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Friday, 10 March 2017 16:29

An overview of the epidemiology and local health services offered for colorectal cancer – Part I

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Kathleen England, Dorianne Farrugia, Dominic Agius, Miriam Dalmas




Colorectal cancer is the second most common cancer in Malta. On average, between 2012-2014, 259 persons have been diagnosed with colorectal cancer and 110 persons died each year. It is a disease of the Western world. The need to target colorectal cancer from prevention through physical exercise and healthy eating, to earlier diagnosis and treatment, through organised screening programmes and fast track referral systems and advanced treatment protocols is crucial to reduce incidence and improve survival.




Colorectal cancer accounts for 9.7% of all cancers worldwide (excluding non-melanotic skin cancer). It is the second most common cancer in Europe and third most common cancer in the world.1 It is far more common in the Western world with age standardised incidence rates being highest in Europe and North America (Table 1) and lowest in Africa and Central America.1


Table 1. Estimated incidence in specific world regions, both sexes, 20121

(age standardised rates using the world standard population)




Crude Rate










Central America




South America




Northern America








Central and Eastern Europe




Northern Europe




Southern Europe








Western Europe





There is variation in the trends in incidence and mortality of colorectal cancer in different countries with three main patterns being observed:

  • Increase in incidence and mortality is being seen in rapidly transitioning regions such as Eastern Europe, Asia and South America;
  • Increase in incidence with a decrease in mortality is being seen in some European countries such as Denmark, Sweden, United Kingdom and Malta amongst others as well as Canada and Singapore;
  • In countries such as the United States, Japan and other Western countries both incidence and mortality have stabilised or have even started to decline.2


Colorectal cancer is associated with a number of modifiable risk factors including diets rich in animal fat and protein, obesity and lack of physical activity, smoking and excessive alcohol consumption. Inherited conditions such as familial adenomatous polyposis (FAP) as well as a personal history of inflammatory bowel diseases3 are associated with a high risk of developing colorectal cancer. The latter risk conditions account for only a small proportion of all colorectal cancer cases.        


A reduction in colorectal cancer incidence and mortality is achievable through a number of measures which include primary prevention through improved nutrition and increased physical activity, and organised population-based cancer screening programmes. New and advanced treatments are also contributing towards improvements in the outcomes of colorectal cancer care. There are wide variations worldwide in the state of implementation of colorectal screening with countries such as the United States and Japan having organised screening programmes since the 1990s.4 On the other hand, by 2008, only 19 out of the 27 EU countries had or were developing a screening programme.5 By 2015, this implementation figure has gone up to 24 out of 28 EU countries.However, to date there are still several countries worldwide with no organised screening programme in place despite having a high incidence and mortality from the disease.4



Epidemiology of colorectal cancer in Malta


Colorectal cancer incidence


Colorectal cancer is the second commonest cancer for Malta in both genders combined following breast cancer. On average, 146 males and 113 females (3 year average of 2012-2014) are diagnosed each year with colorectal cancer. The incidence of colorectal cancer increases with age (Figure 1) and age-specific incidence rates in males are much higher than those in females for most age groups.6



The standardised incidence rate of colorectal cancer in Malta has remained relatively stable in females (Figure 2) but seems to show a rising trend in males. Incidence rates in Malta in both males and females are lower than the EU average (Malta: M: 42.1, F: 35.2; EU-27 average: M: 59.0, F: 36.1 in 2012 per 100,000 pop (ESP)).7   


Colorectal cancer mortality

On average there are 61 male deaths and 49 female deaths due to colorectal cancer each year (average of 2012-2014). Colorectal cancer is the second most common cause of cancer death in both sexes combined following lung cancer. Average age at death for both genders is 73 years (2012-2014). The age standardised mortality rate has remained relatively stable in males over the past years (Figure 3) but is showing a downward trend in females.6 Mortality rates in Malta in both males and females are slightly above the EU average (Malta: M: 23.9, F: 15.9; EU-27 average: M: 23.8, F: 14.2 in 2012 per 100,000 pop (ESP)).7   



Acknowledgments: Ms Danika Marmara, Dr Stephanie Xuereb




  1. Ferlay J, Soerjomataram I, Dikshit R et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015;136(5):E359-86.
  2. Arnold M, Sierra M, Laversanne M, et al. Global patterns and trends in colorectal cancer incidence and mortality. Gut 2016; Epub ahead of print.
  3. Haggar FA, Boushey RP. Colorectal Cancer Epidemiology: Incidence, Mortality, Survival, and Risk Factors. Clinics in Colon and Rectal Surgery 2009;22(4):191-197.
  4. Schreuders E, Ruco A, Rabeneck L et al. Colorectal screening: a global overview of existing programmes. Gut 2015;64:1637-1649.
  5. Von Karsa L, Anttila A, Ronco G et al. Cancer screening in the European Union. Report on the implementation of the Council Recommendation on cancer screening- First Report. 2008. Available from:
  6. Directorate of Health Information and Research. Malta National Cancer Registry. Available from:
  7. Ferlay J, Steliarova-Foucher E, Lortet-Tieulent J et al. Cancer incidence and mortality patterns in Europe: Estimates for 40 countries in 2012. European Journal of Cancer 2013; 49:1274-1403.


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