorectal cancer may be a worthwhile approach to
reduce the burden of colorectal cancer in Malaysia.
Average-risk individuals with a positive result on noninva-
sive fecal occult blood tests, along with individuals having a
family history of colorectal cancer and other risk factors
can be prioritized for early colonoscopy.5 The use of a risk-
based algorithm can direct screening of high-risk individuals
by colonoscopy, which permits a more efficient allocation
of limited healthcare resources.5,39,61
4. Conclusion
The above description of existing colorectal cancer pattern
in Malaysia calls for a wide variety of interventions to
reduce the burden of the disease. These include balanced
investment in awareness programs targeting general pop-
ulation and primary care providers, focused to increase the
487
knowledge on symptoms and risk factors of colorectal
cancer, awareness on benefits of screening, and promotion
of healthy life styles to prevent this important disease.
Empowering primary care providers by providing them with
resources to undertake preliminary screening, or devel-
oping a referral strategy for early clinical diagnosis of pa-
tients who are symptomatic, is an important approach that
requires to be promoted. Introduction of organized
screening programs should be undertaken in a phased
manner for the early detection of cancer, which can ulti-
mately reduce the economic burden of colorectal cancer.
The financial consequences and benefits of different
screening approaches must be assessed prior to the
implementation. A set of screening guidelines that suit the
present needs of Malaysia should be promulgated, based on
the recommendations from international organizations and
local professional bodies, and the data from the local
research and cancer registries. Further research on the
epidemiology and characteristics of colorectal cancer in
the Malaysian population, and public perception and pro-
fessional attitude on screening and screening behavior of
the population are required. Further development of a
colorectal cancer registry comprising data from public and
private sectors is required to observe trends relating to
colorectal cancer, and to evaluate the performance of
health systems and patterns of care in the country.
Healthcare infrastructures, accessible treatment services,
and the number of healthcare specialists for colorectal
cancer screening and treatment need to be increased in a
phased manner, and must be consistently accessible in both
rural and urban areas of the country. Treatment of colo-
rectal cancer is resource intensive and often multidimen-
sional, involving surgery, chemotherapy, radiotherapy,
palliative care, and rehabilitation. Development and
implementation of evidence-based management guidelines
and follow-up care for colorectal cancer should be
strengthened for effective and optimum use of resources
throughout the nation. The above initiatives require com-
mitments from political and professional bodies and the
recognition of the fact that colorectal cancer will be an
increasing public health problem in Malaysia.
Acknowledgments
The authors wish to thank Mr Razman Shah Mohd Razali,
reference librarian, International Medical University, Kuala
Lumpur, Malaysia, for providing full-text articles whenever
needed.
References
1. Ferlay J, Soerjomataram I, Dikshit R, et al. Cancer incidence
and mortality worldwide: sources, methods and major patterns
in GLOBOCAN 2012. Int J Cancer. 2015;136:E359eE386.
2. Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J,
Jemal A. Global cancer statistics, 2012. CA Cancer J Clin. 2015;
65:87e108.
3. Allemani C, Weir HK, Carreira H, et al. Global surveillance of
cancer survival 1995-2009: analysis of individual data for
25,676,887 patients from 279 population-based registries in 67
488
countries (CONCORD-2). Lancet Lond Engl. 2015;385:
977e1010.
4. GLOBOCAN. Estimated Cancer Incidence, Mortality and Prev-
alence Worldwide. International Agency for Research on Can-
cer; 2012. Available at: http://globocan.iarc.fr/Default.aspx.
Accessed 04.08.15.
5. Sung JJY, Ng SC, Chan FKL, et al. An updated Asia Pacific
Consensus recommendations on colorectal cancer screening.
Gut. 2015;64:121e132.
6. Peng LH, et al. Singapore cancer registry interim annual report.
Trends in cancer incidence in Singapore, 2010e2014. National
Registry of Diseases Office; 2015. Available at: https://www.
nrdo.gov.sg/docs/librariesprovider3/default-document-
library/cancer-trends-2010-2014_interim-annual-report_final-
(public)_220615.pdf?sfvrsnZ0, Accessed 04.08.15.
7. Levin B, Rozen P, Spann SJ, Young GP. Colorectal Cancer in
Clinical Practice: Prevention, Early Detection and Manage-
ment. 2nd ed. Oxon, United Kingdom: Taylor & Francis,
Abingdon; 2006.
8. Yusoff SN, Zulkifli Z. Rethinking of old age: the emerging
challenge for Malaysia. IPEDR. 2014;71:69. Accessed 08.08.15.
9. Center MM, Jemal A, Smith RA, Ward E. Worldwide variations in
colorectal cancer. CA Cancer J Clin. 2009;59:366e378.
10. Lim GCC, et al. Cancer incidence in Peninsular Malaysia,
2003e2005. The Third Report of the National Cancer Registry,
Ministry of Health, Malaysia; 2008. Available at: http://www.
moh.gov.my/images/gallery/Report/Cancer/
CancerIncidenceinPeninsularMalaysia2003-2005x1x.pdf,
Accessed 10.08.15.
11. Rashid MRA, Aziz AFA, Ahmad S, Shah SA, Sagap I. Colorectal
cancer patients in a tertiary referral centre in Malaysia: a five
year follow-up review. Asian Pac J Cancer Prev. 2009;10:
1163e1166.
12. Goh KL, Quek KF, Yeo GTS, et al. Colorectal cancer in Asians: a
demographic and anatomic survey in Malaysian patients un-
dergoing colonoscopy. Aliment Pharmacol Ther. 2005;22:
859e864.
13. Ezat SW, Natrah MS, Syed MA, et al. Economic evaluation of
monoclonal antibody in the management of colorectal cancer
in Malaysia. BMC Health Serv Res. 2012;12(Suppl 1):P3.
14. Wan Puteh SE, Saad NM, Aljunid SM, et al. Quality of life in
Malaysian colorectal cancer patients. Asia Pac Psychiatry Off J
Pac Rim Coll Psychiatr. 2013;5(Suppl 1):110e117.
15. Syful Azlie MF, Hassan MR, Junainah S, Rugayah B. Immuno-
chemical faecal occult blood test for colorectal cancer
screening: a systematic review. Med J Malaysia. 2015;70:
24e30.
16. Sankaranarayanan R, Ramadas K, Qiao Y. Managing the
changing burden of cancer in Asia. BMC Med. 2014;12:3.
17. Su TT, Goh JY, Tan J, et al. Level of colorectal cancer
awareness: a cross sectional exploratory study among multi-
ethnic rural population in Malaysia. BMC Cancer. 2013;13:376.
18. Department of statistics Malaysia. Official portal. The source of
Malaysia’s official statistics. Tableau Software. 2014. Available
at: https://www.statistics.gov.my/. Accessed 24.06.15.
19. Peng LH, et al. Singapore cancer registry interim annual reg-
istry report. Trends in cancer incidence in Singapore,
2009e2013; 2014. Available at: https://www.nrdo.gov.sg/
docs/librariesprovider3/Publications-Cancer/trends-in-
cancer-incidence-in-singapore-2009-2013-interim.pdf?
sfvrsnZ0, Accessed 10.08.15.
20. MOH, Malaysia. Malaysian Burden of Disease and Injury Study.
Health Prioritization: Burden of Disease Approach. Malaysia:
Division of Burden of Disease, Institute for Public Health, Na-
tional institutes of Health, Ministry of Health; 2004.
21. Yabroff KR, Borowski L, Lipscomb J. Economic studies in
colorectal cancer: challenges in measuring and comparing
costs. JNCI Monogr. 2013;2013:62e78.
S.K. Veettil et al.
22. Mohd N, Ezad S, Aljunid SM, et al. Cost analysis of colo-
rectal cancer (CRC) management in UKM Medical Centre
using clinical pathway. BMC Public Health. 2012;12(Suppl
2):A40.
23. Shah SA, Neoh HM, Rahim SSSA, et al. Spatial analysis of
colorectal cancer cases in Kuala Lumpur. Asian Pac J Cancer
Prev. 2014;15:1149e1154.
24. Hansen RM, et al. Statistical Yearbook for Asia and the Pacific.
Bangkok, Thailand: United Nations Publication; 2011.
25. Sivasampu S. National Healthcare Establishments and Work-
force Statistics (Hospital) 2008e2009. Ministry of Health
Malaysia; 2011. Available at: http://www.crc.gov.my/nhsi/
wp-content/uploads/document/publication/Hospitals_
Report.pdf. Accessed 20.08.15.
26. PFA Asia. Wise money planning: treatment costs for cancers in
Malaysia 2010/2011. PFA ASIA e WISE MONEY Plan. 2011.
Available at: http://prajna-advisors.blogspot.com/2011/04/
treatment-costs-for-cancers-in-malaysia.html. [Accessed 13
July 2015].
27. Shin JY, Kim SY, Lee KS, et al. Costs during the first five years
following cancer diagnosis in Korea. Asian Pac J Cancer Prev.
2012;13:3767e3772.
28. Lim GH, Chow KY, Lee HP. Singapore cancer trends in the last
decade. Singapore Med J. 2012;53:3e9. quiz 10.
29. Levin B, Lieberman DA, McFarland B, et al. Screening and
surveillance for the early detection of colorectal cancer and
adenomatous polyps, 2008: a joint guideline from the Amer-
ican Cancer Society, the US Multi-Society Task Force on Colo-
rectal Cancer, and the American College of Radiology. CA
Cancer J Clin. 2008;58:130e160.
30. U.S. Preventive Services Task Force. Screening for colorectal
cancer: U.S. Preventive Services Task Force recommendation
statement. Ann Intern Med. 2008;149:627e637.
31. Davila RE, Rajan E, Baron TH, et al. ASGE guideline: colorectal
cancer screening and surveillance. Gastrointest Endosc. 2006;
63:546e557.
32. European Colorectal Cancer Screening Guidelines Working
Group, von Karsa L, Patnick J, et al. European guidelines for
quality assurance in colorectal cancer screening and diagnosis:
overview and introduction to the full supplement publication.
Endoscopy. 2013;45:51e59.
33. Myers EA, Feingold DL, Forde KA, Arnell T, Jang JH, Whelan RL.
Colorectal cancer in patients under 50 years of age: a retro-
spective analysis of two institutions’ experience. World J
Gastroenterol. 2013;19:5651e5657.
34. Pal M. Proportionate increase in incidence of colorectal cancer
at an age below 40 years: an observation. J Cancer Res Ther.
2006;2:97e99.
35. Fu J, Yang J, Tan Y, et al. Young patients ( 35 years old) with
colorectal cancer have worse outcomes due to more advanced
disease: a 30-year retrospective review. Medicine (Baltimore).
2014;93:e135.
36. Qureshi MA, Raj M, Thiam OK, et al. Consensus/Clinical Prac-
tice Guidelines on Screening for Colorectal Cancer in Malaysia.
Malaysian Society of Gastroenterology & Hepatology, College
of Surgeons of Malaysia, Academy of Medicine of Malaysia;
2001. Available at: http://www.acadmed.org.my/index.cfm?
&menuidZ28. Accessed 10.08.15.
37. Wang H, Seow A, Lee HP. Trends in cancer incidence among
Singapore Malays: a low-risk population. Ann Acad Med
Singapore. 2004;33:57e62.
38. Sung JJY, Lau JYW, Goh KL, Leung WK, Asia Pacific Working
Group on Colorectal Cancer. Increasing incidence of colorectal
cancer in Asia: implications for screening. Lancet Oncol. 2005;
6:871e876.
39. Law CW, Rampal S, Roslani AC, Mahadeva S. Development of a
risk score to stratify symptomatic adults referred for colonos-
copy. J Gastroenterol Hepatol. 2014;29:1890e1896.
Burden of colorectal cancer in Malaysia
40. Radzi bin Abu Hassan M. The First Annual Report of the Na-
tional Cancer Patient Registry-Colorectal Cancer 2007e2008.
Malaysia; 2010. Available at: http://www.crc.gov.my/wp-
content/uploads/documents/report/NCPR2010.pdf. Accessed
12.08.15.
41. Ghazali AK, Musa KI, Naing NN, Mahmood Z. Prognostic factors
in patients with colorectal cancer at Hospital Universiti Sains
Malaysia. Asian J Surg Asian Surg Assoc. 2010;33:127e133.
42. Azizah Ab M, Devaraj T, Bina Rai S, Norbaiyah Y, Nooraihan M,
Noorshila S. Penang Cancer Registry Report, 2004e2008.
Penang State Health Department; 2010. Available at: http://
www.ncsmpenang.org/storage/upload/ncsm/files/
PCR20042008(1).pdf. Accessed 12.08.15.
43. Allemani C, Rachet B, Weir HK, et al. Colorectal cancer survival
in the USA and Europe: a CONCORD high-resolution study. BMJ
Open. 2013;3.
44. National Registry of Diseases. Trends of Colorectal Cancer in
Singapore 2007e2011; 2013. Available at: https://www.nrdo.
gov.sg/publications/cancer. Accessed 14.08.15.
45. Clegg LX, Reichman ME, Miller BA, et al. Impact of socioeco-
nomic status on cancer incidence and stage at diagnosis:
selected findings from the surveillance, epidemiology, and end
results: National Longitudinal Mortality Study. Cancer Causes
Control. 2009;20:417e435.
46. Kong CK, Roslani AC, Law CW, Law SCD, Arumugam K. Impact of
socio-economic class on colorectal cancer patient outcomes in
Kuala Lumpur and Kuching, Malaysia. Asian Pac J Cancer Prev.
2010;11:969e974.
47. Norwati D, Harmy MY, Norhayati MN, Amry AR. Colorectal
cancer screening practices of primary care providers: results of
a national survey in Malaysia. Asian Pac J Cancer Prev. 2014;15:
2901e2904.
48. Harmy MY, Norwati D, Noor NM, Amry AR. Knowledge and
attitude of colorectal cancer screening among moderate risk
patients in West Malaysia. Asian Pac J Cancer Prev. 2011;12:
1957e1960.
49. Koo JH, Leong RWL, Ching J, et al. Knowledge of, attitudes
toward, and barriers to participation of colorectal cancer
screening tests in the Asia-Pacific region: a multicenter study.
Gastrointest Endosc. 2012;76:126e135.
50. Al-Naggar RA, Bobryshev YV. Knowledge of colorectal cancer
screening among young Malaysians. Asian Pac J Cancer Prev.
2013;14:1969e1974.
51. Haggar FA, Boushey RP. Colorectal cancer epidemiology: inci-
dence, mortality, survival, and risk factors. Clin Colon Rectal
Surg. 2009;22:191e197.
489
52. Sankaranarayanan R, Swaminathan R, Brenner H, et al. Cancer
survival in Africa, Asia, and Central America: a population-
based study. Lancet Oncol. 2010;11:165e173.
53. American Cancer Society. Colorectal Cancer Facts & Figures
2014e2016. American Cancer Society; 2014. Available at:
http://www.cancer.org/acs/groups/content/documents/
document/acspc-042280.pdf. Accessed 15.08.15.
54. Gul YA. Management of colorectal cancerdcan we do better?
Med J Malaysia. 2008;63:89e90.
55. International Cancer Screening Network. Inventory of Colo-
rectal Cancer Screening Activities in ICSN Countries. National
Cancer Institute; 2008. Available at: http://appliedresearch.
cancer.gov/icsn/colorectal/screening.html#malaysia.
Accessed 30.05.15.
56. Hilmi I, Hartono JL, Goh K. Negative perception in those at
highest riskdpotential challenges in colorectal cancer
screening in an urban Asian population. J Cancer Prev. 2010;11:
815e822.
57. Naing C, Jun YK, Yee WM, et al. Willingness to take a screening
test for colorectal cancer: a community-based survey in
Malaysia. Eur J Cancer Prev. 2014;23:71e75.
58. Wee CC, McCarthy EP, Phillips RS. Factors associated with
colon cancer screening: the role of patient factors and physi-
cian counseling. Prev Med. 2005;41:23e29.
59. Hwong WY, et al. National Healthcare Establishment and
Workforce Statistics (primary care), Ministry of Health,
Malaysia. National Healthcare Statistics Initiative; 2014.
Available at: http://www.crc.gov.my/nhsi/category/primary-
care-establishment-workforce/. Accessed 16.07.15.
60. Zavoral M, Suchanek S, Zavada F, et al. Colorectal cancer
screening in Europe. World J Gastroenterol. 2009;15:
5907e5915.
61. Yeoh KG, Ho KY, Chiu HM, et al. The Asia-Pacific colorectal
screening score: a validated tool that stratifies risk for colo-
rectal advanced neoplasia in asymptomatic Asian subjects.
Gut. 2011;60:1236e1241.
62. Edge SB, Compton CC. The American Joint Committee on
Cancer: the 7th edition of the AJCC cancer staging manual and
the future of TNM. Ann Surg Oncol. 2010 Feb 24;17:1471e1474.
63. Cancer Research UK. Bowel Cancer Survival Statistics; 2014.
Available at: http://www.cancerresearchuk.org/health-
professional/cancer-statistics/statistics-by-cancer-type/
bowel-cancer/survival. Accessed 09.07.15.
64. O’Connell JB, Maggard MA, Ko CY. Colon cancer survival rates
with the New American Joint Committee on Cancer sixth edi-
tion staging. J Natl Cancer Inst. 2004;96:1420e1425.