A chain is only as strong as its weakest link: Care pathways in colorectal cancer, from emergency interventions to preventive strategies

The Great Wall of China (Wànlĭ Chángchéng, which means Ten-Thousand Mile Long Wall), is one of the largest human architectural structures ever built in the world and spans more than 21,000 km in length extending from the Bohai Sea in the east to the Gobi Desert in the northwestern part of China [Figure 1a and b]. The Great Wall of China was constructed over a period of more than 2000 years. In fact, the Great Wall of China is not a single wall but a succession of walls present sometimes in parallel, towers, fortresses, and natural barriers like rivers and hills.Figure 1: (a) The great wall of China is a series of walls in succession that exist sometime in parallel consisting of towers, fortresses, and natural barriers like rivers and hills. AI-generated image using Grok. (b) The great wall of China spans more than 21,000 km in length and extends from the Bohai Sea in the east to the Gobi Desert in the northwestern part of ChinaAlthough the wall had multiple functions including border and trade control, the main reason for its construction was for the defence against invasions from neighboring nations. The Great Wall of China was not foolproof and failed to serve its main function at times due to numerous factors including its length requiring enormous resources to build, maintain, and patrol. In certain periods, soldiers guarding the wall were underpaid, overworked, or left without supplies, creating willingness to collude with invaders. Additionally, internal conflicts and political tensions within the Chinese dynasties deviated resources from border defense, weakening the wall’s effectiveness. These system-based failures affecting the function of the Great Wall of China could be used as case studies for other processes including that in healthcare systems. In 2017, the third ranking cause of disability-adjusted life-years in Saudi Arabia was neoplastic diseases, which has been progressively increasing over recent years.[1] In the case of colon cancer, this is despite the availability of national guidelines for colorectal cancer screening,[2] which is due for an update, and one cost-effectiveness study that demonstrated colorectal cancer screening is worthwhile, even in the context of relatively low-age-adjusted incidence of colorectal cancer in Saudi Arabia compared to other countries.[3] These economic-based studies have assumptions, and when they are not met, these models fall apart. The Ministry of Health in Saudi Arabia has set up a national screening program with the aim of curbing recent increase in neoplastic disease incidence for both colorectal cancer and breast cancer. There are numerous studies that attempted to measure different facets of care pathways for colorectal cancer screening or colorectal cancer spectrum in Saudi Arabia including public perception of colorectal cancer screening,[4] results of a healthcare system-based colorectal cancer screening program using high-sensitivity guaiac-based-fecal occult blood test,[5] incidence of colorectal polyps in screening colonoscopies,[6-8] colonoscopy quality metrics,[9,10] outcomes of surgery,[11] chemotherapy,[12] and surveillance after resection.[13] Some of the results and challenges that have been realized in rolling out the national program for colorectal cancer screening in Saudi Arabia have been reported.[14] Furthermore, for the first time, the National Cancer Center at the Saudi Health Council published its national cancer survival report for the period of 2005 to 2019.[15] The report showed that the age-standardized 1-year net survival was the highest for colorectal cancer and worst for pancreatic cancer, as expected, when focusing on gastrointestinal cancers and there were no appreciated differences between males and females [Figure 2a and b]. A similar picture was seen for the age-standardized 5-year net survival [Figure 2c and d]. What is concerning is the lack of improvement in survival when looking at the 1-year and 5-year survival rates comparing different time periods for the various gastrointestinal tumors and even a lower 5-year survival rate for males with rectal cancer in the period from 2015 to 2019 compared to those diagnosed in 2005 to 2009. There are various arguments and speculations on why this might be, and even if it is true to start off with, given the various challenges in capturing data in the current healthcare system and possible unmeasured confounders. A similar concern is raised given the declined survival rate of patients with colon cancer who have distant metastasis during 2015 to 2019 compared to those diagnosed in 2005 to 2009 [Figure 3], which is an area that should be investigated.Figure 2: (a) Age-standardized 1-year net survival for gastrointestinal tumors in Saudi Arabia by stage over 15 years (2005–2019). (b) Age-standardized 1-year net survival for gastrointestinal tumors in Saudi Arabia by stage over 15 years by sex (2005–2019). (c) Age-standardized 5-year net survival for gastrointestinal tumors in Saudi Arabia by stage over 15 years (2005–2019). (d) Age-standardized 5-year net survival for gastrointestinal tumors in Saudi Arabia by stage over 15 years by sex (2005–2019)Figure 3: Age-standardized 5-year net survival and 95% confidence intervals for colon cancer in Saudi Arabia by stage over 15 years (2005–2019) (Number included in the analysis 14,565 cases, males 7809, females 6756)[ 15 ]In this issue of the Saudi Journal of Gastroenterology, the study by Alhassan et al.[16] looked at the impact of emergency versus elective presentation on surgical outcomes in colon cancer. The authors showed that in emergency procedures, the outcomes were, as expected, less favorable in the surgical, outcomes, as well as postoperative care. Residual confounding always remains an issue in such studies given the methodology and might include surgeon expertise, perioperative care protocols, and variations in patient comorbidities; this may not be captured by the ASA score alone. Nonetheless, this study adds to the local data that reinforce the fact that in the care for patients with colorectal cancer, the best intervention is working upstream on modifying risk factors and screening for colorectal cancer to detect and prevent disease early in its course where clinical outcomes are more favorable [Table 1].Table 1: Part of a framework for colorectal cancer screeningThe Great Wall of China was not built in a day, and failure of the Wall resulted from a combination of physical limitations, strategic vulnerabilities, and the human element. This shows that a physical barrier alone is not sufficient for defense without a strong and well-supported military and a cohesive political structure. Thus, the analogy of the Great Wall of China could be barrowed in our instance and a similar conclusion could be made about a colorectal cancer screening program that will take time to rollout and scale and will need constant iterations and adaptations to the ever-changing healthcare landscape. Furthermore, introducing technologies would improve workflows, processes, outcomes, and the patient journey through the healthcare system. There are various risks that could mitigate the effectiveness of the colorectal cancer screening program and could become an access cost with no real impact on the healthcare system.

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