Colorectal Cancer Worldwide: WHO Perspective

In the latest Global Cancer Movement event by OncoDaily, Andre Ilbawi, Technical Lead for Cancer Control at the World Health Organization, discusses the urgent need to transform colorectal cancer care by addressing the disparities and challenges in prevention, detection, and treatment. Held from December 6-8, 2024, this session brought together experts to explore innovative strategies for combating one of the most underperforming cancers globally.

It’s a great privilege to be able to join you today on such an important occasion. This idea of how do we change the status quo is one that we need to be thinking about because for so many years, as I will reflect on shortly, we’ve been doing business as usual in cancer, and it has worked. We have made progress, but there are so many that are being left behind.

In the next 20 minutes, I want to spend a little time reflecting with you on this idea of a movement. That, again, is why OncoDaily should be applauded for thinking outside the box, because we do need to create a movement. Let’s start with that question of what does it mean to have a global movement?

Of course, implicit in the term movement is that we are working towards a specific target. Let us be very clear, what is it that we’re hoping to achieve? We’ll spend a few moments reflecting on that.

Then, how do we get there? There is always a challenge for us in the cancer community of achieving the balance between having a cancer-specific approach, breast cancer, cervical cancer, or treatment-based approach, radiotherapy, surgery. How do we get there without creating so much fragmentation in the cancer community?

Why a global movement for colorectal cancer? What are the types of specificities that we should be thinking about? Finally, what are some ways that we can get there faster?

What are the innovations that we’re expecting? What are the unexpected turns? How can we foster a community that enables those turns to happen?

What is the target? Let’s start again with that as the guiding principle. There are many political commitments to health, to NCDs, and of course, to cancer.

The one we use as a reference is universal health coverage, and also the sustainable development goal target to reduce premature mortality from all NCDs, including cancer. So we took a step back and looked at the current situation. How are we doing in cancer?

So reduction in premature mortality is supposed to be a way of saying, we want anyone who has cancer to avoid death, so death from cancer. We focus on measuring 30 to 69 because it is a proxy for what is happening more broadly with the impact of cancer. So let’s look at that population.

Let’s look at the trends in the past 20 years and how close we are to getting to our target for that one-third reduction by 2030. Unfortunately, there are very few countries on track. This is a theme that we will be repeating, and we hope it does not fall on deaf ears.

But the principle here is that we are not on track. And the reason we’re not on track is where we’ll spend a bit more time in the upcoming 10, 15 minutes. But we have to ask ourselves, what is it that drives premature mortality reduction?

And how can we reverse the trends, challenge the status quo in colorectal cancer, in cancer, in NCDs? So we took that question and tried to analyze it in detail, and we looked at all cancers. So we said, of all cancers, we can learn lessons by seeing which cancers are we seeing the fastest acceleration or decrease in premature mortality.

So we looked at different cancers, we looked at different income levels, we looked at different regions of the world. And not surprisingly, the countries that are doing best are high-income countries. So you can see that at the top of the figure in the center of the screen.

We also start to look by region. And on the whole, it is the regions where cancer has not historically been a significant epidemiologic burden of disease, that the progress has been the slowest. Now, let’s start looking between cancers, and let’s try to understand what is it that is driving premature mortality?

Is it better treatment? Is it screening? Is it prevention?

And so we looked at each cancer one by one and started analyzing at a global level, what really is driving that reduction in premature mortality? And effectively, there are three groups of cancers that we can look at. So the first are the ones in which premature mortality is decreasing the fastest, gastric and liver cancer.

Now, I think for our cancer community, this is a real challenge, because it’s saying to us, in fact, one of the reasons why high-income countries are achieving reductions in premature mortality, it is because the investments that they made in prevention from decades ago. So gastric cancer, yes, of course, we know that there have been improvements in treatment, but most of these reductions are happening because of reduction in incidence. The same thing is true with liver cancer.

And then there is the second cohort countries, or excuse me, cancers for which we’re making some progress, some due to prevention, some due to improved treatment. Again, cervix, improvement in prevention, early detection, lung, obviously the tobacco interventions from the past two decades in many of the high-income countries. And then of course, there’s the question of what about breast and colorectal?

So this is us. This is why today’s discussion is so important. Colorectal is the cancer that has seen the lowest decrease in premature mortality.

So we know what we’re moving towards. We have all governments, non-state actors, professional societies, we’ve made a commitment to reduce premature mortality, and colorectal is the most underperforming of all cancers. Let’s understand, again, a bit more, why is that the case?

So let’s go back to that first figure, understand which regions, which countries, and the good news is that in high-income countries, there is a prospect for success. So we can reduce premature mortality. You can see it’s in green, meaning overall, there’s a good trend to reducing deaths from colorectal cancer.

When we look at every other income level, when we look at so many of the regions across the world, they’re not only seeing the failure to decrease it at the one-third target, they’re seeing an increase in premature mortality. This is one of the very few cancers for which upper-middle-income countries, lower-middle-income countries, and low-income countries are all seeing the same phenomenon. More deaths, more cases, and unfortunately, worse outcomes.

Now, this is the challenge for the status quo. Regions, almost everyone outside of Europe and North America, all equally affected, and all to a significant negative extent. So we must ask the question, how are high-income countries achieving this?

And what are the paradigm shifts that we need to envision so this can also achieve countries around the world? The two hypotheses I will unpack, one is because of incidence, and the second is because of treatment or management strategies. So let’s explore that a bit more.

Is it, in fact, that it’s a reduce in incidence that is driving reductions in premature mortality? Well, unfortunately, not very much. If you look at total cases across the world, look how quickly colorectal cancer is increasing year over year.

Almost a doubling in a 15-year period. Mortality, same thing. So we can’t say is it incidence or mortality or both.

Unfortunately, for most countries around the world, incidence will go up and mortality will go up. But that’s not entirely true when we start looking at age-standardized incidence and mortality rates. So in many of the high-income countries, you see that there is, again, that plateau or decrease in age-standardized mortality rates.

That’s the middle figure. But we have to accept that there is an increasing incidence for so many countries and populations across the world. Now, why is it going up?

This is an interesting study that also was done by the Global Burden of Disease Group in Seattle, IHME. They looked at different factors, and the reason I put all factors here is because I think it’s interesting to reflect on them. I can pause for a second and ask if you want to take an estimation, which of the risk factors that you see on the left are the reason why incidence rates are increasing the fastest in countries around the world?

Looking at the list, I mean, obviously high BMI pops out. That’s one that we know. Alcohol and smoking, those are also important.

There was a huge discussion on red meat. There’s obviously, let’s keep colon health intact with fiber intake. So which of these is really driving it?

And the challenge is, it’s in fact all of them. What’s interesting is I’ve listed them in rank order. So the one that seems to be, according to this study that was published again in Atlanta now three years ago, one of the primary drivers is a diet low in calcium and in milk.

Very interesting findings. Tobacco high as a cause of colorectal cancer incidence increases in so many places. And that again explains why in high-income countries we’re seeing the decrease.

The low fiber intake, the red meat that we’ve been discussing about so much, those are important. We have to touch all of them in our community. We need again to challenge the status quo.

All of these risk factors are important for colorectal cancer. Now let’s look at survival management. We see that this is in the UK, the great work done by IARC as part of their Servemark.

When we look at the benchmarking of countries in survival, you can see in the green line on the left side that survival has improved about 15%. Now there are four reasons why survival improves. So this is not, we’re removing prevention, accepting that prevention is going to be a challenge.

Now let’s focus on what can help us improve management. So is it early detection? Is it improved treatment complexity, meaning new medicines on the market, new surgical techniques, new radiotherapy approaches?

Is it treatment quality, meaning in the past we would do incomplete receptions of a low-lying rectal cancer and now we’re able to do it more effectively? Or is it access? And now for a population like the UK, it’s generally not access, but at a global level, we must think about that as a primary driver as well.

Let’s take a look at the earlier detection. So the way we would identify this is looking at stage shifts over time. This is US and Germany.

You can see over the past 20 years, there in fact hasn’t been that much progress in stage shifting. It’s not to say that early detection is not a priority. It is always a priority, but we have to acknowledge the progress that we’re achieving has to be explained by more than just stage shifting.

And to reinforce it, let’s even look at the percent of distant disease. It’s gone up in that period. So stage shifting is a priority.

We know that’s the case. Immediately we’re going to ask ourselves, okay, let’s focus on screening. Screening is important and we should prioritize screening as part of this challenging the status quo.

We can’t have survival increasing if we’re only seeing screening participation rates at 10%, 15%. We need to hit those benchmarks of 70% or higher. But what’s interesting is what if we just focus on the current reality in the country here?

This is great data that was produced by the UK government where a fair percentage of people are being screened. What percentage of people are being diagnosed through screening? One would assume screening in the UK is 50 plus percent.

It should be quite high, right? But 9% of colorectal cancer cases in the UK are detected through screening. The reason we raised this again is because we have to look at the broader paradigm, the current status quo.

We must continue to focus on screening, but we have to realize that there are so many more pathways for us to detect cancer earlier. Avoiding situation where people are coming to the emergency room with an obstructing tumor in their colon. Avoiding the situation where someone presents to their primary care provider and they go through a two plus week wait or longer.

And obviously this is the one that we wanna focus on. Getting early and timely diagnosis through primary care. Is there a role for screening?

Yes. We can see it here. We’ll see it in many studies.

If a cancer is detected by screening, the outcomes are better. The stage is earlier. And for colorectal cancer, we can also see significant reductions in incidence.

So this again is an additional study from the Lancet that looked at trends in colorectal cancer screening in different UK countries and the impact that it has on incidence and mortality. What we see for non-colonoscopy screening populations, yes, they may detect it earlier, but compared to countries where colonoscopies are done, we don’t yet see that full acceleration in the decrease of the cancer incidence burden from colorectal cancers. And then quality.

So we’ve already said early detection, yes, important. Treatment complexity, yes, it’s important. How about treatment quality?

This is some very important data that was recently released in Nature that looked at what is the impact of resecting a primary tumor in someone who has metastatic disease. You can see that it has doubled survival for metastatic colorectal cancer. So it is in fact a major driver as is access.

This is a study we haven’t yet done in colorectal cancer. We just started looking at the data sets, but we did this in breast cancer. And the two cancers are quite similar.

If I could replace what I just said with breast and colorectal, the premature mortality as I was reflecting on the importance of prevention and early detection, all of it is relevant. So when I looked at this in breast cancer and said, what drives reductions in premature mortality from breast cancer? It wasn’t whether or not a country had a mammographic screening program.

What actually mattered is, does everyone have access? Meaning, is universal health coverage available in that country and treatment quality? Same message in breast, same message in colorectal.

And that’s where we need to focus on that and inequalities. Because inequalities, and I won’t spend much time on this, but we do need to flag that so many are being left behind in high income countries, middle income countries, and low income countries. And a lot of this has to do with health literacy and stigma around colorectal cancer.

So this will in fact change. This is a slide showing premature mortality trends. Looking at different education levels, you can see how quickly health literacy becomes a challenge.

So how do we address those types of structural aspects that discriminate against people who have lower health literacy, who live in rural areas, or who suffer from any other status as a vulnerable group? So we know our target. We need to reduce premature mortality.

How are we gonna do it? Access, equity, quality, and of course, continue to focus on early detection, including screening. How are we gonna get there?

So how are we gonna get there? This is something where we should spend some time reflecting, because the instinct again is let’s launch a global initiative for colorectal cancer. But that isn’t always going to work.

So we started with the discussion of what do we see in cancer? And then what do we see in colorectal cancer? We have to ask ourselves how much of this is being done because of cancer specific focus or because of health system strengthening through overall investments in cancer prevention and control.

And most of the data are showing us that when we invest in cancer agnostic to the cancer type, it can make a difference. It in fact will be the driver of reducing premature mortality from colorectal cancer. At the same point, every cancer has specificities that we should address.

Why do we talk about specificities? These are terms that you hear in the public health community. Let’s use the cancer as an entry point.

Let’s use it as a tracer. Let’s use it as a catalyst. These things are all important, but we have to ask ourselves what are we hoping to achieve by looking specifically at colorectal?

The answer is depends. There isn’t a single answer to this, but it is important to acknowledge that a cancer specific approach can accelerate progress. It can build momentum.

It can strengthen network. And it can also address some of the unique aspects of that specific cancer type. Cervical cancer, we know it’s about elimination.

Breast cancer, it’s about women’s health, access to medicines, screening. Childhood cancer, a unique population with special needs for a significant population impact. Lung cancer, tobacco, even bringing in AI and digital health and lung cancer because that’s a cancer in which there seems to be some of the most active work being done.

Prostate cancer, men’s health. So what is it for us in colorectal cancer that we should be thinking about? Is it a burden?

Okay, yeah, the burden is definitely an aspect. Is it the diagnostic approach? Yes.

We know that for colorectal cancer, it is more than just do you have access to a pathologist or to a radiologist. For colorectal cancer, we’re talking about multidisciplinary care. Do you have the proper endoscopy capabilities, whether it’s a gastroenterologist or a surgeon?

And of course, all of the other aspects that would be required for a timely diagnosis of colorectal cancer. So that is a specificity for us to think about. Now systemic therapy, unfortunately, there is not a unique treatment medicine for colorectal cancer that is obviously a need, but that’s not going to be our entry point to build momentum around colorectal cancer screening.

Same for radiotherapy. Other therapeutic interventions are obviously needed. For surgery, there is the interest in robots, but that’s not going to be the driver of why we should focus on colorectal cancer.

There’s another aspect to talk about, which is it is a unique community. And I’ll unpack a bit more what that means. What are the specific needs of people who have been affected by colorectal cancer?

So let’s take a step back and let’s look at, is there any evidence that colorectal cancer has been put in its right position given the disease burden that we had raised earlier? So let’s look at a few just reference statistics. Colorectal cancer, 97 countries in which it’s a top three leading cause of death from cancer.

Most cancer deaths and cases are not preventable, although cases can be prevented, as you know, with increased uptake of colonoscopy. As we shared earlier, the vast majority will not be detected through screening. And when we looked at benefit package, a point that I’ll share shortly, most countries are not prioritizing colorectal cancer.

They may prioritize childhood cancer, they may prioritize breast or cervix, but colorectal is not a high priority. So that is the consequence is that we don’t have a public health agenda around colorectal cancer. So let’s take that concept into proof.

One way that we can look at it is do we see a resolution for colorectal cancer? Is it included in political declarations? No.

Is it a best buy? Yes. We’ve already shown that at WHO that colorectal cancer management is a best buy.

But it hasn’t yet translated into specific political or financial commitments. So what’s the next step? How about in research and innovation?

You can see on the right, this is the cancer burden according, ranked according to mortality. Colorectal cancer is the second leading cause of death and I’m sure will impact the epidemiology of cancer more. How about research and innovation?

It should be high on the list. OK, it’s fourth. It’s not so bad, but it is not, again, reflecting where the colorectal cancer burden is.

So do we need to focus a bit more on research and innovation? Community concerns. This is an extremely interesting.

This is Google Analytics about website hits. So comparing breast and colorectal. Colorectal is about 50 times less addressed in our community than breast cancer.

It’s not a comparison. No one wants to rank cancers as to which one is the most important. But the principle is that colorectal cancer does deserve more attention.

It’s interesting also, and I won’t be able to go into detail, but you can see the spikes for breast cancer, just as a parenthetical point. That’s for October. So Breast Cancer Awareness Month.

Look at the power of advocacy. And yet look at colorectal. A very small wave on the bottom of the screen, not getting very much community attention.

And yet this is a population that lives, that can live under very difficult criticisms, stigma, concerns about body health and image. You can see up to 80% of people with colorectal cancer, particularly those that are managed with either a temporary or permanent ostomy, live with some body image distress. And this is not an uncommon phenomenon.

In the US, it is estimated here that at this exact moment in time, let’s say almost half a percent of Americans have an ostomy. But when you actually look it across entire lifetimes of people, it can be two, three, even 5% of people will have an ostomy at some point in their life. We should talk more about that.

We have to address the stigma of what people with colorectal cancer, and this has affected my personal family. My aunt didn’t want care because she feared living with an ostomy appliance. Why don’t we talk about that?

That is part of changing the paradigm, being honest to our community and accepting that there are difficult realities when you’re told you have colorectal cancer. Now let’s go for what’s on the horizon. What is it that is the areas of innovation?

Now, I won’t go very much into that because I know this is the point of the next few days as we discuss this in details. We have world-leading experts to hear from. What is it that we want to challenge ourselves with and say, how can we take that unexpected turn?

How can we drive innovation in a way that meets community needs? And that’s an area that I ask all of us to spend time on because yes, we know we want to reduce premature mortality. Yes, we know colorectal cancer is not a political priority and that there is sufficient justification to make it such.

But what is it that we think can happen that will change the landscape of colorectal cancer? What type of innovation is there? Now, again, before going into that in detail, let’s just look at the general principles.

One is let’s not just focus on rapid and dramatic paradigm shifts. Let’s think about how can we build on work that’s already being done? This is a high priority for us at WHO.

We’ve launched a campaign to better engage people affected by cancer. We will reflect a lot of these challenges with colorectal cancer in the Global Status Report, an area that we have been very pleased to talk about with valued collaborators like Dr. Gevorg. Let’s talk about building it into what already exists.

Let’s not just knock everything down and say we need to start afresh. Of course, we need to change the status quo, but let’s build on something that already exists and look at cross-cutting work streams to build into them. The second is even if it is a cancer and a cancer initiative by Dr. Joe or by other stakeholders that doesn’t look to be inclusive of colorectal cancer, let’s still bring ourselves there. There is likely a point of synergy. Breast cancer already showed early detection, screening early diagnosis interventions. Perfect synergies.

Cervical cancer, same thing. Very few cancers can you actually reduce incidents through a clinical or public health intervention. Colorectal and cervix, you can.

So how do we build into those narratives? How do we align with those cancer initiatives? So as we build global momentum, we’re doing so that also shows alignment and integration.

And then finally, how can we create and develop new strategic opportunities? Of course, that takes money, that takes momentum, that takes people power. All of that is needed.

And we should keep an eye on that because that will trigger the paradigm shift. At the same point, let’s also remember the approaches to collaboration one and two. So what does it mean to innovate?

Innovation. We should be focusing on breakthroughs that are fit for purpose. Now, I’m not saying CT colonography is useless.

You can see the CT colonography has been described as a promising technique for almost a decade. Now, when we look at how many people have been using CT colonography, it’s still less than 2% of all screening procedures done in the US. Now, or I should say, a few years ago, it almost approached 5%.

So 5% or less, still a minor screening technology. And it’s in part because we have to challenge ourselves with is this a technology that is meeting a care gap? Or is this a technology that is being applied because it may help?

There’s a distinction. One is innovation that happens because we have our target, our movement towards that target in mind. And another is, oh, maybe that will work for us also.

That’s a distinction in innovation we should be thinking about in cancer. There is an ad hoc approach to innovation and there’s intentional innovation. How do we drive intentional innovation?

And the best way to do that is start with what is it that our communities are asking us for in terms of meaningful early detection and treatment of colorectal cancer? Second, it is time to start looking at what are the systemic therapy needs in colorectal cancer. You can see data here.

Many of you are aware about the Avastin heralded as this game-changing medicine from now almost two decades ago. You can see how much is spent per year on Avastin and other anti-VEGF therapies. It’s not a criticism of those.

We know that the population impact hasn’t been huge. We still are lacking meaningful innovation. We need new therapeutic targets, new therapeutic approaches.

We need clinical trials that promote organ preservation. And this is something that’s happening a bit more in rectal cancer. How do we preserve organs, including the anus or the colon and rectum?

And also we need more than just this simple armamentarium that we have. We see CAR-T therapies emerging. We see immuno-oncology.

And yet time and time again, it is still a very small part of our armamentarium for colorectal cancer. So what is it that would drive a research agenda around colorectal cancer? We cannot ignore the realities that it’s such a huge impact of the disease.

And then finally, how do we innovate thinking about the social impact of cancer, the impact of people with colorectal cancer, anxiety, depression, stigma, the children that are left behind, the difficulty returning to work when you have an ostomy appliance and need to manage it, the distress, financial distress that people experience. These are very real. And this should help shape our agenda moving forward for more meaningful innovation.

Have it be community-driven. One last point from our side at WHO. It is a big year, 2025.

When you look at the political declarations from previous UN high-level meetings, you will see breasts, cervix get called out. Colorectal belongs on that plane. It is an important and a high-priority disease.

We cannot ignore it because of all the factors that have been discussed already. So we have months to influence it. And I think to follow me is a dear friend and source of inspiration, Dr. Ben Nicholson. I’m sure she’ll be introduced by Dr. Ravi. But I also want to acknowledge that she has been the brain trust of our community to lead forward. How do we transform the NCD and cancer agenda using these opportunities, these political processes?

It is an opportunity for us to take what we want in that paradigm shift to challenge the status quo, bring it to policymakers and include it in political declarations. The timeline is short. There’s been a long buildup process and it’s time for us to include colorectal cancer in a meaningful way and also driven entirely by community priorities.

Let’s put them at the middle and recognize that we need to have more people at the table. That is what will drive our success. So colorectal cancer, we need more.

We need more. We need more faster. We need not just financial investments.

We need human capital. We need ownership by the community. And that’s where it should start.

This is the foundation of any movement is are we meeting the needs of people who have been affected? And so how do we have those dialogues with them? How do we take decisions and influence the policymakers at the right time so it aligns with policy discussions, political dialogues and processes?

We are here. WHO, I know IAEA and IARC are also to make comments and interventions. Please know the UN agency has prioritized cancer again because of the leadership of Dr. Mickelson and many others. We are ready to have this discussion. And this is why we thank Uncle Daly for the privilege of being able to open this very important occasion. Please lean on us and we will lean on you.

This will need to be a community-based movement and we will have a sounding board within the UN to then take it to political actors and change and challenge that status quo. But we have to have priorities that are driven and that are set through forums like what we’re having in these days ahead. Colorectal cancer has that spot.

It has a very strong justification for not only talking about the cancer agenda but other aspects of the broader health agenda, whether it’s improvements in early detection through technologies like liquid biopsies, whether it’s improving the health literacy and addressing vulnerable communities or addressing the stigma around the diagnosis of colorectal cancer and the prospect of living with an ostomy. Let’s leave these priorities as shared priorities focused on a person-centered approach and bringing in all sectors.

Obviously, we say these in all meetings, but this is, if we are going to create the movement, this could be day one. So let us make sure it’s inclusive and participatory. And please, again, know that we at WHO stand with you, ready to have further discussions because the benefit is real.

There are millions of lives that can be impacted if we change and challenge the status quo. Thank you again for the privilege of speaking and I look forward to a productive discussion.