The risk of colorectal cancer with symptoms at different ages and between the sexes: a case-control study

Clinical features of bowel disease in patients aged <50 years in primary care: a large case-control study

Background

Incidences of colorectal cancer (CRC) and inflammatory bowel disease (IBD) are increasing in those aged <50 years.

Aim

To identify and quantify clinical features in primary care of CRC/IBD in those aged <50 years. This study considered the two conditions together and aimed to determine which younger patients, presenting in primary care with symptoms, would benefit from investigation for potentially serious colorectal disease.

Design and setting

Matched case-control study using primary care records from the Clinical Practice Research Datalink, UK.

Method

Incident cases (aged <50 years) of CRC (n = 1661) and IBD (n = 9578) diagnosed between 2000 and 2013 were each matched with up to three controls (n = 3979 CRC; n = 22 947 IBD). Odds ratios (OR) and positive predictive values (PPV) were estimated for features of CRC/IBD in the year before diagnosis.

Results

Ten features were independently associated with CRC/IBD (all P<0.001): rectal bleeding, change in bowel habit, diarrhoea, raised inflammatory markers, thrombocytosis, abdominal pain, low mean cell volume (MCV), low haemoglobin, raised white cell count, and raised hepatic enzymes. PPVs were >3% for rectal bleeding with diarrhoea, thrombocytosis, low MCV, low haemoglobin or raised inflammatory markers; for change in bowel habit with low MCV, thrombocytosis or low haemoglobin; and for diarrhoea with thrombocytosis.

Conclusion

This study quantified the risk of serious bowel disease in symptomatic patients aged <50 years in primary care. Rectal bleeding and change in bowel habit are strongly predictive of CRC/IBD when combined with abnormal haematology. The present findings help prioritise patients for colonoscopy where the diagnosis is not immediately apparent.

Poor predictive value of lower gastrointestinal alarm features in the diagnosis of colorectal cancer in 1981 patients in secondary care

BACKGROUND

Clinicians are advised to refer patients with lower gastrointestinal (GI) alarm features for urgent colonoscopy to exclude colorectal cancer (CRC). However, the utility of alarm features is debated.

AIM

To assess whether performance of alarm features is improved by using a symptom frequency threshold to trigger referral, or by combining them into composite variables, including minimum age thresholds, as recommended by the National Institute for Health and Care Excellence (NICE).

METHODS

We collected data prospectively from 1981 consecutive adults with lower GI symptoms. Assessors were blinded to symptom status. The reference standard to define CRC was histopathological confirmation of adenocarcinoma in biopsy specimens from a malignant-looking colorectal lesion. Controls were patients without CRC. Sensitivity, specificity, positive predictive values (PPVs) and negative predictive values were calculated for individual alarm features, as well as combinations of these.

RESULTS

In identifying 47 (2.4%) patients with CRC, individual alarm features had sensitivities ranging from 11.1% (family history of CRC) to 66.0% (loose stools), and specificities from 30.5% (loose stools) to 75.6% (family history of CRC). Using higher symptom frequency thresholds improved specificity, but to the detriment of sensitivity. NICE referral criteria also had higher specificities and lower sensitivity, with PPVs above 4.8%. More than 80% of those with CRC met at least one of the NICE referral criteria.

CONCLUSIONS

Using higher symptom frequency thresholds for alarm features improved specificity, but sensitivity was low. NICE referral criteria had PPVs above 4.8%, but sensitivities ranged from 2.2% to 32.6%, meaning many cancers would be missed.

Improving early diagnosis of symptomatic cancer

Much time, effort and investment goes into the diagnosis of symptomatic cancer, with the expectation that this approach brings clinical benefits. This investment of resources has been particularly noticeable in the UK, which has, for several years, appeared near the bottom of international league tables for cancer survival in economically developed countries. In this Review, we examine expedited diagnosis of cancer from four perspectives. The first relates to the potential for clinical benefits of expedited diagnosis of symptomatic cancer. Limited evidence from clinical trials is available, but the considerable observational evidence suggests benefits can be obtained from this approach. The second perspective considers how expedited diagnosis can be achieved. We concentrate on data from the UK, where extensive awareness campaigns have been conducted, and initiatives in the primary-care setting, including clinical decision support, have all occurred during a period of considerable national policy change. The third section considers the most appropriate patients for cancer investigations, and the possible community settings for identification of such patients; UK national guidance for selection of patients for investigation is discussed. Finally, the health economics of expedited diagnosis are reviewed, although few studies provide definitive evidence on this topic.

Identification of patients with non-metastatic colorectal cancer in primary care: a case-control study

BACKGROUND

Colorectal cancer is the third most common cancer worldwide and second most common in Europe. Despite screening, it is often diagnosed at an unfavourable stage.

AIM

To identify and quantify features of non-metastatic colorectal cancer in primary care to enable earlier diagnosis by GPs.

DESIGN AND SETTING

A case-control study was conducted using diagnostic codes from national and regional healthcare databases in Sweden.

METHOD

A total of 542 patients diagnosed with non-metastatic colorectal cancer in 2011 and 2139 matched controls were selected from the Swedish Cancer Register (SCR) and a regional healthcare database respectively. All diagnostic codes (according to ICD-10) from primary care consultations registered the year before the date of cancer diagnosis (according to the SCR) were collected from the regional database. Odds ratios were calculated for variables independently associated with non-metastatic colorectal cancer using multivariable conditional logistic regressions. Positive predictive values (PPVs) of these variables were calculated, both individually and in combination with each other.

RESULTS

Five features were associated with colorectal cancer before diagnosis: bleeding, including rectal bleeding, melaena, and gastrointestinal bleeding (PPV 3.9%, 95% confidence interval [CI] = 2.3 to 6.3); anaemia (PPV 1.4%, 95% CI = 1.1 to 1.8); change in bowel habit (PPV 1.1%, 95% CI = 0.9 to 1.5; abdominal pain (PPV 0.9%, 95% CI = 0.7 to 1.1); and weight loss (PPV 1.0%, 95% CI = 0.3 to 3.0); all P-value <0.05. The combination of bleeding and change in bowel habit had a PPV of 13.7% (95% CI = 2.1 to 54.4); for bleeding combined with abdominal pain this was 12.2% (95% CI = 1.8 to 51.2). A risk assessment tool for non-metastatic colorectal cancer was designed.

CONCLUSION

Bleeding combined with either diarrhoea, constipation, change in bowel habit, or abdominal pain are the most powerful predictors of non-metastatic colorectal cancer and should result in prompt referral for colorectal investigation.

Published diagnostic models safely excluded colorectal cancer in an independent primary care validation study

OBJECTIVE

To validate published diagnostic models for their ability to safely reduce unnecessary endoscopy referrals in primary care patients suspected of significant colorectal disease.

STUDY DESIGN AND SETTING

Following a systematic literature search, we independently validated the identified diagnostic models in a cross-sectional study of 810 Dutch primary care patients with persistent lower abdominal complaints referred for endoscopy. We estimated diagnostic accuracy measures for colorectal cancer (N = 37) and significant colorectal disease (N = 141; including colorectal cancer, inflammatory bowel disease, diverticulitis, or >1-cm adenomas).

RESULTS

We evaluated 18 models-12 specific for colorectal cancer-, of which most were able to safely rule out colorectal cancer: the best model (National Institute for Health and Care Excellence-1) prevented 59% of referrals (95% confidence interval [CI]: 56-63%), with 96% sensitivity (95% CI: 83-100%), 100% negative predictive value (NPV; 95% CI: 99-100%), and an area under the receiver operating characteristics curve (AUC) of 0.86 (95% CI: 0.80-0.92). The models performed less for significant colorectal disease: the best model (Brazer) prevented 23% of referrals (95% CI: 20-26%), with 95% sensitivity (95% CI: 90-98%), 96% NPV (95% CI: 92-98%), and an AUC of 0.73 (95% CI: 0.69-0.78).

CONCLUSION

Most models safely excluded colorectal cancer in many primary care patients with lower gastrointestinal complaints referred for endoscopy. Models performed less well for significant colorectal disease.

Delayed Workup of Rectal Bleeding in Adult Primary Care: Examining Process-of-Care Failures

BACKGROUND

Although delayed colorectal cancer diagnoses figure prominently in medical malpractice claims, little is known about the quality of primary care clinicians' workup of rectal bleeding.

METHODS

In this study, 438 patients were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for rectal bleeding, hemorrhoids, and blood in the stool at 10 Boston adult primary care practices. Following nurse chart abstraction, physician reviewers assessed the overall quality of care and key care processes. Subjects' characteristics and physician reviewers' processes-of-care assessments were tabulated, and logistic regression models were used to examine the association of process failures with overall quality and guideline concordance.

RESULTS

Although reviewers judged the overall quality of care to be good or excellent in 337 (77%) of 438 cases, 312 (71%) patients experienced at least one process-of-care failure in the workup of rectal bleeding. Clinicians failed to obtain an adequate family history in 38% of cases, complete a pertinent physical exam in 23%, and order laboratory tests in 16%. Failure to order or perform tests, or to make follow-up plans were associated with increased odds of poor or fair care. Guideline concordance bore little relationship with quality judgments. Reviewers judged that 128 delays could have been reduced or prevented.

CONCLUSION

Process-of-care failures among adult primary care patients with rectal bleeding were frequent and associated with fair or poor quality. Educating practitioners and creating systems to ensure adequate history taking, physical examination, and processes for ordering, performing, and interpreting diagnostic tests may improve performance.

Understanding of a negative bowel screening result and potential impact on future symptom appraisal and help-seeking behaviour: a focus group study

Background

Colorectal cancer (CRC) screening using a faecal occult blood test (FOBt) has the potential to reduce cancer‐related mortality. Symptom vigilance remains crucial as a proportion of cancers will be diagnosed between screening rounds. A negative FOBt has the potential to influence how participants respond to future symptoms of CRC.

Objective

To explore (i) understanding of a negative FOBt and (ii) the potential impact of a negative FOBt upon future symptom appraisal and help‐seeking behaviour.

Design

Qualitative methodology utilizing focus groups with participants who received a negative FOBt within the National Bowel Cancer Screening Programme in Coventry and Lothian. Topics explored included: experience of screening participation, interpretation and understanding of a negative result, symptom awareness and attitudes towards help‐seeking.

Results

Four broad themes were identified: (i) emotional response to a negative FOBt, (ii) understanding the limitations of FOBt screening, (iii) symptom knowledge and interpretation and (iv) over‐reassurance from a negative FOBt. Participants were reassured by a negative FOBt, but there was variability in the extent to which the result was interpreted as an “all clear”. Some participants acknowledged the residual risk of cancer and the temporal characteristic of the result, while others were surprised that the result was not a guarantee that they did not have cancer.

Discussion and conclusions

Participants recognized that reassurance from a negative FOBt could lead to a short‐term delay in help‐seeking if symptoms developed. Screening programmes should seek to emphasize the importance of the temporal nature of FOBt results with key messages about symptom recognition and prompt help‐seeking behaviour.

Risk prediction models for colorectal cancer in people with symptoms: a systematic review

Background

Colorectal cancer (CRC) is the fourth leading cause of cancer-related death in Europe and the United States. Detecting the disease at an early stage improves outcomes. Risk prediction models which combine multiple risk factors and symptoms have the potential to improve timely diagnosis. The aim of this review is to systematically identify and compare the performance of models that predict the risk of primary CRC among symptomatic individuals.

Methods

We searched Medline and EMBASE to identify primary research studies reporting, validating or assessing the impact of models. For inclusion, models needed to assess a combination of risk factors that included symptoms, present data on model performance, and be applicable to the general population. Screening of studies for inclusion and data extraction were completed independently by at least two researchers.

Results

Twelve thousand eight hundred eight papers were identified from the literature search and three through citation searching. 18 papers describing 15 risk models were included. Nine were developed in primary care populations and six in secondary care. Four had good discrimination (AUROC > 0.8) in external validation studies, and sensitivity and specificity ranged from 0.25 and 0.99 to 0.99 and 0.46 depending on the cut-off chosen.

Conclusions

Models with good discrimination have been developed in both primary and secondary care populations. Most contain variables that are easily obtainable in a single consultation, but further research is needed to assess clinical utility before they are incorporated into practice.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-016-0475-7) contains supplementary material, which is available to authorized users.

Association Between Exposure to Environmental Tobacco Smoke at the Workplace and Risk for Developing a Colorectal Adenoma: A Cross-Sectional Study

Purpose

A colorectal adenoma (CRA) is a well-defined precursor to colorectal cancer (CRC). Additionally, smoking is a potent risk factor for developing a CRA, as well as CRC. However, the association between exposure to environmental tobacco smoke (ETS) and the risk for developing a CRA has not yet been fully evaluated in epidemiologic studies. We performed a cross-sectional analysis on the association between exposure to ETS at the workplace and the risk for developing a CRA.

Methods

The study was conducted on subjects who had undergone a colonoscopy at a health promotion center from January 2012 to December 2012. After descriptive analyses, overall and subgroup analyses by smoking status were performed by using a multivariate logistic regression.

Results

Among the 1,129 participants, 300 (26.6%) were diagnosed as having CRAs. Exposure to ETS was found to be associated with CRAs in all subjects (fully adjusted odds ratio [OR], 1.95; 95% confidence interval [CI], 1.08–2.44; P = 0.001). In the subgroup analysis, exposure to ETS in former smokers increased the risk for developing a CRA (fully adjusted OR, 4.44; 95% CI, 2.07–9.51; P < 0.001).

Conclusion

Exposure to occupational ETS at the workplace, independent of the other factors, was associated with increased risk for developing a CRA in all subjects and in former smokers. Further retrospective studies with large sample sizes may be necessary to clarify the causal effect of this relationship.

Lower Gastrointestinal Bleeding And Risk of Gastrointestinal Cancer

OBJECTIVES

Lower gastrointestinal (GI) bleeding is a well-known symptom of colorectal cancer (CRC). Whether incident GI bleeding is also a marker of other GI cancers remains unclear.

METHODS

This nationwide cohort study examined the risk of various GI cancer types in patients with lower GI bleeding. We used Danish medical registries to identify all patients with a first-time hospital diagnosis of lower GI bleeding during 1995-2011 and followed them for 10 years to identify subsequent GI cancer diagnoses. We computed absolute risks of cancer, treating death as a competing risk, and calculated standardized incidence ratios (SIRs) by comparing observed cancer cases with expected cancer incidence rates in the general population.

RESULTS

Among 58,593 patients with lower GI bleeding, we observed 2,806 GI cancers during complete 10-year follow-up. During the first year of follow-up, the absolute GI cancer risk was 3.6%, and the SIR of any GI cancer was 16.3 (95% confidence interval (CI): 15.6-17.0). Colorectal cancers accounted for the majority of diagnoses, but risks of all GI cancers were increased. During 1-5 years of follow-up, the SIR of any GI cancer declined to 1.36 (95% CI: 1.25-1.49), but risks remained increased for several GI cancers. Beyond 5 years of follow-up, the overall GI cancer risk was close to unity, with reduced risk of rectal cancer and increased risk of liver and pancreatic cancers.

CONCLUSIONS

A hospital-based diagnosis of lower GI bleeding is a strong clinical marker of prevalent GI cancer, particularly CRC. It also predicts an increased risk of any GI cancer beyond 1 year of follow-up.

The value of reasons for encounter in early detection of colorectal cancer

BACKGROUND

Symptoms with a high predictive power for colorectal cancer (CRC) do not exist.

OBJECTIVE

To explore the predictive value of patients' reason for encounter (RFE) in the two years prior to the diagnosis of CRC.

METHODS

A retrospective nested case-control study using prospectively collected data from electronic records in general practice over 20 years. Matching was done based on age (within two years), gender and practice. The positive likelihood ratios (LR+) and odds ratios (OR) were calculated for RFE between cases and controls in the two years before the index date.

RESULTS

We identified 184 CRC cases and matched 366 controls. Six RFEs had significant LR + and ORs for CRC, which may have high predictive power. These RFEs are part of four chapters in the International Classification of Primary Care (ICPC) that include tiredness (significant at 3-6 months prior to the diagnosis; LR+ 2.6 and OR 3.07; and from 0 to 3 months prior to the diagnosis; LR+ 2.0 and OR 2.36), anaemia (significant at three months before diagnosis; LR+ 9.8 and OR 16.54), abdominal pain, rectal bleeding and constipation (significant at 3-6 months before diagnosis; LR+ 3.0 and OR 3.33; 3 months prior to the diagnosis LR+ 8.0 and OR 18.10) and weight loss (significant at three months before diagnosis; LR+ 14.9 and OR 14.53).

CONCLUSION

Data capture and organization in ICPC permits study of the predictive value of RFE for CRC in primary care.

Oral concentrated grape juice suppresses expression of NF-kappa B, TNF-α and iNOS in experimentally induced colorectal carcinogenesis in Wistar rats

The aim of this study was to evaluate the effects of grape juice on colon carcinogenesis induced by azoxymethane (AOM) and expression of NF-kB, iNOS and TNF- α.

METHODS

Forty male Wistar rats were divided into 7 groups: G1, control; G2, 15 mg/kg AOM; G3, 1% grape juice 2 weeks before AOM; G4, 2% grape juice 2 weeks before AOM; G5, 1% grape juice 4 weeks after AOM; G6, 2% grape juice 4 weeks after AOM; G7, 2% grape juice without AOM. Histological changes and aberrant crypt foci (ACF) were studied, while RNA expression of NF- kB, TNF- and iNOS was evaluated by qPCR.

RESULTS

The number of ACF was higher in G2, and G4 presented a smaller number of crypts per focus than G5 (p=0.009) and G6. Small ACF (1-3) were more frequent in G4 compared to G2, G5 and G6 (p=0.009, p=0.009 and p=0.041, respectively). RNA expression of NF-kB was lower in G3 and G4 compared to G2 (p=0.004 and p=0.002, respectively). A positive correlation was observed between TNF- α and NF-kB gene expression (p=0.002). In conclusion, the administration of 2% grape juice before AOM reduced the crypt multiplicity, attenuating carcinogenesis. Lower expression of NF-kB was observed in animals exposed to grape juice for a longer period of time, regardless of concentration.

Electronic Trigger-Based Intervention to Reduce Delays in Diagnostic Evaluation for Cancer: A Cluster Randomized Controlled Trial

PURPOSE

We tested whether prospective use of electronic health record-based trigger algorithms to identify patients at risk of diagnostic delays could prevent delays in diagnostic evaluation for cancer.

METHODS

We performed a cluster randomized controlled trial of primary care providers (PCPs) at two sites to test whether triggers that prospectively identify patients with potential delays in diagnostic evaluation for lung, colorectal, or prostate cancer can reduce time to follow-up diagnostic evaluation. Intervention steps included queries of the electronic health record repository for patients with abnormal findings and lack of associated follow-up actions, manual review of triggered records, and communication of this information to PCPs via secure e-mail and, if needed, phone calls to ensure message receipt. We compared times to diagnostic evaluation and proportions of patients followed up between intervention and control cohorts based on final review at 7 months.

RESULTS

We recruited 72 PCPs (36 in the intervention group and 36 in the control group) and applied the trigger to all patients under their care from April 20, 2011, to July 19, 2012. Of 10,673 patients with abnormal findings, the trigger flagged 1,256 patients (11.8%) as high risk for delayed diagnostic evaluation. Times to diagnostic evaluation were significantly lower in intervention patients compared with control patients flagged by the colorectal trigger (median, 104 v 200 days, respectively; n = 557; P < .001) and prostate trigger (40% received evaluation at 144 v 192 days, respectively; n = 157; P < .001) but not the lung trigger (median, 65 v 93 days, respectively; n = 19; P = .59). More intervention patients than control patients received diagnostic evaluation by final review (73.4% v 52.2%, respectively; relative risk, 1.41; 95% CI, 1.25 to 1.58).

CONCLUSION

Electronic trigger-based interventions seem to be effective in reducing time to diagnostic evaluation of colorectal and prostate cancer as well as improving the proportion of patients who receive follow-up. Similar interventions could improve timeliness of diagnosis of other serious conditions.

Could it be colorectal cancer? General practitioners' use of the faecal occult blood test and decision making--a qualitative study

Background

Abdominal complaints are common reasons for contacting primary care physicians, and it can be challenging for general practitioners (GPs) to identify patients with suspected colorectal cancer (CRC) for referral to secondary care. The immunochemical faecal occult blood test (iFOBT) is used as a diagnostic aid in primary care, but it is unclear how test results are interpreted. Studies show that negative tests are associated with a risk of delayed diagnosis of CRC and that some patients with positive tests are not investigated further. The aim of this study was to explore what makes GPs suspect CRC and to investigate their practices regarding investigation and referral, with special attention on the use of iFOBTs.

Method

Semi-structured individual interviews were conducted with eleven purposely selected GPs and registrars in Region Jämtland Härjedalen, Sweden, and subjected to qualitative content analysis.

Results

In the analysis of the interviews four categories were identified that described what made the physicians suspect CRC and their practices. Careful listening—with awareness of the pitfalls: Attentive listening was described as essential, but there was a risk of being misled by, for example, the patient’s own explanations. Tests can help—the iFOBT can also complicate the diagnosis: All physicians used iFOBTs to various extents. In the absence of guidelines, all found their own ways to interpret and act on the test results. To refer or not to refer—safety margins are necessary: Uncertainty was described as a part of everyday work and was handled in different ways. Common vague symptoms could be CRC and thus justified referral with safety margins. Growing more confident—but also more humble: With increasing experience, the GPs described becoming more confident in their decisions but they were also more cautious.

Conclusions

Listening carefully to the patient’s history was essential. The iFOBT was frequently used as support, but there were considerable variations in the interpretation and handling of the results. The diagnostic process can be described as navigating uncertain waters with safety margins, while striving to keep the patient’s best interests in mind. The iFOBT may be useful as a diagnostic aid in primary care, but more research and evidence-based guidelines are needed.

Patient-doctor continuity and diagnosis of cancer: electronic medical records study in general practice

Background

Continuity of care may affect the diagnostic process in cancer but there is little research.

Aim

To estimate associations between patient–doctor continuity and time to diagnosis and referral of three common cancers.

Design and setting

Retrospective cohort study in general practices in England.

Method

This study used data from the General Practice Research Database for patients aged ≥40 years with a diagnosis of breast, colorectal, or lung cancer. Relevant cancer symptoms or signs were identified up to 12 months before diagnosis. Patient–doctor continuity (fraction-of-care index adjusted for number of consultations) was calculated up to 24 months before diagnosis. Time ratios (TRs) were estimated using accelerated failure time regression models.

Results

Patient–doctor continuity in the 24 months before diagnosis was associated with a slightly later diagnosis of colorectal (time ratio [TR] 1.01, 95% confidence interval [CI] =1.01 to 1.02) but not breast (TR = 1.00, 0.99 to 1.01) or lung cancer (TR = 1.00, 0.99 to 1.00). Secondary analyses suggested that for colorectal and lung cancer, continuity of doctor before the index consultation was associated with a later diagnosis but continuity after the index consultation was associated with an earlier diagnosis, with no such effects for breast cancer. For all three cancers, most of the delay to diagnosis occurred after referral.

Conclusion

Any effect for patient–doctor continuity appears to be small. Future studies should compare investigations, referrals, and diagnoses in patients with and without cancer who present with possible cancer symptoms or signs; and focus on ‘difficult to diagnose’ types of cancer.

Quantifying the risk of non-Hodgkin lymphoma in symptomatic primary care patients aged ≥40 years: a large case-control study using electronic records

BACKGROUND

Non-Hodgkin lymphoma (NHL) is the sixth most common cancer in the UK; approximately 35 people are diagnosed and 13 die from the disease daily.

AIM

To identify the primary care clinical features of NHL and quantify their risk in symptomatic patients.

DESIGN AND SETTING

Matched case-control study using Clinical Practice Research Datalink patient records.

METHOD

Putative clinical features of NHL were identified in the year before diagnosis. Results were analysed using conditional logistic regression and positive predictive values (PPVs).

RESULTS

A total of 4362 patients aged ≥40 years, diagnosed with NHL between 2000 and 2009, and 19 468 age, sex, and general practice-matched controls were studied. Twenty features were independently associated with NHL. The five highest risk symptoms were lymphadenopathy, odds ratio (OR) 263 (95% CI = 133 to 519), head and neck mass not described as lymphadenopathy OR 49 (95% CI = 32 to 74), other mass OR 12 (95% CI = 10 to 16), weight loss OR 3.2 (95% CI = 2.3 to 4.4), and abdominal pain OR 2.5 (95% CI = 2.1 to 2.9). Lymphadenopathy has a PPV of 13% for NHL in patients ≥60 years. Weight loss in conjunction with repeated back pain or raised gamma globulin had PPVs >2%.

CONCLUSION

Unexplained lymphadenopathy in patients aged ≥60 years produces a very high risk of NHL in primary care. These patients warrant urgent investigation, potentially sooner than 6 weeks from initial presentation where the GP is particularly concerned.

General practitioners' anticipated risk of cancer at referral and their attitude to risk taking and to their role as gatekeeper

OBJECTIVES

General practitioners have to deal with situations characterized by real but low likelihoods of serious illness. We aimed to investigate variations in general practitioners' anticipated risk of cancer when referring a patient and associations both with general practitioners' attitudes to risk taking and with their gatekeeper role.

METHODS

In January 2012, all 835 active general practitioners in the county of Aarhus, Denmark, received a questionnaire including the Physician Reaction to Uncertainty scale, The Tolerance for Ambiguity scale, the Physician Risk Attitude scale and a number of single items assessing anticipated risk of cancer when referring a hypothetical 50-year-old patient, use of intuition and perception of their role as a gatekeeper.

RESULTS

A total of 568 (68.0%) practitioners completed and returned the questionnaire. The median anticipated risk of cancer was 30% (inter-quartile range: 15%-50%) and the 5%-95% centiles were 5% and 80%. Increasing tolerance for ambiguity was strongly related to a declining anticipated risk of cancer. None of the other risk attitudes were associated with the anticipated risk of cancer at referral. Increased general practitioners' age was related to increased anticipated risk of cancer when referring (25% for general practitioners under 45 years to 43% for those 60 years or over) but not statistically important.

CONCLUSIONS

General practitioners either overestimate the risk of cancer when referring for suspected cancer or they appear to need to be very sure of the cancer diagnosis before referral. Further, focus on tolerance for ambiguity should be included in the education of general practitioners.

Computed tomographic colonography compared with colonoscopy or barium enema for diagnosis of colorectal cancer in older symptomatic patients: two multicentre randomised trials with economic evaluation (the SIGGAR trials)

BACKGROUND

Computed tomographic colonography (CTC) is a relatively new diagnostic test that may be superior to existing alternatives to investigate the large bowel.

OBJECTIVES

To compare the diagnostic efficacy, acceptability, safety and cost-effectiveness of CTC with barium enema (BE) or colonoscopy.

DESIGN

Parallel randomised trials: BE compared with CTC and colonoscopy compared with CTC (randomisation 2 : 1, respectively).

SETTING

A total of 21 NHS hospitals.

PARTICIPANTS

Patients aged ≥ 55 years with symptoms suggestive of colorectal cancer (CRC).

INTERVENTIONS

CTC, BE and colonoscopy.

MAIN OUTCOME MEASURES

For the trial of CTC compared with BE, the primary outcome was the detection rate of CRC and large polyps (≥ 10 mm), with the proportion of patients referred for additional colonic investigation as a secondary outcome. For the trial of CTC compared with colonoscopy, the primary outcome was the proportion of patients referred for additional colonic investigation, with the detection rate of CRC and large polyps as a secondary outcome. Secondary outcomes for both trials were miss rates for cancer (via registry data), all-cause mortality, serious adverse events, patient acceptability, extracolonic pathology and cost-effectiveness.

RESULTS

A total of 8484 patients were registered and 5384 were randomised and analysed (BE trial: 2527 BE, 1277 CTC; colonoscopy trial: 1047 colonoscopy, 533 CTC). Detection rates in the BE trial were 7.3% (93/1277) for CTC, compared with 5.6% (141/2527) for BE (p = 0.0390). The difference was due to better detection of large polyps by CTC (3.6% vs. 2.2%; p = 0.0098), with no significant difference for cancer (3.7% vs. 3.4%; p = 0.66). Significantly more patients having CTC underwent additional investigation (23.5% vs. 18.3%; p = 0.0003). At the 3-year follow-up, the miss rate for CRC was 6.7% for CTC (three missed cancers) and 14.1% for BE (12 missed cancers). Significantly more patients randomised to CTC than to colonoscopy underwent additional investigation (30% vs. 8.2%; p < 0.0001). There was no significant difference in detection rates for cancer or large polyps (10.7% for CTC vs. 11.4% for colonoscopy; p = 0.69), with no difference when cancers (p = 0.94) and large polyps (p = 0.53) were analysed separately. At the 3-year follow-up, the miss rate for cancer was nil for colonoscopy and 3.4% for CTC (one missed cancer). Adverse events were uncommon for all procedures. In 1042 of 1748 (59.6%) CTC examinations, at least one extracolonic finding was reported, and this proportion increased with age (p < 0.0001). A total of 149 patients (8.5%) were subsequently investigated, and extracolonic neoplasia was diagnosed in 79 patients (4.5%) and malignancy in 29 (1.7%). In the short term, CTC was significantly more acceptable to patients than BE or colonoscopy. Total costs for CTC and colonoscopy were finely balanced, but CTC was associated with higher health-care costs than BE. The cost per large polyp or cancer detected was £4235 (95% confidence interval £395 to £9656).

CONCLUSIONS

CTC is superior to BE for detection of cancers and large polyps in symptomatic patients. CTC and colonoscopy detect a similar proportion of large polyps and cancers and their costs are also similar. CTC precipitates significantly more additional investigations than either BE or colonoscopy, and evidence-based referral criteria are needed. Further work is recommended to clarify the extent to which patients initially referred for colonoscopy or BE undergo subsequent abdominopelvic imaging, for example by computed tomography, which will have a significant impact on health economic estimates.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN95152621.

The challenges in defining and measuring diagnostic error

Diagnostic errors have emerged as a serious patient safety problem but they are hard to detect and complex to define. At the research summit of the 2013 Diagnostic Error in Medicine 6th International Conference, we convened a multidisciplinary expert panel to discuss challenges in defining and measuring diagnostic errors in real-world settings. In this paper, we synthesize these discussions and outline key research challenges in operationalizing the definition and measurement of diagnostic error. Some of these challenges include 1) difficulties in determining error when the disease or diagnosis is evolving over time and in different care settings, 2) accounting for a balance between underdiagnosis and overaggressive diagnostic pursuits, and 3) determining disease diagnosis likelihood and severity in hindsight. We also build on these discussions to describe how some of these challenges can be addressed while conducting research on measuring diagnostic error.

Symptoms, signs, and tests: The general practitioner's comprehensive approach towards a cancer diagnosis

OBJECTIVE

To study the relative importance of different tools a GP can use during the diagnostic process towards cancer detection.

DESIGN

Retrospective cohort study with prospective registration of cancer in general practice.

SETTING AND SUBJECTS

One hundred and fifty-seven Norwegian general practitioners (GPs) reported 261 cancer patients.

METHOD

During 10 consecutive days, GPs registered all patient consultations and recorded any presence of seven focal symptoms and three general symptoms, commonly considered as warning signs of cancer (WSC). Follow-up was done six to 11 months later. For each patient with new or recurrent cancer, the GP completed a questionnaire with medical-record-based information concerning the diagnostic procedure.

RESULTS

In 78% of cancer cases, symptoms, signs, or tests helped diagnose cancer. In 90 cases, there were 131 consultation-recorded WSC that seemed related to the cancer. Further symptoms were reported for another 74 cases. Different clinical signs were noted in 41 patients, 16 of whom had no previous recording of symptoms. Supplementary tests added information in 59 cases; in 25 of these there were no recordings of symptoms or signs. Sensitivity of any cancer-relevant symptom or clinical finding ranged from 100% for patients with uterine body cancer to 57% for patients with renal cancer.

CONCLUSION

WSC had a major role as initiator of a cancer diagnostic procedure. Low-risk-but-not-no-risk symptoms also played an important role, and in 7% of patients they were the only symptoms. Clinical findings and/or supplementary procedures were sometimes decisive for rapid referral.

Diagnostic value of rectal bleeding in predicting colorectal cancer: a systematic review

This study aimed at summarizing published study findings on the diagnostic value of rectal bleeding (RB) and informing clinical practice, preventive interventions and future research areas. We searched Medline and Embase for studies published by September 13, 2013 examining the risk of colorectal cancer in patients with RB using highly inclusive algorithms. Data for sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and positive predictive value (PPV) of RB were extracted by two researchers and analyzed applying Meta-Disc (version 1.4) and Stata (version 11.0). Methodological quality of studies was assessed according to QUADAS. A total of 38 studies containing 5,626 colorectal cancer patients and 73,174 participants with RB were included. The pooled sensitivity and specificity were 0.47 (95% CI: 0.45-0.48) and 0.96 (95% CI: 0.96-0.96) respectively. The overall PPVs ranged from 0.01 to 0.21 with a pooled value of 0.06 (95% CI: 0.05-0.08). Being over the age of 60 years, change in bowel habit, weight loss, anaemia, colorectal cancer among first-degree relatives and feeling of incomplete evacuation of rectum appeared to increase the predictive value of RB. Although RB greatly increases the probability of diagnosing colorectal cancer, it alone may not be sufficient for proposing further sophisticated investigations. However, given the high specificity, subjects without RB may be ruled out of further investigations. Future studies should focus on strategies using RB as an "alarm" symptom and finding additional indications to justify whether there is a need for further investigations.

Colon cancer surgery following emergency presentation: effects on admission and stage-adjusted outcomes

BACKGROUND

Emergency presentation with colon cancer is intuitively related to advanced disease. We measured its effect on outcomes of surgically treated colon cancer.

METHODS

A retrospective cohort of 1,071 surgical colon cancer patients (2004 to 2011), with 102 emergency cases requiring surgery within the index admission, was analyzed.

RESULTS

Emergency patients required longer surgeries (median 141 vs 124 minutes; P = .04), longer median admissions (8% vs 5%; P < .001), more readmissions (12.7% vs 7.1%; P = .040), and perioperative mortality (7.8% vs .8%; P < .001). Surgical pathology displayed higher rates of node-positive disease (56.6% vs 38.6%; P < .001), extramural vascular invasion (39.6% vs 29.1%; P = .021), and metastatic disease (19.6% vs 8%; P < .001). Consequently, adjusting for staging, emergency presentations had considerably higher mortality (odds ratio = 2.07; P = .003) and shorter disease-free survival (hazard ratio = 1.39; P = .042).

CONCLUSIONS

Emergency presentation is a stage-independent poor prognostic factor associated with aggressive tumor biology, resulting in longer surgeries and admissions, frequent readmissions, worsening outcomes, and increasing healthcare costs.

Differences in the symptom experience of older oncology outpatients

CONTEXT

The relatively low number of older patients in cancer trials limits knowledge of how older adults experience symptoms associated with cancer and its treatment.

OBJECTIVES

This study evaluated for differences in the symptom experience across four older age groups (60-64, 65-69, 70-74, ≥75 years).

METHODS

Demographic, clinical, and symptom data from 330 patients aged >60 years who participated in one Australian and two U.S. studies were evaluated. The Memorial Symptom Assessment Scale was used to evaluate the occurrence, severity, frequency, and distress of 32 symptoms commonly associated with cancer and its treatment.

RESULTS

On average, regardless of the age group, patients reported 10 concurrent symptoms. The most prevalent symptoms were physical in nature. Worrying was the most common psychological symptom. For 28 (87.5%) of the 32 Memorial Symptom Assessment Scale symptoms, no age-related differences were found in symptom occurrence rates. For symptom severity ratings, an age-related trend was found for difficulty swallowing. As age increased, severity of difficulty swallowing decreased. For symptom frequency, age-related trends were found for feeling irritable and diarrhea, with both decreasing in frequency as age increased. For symptom distress, age-related trends were found for lack of energy, shortness of breath, feeling bloated, and difficulty swallowing. As age increased, these symptoms received lower average distress ratings.

CONCLUSION

Additional research is warranted to examine how age differences in symptom experience are influenced by treatment differences, aging-related changes in biological or psychological processes, or age-related response shift.

Factors associated with delayed patient appraisal of colorectal cancer symptoms

OBJECTIVE

To evaluate the relationship between symptoms, financial and cognitive barriers with patient delays in seeking evaluation of symptoms.

METHODS

Data were collected from 252 colorectal cancer patients from academic and community oncology practices in Virginia and Ohio. We used a cross-sectional, mixed methods design collected data through patient interviews and medical record reviews. Structural equation modeling (SEM) tested the hypothesized relationships between symptoms, financial and cognitive barriers and patient care seeking delays.

RESULTS

In bivariate analyses, patients who reported a financial barrier to accessing health care (t (246) = -2.6, p < 0.01) were more likely to have greater care-seeking delays. Model testing revealed that experiencing cognitive barriers was a significant, positive, direct predictor of appraisal delay (0.35; p < 0.01). Indirect pathways from symptoms (0.07; p < 0.05) and financial barriers (0.09; p < 0.05) to appraisal delay via cognitive barriers were significant.

CONCLUSIONS

Patient interpretations of symptoms were influenced by financial barriers. Conceptualizing financial barriers as a component of the symptom appraisal process is conceptually different from viewing it as only a structural barrier preventing healthcare access. Implications for practice These findings extend our understanding of why and how patients seemingly ignore serious symptoms, which hamper physician ability to provide curative therapy. In addition to uninsured patients, this may have important implications for the treatment and care of those who are underinsured.

Approaches for classifying the indications for colonoscopy using detailed clinical data

Background

Accurate indication classification is critical for obtaining unbiased estimates of colonoscopy effectiveness and quality improvement efforts, but there is a dearth of published systematic classification approaches. The objective of this study was to evaluate the effects of data-source and adjudication on indication classification and on estimates of the effectiveness of screening colonoscopy on late-stage colorectal cancer diagnosis risk.

Methods

This was an observational study in members of four U.S. health plans. Eligible persons (n = 1039) were age 55–85 and had been enrolled for 5 years or longer in their health plans during 2006–2008. Patients were selected based on late-stage colorectal cancer diagnosis in a case–control design; each case patient was matched to 1–2 controls by study site, age, sex, and health plan enrollment duration. Reasons for colonoscopies received in the 10-year period before the reference date were collected from three medical records sources (progress notes; referral notes; procedure reports) and categorized using an algorithm, with committee adjudication of some tests. We evaluated indication classification concordance before and after adjudication and used logistic regressions with the Wald Chi-square test to compare estimates of the effects of screening colonoscopy on late-stage colorectal cancer diagnosis risk for each of our data sources to the adjudicated indication.

Results

Classification agreement between each data-source and adjudication was 78.8-94.0% (weighted kappa = 0.53-0.72); the highest agreement (weighted kappa = 0.86-0.88) was when information from all data sources was considered together. The choice of data-source influenced the association between screening colonoscopy and late-stage colorectal cancer diagnosis; estimates based on progress notes were closest to those based on the adjudicated indication (% difference in regression coefficients = 2.4%, p-value = 0.98), as compared to estimates from only referral notes (% difference in coefficients = 34.9%, p-value = 0.12) or procedure reports (% difference in coefficients = 27.4%, p-value = 0.23).

Conclusion

There was no single gold-standard source of information in medical records. The estimates of colonoscopy effectiveness from progress notes alone were the closest to estimates using adjudicated indications. Thus, the details in the medical records are necessary for accurate indication classification.

Risk of childhood cancer with symptoms in primary care: a population-based case-control study

BACKGROUND

Guidelines describing symptoms in children that should alert GPs to consider cancer have been developed, but without any supporting primary-care research.

AIM

To identify symptoms and signs in primary care that strongly increase the likelihood of childhood cancer, to assist GPs in selection of children for investigation.

DESIGN AND SETTING

A population-based case-control study in UK general practice.

METHOD

Using electronic primary care records from the UK General Practice Research Database, 1267 children aged 0-14 years diagnosed with childhood cancer were matched to 15 318 controls. Clinical features associated with subsequent diagnosis of cancer were identified using conditional logistic regression, and likelihood ratios and positive predictive values (PPVs) were estimated for each.

RESULTS

Twelve symptoms were associated with PPVs of ≥0.04%, which represents a greater than tenfold increase in prior probability. The six symptoms with the highest PPVs were pallor (odds ratio, OR = 84; PPV = 0.41% (95% confidence interval [CI] = 0.12% to 1.34%), head and neck masses (OR = 17; PPV = 0.30%; 95% CI = 0.10% to 0.84%), masses elsewhere (OR = 22; PPV = 0.11%; 95% CI = 0.06% to 0.20%), lymphadenopathy (OR = 10; PPV = 0.09%; 95% CI = 0.06% to 0.13%), symptoms/signs of abnormal movement (OR = 16; PPV = 0.08%; 95% CI = 0.04% to 0.14%), and bruising (OR = 12; PPV = 0·08%; 95% CI = 0.05% to 0.13%). When each of these 12 symptoms was combined singly with at least three consultations in a 3-month period, the probability of cancer was between 11 and 76 in 10 000.

CONCLUSION

Twelve features of childhood cancers were identified, each of which increased the risk of cancer at least tenfold. These symptoms, particularly when combined with multiple consultations, warrant careful evaluation in general practice.

Preferences for cancer investigation: a vignette-based study of primary-care attendees

BACKGROUND

The UK lags behind many European countries in terms of cancer survival. Initiatives to address this disparity have focused on barriers to presentation, symptom recognition, and referral for specialist investigation. Selection of patients for further investigation has come under particular scrutiny, although preferences for referral thresholds in the UK population have not been studied. We investigated preferences for diagnostic testing for colorectal, lung, and pancreatic cancers in primary-care attendees.

METHODS

In a vignette-based study, researchers recruited individuals aged at least 40 years attending 26 general practices in three areas of England between Dec 6, 2011, and Aug 1, 2012. Participants completed up to three of 12 vignettes (four for each of lung, pancreatic, and colorectal cancers), which were randomly assigned. The vignettes outlined a set of symptoms, the risk that these symptoms might indicate cancer (1%, 2%, 5%, or 10%), the relevant testing process, probable treatment, possible alternative diagnoses, and prognosis if cancer were identified. Participants were asked whether they would opt for diagnostic testing on the basis of the information in the vignette.

FINDINGS

3469 participants completed 6930 vignettes. 3052 individuals (88%) opted for investigation in their first vignette. We recorded no strong evidence that participants were more likely to opt for investigation with a 1% increase in risk of cancer (odds ratio [OR] 1·02, 95% CI 0·99-1·06; p=0·189), although the association between risk and opting for investigation was strong when colorectal cancer was analysed alone (1·08, 1·03-1·13; p=0·0001). In multivariable analysis, age had an effect in all three cancer models: participants aged 60-69 years were significantly more likely to opt for investigation than were those aged 40-59 years, and those aged 70 years or older were less likely. Other variables associated with increased likelihood of opting for investigation were shorter travel times to testing centre (colorectal and lung cancers), a family history of cancer (colorectal and lung cancers), and higher household income (colorectal and pancreatic cancers).

INTERPRETATION

Participants in our sample expressed a clear preference for diagnostic testing at all risk levels, and individuals want to be tested at risk levels well below those stipulated by UK guidelines. This willingness should be considered during design of cancer pathways, particularly in primary care. The public engagement with our study should encourage general practitioners to involve patients in referral decision making.

FUNDING

The National Institute for Health Research Programme Grants for Applied Research programme.

The role of primary care in early detection and follow-up of cancer

Primary care providers have important roles across the cancer continuum, from encouraging screening and accurate diagnosis to providing care during and after treatment for both the cancer and any comorbid conditions. Evidence shows that higher cancer screening participation rates are associated with greater involvement of primary care. Primary care providers are pivotal in reducing diagnostic delay, particularly in health systems that have long waiting times for outpatient diagnostic services. However, so-called fast-track systems designed to speed up hospital referrals are weakened by significant variation in their use by general practitioners (GPs), and affect the associated conversion and detection rates. Several randomized controlled trials have shown primary care-led follow-up care to be equivalent to hospital-led care in terms of patient wellbeing, recurrence rates and survival, and might be less costly. For primary care-led follow-up to be successful, appropriate guidelines must be incorporated, clear communication must be provided and specialist care must be accessible if required. Finally, models of long-term cancer follow-up are needed that provide holistic care and incorporate management of co-morbid conditions. We discuss all these aspects of primary care, focusing on the most common cancers managed at the GP office-breast, colorectal, prostate, lung and cervical cancers.

Patient delay in colorectal cancer patients: associations with rectal bleeding and thoughts about cancer

Rectal bleeding is considered to be an alarm symptom of colorectal cancer. However, the symptom is seldom reported to the general practitioner and it is often assumed that patients assign the rectal bleeding to benign conditions. The aims of this questionnaire study were to examine whether rectal bleeding was associated with longer patient delays in colorectal cancer patients and whether rectal bleeding was associated with cancer worries. All incident colorectal cancer patients during a 1-year period in the County of Aarhus, Denmark, received a questionnaire. 136 colorectal cancer patients returned the questionnaire (response rate: 42%). Patient delay was assessed as the interval from first symptom to help-seeking and was reported by the patient. Patients with rectal bleeding (N = 81) reported longer patient intervals than patients without rectal bleeding when adjusting for confounders including other symptoms such as pain and changes in bowel habits (HR = 0.43; p = 0.004). Thoughts about cancer were not associated with the patient interval (HR = 1.05; p = 0.887), but more patients with rectal bleeding reported to have been wondering if their symptom(s) could be due to cancer than patients without rectal bleeding (chi² = 15.29; p<0.001). Conclusively, rectal bleeding was associated with long patient delays in colorectal cancer patients although more patients with rectal bleeding reported to have been wondering if their symptom(s) could be due to cancer than patients without rectal bleeding. This suggests that assignment of symptoms to benign conditions is not the only explanation of long patient delays in this patient group and that barriers for timely help-seeking should be examined.

Association between constipation and colorectal cancer: systematic review and meta-analysis of observational studies

OBJECTIVES

Constipation is common in the community, and may affect survival adversely. An association between constipation and development of colorectal cancer (CRC) could be one possible explanation. We performed a systematic review and meta-analysis examining this issue.

METHODS

We searched MEDLINE, EMBASE, and EMBASE Classic (through July 2012). Eligible studies were cross-sectional surveys, cohort studies, or case-control studies reporting the association between constipation and CRC. For cross-sectional surveys and cohort studies, we recorded number of subjects with CRC according to the constipation status, and for case-control studies, number of subjects with constipation according to CRC status were recorded. Study quality was assessed according to published criteria. Data were pooled using a random effects model, and the association between CRC and constipation was summarized using an odds ratio (OR) with a 95% confidence interval (CI).

RESULTS

The search strategy identified 2,282 citations, of which 28 were eligible. In eight cross-sectional surveys, presence of constipation as the primary indication for colonoscopy was associated with a lower prevalence of CRC (OR=0.56; 95% CI 0.36-0.89). There was a trend toward a reduction in odds of CRC in constipation in three cohort studies (OR=0.80; 95% CI 0.61-1.04). The prevalence of constipation in CRC was significantly higher than in controls without CRC in 17 case-control studies (OR=1.68; 95% CI 1.29-2.18), but with significant heterogeneity, and possible publication bias.

CONCLUSIONS

Prospective cross-sectional surveys and cohort studies demonstrate no increase in prevalence of CRC in patients or individuals with constipation. The significant association observed in case-control studies may relate to recall bias.

Features of cancer in teenagers and young adults in primary care: a population-based nested case-control study

BACKGROUND

Teenagers and young adults (TYA, 15-24 years) diagnosed with cancer report repeated visits to primary care before referral. We investigated associations of symptoms and consultation frequency in primary care with TYA cancers.

METHODS

Population-based, case-control study was carried out using data from the Clinical Practice Research Datalink (CPRD). A total of 1064 TYA diagnosed with cancer were matched to 13,206 controls. Symptoms independently associated with specific cancers were identified. Likelihood ratios (LRs) and positive predictive values (PPVs) were calculated.

RESULTS

In the 3 months before diagnosis, 397 (42.9%) cases consulted > or =4 times vs 593(11.5%) controls (odds ratio (OR): 12.1; 95% CI: 9.7, 15.1), yielding a PPV for any cancer of 0.018%. The LR of lymphoma with a head/neck mass was 434 (95% CI: 60, 3158), with a PPV of 0.5%. Corresponding figures in other cancers included - LR of leukaemia with lymphadenopathy (any site): 29 (95% CI: 8, 112), PPV 0.015%; LR of CNS tumour with seizure: 56 (95% CI: 19, 163), PPV 0.024%; and LR of sarcoma with lump/mass/swelling: 79 (95% CI: 24, 264), PPV 0.042%.

CONCLUSION

Teenagers and young adults with cancer consulted more frequently than controls in the 3 months before diagnosis. Primary care features of cancer match secondary care reports, but were of very low risk; nonetheless, some features increased the likelihood of cancer substantially and should be taken seriously when assessing TYA.

Differences in the symptom experience of older versus younger oncology outpatients: a cross-sectional study

Background

Mortality rates for cancer are decreasing in patients under 60 and increasing in those over 60 years of age. The reasons for these differences in mortality rates remain poorly understood. One explanation may be that older patients received substandard treatment because of concerns about adverse effects. Given the paucity of research on the multiple dimensions of the symptom experience in older oncology patients, the purpose of this study was to evaluate for differences in ratings of symptom occurrence, severity, frequency, and distress between younger (< 60 years) and older ( ≥ 60 years) adults undergoing cancer treatment. We hypothesized that older patients would have significantly lower ratings on four symptom dimensions.

Methods

Data from two studies in the United States and one study in Australia were combined to conduct this analysis. All three studies used the MSAS to evaluate the occurrence, severity, frequency, and distress of 32 symptoms.

Results

Data from 593 oncology outpatients receiving active treatment for their cancer (i.e., 44.4% were < 60 years and 55.6% were ≥ 60 years of age) were evaluated. Of the 32 MSAS symptoms, after controlling for significant covariates, older patients reported significantly lower occurrence rates for 15 (46.9%) symptoms, lower severity ratings for 6 (18.9%) symptoms, lower frequency ratings for 4 (12.5%) symptoms, and lower distress ratings for 14 (43.8%) symptoms.

Conclusions

This study is the first to evaluate for differences in multiple dimensions of symptom experience in older oncology patients. For almost 50% of the MSAS symptoms, older patients reported significantly lower occurrence rates. While fewer age-related differences were found in ratings of symptom severity, frequency, and distress, a similar pattern was found across all three dimensions. Future research needs to focus on a detailed evaluation of patient and clinical characteristics (i.e., type and dose of treatment) that explain the differences in symptom experience identified in this study.

A population-based audit of the clinical use of faecal occult blood testing in primary care for colorectal cancer

AIM

Symptoms related to colorectal cancer (CRC) are common. We investigated the value of the faecal occult blood test (FOBT), when administered in primary care, in the diagnosis of CRC.

METHOD

All patients who underwent a FOBT (Hemoccult II) at 20 public primary care centres in Sörmland County, Sweden, during 2000-2005, were included (n=9048). Linkage to the Swedish Cancer Registry identified all cases of CRC. Symptoms recorded at the time of the FOBT were retrieved from the patient records. The outcome from the FOBT to diagnosis and subsequent survival was compared between patients who were FOBT negative and patients who were FOBT positive.

RESULTS

One-hundred and sixty-one patients were diagnosed with CRC within 2 years after undergoing a FOBT in primary care. These comprised 18% of all 917 patients diagnosed with CRC in the county during the study period. In 41 (25.4%) of the 161 patients the test was negative. Symptoms related to CRC were documented for 158 (98%) patients at the time the FOBT was administered. The median investigation time from the FOBT test to the diagnosis of CRC was 91 days: 80 days for FOBT-positive patients and 188 days for FOBT-negative patients (P<0.001). This difference was significant independent of age, sex and site of tumour. The hazard ratio for FOBT negativity, 3 years after the FOBT, when adjusted for age and sex, was 1.47 (95% CI, 0.81-2.68).

CONCLUSION

Despite having suggestive symptoms, 41 (4.5%) of 917 CRC patients had a negative FOBT result in primary care. This was associated with diagnostic delay and, potentially, a worse outcome.

Identifying patients with undetected colorectal cancer: an independent validation of QCancer (Colorectal)

Background:

Early identification of colorectal cancer is an unresolved challenge and the predictive value of single symptoms is limited. We evaluated the performance of QCancer (Colorectal) prediction model for predicting the absolute risk of colorectal cancer in an independent UK cohort of patients from general practice records.

Methods:

A total of 2.1 million patients registered with a general practice surgery between 01 January 2000 and 30 June 2008, aged 30-84 years (3.7 million person-years) with 3712 colorectal cancer cases were included in the analysis. Colorectal cancer was defined as incident diagnosis of colorectal cancer during the 2 years after study entry.

Results:

The results from this independent and external validation of QCancer (Colorectal) prediction model demonstrated good performance data on a large cohort of general practice patients. QCancer (Colorectal) had very good discrimination with an area under the ROC curve of 0.92 (women) and 0.91 (men), and explained 68% (women) and 66% (men) of the variation. QCancer (Colorectal) was well calibrated across all tenths of risk and over all age ranges with predicted risks closely matching observed risks.

Conclusion:

QCancer (Colorectal) appears to be a useful tool for identifying undetected cases of undiagnosed colorectal cancer in primary care in the United Kingdom.

Exfoliated colonocyte DNA levels and clinical features in the diagnosis of colorectal cancer: a cohort study in patients referred for investigation

AIM

Selection of patients for investigation of suspected colorectal cancer is difficult. One possible improvement may be to measure DNA isolated from exfoliated cells collected from the rectum.

METHOD

This was a cohort study in a surgical clinic. Participants were aged ≥40 years and referred for investigation of suspected colorectal cancer. Exclusion criteria were inflammatory bowel disease, previous gastrointestinal malignancy, or recent investigation. A sample of the mucocellular layer of the rectum was taken with an adapted proctoscope (the Colonix system). Haemoglobin, mean cell volume, ferritin, carcino-embryonic antigen and faecal occult bloods were tested. Analysis was by logistic regression.

RESULTS

Participation was offered to 828 patients, of whom 717 completed the investigations. Three were lost to follow up. Seventy-two (10%) had colorectal cancer. Exfoliated cell DNA was higher (P<0.001) in cancer (median 5.4 μg/ml [inter-quartile range 1.8,12]) compared with those without cancer (2.0 μg/ml [IQR 0.78,5.5]). Seven variables were independently associated with cancer, including age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.02,1.08; P<0.001) DNA (OR, 1.05; CI, 1.01,3.6; P=0.01), mean cell volume (OR, 0.93; CI, 0.89,0.97; P=0.001), carcino-embryonic antigen 1.02 per μg/l (CI, 1.00,1.04; P=0.02), male sex (OR, 2.0; CI, 1.1,3.6; P=0.02), rectal bleeding (OR, 2.4; CI, 1.3,4.5; P=0.007) and positive faecal occult blood (OR, 6.7; CI, 3.4, 13; P<0.001). The area under the receiver-operating characteristic curve for the DNA score was 0.65 (0.58-0.72) and for the seven variable model 0.88 (CI, 0.84-0.92).

CONCLUSION

Quantification of exfoliated DNA from rectal cellular material has promise in the diagnosis of colorectal cancer, but this requires confirmation in a larger study.

Features of childhood cancer in primary care: a population-based nested case-control study

BACKGROUND

This study investigated the risk of cancer in children with alert symptoms identified in current UK guidance, or with increased consultation frequency in primary care.

METHODS

A population-based, nested case-control study used data from the General Practice Research Database. In all, 1267 children age 0-14 years diagnosed with childhood cancer were matched to 15,318 controls. Likelihood ratios and positive predictive values (PPVs) were calculated to assess risk.

RESULTS

Alert symptoms recorded in the 12 and 3 months before diagnosis were present in 33.7% and 27.0% of cases vs 5.4% and 1.4% of controls, respectively. The PPV of having cancer for any alert symptom in the 3 months before diagnosis was 0.55 per 1000 children. Cases consulted more frequently particularly in the 3 months before diagnosis (86% cases vs 41% controls). Of these, 36% of cases and 9% of controls had consulted 4 times or more. The PPV for cancer in a child consulting 4 times or more in 3 months was 0.13 per 1000 children.

CONCLUSION

Alert symptoms and frequent consultations are associated with childhood cancer. However, individual symptoms and consultation patterns have very low PPVs for cancer in primary care (e.g., of 10,000 children with a recorded alert symptom, approximately 6 would be diagnosed with cancer within 3 months).

The diagnostic value of symptoms for colorectal cancer in primary care: a systematic review

BACKGROUND

Over 37,000 new colorectal cancers are diagnosed in the UK each year. Most present symptomatically to primary care.

AIM

To conduct a systematic review of the diagnostic value of symptoms associated with colorectal cancer.

DESIGN

Systematic review.

METHOD

MEDLINE, Embase, Cochrane Library, and CINAHL were searched to February 2010, for diagnostic studies of symptomatic adult patients in primary care. Studies of asymptomatic patients, screening, referred populations, or patients with colorectal cancer recurrences, or with fewer than 100 participants were excluded. The target condition was colorectal cancer. Data were extracted to estimate the diagnostic performance of each symptom or pair of symptoms. Data were pooled in a meta-analysis. The quality of studies was assessed with the QUADAS tool.

RESULTS

Twenty-three studies were included. Positive predictive values (PPVs) for rectal bleeding from 13 papers ranged from 2.2% to 16%, with a pooled estimate of 8.1% (95% confidence interval [CI] = 6.0% to 11%) in those aged ≥ 50 years. Pooled PPV estimates for other symptoms were: abdominal pain (three studies) 3.3% (95% CI = 0.7% to 16%); and anaemia (four studies) 9.7% (95% CI = 3.5% to 27%). For rectal bleeding accompanied by weight loss or change in bowel habit, pooled positive likelihood ratios (PLRs) were 1.9 (95% CI = 1.3 to 2.8) and 1.8 (95% CI = 1.3 to 2.5) respectively, suggesting higher risk when both symptoms were present. Conversely, the PLR was one or less for abdominal pain, diarrhoea, or constipation accompanying rectal bleeding.

CONCLUSION

The findings suggest that investigation of rectal bleeding or anaemia in primary care patients is warranted, irrespective of whether other symptoms are present. The risks from other single symptoms are lower, though multiple symptoms also warrant investigation.

A telematic tool to predict the risk of colorectal cancer in white men and women: ColoRectal Cancer Alert (CRCA)

Colorectal cancer is an important disease because of its severity and also since it affects much of the population. Nothing helps patients and doctors to determine the risk of suffering from colorectal cancer during their lives, except for medical tests such as the colonoscopy. There have been several studies and research to try to estimate the relative risks of colorectal cancer based on various factors and the applications to calculate the risk of this cancer, but these are not within everyone's research. This project offers a multilingual Web tool, called ColoRectal Cancer Alert (CRCA), to calculate the risk of colorectal cancer for life in men and women of white race. With this application, doctors can carry out research in a few minutes to explore this risk when they are seeing a patient. The platform is designed in such a way that anyone can use it. It is easy to use and intuitive. We should keep in mind that this tool does not replace diagnostic tests such as the colonoscopy or the sigmoidoscopy. It is designed so that users with the assistance of their doctor know the risk and act accordingly (for example, having more checkups on the disease in case of high risk). To access the tool a computer with Internet connection will be required. Currently, 250 users of white race under the supervision of a specialist have completed the questionnaire.

Positive predictive values of ≥5% in primary care for cancer: systematic review

BACKGROUND

The positive predictive value (PPV) for cancer of symptoms, signs, and non-diagnostic test results of patients routinely consulting a GP (unselected primary care populations) can help to determine when malignancy should be excluded. Comparisons with other illness indicate that a value of 5% or more may be regarded as highly predictive.

AIM

To identify symptoms, signs, and non-diagnostic test results in unselected primary care populations that are highly predictive of cancer.

DESIGN OF STUDY

Systematic review.

SETTING

Primary care.

METHOD

Fourteen bibliographic databases were searched, using terms for primary care, cancer, and predictive values. Reference lists of relevant papers were hand-searched. Data were extracted and the quality of each paper was assessed using predefined criteria, and checked by a second reviewer.

RESULTS

Twenty-five studies were identified. PPVs of 5% or more in specific age and sex groups were reported for: rectal bleeding, change in bowel habit, and iron deficiency anaemia and colorectal cancer; haematuria and urological cancer; malignant rectal examination and prostate cancer; haemoptysis and lung cancer; dysphagia and oesophageal cancer; breast lump and breast cancer; and postmenopausal bleeding and gynaecological cancer.

CONCLUSION

Robust evidence was found for eight symptoms, signs, and non-diagnostic test results as strongly indicative of cancer for specific age and sex groups in unselected primary care populations. These have the potential to improve the early diagnosis of some cancers in primary care by the use of computer warning flags, improved guidelines, audit, and appraisal.

Abdominal symptom-related QOL in individuals visiting an outpatient clinic and those attending an annual health check

OBJECTIVE

Quality of life (QOL) impairment of patients who visit an outpatient clinic for abdominal symptoms has not been clarified. We investigated symptom-related QOL impairment that led patients to seek medical care.

PATIENTS AND METHODS

Abdominal symptom-related QOL was determined using the Izumo scale instrument in 172 patients who visited a clinic for their abdominal symptoms and in 961 healthy subjects who attended an annual health check.

RESULTS

QOL was more strongly impaired in the patients with abdominal symptoms than in subjects who attended health checks. Patients with heartburn consulted physicians even when QOL impairment was minimal, while those with epigastric fullness tended to consult a physician only when QOL impairment was significant.

CONCLUSION

Abdominal symptom-related QOL impairment is considered to lead patients to seek medical care, though different symptoms have varying levels of influence.

Cancer diagnosis in primary care

Around a quarter of those in the developed world die of cancer. Most cancers present to primary care with symptoms, even when there is a screening test for the particular cancer. However, the symptoms of cancer are also symptoms of benign disease, and the GP has to judge whether cancer is a possible explanation. Very little research examined this process until relatively recently. This review paper examines the process of primary care diagnosis, especially the selection of patients for rapid investigation. It concentrates on the four commonest UK cancers: breast, lung, colon, and prostate as these have been the subject of most recent studies.

The CAPER studies: five case-control studies aimed at identifying and quantifying the risk of cancer in symptomatic primary care patients

Background:

This paper reviews the background to five primary care case-control studies, collectively known as the CAPER studies (Cancer Prediction in Exeter). These studies, on colorectal, lung, prostate and brain tumours, sought to identify the particular features of cancer as reported to primary care. They also sought to quantify the risk of cancer for symptoms and primary care investigations, both individually and paired together.

Methods:

Two studies were on colorectal cancer: the former with 349 cases used hand searching and coding of entries, while the latter obtained 6442 cases from a national electronic database. The lung and prostate studies had 247 and 217 cases, respectively, and used manual methods. The brain study also used a national electronic database, which provided 3505 cases.

Results:

Generally, the symptoms matched previous series from secondary care, though the risks of cancer, expressed as positive predictive values, were lower. Rectal bleeding in colorectal cancer, and haemoptysis in lung cancer both had positive predictive values of 2.4%. The risk of a brain tumour with headache was one in a thousand.

Interpretation:

The results identify areas where current guidance on urgent referral for investigation of suspected cancer could be improved.

Validation of computerized diagnostic information in a clinical database from a national equine clinic network

BACKGROUND

Computerized diagnostic information offers potential for epidemiological research; however data accuracy must be addressed. The principal aim of this study was to evaluate the completeness and correctness of diagnostic information in a computerized equine clinical database compared to corresponding hand written veterinary clinical records, used as gold standard, and to assess factors related to correctness. Further, the aim was to investigate completeness (epidemiologic sensitivity), correctness (positive predictive value), specificity and prevalence for diagnoses for four body systems and correctness for affected limb information for four joint diseases.

METHODS

A random sample of 450 visits over the year 2002 (nvisits=49,591) was taken from 18 nation wide clinics headed under one company. Computerized information for the visits selected and copies of the corresponding veterinary clinical records were retrieved. Completeness and correctness were determined using semi-subjective criteria. Logistic regression was used to examine factors associated with correctness for diagnosis.

RESULTS

Three hundred and ninety six visits had veterinary clinical notes that were retrievable. The overall completeness and correctness were 91% and 92%, respectively; both values considered high. Descriptive analyses showed significantly higher degree of correctness for first visits compared to follow up visits and for cases with a diagnostic code recorded in the veterinary records compared to those with no code noted. The correctness was similar regardless of usage category (leisure/sport horse, racing trotter and racing thoroughbred) or gender.For the four body systems selected (joints, skin and hooves, respiratory, skeletal) the completeness varied between 71% (respiration) and 91% (joints) and the correctness ranged from 87% (skin and hooves) to 96% (respiration), whereas the specificity was >95% for all systems. Logistic regression showed that correctness was associated with type of visit, whether an explicit diagnostic code was present in the veterinary clinical record, and body system. Correctness for information on affected limb was 95% and varied with joint.

CONCLUSION

Based on the overall high level of correctness and completeness the database was considered useful for research purposes. For the body systems investigated the highest level of completeness and correctness was seen for joints and respiration, respectively.