Key Facts and Figures:
According to the Ministry of Health's National Cancer Registry and National Center for Disease Control statistics:
In 2011, 3,259 new patients were diagnosed with invasive colorectal cancer, and 1,247 patients succumbed to the disease in 2011.
Incidence - colorectal cancer incidence rates have decreased among the Jewish population (women and men) over the past two decades. An increase in incidence rates has been observed among the Arab population (women and men), however, there has been a trend towards stabilization over the past five years.
Early detection - Early stage diagnosis of the disease has nearly doubled over the past two decades (from 20% to 39%), as a result of widespread public information and education activity, and an increase in public awareness.
Survival - there has been an upward trend in colorectal cancer survival rates, both among men and women and among both populations - Jewish and Arab.
Mortality rates - there has been a decline in colorectal cancer mortality rates over the past two decades among the Jewish population. Among the Arab population, there has been an upward trend in colorectal cancer mortality rates, however, a trend towards stabilization has been observed over the past five years, and there has been a decline over the past two years.
In 2012, the national compliance with colorectal cancer screening tests stood at 54.1% of the target population (ages 50-74), and is on the rise compared to previous years.
The colorectal cancer screening compliance rates, as per 2012, according to a distribution by healthcare funds, gender, age, and socio-economic status, are published in a Report issued by the National Program for the Quality Indicators in Community Healthcare in Israel of the Ministry of Health, the Israel National Institute for Health Policy and Health Services Research and the National Health Council, in addition to national statistics.
Who are the "non-screeners" who refuse to comply with colorectal cancer screening tests? Several new studies that have been conducted recently in Israel characterize the compliance, knowledge, attitudes and factors that have an impact on family members of cancer patients upon undergoing a colonoscopy.
In this study, it also emerged that a significant percentage (about a fourth) of the patients who had positive fecal occult blood test results refused to undergo a colonoscopy to identify the finding, as required.
The Ministry of Health's Cancer Registry and National Center for Disease Control presented the following statistics:
Colorectal cancer is the second most common cancer in Israel. In 2011, 3,259 Israelis were diagnosed with invasive colorectal cancer, of whom 1,456 were Jewish men, 1,391 were Jewish women, 129 were Arab men, 124 were Arab women, and the remaining patients were defined as "others" (Christians and individuals who are religiously unaffiliated).
According to Dr. Lital Keinan-Boker, Deputy Director of the National Center for Disease Control of the Ministry of Health, the incidence rates in 2011 were lower than those observed among men (23% drop) and women (21% drop) in 1990. The main decline has been observed since the mid-2000's. Among the Arab population, there has been an increase in incidence rates in comparison to the rates observed in 1990 (in men there has been a 168% increase and in women a 126% increase). However, over the past five years, incidence rates have remained stable among the Arab population, and over the past two years a downward trend in incidence rates has been observed among this sector.
Relative survival rates have increased by 20%, both among Jewish men and among Jewish women (increasing to 67% in men and 66% in women), in Arab men there has been a 15% increase (to 61%) and in Arab women, a 24% increase (to 57%).
Similarly, it has been reported that the mortality rates in the Jewish population and in Arab women in 2011 saw a decrease as compared to rates observed in 1990. In Arab men, the mortality rates recorded in 2011 exceed those observed in 1990.
International comparison: Colorectal incidence and mortality rates in Israel were compared to those of 20 countries with the highest rates worldwide, through the Globocan database of the International Agency for Research on Cancer (IARC), for 2012. This comparison reveals that Israeli men rank 14th in colorectal cancer incidence rates worldwide, and 19th in global mortality rates. Israeli women rank 8th in colorectal cancer incidence rates worldwide and 10th in global mortality rates.
Please click here to view the complete report (in Hebrew).
Compliance with colorectal cancer screening tests:
According to a report issued by the National Program for the Quality Indicators in Community Healthcare in Israel of the Ministry of Health, the Israel National Institute for Health Policy and Health Services Research and the National Health Council for 2010-2012, in 2012, 54.1% of the target population (ages 50-74) underwent a colorectal screening test (fecal occult blood test over the past year, or a colonoscopy over the past 8 years).
The screening compliance rate has been steadily rising over the years: a compliance rate of nearly 30% was reported in 2007, in 2008, the compliance rate rose to nearly 32%, in 2009, it was reported that a third of the target population underwent screening, and in 2010, the compliance rate rose to 48.6%, to 50.7% in 2011, and as mentioned, to 54.1% in 2012.
The screening compliance rate increases with age, from 48.0% among 50-59 year olds, 59.4% among 60-69 year olds, and 61.6% among 70-74 year olds.
The screening compliance rate among women is 55.5%, and it is slightly higher in comparison to the compliance rate among men, 52.4%.
The quality indicators report for 2012 delineates the screening compliance rates according to a distribution by healthcare funds, gender, age and socio-economic status, which is established according to entitlement to an exemption or discount off the deductibles upon receiving health services.
New research studies that have been compiled by the Israel Cancer Association Information Center:
Do individuals with a family history of colorectal cancer adhere to medical recommendations for the prevention of colorectal cancer?Relatives of colorectal cancer patients - "the non-screeners", the "non-adherent screeners" and the "adherent screeners" relatives who comply with screening tests.
Karen Bronner, Ilise Mesters, Ahuva Weiss-Meilnik, Ravit Geva, Guy Rozner, Hana Strul, Moshe Inbar, Zamir Halpern, Revital Kariv
Three new research studies conducted by investigators from Tel Aviv Sourasky Medical Center and Maastricht University, The Netherlands, reviewed diverse issues among 318 siblings (males and females), and children of colorectal cancer patients, who are entitled to a colonoscopy test under the health basket, and who, theoretically, are supposed to adhere more than any other population sector to medical recommendations, in view of their increased risk of developing the disease.
The first study examined determinants of adherence to screening by colonoscopy in first-degree relatives of colorectal cancer patients and their adherence to healthy lifestyle behavior recommendations.
The research study revealed that:
46% of the sample of participants did not undergo any early detection screening for colorectal cancer ("non-screeners"), about 14% of the subjects underwent a colonoscopy for the following symptoms: a change and/or irregularity in bowel habits, rectal bleeding ("the "diagnostic screeners").
About 17% underwent screening tests while not adhering to any specific medical recommendations ("the non-adherent screeners"), and in fact, only 23% of first-degree relatives underwent a colonoscopy screening according to medical recommendations ("the adherent screeners").
Regarding the adoption of healthy lifestyle behaviors to prevent colorectal cancer:
Nearly a fourth of the sample defined themselves as smokers, a fifth reported a high calorie diet, rich in fat, and about 80% did not succeed in adhering to guidelines regarding the recommended daily intake of fruits and vegetables.
Similarly, about half the sample did not engage in any physical activity whatsoever and only about a fourth of the respondents adhered to the standard guidelines for 150 minutes of moderate physical activity a week and/or 75 minutes of intense physical activity a week. Moreover, a significant positive correlation emerged between maintaining a healthy lifestyle and adherence to screening for the early detection of colorectal cancer.
The majority of relatives of colorectal cancer patients do not undergo periodical screening tests as recommended, and do not adhere to medical recommendations for the maintenance of a healthy lifestyle, which may potentially protect them for contracting the disease.
This research study was published in Familial Cancer in 2013.
Please click here to view the study.
The second research study conducted by the same group of investigators, headed by Karen Bronner, focused on knowledge and attitudes of first-degree relatives (318) of colorectal cancer patients.
The findings show that all the sample participants (99%) were aware of the familial history of the disease; most of them knew about it from the relative who had colorectal cancer (over 70%).
About a third of the sample was of the opinion that the disease may not be prevented, and about a fourth believed that the disease may be detected only if there are apparent symptoms.
40% of the respondents were unaware of all the risk factors for the disease, and did not know exact details concerning screening tests (they erroneously believed that the screening test was not included in the health basket, and that a colonoscopy requires hospital admittance, and had other erroneous assumptions).
Additionally, the disease is perceived as a male disease (despite the fact that there are no significant differences in incidence between men and women).
Exposure to the subject: 40% reported that they had never read about the subject, and over a half of the sample never received a recommendation from medical staff to go to get screened.
Self-risk perception: 53% of the respondents defined themselves to be at low risk of developing the disease in the future.
The investigators indicate that there are knowledge discrepancies and erroneous assumptions regarding colorectal cancer, and the ways of preventing it, among relatives of colorectal cancer patients. Similarly, there are negative emotional attitudes regarding the utilization of colonoscopy, such as; shame, discomfort, fear of screening and its results, alongside barriers such as lack of availability, time, and money (despite the fact that as mentioned, a colonoscopy screening test is included in the health basket for relatives [of colorectal cancer patients]).
The research study was conducted at the Department of Gastroenterology and Liver Disease at Tel Aviv Sourasky Medical Center. The following are segments from the research study which was published in the Patient Education and Counseling Journal in 2013.
Please click here to view the research study in Hebrew.
In the third research study, Determinants of adherence to screening by colonoscopy in individuals with a family history of colorectal cancer, the investigators, headed by Karen Bronner, examined the factors that have an impact on the utilization of colonoscopy among relatives of colorectal cancer patients according to the Integrated Model for Behavioral Change (I Change Model).
The investigators concluded that prevention and intervention efforts should be invested in young first degree relatives of colorectal cancer patients, those of low socio-economic status, who lead an unhealthy lifestyle, and underutilize preventive medicine and early detection screening tests.
This research study was conducted at the Department of Gastroenterology and Liver Disease at Tel Aviv Sourasky Medical Center and was published in the Patient Education and Counseling Journal in 2013.
Please click here to view the study (in Hebrew).
Another research study that was conducted at the Rabin Medical Center also underscores the significant role played by the physician in monitoring test results for patients who have undergone early detection screening, and encouraging patients who received a positive finding to continue to identify the finding.
It turns out that over 25% respondents who received a positive fecal occult blood test did not undergo a colonoscopy as required.
Characterization of patients with a positive fecal occult blood test:
Investigators: Prof. Yaron Yaniv, Dr. Lev Lichtenshtein, Dr. Yelena Klenner, Dr. Zohar Levi, Dr. Dorit Erlich.
Patients with a positive fecal occult blood test are at 30%-50% risk of a colorectal lesion finding - in most cases benign polyps, and in a minority of cases, a cancerous finding. These patients are referred for a colonoscopy, which is included in the health basket, but a significant portion of them do not utilize this screening test within a reasonable amount of time.
As part of the research study that was conducted at the Gastroenterology Dept. at Rabin Medical Center, Clalit Healthcare Services, there was an attempt to find patients with a positive fecal occult blood test result, who did not undergo a colonoscopy for continued clarification/monitoring, and to actively refer them for a screening. Similarly, there was an attempt to convince the "non-screeners" to undergo a follow up test.
Among the insureds with a positive finding, 64.3% - 1,025 men and women underwent a colonoscopy screening as a follow up test to identify the positive finding.
The research study, which examined the characteristics of patients who had a positive fecal occult blood test result, but did not undergo a colonoscopy, focused on 316 patients: 94 of whom (29.7%) recently underwent a colonoscopy that preceded the utilization of the fecal occult blood test.
As for the rest, 70.3% - 222 men and women, the argument for non-utilization of the critical test was the following: an error in referral for the test (17.2%), unknown (20.2%), severe chronic disease (5.7%), child (2.5%), advanced dementia (2.8%) or deceased (1.9%). 80 patients - 25.6% who constituted the large group, refused to undergo a colonoscopy to clarify the positive fecal occult blood test.
In short, it is important that the attending physician monitor the utilization of the screening test in the case of a positive finding.
Excerpt from the "Quality at Clalit Healthcare Services" 2013 Conference Poster.
Please click here to view original poster (in Hebrew).
Does adding folic acid to one's diet prevent colorectal cancer?
In recent years, a decline in incidence rates of colorectal cancer has been observed in the United States, despite increasing prevalence of colorectal cancer major risk factors, including the Western dietary pattern and obesity.
This decline can be partly accounted for by the utilization of screening tests, a general decrease in the number of smokers and consumption of calcium and aspirin supplements, however this explanation does not suffice and the investigators assume that there is an additional protective factor.
In this study, investigators from the Department of Nutrition and Epidemiology, Harvard School of Public Health, Harvard University, U.S., raised the hypothesis that the increase in the levels of folic acid among the population in the United States, led to decreasing morbidity.
This increase derived from the adoption of the U.S. Food and Drug Administration (FDA) regulations, which required folic acid fortification of flour and cereals. Folic acid is the synthetic form of vitamin B9 which is administered as a food supplement, while vitamin B found naturally in foods is called folate.
The investigators participating in this study collected data from a data base of the U.S. National Cancer Institute, on colorectal cancer incidence over a period of 34 years - from 1975 to 2009 by age, ethnic background and gender.
In the data analysis, the investigators took several facts into account: the long induction period between the increase in folate levels in the body and the potential development of colorectal cancer, an increased early detection of intestinal polyps which led to a decrease in colorectal cancer incidence over the years, changes in the FDA regulations in 1973, when it increased the daily maximum dose of folic acid allowed in supplements and food to 400 µg, and the establishment of a regulation at the end of the 90s, which required folic acid fortification of flour and cereals due to congenital defects in the nervous system of the early embryo.
Aside from the statistical analysis of the above data, the investigators quote a Chinese study that was recently conducted, which found that among study participants who had a low folate intake, a supplement of 1000 mg per day of folic acid, reduced the risk of developing intestinal polyps. Polyps are intestinal tumors which constitute a significant risk factor for the development of colorectal cancer.
The research investigators establish that adequate folic status, particularly between the ages of 45 and 64, may constitute a protective factor against the development of colorectal cancer in later life. Fortifying foods with folic acid may account for the downward trend in colorectal cancer incidence in the United States.
This research study was published in the March 2014 issue of the American Journal of Preventive Medicine.
What is happening in Israel?
As early as 2001- the Ministry of Health considered fortifying bread with folic acid and vitamins.
According to an interim draft of the "National Program for the Promotion of a Healthy Lifestyle of the Ministry of Health, 2012": "In Israel it was established that there is a need for the mandatory fortification of flour designated for the manufacture of bread so that it will reach the majority of the population, and will provide folic acid and additional essential nutritional ingredients. The ingredients included in the mandatory fortification are thiamin, riboflavin, niacin, folic acid and iron, as well as the possibility of fortification with pyridoxine, pathogenic acid, magnesium and calcium. A draft of the regulations will be sent to the public for comments/feedback towards the end of 2012".
Please click here for a link to the complete study (in Hebrew)
In 2014, the Ministry of Health and the Ministry of Education began a joint pilot project for the fortification of food among the Bedouin population. In the United States, the fortification of flour with folic acid is ingrained in the country's legislation.
Internet use and cancer-preventive behaviors:
Investigators from the Universidade do Sul de Santa Catarina, Brazil, and University College of London, London, United Kingdom, examined the association between internet use as a source of health information, and cancer-preventive behaviors among older adults in the United Kingdom.
5,943 men and women 50 years or older participated in the 8-year research study in Britain, from 2002 to 2011. The investigators collected information about internet use patterns, demographic data about the respondents and data about their cognitive and physical status. Similarly, the rate of their compliance with screening tests for the early detection of breast and colorectal cancer was also examined, according to the recommendations of the British Health Services, the rate of their engagement in physical activity, fruit and vegetable consumption, and smoking status.
Of the overall respondents, 41.4% did not report any Internet use ("never users"), 38.3% reported using it in one to three waves ("intermittent users"), and 20.3% used it in all waves ("consistent users"). Internet use was 41% higher in male respondents than in female respondents. White, 50- 59 year old, more educated, and wealthier men figured more prevalently among the consistent users of Internet. Similarly, there were proportionally more people with higher cognitive function and without physical limitations than others among consistent users.
The research data indicated a positive significant association between Internet use and the adoption of cancer-preventive behaviors:
Colorectal screening tests were conducted among overall respondents of ages 62 to 69, by 72.9% of the consistent Internet users, 62.5% of the intermittent users and 51.7% of the never users.
Moderate to vigorous physical activity was carried out on a weekly basis among 88.3% of the consistent users, 77.9% of the intermittent users, and 59% of the never users.
A high fruit and vegetable intake on a daily basis was observed among 62.6%, 59%, and 52.9%, respectively proportionate to Internet use, and current smoking status was 6.6%, 11.4%, and 13.3%, respectively.
It further emerged that the more routine and the longer the Internet use, the greater the amount of information to which the individuals [Internet users] were exposed about the ways of preventing cancer and consequently, the chances of their adherence to cancer-preventive behaviors increased, compared to non-Internet users. Among women ages 58 to 72, the rates of compliance with mammography screening were higher in all groups, regardless of the scope of Internet use.
The investigators emphasize that in the future, the use of Internet as a tool for delivering health information may become more prevalent, and therefore call upon the health establishment to promote Internet use among the aging population of a diverse socio-economic background. Nevertheless, they also caution against the quality of Internet-based information, which for the most part is uncontrolled, and as such, may contradict evidence-based messages about cancer. The investigators suggest that information skills be honed among users so that they may evaluate health-related information; additionally, they recommend that additional research studies be conducted to evaluate the association between Internet use patterns and cancer-preventive behaviors.
This research study was published in the November 2013 issue of the Cancer Epidemiology, Biomarkers & Prevention Journal.
Are there gender differences in attitudes impeding the utilization of screening for the early detection of colorectal cancer?
Barriers and erroneous perceptions prevent or impede female and male populations from undergoing colorectal cancer early detection tests. Investigators from Canada sought to examine the differences between females and males in terms of these perceptions.
The investigators called 4,459 people in Ontario, Canada, who meet the criteria for the utilization of screening tests for colorectal cancer, ages 50 or older, who never underwent any colorectal cancer screening tests prior to the study, and are entitled to undergo the various tests free of charge: fecal occult blood test, sigmoidoscopy, (enables the examination of the inside of the large intestine from the rectum through the last part of the colon) and colonoscopy (examination of the entire colon).
The investigators indicated the great difficulty in recruiting interviewees for the research study, only 81 individuals, 49 women, ages 51 to 84, and 32 men, ages 50 to 77, agreed to be interviewed. The difficulty was observed particularly among men. The investigators classified subjects according to three groups, according to their attitudes regarding screening: those who were completely unaware of the modalities, those who had not yet decided which test to undergo, and those who made a decision to take a specific test. Standard explanations were given in cases in which it was observed that the interviewees lacked information or had erroneous information about the various modalities.
Based on this study, it emerges that among both genders, the number of interviewees who belonged to the group of those who are completely unaware of the modalities and those who have not yet decided which test to take, was significantly higher than those who had made a decision to undergo a specific test. For example: 66.3% of the women and 65.6% of the men were unaware and were undecided as to obtaining fecal occult blood test screening, as opposed to 34.7% and 34.4% respectively, who had decided to obtain screening.
Similarly, a high percentage of men, as compared to women, were unaware of various modalities: for instance: fecal occult blood test - 31.2%, sigmoidoscopy - 34.4%, and colonoscopy - 34.4%, while among women - 8.1%, 8.1% and 6.1% respectively.
The interviews and data processing show that among women there were feelings of anxiety and concern in relation to the bodily intrusion of the colonoscopy and sigmoidoscopy tests, anxieties specific to physical injury, such as perforation of the intestines, embarrassment in relation to medical professionals, and revulsion in relation to the fecal occult blood test for hygienic reasons. The men's responses indicated a tendency toward stalling (a tendency toward deferring the task of completing screening) and procrastination due to fatalism about incurable cancer, a disbelief in the necessity of screening for a currently non-existent disease, and objection to being in a vulnerable role position.
To conclude, the investigators recommend future intervention which will focus on exploring ways to reduce anxiety among women, as well as means of overcoming procrastination among men.
This research study was published in the May 2013 issue of the BMC Public Health Journal.
During the month of March, the ICA will hold various activities to increase prevention and early detection awareness as well as to heighten awareness about therapeutic modalities for colorectal cancer:
A seminar on colorectal cancer will be held on March 12 2014, free of charge, for patients, survivors and their families at ICA Headquarters in Givatayim, starting at 9.30.
The seminar will be held courtesy of Roche Pharmaceuticals which initiated the "Roche Lends a Hand to Patients" Project.
Please click here for more details about the seminar (in Hebrew)
An additional Colorectal Cancer Awareness Seminar will be taking place in Beer Sheva on March 23, 2014 at Soroka Medical Center, "Stern" Hall. The seminar, geared towards patients, survivors and their families, will be held free of charge.
The seminar has been made possible thanks to the generous support of the "Roche Lends a Hand to Patients" Project.
Please click here for more details about the seminar (in Hebrew)
Additionally, the ICA will hold an extensive public information campaign via the various media channels, in the written press, and on the Internet during the month of March; this media campaign will focus on the importance of early detection.
Callers may receive information over the phone or written information free of charge from the ICA Telemeida Tele-Information Center.
Informations: Tel: 1-800-599-995 and on the ICA website.