The majority of colorectal cancers in Oman are detected in adults over the age of 50 (65.3%), with males having a larger proportion than females, as shown in Figure 38. Before the age of 40, both sexes have a comparable age distribution of CRC cases; however, the discrepancy widens as one gets older.

Figure 4 illustrates the stage of colorectal cancer at diagnosis in 2017, 2018, and 2019 8. The stage of colorectal cancer has shifted over time, with a smaller proportion of cancers being detected at an early stage and a greater proportion at a late stage, increasing the overall health and economic cost. In 2019, only 5% of cancers were identified in stage one, while over half were detected at stage 3 or stage 4. The possible underlying cause of the late diagnosis could be ascribed to a lack of knowledge of CRC symptoms along with a suboptimal healthcare system capable of detecting colorectal cancer at an early stage.

The incidence and mortality rate of colorectal cancer are expected to rise over time in Oman, as shown in Figure 5. The total number of cases is anticipated to rise from 385 in 2020 to 824 by 2040, with male incidence being threefold higher than female incidence. Similarly, the predicted number of deaths is expected to rise from 213 in 2020 to 463 in 2040 5.

Several factors may raise the risk of colorectal cancer, including alcohol intake, smoking, red and processed meat, obesity, and family history of the disease 10. There is a paucity of public health awareness of colorectal cancer and its risk factors in Oman, necessitating a concerted effort to raise public perception and knowledge about this public health problem. A study was conducted to investigate the knowledge of risk factors, symptoms, and the time needed to explore the medical care for stomach cancer and colorectal cancer (CRC) among Omani participants attending 28 local health centres (LHCs) in the governorate of Muscat, Oman 11. The most recognised risk factors were excessive alcohol consumption and smoking. Risk factors for CRC were most recognised by young participants, highly educated participants, and married participants 11. One in every two respondents would have a colonoscopy if the doctors recommended it; the primary reasons for refusal were embarrassment, lack of trust in the doctors, and religious or cultural beliefs 11. Another study of people attending Sultan Qaboos University Hospital (SQUH) found that three out of every four participants had never heard of colorectal cancer screening; however, over two-thirds (70.6%) said they would do it if it was recommended 12. Males were more aware of CRC screening than females. The most prevalent barriers were embarrassment at the prospect of a colonoscopy, the absence of CRC symptoms, and fear of being diagnosed with CRC 12.

Oman spent around 2.6% of its GDP (11% of the budget) on health care, rising by 12.9% annually 13. Only two hospitals (SQUH and Royal Hospital) have a cancer care services unit. The government funds and operates 80% of hospitals, and population growth is putting additional pressure on this public health care system. In 2014, the government commenced a long-term plan for the healthcare sector entitled Health Vision 2050, which envisions large-scale investment in the healthcare sector to create a well-organized, equitable, efficient, and responsive health system 13; however, this will need more investment in infrastructure and human resources to meet this vision.

Oman has a population-based cancer registry that tracks and reports the trend of various cancers over time. There is no population-based CRC screening program; instead, opportunistic screening with a faecal occult blood test (gFOBT) is performed upon request. The gFOBT is also performed as part of an elderly care program that targets individuals aged 60 and older, with those who have a positive result referred for additional diagnostic procedures (colonoscopy). The referral pathway for positive gFOBT is significantly inefficient, with individuals having to wait for specialist evaluations and other diagnostic procedures for prolonged periods of time, potentially delaying early diagnosis and treatment. Even though CRC is considered a public health issue in Oman, there is no agreed-upon strategy in place to establish and implement a population-based screening program in the near future.

The goal of cancer screening is to identify individuals in an apparently healthy population who are at risk for health problems, allowing for early treatment or intervention and potentially improving outcomes. It reduces the incidence, mortality, and severity of illness by detecting diseases early in a person's life when more treatment options are available. Wilson and Junger proposed ten principles for determining if cancer screening is a suitable course of action for improving public health 14. Before launching a population-based screening program, policymakers should assess the Wilson and Jungner criteria to ensure that all practicable, cost-effective preventative interventions have been applied 14.

In Oman, colorectal cancer is the second most common cancer in both sexes, the most common in men, with the greatest fatality rate also among men, making it a major and escalating public health problem. The natural history and latency period of the disease are well recognised. CRC pathogenesis is characterised by a gradual progression from benign adenomas to malignant adenocarcinomas, which can take up to ten years 15. Up to 90% of deaths can be avoided if the disease is detected early 15. The target population for screening is different across nations 15; however, it can be easily identified at primary health care levels in Oman.

There are effective non-invasive CRC screening tests that can detect the disease at an early stage and, hence, improve the outcome. These include the faecal immunochemical test, the faecal occult blood test (gFOBT), and the stool DNA test, Table 115. The faecal occult blood test (gFOBT) is used in primary care as part of geriatric care and is extremely specific; nevertheless, it requires dietary restrictions. The FIT test, on the other hand, is highly sensitive and specific and doesn't require diet restriction; however, it is not available in Oman. The three tests are straightforward, acceptable, and affordable. There is an agreed-upon plan of action for investigating participants who have positive screening tests, which includes diagnostic testing, treatment, and follow-up care, all of which are available at selected secondary and tertiary health care facilities in Oman.

There is adequate infrastructure in Oman for a comprehensive cancer screening program, including financial resources, health human resources, information technology, buildings, equipment, and test technologies. The health system has a clear diagnostic and treatment pathway for those with abnormal gFOBT results. The population-based screening program is considered clinically, socially, and ethically acceptable. The benefits and harms of screening programs are well-established globally 14; however, there should be a robust quality assurance system in place to ensure the program runs effectively and meets performance standards. Despite the adequacy of infrastructure, Oman has yet to establish a comprehensive population-based cancer screening program that achieves the intended public health goals.

Table 2Summarize the Wilson and Jungner criteria for launching a CRC screening program in Oman.

Implementing a population-based colorectal screening program requires a comprehensive strategy that includes a clinical governance framework, leadership, coordination, and management 14. This framework should cover aspects such as clinical guidelines, monitoring performance, local service delivery, financing and payment systems, access to personal data, and quality assurance systems. Leadership, coordination, and management are crucial for the successful implementation of the program.

Mapping the full screening pathway in a country's health system helps describe the process from target population identification to diagnosis and treatment. Regular training of personnel is essential for maintaining their skills. Health information systems are critical for the success of cancer screening programs, connecting screening procedures, and quality assurance. They rely on various sources, such as hospitals, laboratory services, and death certificates 14.

Adequate funding is essential for screening programs, as intermittent and uncertain funding can hinder cost-effectiveness. Health system capacity should be considered when planning screening programs, as reallocating resources can negatively impact other healthcare areas and lower the quality of care for people with symptomatic conditions. Information and communication should be unbiased and easy to understand so people can make an informed decision about whether to participate or not in the screening program. Overall, Oman now has a window of opportunity to establish a population-based colorectal screening program that can improve health and economic impact in a dramatic fashion.

To develop an effective population-based colorectal screening program, there should be an extensive planning. Table 3 summarises the strategies through which a CRC program can be developed in Oman, which are based on countries experience in developing and implementing CRC program1419.

The provision of a population-based colorectal cancer screening program in Oman aims to detect pre-cancerous adenomas in the intestinal lining in “average risk” individuals, making it a preventative health strategy that reduces treatment burden on individuals and the health system. The program will provide free screening to eligible people on a two-year cycle, with primary healthcare facilities determining eligible individuals in their catchment areas.

Figure 6 illustrates the provisional overview of a pathway for a population-based colorectal cancer screening program in Oman. The inclusion criteria for “average-risk individuals” are males and females aged 60 to 69, with a plan to expand it to 50 to 74 years, with no personal history of colorectal adenomatous polyps or CRC or inflammatory bowel disease, and no family history of colorectal cancer. The exclusion criteria are individuals aged less than 60 years or older than 74 years; individuals aged 60 to 69 with a bowel cancer diagnosis; and individuals who do not have a colon. Individuals who do not meet the eligibility criteria but are concerned about colorectal cancer should consult their GP. Moderate- and high-risk individuals are not included in the population-based screening program and thus should have a different pathway determined by their GP.

Participants will be invited via the health system to participate, and they will collect the faecal immunochemical test from their local health center and complete the test at home. Participants with normal results will be notified, and they will be advised to retake the test in two years. Those with abnormal results will be contacted for further assessment by their GP before being referred to secondary care for further evaluation. To guarantee timely evaluation and management of screening program patients, a distinct referral pathway should be established.

For a population-based colorectal cancer screening program to be effective, there should be a well-established quality assurance system to ensure that the program is working efficiently and effectively. Each step in the screening process should be monitored and assessed on a regular basis using a set of standards to verify the efficacy of the CRC screening program.