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Cover Story: Young at risk of colon cancer too

10-Mar-2011 (Thu) Mind Your Body, The Straits Times

Two to three out of every 100 patients seen at some hospitals here are below the age of 40. Experts want to draw attention to the rising number of patients across all age groups as part of Colorectal Cancer Awareness Month

By Lea Wee

More than 90% of colorectal cancers are caused by polyps, such as this one pictured here, which are abnormal growths that can be detected by colonoscopy. -- PHOTO: NUH

Every day for three months in 2009, Ms Loh Hui Ping passed blood in her stool. But she told herself it was nothing because there was no pain.

The medical social worker, now 22, recalled: 'I read on the Internet that blood in the stool could be due to colorectal cancer, but this usually happened to people over 50 years old. I didn't think it would happen to me.'

When she finally saw a doctor four months later in June 2009, she found out she did indeed have stage one rectal cancer (see other story).

Colorectal cancer is so uncommon in those under 40 that its warning signs tend to be ignored, said Associate Professor Tang Choong Leong, who is acting head of colorectal surgery at the Singapore General Hospital (SGH).

'Or they may dismiss blood in the stools for piles,' he said.

The concern is that when the cancer finally comes to light, they may not be as lucky as

Ms Loh and it may be advanced.

People under 40 made up two out of every 100, or about 14, patients with colorectal cancer seen at the SGH last year. The hospital takes in nearly half of all new colorectal cancer cases in Singapore.

At the National University Hospital (NUH), colorectal cancer patients below 40 years old also make up three out of every 100, or about five patients every year, in the last few years.

Across all age groups, there has been a rise in colorectal cancer cases, a consequence of changing lifestyles and, to a lesser extent, earlier detection, so awareness is important.

Latest figures from the Singapore Cancer Registry show that about 1,455 Singaporeans were diagnosed with the cancer every year from 2003 to 2007, a 19 per cent increase from the previous five years. About 638, or more than four out of every 10, colorectal cancer patients die every year.

Colorectal cancer, which affects the large intestine or the rectum, is the most common cancer here and the second most common in women, after breast cancer.

And Singaporeans, together with Americans, have one of the highest rates of colorectal cancer in the world, said NUH senior consultant colorectal surgeon, Assistant Professor Dean Koh.

He believes the high incidence among Singaporeans is partly a price paid for affluence. Rising incomes and the changing nature of jobs have given rise to sedentary lifestyles, obesity and a diet low in fibre and high in calories, red meat such as beef and processed foods such as canned food. All of these have been shown in overseas studies to put a person at higher risk of colorectal cancer.

The increase in the number of people with diabetes, another lifestyle-related condition, may also be contributing to the rise in colorectal cancer, he said.

Though the mechanism of how they are linked is not yet understood, a study by the National University of Singapore in the 2006 issue of the Journal Of The National Cancer Institute confirmed that those with diabetes are more likely to develop colorectal cancer.

Warning signs of colorectal cancer include blood in stools or a change in bowel patterns such as diarrhoea or constipation, or a feeling that the bowel does not empty completely.

But people should not wait for symptoms to appear, said SGH's Professor Tang.

He said: 'By that time, it is likely that the cancer would have spread to the lymph nodes or other organs.'

When this happens, surgery or taking out the affected part of the intestines alone may not be enough.

Treatment such as chemotherapy or radiotherapy might be necessary.

Rather than wait till symptoms show up, individuals should assess their own risk of colorectal cancer and go for the appropriate screening (see table).

A colonoscopy can detect polyps, which usually begin as benign abnormal growths in the colon, so they can be removed. More than 90 per cent of colorectal cancers are caused by polyps, which can take up to 10 years to turn cancerous.

The first risk factor is age, so anyone aged 50 and above should have a faecal occult blood test every year. The test requires them to collect a sample of their stool and send it to a laboratory to be tested for occult or hidden blood, which can indicate cancer.

If occult blood is present, a colonoscopy will be done to confirm cancer.

Last week, the Ministry of Health announced that those aged 50 and above can now use their Medisave funds to pay for a colonoscopy, which can cost around $1,500.

Hopefully, this will spur people who need it to have the procedure done, as the cost has proven before to be a stumbling block, according to a survey by the Singapore Cancer Society a few years back.

The second risk factor is family history. Professor Tang from SGH said that someone with a family member, specifically a parent or a sibling, who has colorectal cancer, is more than twice as likely to develop colorectal cancer as the average person. They should see a doctor and start screening before they turn 50 (see table).

These individuals will need a colonoscopy once every few years.

In a colonoscopy, a thin tube with a camera is inserted into the intestine through the anus to check for abnormalities.

However, most young people under 40 with colorectal cancer do not have a family history, said Associate Professor Charles Tsang, the head of colorectal surgery from NUH.

It is not known what causes them to contract cancer.

So to rule out the worst, it is best for young people to consult their family doctor if they have persistent bleeding in the stools or other bowel symptoms, said Professor Tsang.

One young patient, Mr Louis Ng, a part-time educator, was diagnosed with stage two rectal cancer in 1998, when he was 37.

He had his entire rectum removed and has lived with a stoma bag since then.

Like Ms Loh, he had blood in his stools for more than two months and thought it was piles. He tried a topical Chinese herbal ointment for three days, but the blood started to 'gush out like urine' each time he passed stool. On the third day, he blacked out for a few seconds at home and had to be rushed to hospital and given an emergency blood transfusion.

That was when he was diagnosed with the cancer. Now 49, the bachelor has had no relapses since and his doctor told him he is cured.

Mr Ng, who is the ambassador of the colorectal cancer support group at SGH, said: 'My advice to younger people out there is that, if you have blood in the stools, do not take it lightly. Go see a doctor.'

Blood in stool for three months

DIAGNOSED AT 20: Having survived stage one rectal cancer, Ms Loh (right) is happy to help others now as a medical social worker in a public hospital. -- ST PHOTO: MUGILAN RAJASEGERAN

Ms Loh Hui Ping was midway through her third and final year of studies in social work at the National University of Singapore. After graduation, she had planned to find a job that would help others.

She had a boyfriend and they had talked about marriage.

Her hopes came tumbling down in June 2009, when she found out she had rectal cancer.

She was 20 and though her father had died of lung cancer three years before, there was no history of colorectal cancer in her family, immediate or extended.

And yet, there was a tumour growing in her rectum, which had to be removed entirely.

After the removal of the rectum, which stores stool from the big intestine until it is ready to be passed out, her large intestine had to be re-attached to her anus.

To give the operation site time to heal, a loop of her small intestine had to be connected to a surgically created hole in her abdomen so that she could pass out stools into a stoma bag.

During the month that she lived with the bag, she never felt uglier. She stayed home watching television and hid the bag from the sight of her boyfriend.

Her life had started to unravel earlier that year. For three months, she passed blood in her stool every day. In April, the polyclinic doctor referred her to a colorectal surgeon at National University Hospital (NUH). She chose an appointment in June, after examinations in May.

A colonoscopy scan of her intestine then found a large polyp or growth in her rectum.

When she returned the following week, accompanied by her mother and her boyfriend, the doctor told her the biopsy sample was cancerous.

A week later, the polyp was removed and confirmed as stage one rectal cancer.

Ms Loh, now 22, recalled: 'My mother and I broke down again. All the questions were running through my mind - Why me? Am I going to die?'

With no easy answers forthcoming, she decided to face up to reality. The days immediately after the operation were some of the darkest of her life.

She said: 'I couldn't walk because the operation site was very painful. There were tubes in my stomach. The nights were the worst because I was alone.'

Fortunately, she is an optimistic person, she said. She pulled herself together with the help of her boyfriend and her mother, who quit her job as a company planner to look after her. Ms Loh also has a sister, now 18, and a brother, seven.

A month later, she had another operation to remove the stoma bag and re-route the loop of intestine to the rest of the digestive system.

She now sees the doctor every six months and has a yearly colonoscopy. Her mother, 47, went back to work last year.

Ms Loh's colorectal surgeon at NUH, Associate Professor Charles Tsang, said her cancer has less than a 5 per cent chance of returning.

Aside from occasional stomachaches after having spicy food and carbonated drinks, her health has returned to normal.

What has changed is her diet, which used to consist of instant cup noodles, snacks such as potato chips and processed meat like hotdogs.

Now, she eats more vegetables and fruit. She also climbs the stairs to her Housing Board flat on the seventh floor every other day.

She tries to live each day to the fullest and to enjoy life more.

She said: 'Now, I no longer procrastinate about the things I want to do.'

Her experience also influenced her choice of career as a medical social worker in a public hospital.

She hopes to marry her boyfriend, a 25-year-old human resource executive, and have children eventually, but she does not want to plan or hope for too much at this point.

She said: 'You never know if the cancer will return.'

(Click on the image for a larger view.)