01/12/2026 | Daniela Barros | Medscape

https://portugues.medscape.com/viewarticle/atrasa-diagn%C3%B3stico-cncer-colorretal-brasil-2026a10000wc?form=fpf 

In colorectal cancer, the moment of diagnosis is a silent milestone that separates patients who can still follow a predominantly curative trajectory from those who begin treatment in a scenario of greater clinical complexity, with high costs and a lower probability of prolonged disease control. This is the central message of the study "Colorectal Cancer in Brazil: The Invisible Challenge of Diagnosis," coordinated by the Cancer Foundation, which analyzed 177,575 cases of this type of tumor registered in Brazil between 2013 and 2022.

The majority of patients were ≥ 50 years old (85.9%) and almost half resided in the Southeast region (49.4%), reinforcing that the problem is not limited to areas with fewer resources, but also appears where there is a greater concentration of services and volume of care. More than 60% of cases with reported staging were diagnosed in stages III and IV, when the tumor has already spread beyond the intestine or has become widespread. "This is a catastrophe," states the oncological surgeon Dr. Luiz Augusto Maltoni, executive director of the Cancer Foundation.

“Diagnosis at an advanced stage completely changes the course of care: it increases the need to combine different treatment modalities—such as surgery, chemotherapy, and radiotherapy—raises the risk of complications, and imposes a high cost not only on the healthcare system but also on the patient and their family,” she says.

In stage IV, when the disease is already metastatic, the impact is even more evident, with a lower chance of cure and a worse overall prognosis. In early stages, the chance of cure can be greater than 90%, while in stage IV the five-year survival rate is around 10%.

Oncologist Dr. Luiza Dib, coordinator of clinical research at the Sírio-Libanês Hospital in Brasília (DF), adds that in stage III the disease has already reached the regional lymph nodes, but this does not constitute a single scenario. “Not every stage III is the same. Today we know that there are tumors with low and high risk of recurrence, which changes both the duration of adjuvant chemotherapy and the expectation of cure,” she states. “It is a potentially curable, but heterogeneous disease.”

In this stage of the disease, the therapeutic goal often becomes controlling the disease and preserving quality of life, and how much progress can be made depends on access to tests and treatments, which is unequal in Brazil.

The survey also helps to measure the impact on care: 61.5% of patients underwent surgery as part of their treatment. Although it is the curative pillar in most cases, operating on more advanced tumors tends to be riskier and often requires complementary treatments. In this context, when the diagnosis comes late, the margin for a favorable outcome decreases.

Where the care pathway fails
Late diagnosis does not originate at a single point; it is the predictable result of a care pathway that fails in successive stages. The first error occurs even before symptoms appear, in the screening model. “Brazil still operates predominantly with an opportunistic screening model. The fecal occult blood test (FOBT) is usually offered only from the age of 50 when the patient is already in the health service,” says Dr. Luiz Augusto.

“This model depends on two fragile factors: the professional remembering to offer the exam and the population accepting to undergo it at a time when they are asymptomatic. The result is a system that reacts to cancer when it has already taken hold, instead of acting at a stage where the disease could still be prevented,” he adds.

Even when there is clinical suspicion or a positive exam, another important obstacle arises: “The capacity to perform colonoscopies is limited and unequal in the country, both due to the availability of the service and the lack of qualified professionals. Colonoscopy ends up becoming a critical point in the care pathway in many places,” explains Dr. Luiz.

In the Unified Health System (SUS), histopathological confirmation is one of the least visible bottlenecks in the care pathway. The delay in releasing the biopsy postpones the start of treatment and contributes to many cases progressing to a more advanced stage before patients even receive a definitive diagnosis. Clinical oncologist Dr. Maria Cecília Mathias, from Hospital Santa Izabel in Salvador (BA), illustrates the problem: “It’s common for biopsy results to take weeks to be released. Without the anatomopathological report, the patient cannot begin any treatment.”

When colonoscopy and diagnostic resources are scarce, services end up prioritizing already symptomatic patients, which resolves individual emergencies but worsens the population's overall situation. The oncologist summarizes the effect: "We can only detect the disease when it has already manifested clinically," and in colorectal cancer, this often means an advanced stage.

The idea that this problem is exclusive to the SUS (Brazilian public healthcare system) is also unfounded. In the private sector, there is still a large volume of diagnoses of advanced disease, mainly due to screening failures and low adherence. Dr. Oren Smaletz, clinical oncologist and member of the Management Committee of the Oncology and Hematology Center at the Albert Einstein Israelite Hospital, states that, even in large private centers, almost 50% of patients arrive with advanced disease. "The pattern we frequently see is of people over 60 who have never had a colonoscopy," he says.

“There are several barriers that help explain this behavior: exam preparation, prejudices regarding colonoscopy, and, above all, a gap in medical recommendations. We still see many professionals requesting various check-ups without routinely incorporating colorectal cancer screening into preventive counseling,” says Dr. Luiza.

Thus, the study's findings are not an “epidemiological mystery,” but the natural outcome of a system that screens little, investigates late, and, in parts of the country, confirms slowly, while part of the population, even with access, does not adhere to preventive measures and is not systematically called upon.

Changing the game
Thus, the discussion shifts from focusing on the best screening exam to questioning which policy actually works. In colorectal cancer, colonoscopy occupies a unique position because it is not just a detection tool; it can prevent cancer from arising by allowing the removal of polyps. According to Dr. Luiza, this difference changes the logic of screening: by intervening in the precursor lesion, the examination alters the natural course of the disease before it becomes a tumor.

In the Brazilian public health system (SUS), however, the debate revolves not only around effectiveness, but also around investments that could unlock the system. For Dr. Maria Cecília, expanding access to colonoscopy would have the greatest immediate return, because the examination concentrates three critical steps in a single point of the care pathway: it confirms the diagnosis, allows biopsy, and also favors the treatment of precursor lesions, something that no other isolated resource does with the same population impact.

Dr. Oren, on the other hand, draws attention to the necessary design to transform this priority into a sustainable public policy. “Since colonoscopy demands infrastructure and does not scale instantly to the entire target population, we need a two-step model. The first would be broad screening with SOF; in positive cases, referral for colonoscopy should be organized to avoid collapsing the installed capacity and ensure that the examination reaches first those with the highest probability of significant lesions,” he states.

The age at which screening should begin is the second point of debate. “Starting only at age 50 is too late, because the incidence increases precisely during this period, and screening should precede the age at which tumors appear,” argues Dr. Luiz Augusto.

The specialists who spoke to Medscape reinforce that medical societies already recommend starting screening at age 45 for usual risk, and earlier at age 40 for higher-risk groups with a family history or inflammatory bowel disease.

The third area requiring improvement is therapeutic inequality, which makes prevention even more strategic. “In the Brazilian public health system (SUS), access to precision medicine is uneven: essential molecular panels, such as RAS, BRAF, MSI/dMMR, are not homogeneous. PET-CT is restricted, and high-resolution MRI for rectal cancer is not uniformly available,” describes Dr. Maria Cecília.

“The incorporation of new targeted drugs and high-cost treatments is still limited in the public healthcare system, widening the gap between scientific advances and the treatment that reaches the patient,” says Dr. Oren.

In this scenario, each tumor prevented and each early diagnosis has even greater weight, because they reduce the need for complex and expensive treatments.

The urgency of this debate becomes apparent when looking to the future. Other data from the Cancer Foundation estimate a significant increase in mortality from colon and rectal cancer between 2026 and 2040. This trend, however, can be reversed with public policies for screening and early diagnosis. The analyses also point to an increase in the number of cases and deaths in all regions, with relevant regional differences.

Therefore, the practical conclusion of the study is not only that we have many cases diagnosed at advanced stages, but also that Brazil has a high human and healthcare cost generated by a type of preventable cancer, which is nevertheless treated as if it were inevitable.

For Dr. Luiz Augusto, the immediate priorities are to strengthen registries (to improve decision-making) and implement organized screening with active call-up and a clear flow for colonoscopy, in addition to training those at the front line of the system to recognize symptoms and guide the population.

Given this scenario, the question is no longer whether the country needs to act, but rather how long it is possible to sustain a strategy that has already proven to be flawed.

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Differences in screening
SUS (Brazilian Public Health System)

For people without symptoms and without a relevant family history, the strategy adopted is population-based and in stages. The SUS recommends annual SOF (Symptom Screening) for people aged 50 to 75. If the result is positive, the patient should be referred for colonoscopy.

In people at higher risk, the recommendation changes. Those with a first-degree relative with a history of colorectal cancer should begin colonoscopy at age 40 or 10 years before the age of diagnosis of the relative, repeating the exam every five years.

Individuals with hereditary syndromes, such as Lynch syndrome or familial adenomatous polyposis, need earlier colonoscopy and at shorter intervals. Patients with inflammatory bowel disease should begin regular endoscopic surveillance after eight years of disease onset.

Important: In the Brazilian public health system (SUS), colonoscopy is not used as a population screening exam, being indicated after a positive SOF (Symptom Test) or in people at higher risk.

Recommendations from medical societies

For people at usual risk, medical societies recommend starting screening at age 45, even in the absence of symptoms or family history. The preferred exam is colonoscopy. When it is not available, SOF is considered a valid alternative, with colonoscopy indicated if there is a positive result.

In the highest-risk groups, the recommendations converge with those of the Brazilian Unified Health System (SUS): colonoscopy at age 40 or 10 years before the onset of the disease for those with a first-degree relative affected; intensified surveillance in individuals with hereditary syndromes; and regular colonoscopy after eight years of disease onset in patients with inflammatory bowel disease.

Source: Dr. Luiza Dib.