CANCER CONTROL 2014 71
signs, faecal occult blood tests and appropriate referral. The
diagnosis of CRC in its early stages has immense potential to
improve survival, with 5-year exceeding 90% for stage I CRC.
Given the increasing burden of CRC in low- and middleincome countries7
, assessing symptoms by careful history
taking and physical examination and using early detection
tests such as iFOBT at the PC level are of paramount
importance in the early diagnosis and control of CRC in such
countries in view of the resource constraints in organizing
population-based screening programmes. However, the
challenge is that PC services in many low- and middle-income
countries are already over-crowded and over-extended with
a multitude of tasks added each year without matching
augmentation of resources provided to cope up with
increased demands for additional services. In middle-income
countries, with increasing risk of CRC, early detection
services for CRC at the PC level should be extended by
providing appropriate additional resources and in-service
training for the care providers, as has been shown in the
Lampang pilot introduction of CRC screening through PC
services in Thailand.13 l
Dr R Sankaranarayanan is trained in radiotherapy and clinical
oncology and is currently special adviser on cancer control, the
Head of the Early Detection & Prevention Section and the
Screening Group at the World Health OrganizationInternational Agency for Research
on Cancer (WHO-IARC)
Lyon, France. Dr Sankaranarayanan has a keen interest and
commitment in cancer control and health systems development
and response. He coordinates a global programme of research
including large randomized controlled screening trials, follow-up
and cross-sectional studies and training initiatives in affordable
and effective cancer early detection approaches, to catalyze
worldwide implementation of effective population-based early
detection programmes, particularly in low- and mediumresourced
Dr Parimal Jivarajani is the Head of Preventive Oncology at the
Gujarat Cancer Research Institute, Ahmedabad, India. He
coordinates early detection activities particularly for cervical
and breast cancer through primary care services in Gujarat. He
is actively involved in training and re-orienting primary care
workers in the early detection and prevention of cancer. He also
coordinates cancer control activities in the state of Gujarat and
he is involved in monitoring cancer incidence and outcomes
through operation-based cancer registration in urban and rural
areas of Gujarat.
Professor You-Lin Qiao, MD is Director of the Department of
Cancer Epidemiology at the Cancer Institute/Hospital of the
Chinese Academy of Medical Sciences & Peking Union Medical
College, Beijing, China and the Deputy Director the National
Expert Committee for Cancer Screening and Prevention in China.
He coordinates a large number of breast and cervical cancer
early detection studies in China and has contributed to the
development of the validation of rapid, accurate and affordable
HPV tests for the early detection of cervical neoplasia. His
research efforts have led to the rolling out of large populationbased breast
and cervical screening programmes in China.
1. World Health Organization 1978. Primary Health care. Report of the International
Conference on Primary Health Care. Alma-Ata, USSR, 6-12 September 1978. Geneva:
2. O'Donnell CA. Variation in GP referral rates: what can we learn from the literature?
Fam Pract 2000;17:462-71.
3. Sullivan CO, Omar RZ, Ambler G, et al. Case-mix and variation in specialist referrals in
general practice. Br J Gen Pract 2005;55:529-33.
4. Rule J, Ngo DA, Oanh TT, et al. Strengthening Primary Health Care in Low- and MiddleIncome Countries: Generating
Evidence Through Evaluation. Asia Pac J Public Health
5. Ferlay J, Soerjomataram I, Dikshit R, et al. 2013. GLOBOCAN 2012 v1.0, Cancer
Incidence and Mortality Worldwide: IARC CancerBase No. 10 [Internet]. Lyon: IARC
6. Forman D, Bray F, Brewster DH, et al. 2013. Cancer Incidence in Five Continents, Vol.
X (electronic version). Lyon: IARC. http://ci5.iarc.fr
7. Jemal A, Center MM, DeSantis C, et al. Global patterns of cancer incidence and
mortality rates and trends. Cancer Epidemiol Biomarkers Prev 2010;19:1893-907.
8. Hamilton W, Sharp D. Diagnosis of colorectal cancer in primary care: the evidence base
for guidelines. Fam Pract 2004;21:99-106.
9. Jones R, Latinovic R, Charlton J, et al. Alarm symptoms in early diagnosis of cancer in
primary care: cohort study using General Practice Research Database. BMJ
10. Jellema P, van der Windt DA, Bruinvels DJ, et al. Value of symptoms and additional
diagnostic tests for colorectal cancer in primary care: systematic review and metaanalysis. BMJ
11. Adelstein BA, Macaskill P, Chan SF, et al. Most bowel cancer symptoms do not indicate
colorectal cancer and polyps: a systematic review. BMC Gastroenterol 2011;11:65.
12. Lawrenson R, Logie J, Marks C. Risk of colorectal cancer in general practice patients
presenting with rectal bleeding, change in bowel habit or anaemia. Eur J Cancer Care
(Engl ) 2006;15:267-71.
13. Khuhaprema T, Sangrajrang S, Lalitwongsa S, et al. Organized colorectal cancer
screening in Lampang Province, Thailand: Preliminary results from a pilot
implementation programme. BMJ Open (in press).
14. Wolin KY, Yan Y, Colditz GA, et al. Physical activity and colon cancer prevention: a
meta-analysis. Br J Cancer 2009;100:611-6.
15. Gingras D, Beliveau R. Colorectal cancer prevention through dietary and lifestyle
modifications. Cancer Microenviron 2011;4:133-9.