Redaniel et al. BMC Cancer 2010, 10:100 http://www.biomedcentral.com/1471-2407/10/100 severe. Moreover, due to unawareness of the possibility of malignancy, and with the belief that signs and symp- toms will eventually cease, CRC patients tend to be complacent in seeking medical consultation. Compounding the problem of financial constraints and lack of awareness is physician delay. A slight major- ity of CRC patients were initially misdiagnosed by attending physicians, with Ameobiasis as the most com- mon initial finding [36]. Due to non-specificity of signs and symptoms of early disease, CRC symptoms were sometimes mistaken as that of Ameobiasis or other gas- trointestinal diseases that are common in the country. Furthermore, Filipino patients were reported to pre- sent unique clinicopathological characteristics, including rare occurrence of polyps [37], and histological findings suggest the possibility of an alternative tumorgenesis pathway [37,38]. This implies more difficulty in CRC detection using endoscopic or radiographic procedures, and that prevention measures through polyp removal may not be applicable. Furthermore, the unique pathol- ogy in Filipinos indicate that current screening guide- lines in Western countries might not be appropriate [37]. Various recommendations for CRC screening have been put forward [39,40], but no program currently exists in the country. Nevertheless, there are still some disagreements on what approaches and methods are most appropriate, particularly in Asian countries [39], and more research is needed to determine the best choice of screening strategy. In our analysis, large survival differences between Phi- lippine residents and Filipino-American patients per- sisted even after controlling for stage and other key prognostic factors in the analysis, suggesting an impor- tant role of other factors, including peri- and postopera- tive mortality. The greater proportion of Filipino CRC cases with advanced stage tumors increases the possibi- lity of obstruction and high operative mortality. The additional risks, as well as costs, associated with such procedures contribute significantly to survival. Access to cancer care services remain a major challenge, as these are not affordable for most of the population, even though government hospitals and clinics offer subsidized services. Furthermore, the distribution of specialized centers providing cancer care is disproportionate, with most being located in major cities. Between Filipino-Americans and Caucasians, survival differences are modest, even though very small excess risk of death for Caucasians remained after adjustment for multiple covariates including age. Previous studies have shown that Filipino-Americans have similar CRC survival as that of non-Hispanic white women [5,6], and this could be attributed to the high level of health care access among Filipino-Americans. They are the second largest Asian-American ethnic group and among the Page 7 of 9 most acculturated, with majority being either native-born or naturalized citizens [41]. Among Asian-Americans, Filipino-Americans were among those who have the highest income and educational levels, as well as health insurance and usual source of health care [41]. Although they have the lowest level of CRC screening as compared to other ethnic groups, they also have the lowest inci- dence and mortality rates [42], the latter indicating good access to treatment. More research though is needed to ascertain the possible sources of minor survival discre- pancies between ethnic groups in the US. Some limitations should be considered in the interpre- tation of our survival estimates. Our study only covered variables that were available and comparable in the data- bases, and not all possible factors that could affect survi- val were considered. Information not obtainable includes factors related to cancer services, such as organization, training and skills of health care professionals, applica- tion of diagnostic and treatment guidelines, and clinical factors and histopathologic factors such as tumor differ- entiation and grade. Furthermore, in spite of exhausting measures to locate Philippine patients and to gather survival information, including personal visits to the homes of those who could not otherwise be traced, follow-up was not com- plete. This is primarily because of high population migration and mobility in the NCR. Patients lost to fol- low-up were similar to those not lost to follow-up in terms of age, sex and site-specific distributions. How- ever, there are more patients diagnosed at later stages and with stage information unknown among those who are lost to follow-up (data not shown). It is unlikely that patients lost to follow-up have higher survival than those who were not, since it can be assumed that they have more advanced diseases. Furthermore, it can be surmised that they have not received any form of treat- ment, as follow-up data for these patients were not found in hospitals within the NCR, where majority of specialized cancer care facilities are located, and the availability of cancer treatment is limited in the sur- rounding areas. Given these circumstances, it can be deduced that the survival estimates are higher than what could be expected, should follow-up be complete for all patients. Conclusions In conclusion, the differences in CRC survival between Filipinos and Filipino-Americans underscore the impor- tance of access to health care. Improving access to and utilization of diagnostic and treatment facilities and making them affordable in the Philippines should be emphasized. Likewise, the important role of health edu- cation and advocacy, particularly in promoting early diagnosis and prompt treatment should be given