Duration of colorectal cancer symptoms and survival: the effect of confounding clinical and pathological variables

The effect of time before diagnosis and treatment on colorectal cancer outcomes: systematic review and dose-response meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to evaluate existing evidence on the relationship between diagnostic and treatment intervals and outcomes for colorectal cancer.

METHODS

Four databases were searched for English language articles assessing the role of time before initial treatment in colorectal cancer on any outcome, including stage and survival. Two reviewers independently screened articles for inclusion and data were synthesised narratively. A dose-response meta-analysis was performed to examine the association between treatment interval and survival.

RESULTS

One hundred and thirty papers were included in the systematic review, eight were included in the meta-analysis. Forty-five different intervals were considered in the time from first symptom to treatment. The most common finding was of no association between the length of intervals on any outcome. The dose-response meta-analysis showed a U-shaped association between the treatment interval and overall survival with the nadir at 45 days.

CONCLUSION

The review found inconsistent, but mostly a lack of, association between interval length and colorectal cancer outcomes, but study design and quality were heterogeneous. Meta-analysis suggests survival becomes increasingly poorer for those commencing treatment more than 45 days after diagnosis.

REGISTRATION

This review was registered, and the protocol is available, in PROSPERO, the international database of systematic reviews, with the registration ID CRD42021255864.

A systematic review of methodological considerations in time to diagnosis and treatment in colorectal cancer research

Research focusing on timely diagnosis and treatment of colorectal cancer is necessary to improve outcomes for people with cancer. Previous attempts to consolidate research on time to diagnosis and treatment have noted varied methodological approaches and quality, limiting the comparability of findings. This systematic review was conducted to comprehensively assess the scope of methodological issues in this field and provide recommendations for future research. Eligible articles had to assess the role of any interval up to treatment, on any outcome in colorectal cancer, in English, with no limits on publication time. Four databases were searched (Ovid Medline, EMBASE, EMCARE and PsycInfo). Papers were screened by two independent reviewers using a two-stage process of title and abstract followed by full text review. In total, 130 papers were included and had data extracted on specific methodological and statistical features. Several methodological problems were identified across the evidence base. Common issues included arbitrary categorisation of intervals (n = 107, 83%), no adjustment for potential confounders (n = 65, 50%), and lack of justification for included covariates where there was adjustment (n = 40 of 65 papers that performed an adjusted analysis, 62%). Many articles introduced epidemiological biases such as immortal time bias (n = 37 of 80 papers that used survival as an outcome, 46%) and confounding by indication (n = 73, 56%), as well as other biases arising from inclusion of factors outside of their temporal sequence. However, determination of the full extent of these problems was hampered by insufficient reporting. Recommendations include avoiding artificial categorisation of intervals, ensuring bias has not been introduced due to out-of-sequence use of key events and increased use of theoretical frameworks to detect and reduce bias. The development of reporting guidelines and domain-specific risk of bias tools may aid in ensuring future research can reliably contribute to recommendations regarding optimal timing and strengthen the evidence base.

The impact of COVID-19 pandemic on colorectal cancer patients at an NHS Foundation Trust hospital-A retrospective cohort study

INTRODUCTION

Current NHS guidelines recommend that treatment of colorectal patients referred through the two-week wait referral system should occur within sixty two days from the date of referral. The COVID-19 pandemic which started in March 2020 has however led to significant delays in the delivery of health services, including colorectal cancer treatments. This study investigates the effects of delayed colorectal cancer treatments during the COVID pandemic on disease progression.

METHODS

A retrospective chart review of 107 patients with histologically confirmed diagnosis of colorectal cancer was conducted. The occurrence of cancer upstaging after initial diagnosis was assessed and compared between patients with treatment delays and patients who received treatments within the period recommended by NHS guidelines. A logistic regression was performed to evaluate the association between treatment delays beyond 62 days and cancer upstaging.

RESULTS

The median age of the cohort was 71.2 years and 64.5% of the patients were over 65 years. Treatment delays were observed in 53.3% of reviewed patients. Patients with treatment delays received cancer treatments 95.8 (31.0) days on average after referral, compared to 46.3 (11.5) days in patients who experienced no treatment delays (p-value<0.0001). 38.6% of patients with treatment delays experienced cancer upstaging by the time of treatment, compared to 20% in the non-delay group (p-value = 0.036). Patients who received treatment after sixty two days from date of referral were 3.27 times more likely to experience colorectal cancer upstaging compared to those who received timely treatments.

CONCLUSION

Although an effective response to the Covid-19 pandemic requires the reallocation of healthcare resources, there is a need to ensure that treatments and health outcomes of patients with chronic diseases such as colorectal cancer continue to be prioritized and delivered in timely fashion.

Fall of another myth for colon cancer: Duration of symptoms does not differ between right- or left-sided colon cancers

BACKGROUND/AIMS

Patients with colorectal cancer continue to present with relatively advanced tumors that are associated with poor oncological outcomes. The aim of the present study was to assess the association between localization, symptom duration, and tumor stage.

MATERIALS AND METHODS

A prospective, multicenter cohort study was conducted on patients newly diagnosed with a histologically proven colorectal adenocarcinoma. Standardized questionnaire-interviews were performed. Data were collected on principal presenting symptoms, duration of symptoms (time to first presentation to a doctor and time to diagnosis) and treatment, diagnostic procedures, tumor site, and stage of the tumor (tumor, node, and metastasis (TNM)).

RESULTS

A total of 1795 patients with colorectal cancer were interviewed (mean age: 60.76±13.50 years, male patients: 1057, patients aged >50 years: 1444, colon/rectal cancer: 899/850, right side/left side: 383/1250, stage 0-1-2/stage 3-4: 746/923). No statistically significant correlations were found between duration of symptoms and either tumor site or stage. Principal presenting symptoms were significantly associated with left colon cancer. Patients who had "anemia," "change in bowel habits," "anal pruritus or discharge," "weight loss," and "tumor in right colon" had a significantly longer symptom time.

CONCLUSION

Symptom duration is not associated with localization, nor is the tumor stage. Diagnosis of colorectal cancer at an earlier stage may be best achieved by screening of the population.

Wait times to diagnosis and treatment in patients with colorectal cancer in Hungary

BACKGROUND

Mortality from colorectal cancer (CRC) in Hungary is the highest in Europe. It was the aim of the present study to determine the wait times from first presentation to diagnosis, in a sample of Hungarian patients with CRC, as well as to assess the stages of CRC at diagnosis.

METHODS

A retrospective study based on data from 212 patients with CRC in Baranya county was carried out. Data extraction was performed from 26 GP practices and from the database of the University of Pécs Clinical Center. Total Diagnostic Interval (TDI) was determined as the number of days from the first patient-physician consultation with symptoms until the pathologically confirmed date of diagnosis. Total Treatment Interval (TTI) was calculated until the first day of any form of treatment. Statistical analyses, descriptive analysis and analysis of variance, were performed.

RESULTS

A minority (36.8%) of the diagnosed CRC cases were early stage cancers (Stages I-II), while the majority (59.9%) of the cases were diagnosed as advanced stage (Stages III-IV) cancers. The median TDI was 41 days, and the median TTI was 67 days. There was a wide range between minimum and maximum waiting times regarding both diagnosis and initiation of therapy (369-371 days).

CONCLUSIONS

Wait times to diagnosis and treatment of CRC in Hungary are similar to Western countries however the ratio of advanced cancers at diagnosis is higher. The cause of late diagnosis may be due to patient delay, indicating the need for implementation of primary and secondary prevention.

Time to diagnosis and stage of symptomatic colorectal cancer determined by three different sources of information: A population based retrospective study

BACKGROUND

Survival rates from colorectal cancer (CRC) are highly variable in Europe. This variability could potentially be explained by differences in healthcare system delays in diagnosis. However, even when such delays are reduced, the relationship of the diagnostic interval (time from presentation with symptoms to diagnosis) with outcome is uncertain.

METHODS

A total of 795 patients with CRC from 5 regions of Spain were retrospectively examined in this population-based multicenter study. Consecutive incident cases of CRC were identified from pathology services. The total diagnostic interval (TDI) was defined as the time from the first presentation with symptoms to diagnosis based on 3 different sources of information: (i) patient-recorded data (PR-TDI) by interview, (ii) hospital-recorded data (HR-TDI), and (iii) general practitioner-recorded data (GPR-TDI). Concordance correlation coefficients (CCCs) were used to estimate the agreement of 3 different TDIs. The TDIs of patients with different stages of CRC were also compared using the Kruskal-Wallis test.

RESULTS

The median TDI was 131days based on patient interview data, 91days based on HR data, and 111days based on GPR data. Overall, the agreement of these TDIs was poor (CCC_PRvsHR=0.399, CCC_PRvsGPR=0.518, CCC_HRvsGPR=0.383). Univariate analysis indicated that the TDI was greater in those with less advanced CRC for all 3 methods of calculation, but this association was only statistically significant for the HR-TDI (p=0.021).

CONCLUSION

There is no evidence that patients with more advanced CRC have longer TDIs. In fact, we found an inverse relationship between the TDI and CRC stage, an example of the "waiting time paradox". This association may likely be due to the presence of unmeasured confounders as the stage when symptoms appear or the tumour aggressiveness.

Effect of diagnostic delay on survival in patients with colorectal cancer: a retrospective cohort study

Background

Disparate and contradictory results make studies necessary to investigate in more depth the relationship between diagnostic delay and survival in colorectal cancer (CRC) patients. The aim of this study is to analyse the relationship between the interval from first symptom to diagnosis (SDI) and survival in CRC.

Methods

Retrospective study of n = 942 CRC patients. SDI was calculated as the time from the diagnosis of cancer and the first symptoms of CRC.

Cox regression was used to estimate five-year mortality hazard ratios as a function of SDI, adjusting for age and gender. SDI was modelled according to SDI quartiles and as a continuous variable using penalized splines.

Results

Median SDI was 3.4 months. SDI was not associated with stage at diagnosis (Stage I = 3.6 months, Stage II-III = 3.4, Stage IV = 3.2; p = 0.728). Shorter SDIs corresponded to patients with abdominal pain (2.8 months), and longer SDIs to patients with muchorrhage (5.2 months) and rectal tenesmus (4.4 months).

Adjusting for age and gender, in rectum cancers, patients within the first SDI quartile had lower survival (p = 0.003), while in colon cancer no significant differences were found (p = 0.282). These results do not change after adjusting for TNM stage.

The splines regression analysis revealed that, for rectum cancer, 5-year mortality progressively increases for SDIs lower than the median (3.7 months) and decreases as the delay increases until approximately 8 months. In colon cancer, no significant relationship was found between SDI and survival.

Conclusions

Short diagnostic intervals are significantly associated with higher mortality in rectal but not in colon cancers, even though a borderline significant effect is also observed in colon cancer. Longer diagnostic intervals seemed not to be associated with poorer survival. Other factors than diagnostic delay should be taken into account to explain this “waiting-time paradox”.

Prevalence and characteristics of colorectal polyps in symptomatic and asymptomatic Iranian patients undergoing colonoscopy from 2009-2013

BACKGROUND

Colorectal cancer is the third most common type of cancer in males and the second in females in Iran. Males are more likely to develop CRC than women and age is considered as a main risk factor for colorectal cancer. Prevalence of colorectal cancer has been increasing in Asian countries.

AIM

The object of this study was to determine the clinical and pathology characteristics of colorectal polyps in Iranian patients and to investigate the variation between our populations with other populations.

MATERIALS AND METHODS

A total of 167 patients with colorectal polyps were included in our study. All underwent colonoscopy during 2009-2013 and specimens were taken through polypectomy and transferred to pathology. All data in patient files including pathology reports were collected and analyzed by SPSS 16 software. A two-tailed test was used and a P-value of <0.05 was considered significant.

RESULTS

Mean age of participants was 57±15. Some 84 were females (50.3%) and 83 males (49.7%). Total of 225 polyps were detected which 119 (52.9%) were in males and 106 (47.1%) were in females. Solitary polyps were observed in 124 patients (74%), 26 (15.6%) had two polyps and 17 (10.1%) with more than two polyps (three to five). Rectosigmoid was the site of most of the polyps (63.1%), followed by 19.6% in the descending colon, 7.6% in the transverse, 5.8% in the ascending, and 3.1% in the cecum, data being missing in two cases.

CONCLUSIONS

Recto sigmoid was site of most of the polyps. The most prevalent type of lesion was adenomatous polyps detected in 78 (34.7%). Mixed hyperplastic adenomatous type observed in 70 (31.1%). This high prevalence of adenomatous polyps in Iranian patients implies the urgent need for screening plans to prevent further healthcare problems with colorectal cancer in the Iranian population.

Association of short duration from initial symptoms to specialist consultation with poor survival in soft-tissue sarcomas

INTRODUCTION

The association of symptom duration with survival remains controversial in soft-tissue sarcoma (STS).

MATERIALS AND METHODS

We determined whether the length from initial symptoms to specialist consultation affects prognosis in STSs. We retrospectively reviewed 152 primary STS patients (with 142 non-small round cell sarcomas) who consulted our specialist hospital. The factors that affected the length of the period from the initial symptoms to specialist consultation and the length of the delay at the clinic before specialist hospital referral were investigated. The relation between the length of the period from symptom onset and overall survival was also analyzed.

RESULTS

Unplanned excision and superficial tumor were significantly associated with increasing duration from the initial symptoms to specialist hospital referral. Multivariate analysis revealed that tumors over 5 cm (P=0.002 and 0.005) and symptoms within 6 months (P=0.017 and 0.016) were independent poor prognostic factors of overall survival among the pretreatment factors when analyzing all and non-small round cell STSs.

CONCLUSIONS

This is a first report to show the independent prognostic role of symptom duration in STSs on multivariate analysis. Considering the impact of symptom duration on survival in these heterogenous tumors, careful follow-up and consideration of treatment are necessary for patients with short symptom duration.

Bleeding-related symptoms in colorectal cancer: a 4-year nationwide population-based study

BACKGROUND

Little is known about the major presenting features of patients with colorectal cancer (CRC) in a population-based setting, especially regarding bleeding-related symptoms.

AIM

To determine the proportion of CRC patients presenting with bleeding-related symptoms, to compare bleeders and nonbleeders and to explore the role of anticoagulants in bleeders.

METHODS

This was a nationwide, population-based, retrospective study, investigating all patients diagnosed with CRC in Iceland from 2008 to 2011. Bleeding-related symptoms were defined as overt bleeding, iron deficiency anaemia or a positive faecal occult blood test. Obstructive symptoms were defined as a confirmed diagnosis of ileus or dilated intestines on imaging.

RESULTS

Data were available for 472/496 (95%) patients, males 51%, mean age 69 (±13) years. In all, 348 (74%) patients had bleeding-related symptoms; of these 348 patients, 61% had overt bleeding. Bleeders were less likely than nonbleeders to have metastases at diagnosis, 19% vs. 34% (P < 0.001). Overt bleeders were less likely than nonbleeders to have obstructive symptoms, 2% vs. 16% respectively (P < 0.0001). Occult bleeders were more likely to have proximal cancer (69%) than both overt (17%) and nonbleeders (44%) (P < 0.0001); however, they were less likely than nonbleeders to have metastases (22% vs. 35%, P < 0.05). Bleeders were more likely to use warfarin than nonbleeders (9% vs. 3%, P < 0.05); the use of low-dose aspirin was the same (24%).

CONCLUSIONS

The majority of patients with CRC present with bleeding-related symptoms. Bleeders with CRC present earlier than nonbleeders. Warfarin use may induce bleeding in some patients, resulting in an earlier diagnosis.

Longitudinal measures of proteostasis in live neurons: features that determine fate in models of neurodegenerative disease

Protein misfolding and proteostasis decline is a common feature of many neurodegenerative diseases. However, modeling the complexity of proteostasis and the global cellular consequences of its disruption is a challenge, particularly in live neurons. Although conventional approaches, based on population measures and single "snapshots", can identify cellular changes during neurodegeneration, they fail to determine if these cellular events drive cell death or act as adaptive responses. Alternatively, a "systems" cell biology approach known as longitudinal survival analysis enables single neurons to be followed over the course of neurodegeneration. By capturing the dynamics of misfolded proteins and the multiple cellular events that occur along the way, the relationship of these events to each other and their importance and role during cell death can be determined. Quantitative models of proteostasis dysfunction may yield unique insight and novel therapeutic strategies for neurodegenerative disease.

Factors related with symptom duration until diagnosis and treatment of symptomatic colorectal cancer

Background

Colorectal cancer (CRC) survival depends mostly on stage at the time of diagnosis. However, symptom duration at diagnosis or treatment have also been considered as predictors of stage and survival. This study was designed to: 1) establish the distinct time-symptom duration intervals; 2) identify factors associated with symptom duration until diagnosis and treatment.

Methods

This is a cross-sectional study of all incident cases of symptomatic CRC during 2006–2009 (795 incident cases) in 5 Spanish regions. Data were obtained from patients’ interviews and reviews of primary care and hospital clinical records. Measurements: CRC symptoms, symptom perception, trust in the general practitioner (GP), primary care and hospital examinations/visits before diagnosis, type of referral and tumor characteristics at diagnosis. Symptom Diagnosis Interval (SDI) was calculated as time from first CRC symptoms to date of diagnosis. Symptom Treatment Interval (STI) was defined as time from first CRC symptoms until start of treatment. Nonparametric tests were used to compare SDI and STI according to different variables.

Results

Symptom to diagnosis interval for CRC was 128 days and symptom treatment interval was 155. No statistically significant differences were observed between colon and rectum cancers. Women experienced longer intervals than men. Symptom presentation such as vomiting or abdominal pain and the presence of obstruction led to shorter diagnostic or treatment intervals. Time elapsed was also shorter in those patients that perceived their first symptom/s as serious, disclosed it to their acquaintances, contacted emergencies services or had trust in their GPs. Primary care and hospital doctor examinations and investigations appeared to be related to time elapsed to diagnosis or treatment.

Conclusions

Results show that gender, symptom perception and help-seeking behaviour are the main patient factors related to interval duration. Health service performance also has a very important role in symptom to diagnosis and treatment interval. If time to diagnosis is to be reduced, interventions and guidelines must be developed to ensure appropriate examination and diagnosis during both primary and hospital care.

Factors influencing diagnosis of colorectal cancer: a hospital-based survey in China

OBJECTIVE

To investigate the diagnostic status of colorectal cancer (CRC) and the influence of early diagnosis and cancer stage in a tertiary care hospital in China.

METHODS

Face-to-face interviews were conducted in 364 consecutive CRC patients who had never participated in CRC screening. Initial symptoms, diagnosis and treatment delay were determined using a questionnaire. Factors influencing diagnostic status were analyzed using univariate analysis and logistic regression model.

RESULTS

A total of 307 patients were enrolled, in which 128 were with colon cancer and 179 with rectal cancer. The duration of diagnosis delay was significant longer than that of treatment delay. Unlike rectal cancer, colon cancer was likely to be treated at an advanced stage with a short interval between symptom onset and treatment. Colon cancer patients with a history of biliary tract or gallbladder stones, aged ≥ 50 years and with abdominal mass or intestinal obstruction as the initial symptom were diagnosed and treated much earlier. In rectal cancer, women and non-smokers were diagnosed and treated quickly. Factors correlated with early cancer stage were found in colon cancer, including bloody stool as the initial symptom (OR = 2.63, 95% CI 1.08-6.25, P = 0.034) and a history of appendectomy (OR = 4.00, 95% CI 1.15-14.29, P = 0.029).

CONCLUSIONS

The factors contributing to early cancer detection were identified but their clinical value is limited. Diagnosis by symptoms suggesting CRC needs to be improved and CRC screening should be vigorously promoted.

Factors associated with consultation behaviour for primary symptoms potentially indicating colorectal cancer: a cross-sectional study on response to symptoms

Background

Little data exists on the factors associated with health care seeking behaviour for primary symptoms of colorectal cancer (CRC). This study aimed to identify individual, provider and psychosocial factors associated with (i) ever seeking medical advice and (ii) seeking early medical advice for primary symptoms of colorectal cancer (CRC).

Methods

1592 persons aged 56–88 years randomly selected from the Hunter Community Study (HCS) were sent a questionnaire.

Results

Males and those who had received screening advice from a doctor were at significantly higher odds of ever seeking medical advice for rectal bleeding. Persons who had private health coverage, consulted a doctor because the ‘symptom was serious’, or who did not wait to consult a doctor for another reason were at significantly higher odds of seeking early medical advice (< 2 weeks). For change in bowel habit, persons with lower income, within the healthy weight range, or who had discussed their family history of CRC irrespective of whether informed of ‘increased risk’ were at significantly higher odds of ever seeking medical advice. Persons frequenting their GP less often and seeing their doctor because the symptom persisted were at significantly higher odds of seeking early medical advice (< 2 weeks).

Conclusions

The seriousness of symptoms, importance of early detection, and prompt consultation must be articulated in health messages to at-risk persons. This study identified modifiable factors, both individual and provider-related to consultation behaviour. Effective health promotion efforts must heed these factors and target sub-groups less likely to seek early medical advice.

Does diagnostic delay of colorectal cancer result in malpractice claims? A retrospective analysis of the Swedish board of malpractice from 1995-2008

Aim

Delay in the diagnosis of colorectal cancer (CRC) may have important clinical and medico-legal implications. This study identifies the claims made on the basis of delay in the diagnosis of CRC to the Swedish insurance agency (whose English name is The County Council´s Mutual Insurance Company) and the impact and consequences of the delay on prognosis, treatment and survival for patients who reported the claims. The Company handles claims of medical malpractice where claimants seek compensation for alleged suffering and/or negative clinical impacts of diagnostic delays.

Material and methods

Between January 1, 1995 and December 31, 2008, a total of 80 patients filed claims for negative effects resulting from delays in the diagnosis of CRC. Review of the claims led to identification of delay for 62 patients. The clinical symptoms that were overlooked and other causes of delay that had any relation to therapy, prognosis and economic compensation were evaluated.

Results

The median delay in the diagnosis of CRC was six months. This delay was considered to have had an impact on the therapy in 20 % of the cases. The prognosis was postulated to have been adversely affected for 15 % of the patients. The delay was mainly caused by incomplete consideration of the symptoms hematoschisis or anaemia, changed bowel routine, or incomplete clinical or radiological examination and by misinterpretations of the results. No impact of duration of delay on survival was identified. The importance of identifying concomitant metastatic disease at diagnosis was overwhelming. Economic compensation was given in 79 % of the cases.

Conclusion

This study found that claims for compensation for delay in diagnosis of CRC are rare. The delay in the diagnosis of the primary tumour was considered to have had an impact on the magnitude of therapeutic measures for a fifth of the patients who filed claims. Economic compensation for the patients´ injuries was given in almost 80 % of the cases.

Most bowel cancer symptoms do not indicate colorectal cancer and polyps: a systematic review

BACKGROUND

Bowel symptoms are often considered an indication to perform colonoscopy to identify or rule out colorectal cancer or precancerous polyps. Investigation of bowel symptoms for this purpose is recommended by numerous clinical guidelines. However, the evidence for this practice is unclear. The objective of this study is to systematically review the evidence about the association between bowel symptoms and colorectal cancer or polyps.

METHODS

We searched the literature extensively up to December 2008, using MEDLINE and EMBASE and following references. For inclusion in the review, papers from cross sectional, case control and cohort studies had to provide a 2×2 table of symptoms by diagnosis (colorectal cancer or polyps) or sufficient data from which that table could be constructed. The search procedure, quality appraisal, and data extraction was done twice, with disagreements resolved with another reviewer. Summary ROC analysis was used to assess the diagnostic performance of symptoms to detect colorectal cancer and polyps.

RESULTS

Colorectal cancer was associated with rectal bleeding (AUC 0.66; LR+ 1.9; LR- 0.7) and weight loss (AUC 0.67, LR+ 2.5, LR- 0.9). Neither of these symptoms was associated with the presence of polyps. There was no significant association of colorectal cancer or polyps with change in bowel habit, constipation, diarrhoea or abdominal pain. Neither the clinical setting (primary or specialist care) nor study type was associated with accuracy.Most studies had methodological flaws. There was no consistency in the way symptoms were elicited or interpreted in the studies.

CONCLUSIONS

Current evidence suggests that the common practice of performing colonoscopies to identify cancers in people with bowel symptoms is warranted only for rectal bleeding and the general symptom of weight loss. Bodies preparing guidelines for clinicians and consumers to improve early detection of colorectal cancer need to take into account the limited value of symptoms.

Symptoms and signs in patients with colorectal cancer

The symptoms and signs of colorectal cancer vary from the general population to primary care and in the referred population to secondary care. This review aims to address the diverse symptoms, signs and combinations with relevance to colorectal cancer at various points in the diagnostic pathway and tries to shed light on this complex and confusing area. A move towards a lower threshold for referral and increased use of diagnostics might be a more reliable option for early diagnosis.

Earlier diagnosis and treatment of symptomatic bowel cancer: can it be achieved and how much will it improve survival?

AIM

To determine current delays in diagnosis and treatment of bowel cancer, when and why they occur, and what effect they have on survival.

METHOD

A detailed review of the literature based on the development of the GP referral guidelines in 2000.

RESULTS

There is no evidence of a reduction in the delay to diagnosis and treatment of bowel cancer over the last 60 years. There is no strong theoretical basis for a benefit from earlier diagnosis of symptomatic bowel cancer and this is consistent with observational studies.

CONCLUSION

Campaigns to earlier diagnose bowel cancer will not be successful unless new strategies are developed. There is substantial evidence that earlier diagnosis of symptomatic bowel cancer will not improve survival in the majority of patients. However as excessive delays still occur in some patients it is reasonable to continue to aim to diagnose and treat all bowel cancer within 6 months of the onset of symptoms with an overall median of 3-4 months.

Diagnosis delay and follow-up strategies in colorectal cancer. Prognosis implications: a study protocol

Background

Controversy exists with regard to the impact that the different components of diagnosis delay may have on the degree of invasion and prognosis in patients with colorectal cancer. The follow-up strategies after treatment also vary considerably. The aims of this study are: a) to determine if the symptoms-to-diagnosis interval and the treatment delay modify the survival of patients with colorectal cancer, and b) to determine if different follow-up strategies are associated with a higher survival rate.

Methods/Design

Multi-centre study with prospective follow-up in five regions in Spain (Galicia, Balearic Islands, Catalonia, Aragón and Valencia) during the period 2010-2012. Incident cases are included with anatomopathological confirmation of colorectal cancer (International Classification of Diseases 9th revision codes 153-154) that formed a part of a previous study (n = 953).

At the time of diagnosis, each patient was given a structured interview. Their clinical records will be reviewed during the follow-up period in order to obtain information on the explorations and tests carried out after treatment, and the progress of these patients.

Symptoms-to-diagnosis interval is defined as the time calculated from the diagnosis of cancer and the first symptoms attributed to cancer. Treatment delay is defined as the time elapsed between diagnosis and treatment. In non-metastatic patients treated with curative intention, information will be obtained during the follow-up period on consultations performed in the digestive, surgery and oncology departments, as well as the endoscopies, tumour markers and imaging procedures carried out.

Local recurrence, development of metastases in the follow-up, appearance of a new tumour and mortality will be included as outcome variables.

Actuarial survival analysis with Kaplan-Meier curves, Cox regression and competitive risk survival analysis will be performed.

Discussion

This study will make it possible to verify if the different components of delay have an impact on survival rate in colon cancer and rectal cancer. In consequence, this multi-centre study will be able to detect the variability present in the follow-up of patients with colorectal cancer, and if this variability modifies the prognosis. Ideally, this study could determine which follow-up strategies are associated with a better prognosis in colorectal cancer.

Does delay in diagnosing colorectal cancer in symptomatic patients affect tumor stage and survival? A population-based observational study

Background

Diagnosing colorectal cancer (CRC) at an early stage improves survival. To what extent any delay affects outcome once patients are symptomatic is still unclear.

Our objectives were to evaluate the association between diagnostic delay and survival in symptomatic patients with early stage CRC and late stage CRC.

Methods

Prospective population-based observational study evaluating daily clinical practice in Northern Holland. Diagnostic delay was determined through questionnaire-interviews. Dukes' stage was classified into two groups: early stage (Dukes A or B) and late stage (Dukes C or D) cancer. Patients were followed up for 3.5 years after diagnosis.

Results

In total, 272 patients were available for analysis. Early stage CRC was present in 136 patients while 136 patients had late stage CRC. The mean total diagnostic delay (SE) was 31 (1.5) weeks in all CRC patients. No significant difference was observed in the mean total diagnostic delay in early versus late stage CRC (p = 0.27).

In early stage CRC, no difference in survival was observed between patients with total diagnostic delay shorter and longer than the median (Kaplan-Meier, log-rank p = 0.93).

In late stage CRC, patients with a diagnostic delay shorter than the median had a shorter survival than patients with a diagnostic delay longer than the median (log-rank p = 0.01). In the multivariate Cox regression model with survival as dependent variable and median delay, age, open access endoscopy, number and type of symptoms as independent variables, the odd's ratio for survival in patients with long delay (>median) versus short delay (≤median) was 1.8 (95% confidence interval (CI) 1.1 to 3.0; p = 0.01). Tumor-site was not associated with patient survival. When separating late stage CRC in Dukes C and Dukes D tumors, a shorter delay was associated with a shorter survival in Dukes D tumors only and not in Dukes C tumors.

Conclusion

In symptomatic CRC patients, a longer diagnostic and therapeutic delay in routine clinical practice was not associated with an adverse effect on survival. The time to CRC diagnosis and initiation of treatment did not differ between early stage and late stage colorectal cancer.

Hematochezia in the young patient: a review of health-seeking behavior, physician attitudes, and controversies in management

Hematochezia, defined as the passage of blood or clots from the rectum, is common and can be quite alarming. Few patients in general consult their physicians for this symptom. Various reasons have been explored for this behavior. Physician attitudes also shed some light onto why some patients are referred and others are not. Hematochezia may be associated with an anal cause in most healthy young adults (<50 years of age), but some may end up being diagnosed with colorectal cancer (CRC). Many studies have looked at the usefulness of clinical presentation in helping to decide which patients need further evaluation and what the optimal mode of investigation should be. Of note, studies on patients less than 50 years of age presenting with rectal bleeding have been few and far between. The results of these studies have been contradictory to the point where, today, there is no single set of consensus guidelines on the approach to hematochezia in young patients. In this review, the value of clinical symptoms and the underlying risk of CRC in guiding this clinical decision will be discussed.

Do diagnostic delays in cancer matter?

BACKGROUND

The United Kingdom has poorer cancer outcomes than many other countries due partly to delays in diagnosing symptomatic cancer, leading to more advanced stage at diagnosis. Delays can occur at the level of patients, primary care, systems and secondary care. There is considerable potential for interventions to minimise delays and lead to earlier-stage diagnosis.

METHODS

Scoping review of the published studies, with a focus on methodological issues.

RESULTS

Trial data in this area are lacking and observational studies often show no association or negative ones. This review offers methodological explanations for these counter-intuitive findings.

CONCLUSION

While diagnostic delays do matter, their importance is uncertain and must be determined through more sophisticated methods.

Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis

OBJECTIVES

Delayed diagnosis of colorectal cancer (CRC) is among the most common reasons for ambulatory diagnostic malpractice claims in the United States. Our objective was to describe missed opportunities to diagnose CRC before endoscopic referral, in terms of patient characteristics, nature of clinical clues, and types of diagnostic-process breakdowns involved.

METHODS

We conducted a retrospective cohort study of consecutive, newly diagnosed cases of CRC between February 1999 and June 2007 at a tertiary health-care system in Texas. Two reviewers independently evaluated the electronic record of each patient using a standardized pretested data collection instrument. Missed opportunities were defined as care episodes in which endoscopic evaluation was not initiated despite the presence of one or more clues that warrant a diagnostic workup for CRC. Predictors of missed opportunities were evaluated in logistic regression. The types of breakdowns involved in the diagnostic process were also determined and described.

RESULTS

Of the 513 patients with CRC who met the inclusion criteria, both reviewers agreed on the presence of at least one missed opportunity in 161 patients. Among these patients there was a mean of 4.2 missed opportunities and 5.3 clues. The most common clues were suspected or confirmed iron deficiency anemia, positive fecal occult blood test, and hematochezia. The odds of a missed opportunity were increased in patients older than 75 years (odds ratio (OR)=2.3; 95% confidence interval (CI) 1.3-4.1) or with iron deficiency anemia (OR=2.2; 95% CI 1.3-3.6), whereas the odds of a missed opportunity were lower in patients with abnormal flexible sigmoidoscopy (OR=0.06; 95% CI 0.01-0.51), or imaging suspicious for CRC (OR=0.3; 95% CI 0.1-0.9). Anemia was the clue associated with the longest time to endoscopic referral (median=393 days). Most process breakdowns occurred in the provider-patient clinical encounter and in the follow-up of patients or abnormal diagnostic test results.

CONCLUSIONS

Missed opportunities to initiate workup for CRC are common despite the presence of many clues suggestive of CRC diagnosis. Future interventions are needed to reduce the process breakdowns identified.

The diagnosis of colorectal cancer in patients with symptoms: finding a needle in a haystack

Patients often see primary care physicians with symptoms that might signal colorectal cancer but are also common in adults without cancer. Physicians and patients must then make a difficult decision about whether and how aggressively to evaluate the symptom. Favoring referral is that missed diagnoses lead to unnecessary testing, prolonged uncertainty, and continuing symptoms; also, the physician will suffer chagrin. It is not clear that diagnostic delay leads to progression to a more advanced stage. Against referral is that proper evaluation includes colonoscopy, with attendant inconvenience, discomfort, cost, and risk. The article by Hamilton et al, published this month in BMC Medicine, provides strong estimates of the predictive value of the various symptoms and signs of colorectal cancer and show how much higher predictive values are with increasing age and male sex. Unfortunately, their results also make clear that most colorectal cancers present with symptoms with low predictive values, < 1.2%. Models that include a set of predictive variables, that is, risk factors, age, sex, screening history, and symptoms, have been developed to guide primary prevention and clinical decision-making and are more powerful than individual symptoms and signs alone. Although screening for colorectal cancer is increasing in many countries, cancers will still be found outside screening programs so primary care physicians will remain at the front line in the difficult task of distinguishing everyday symptoms from life-threatening cancer.

Lagtimes in diagnosis and treatment of colorectal cancer: determinants and association with cancer stage and survival

BACKGROUND

Lagtimes to diagnostic colonoscopy have been used as practice performance measures.

AIM

To evaluate the duration, determinants and outcomes of lagtimes between referral for endoscopic evaluation and colorectal cancer (CRC) diagnosis.

METHODS

We examined the medical records of 289 patients with CRC and evaluated lagtimes, their potential determinants and their association with CRC stage at diagnosis as well as overall survival.

RESULTS

Median lag between referral and CRC diagnosis was 41 days (41.5% > 60 days, 30.1% > 90 days). The only significant predictor of lagtime was the initiating event for referral: abnormal symptom, laboratory test or imaging study was associated with shortest and presence of family history was associated with longest lagtimes respectively. Longer lagtimes were associated with lower mortality risk, but this was completely explained by earlier CRC stage. An analysis restricted to 100 patients referred for abnormal CRC screening tests found no association between duration of lag and CRC stage or mortality.

CONCLUSIONS

There seems to be no meaningful association between mortality in patients with CRC and lagtimes between referral for colonoscopy and CRC diagnosis for periods up to 2-3 months. On the contrary, longer lagtimes were inversely associated with CRC stage at the time of diagnosis.

Lack of association between diagnostic and therapeutic delay and stage of colorectal cancer

BACKGROUND

A recent review suggests that there is no association between diagnostic and therapeutic delays and survival in colorectal cancer patients. However, the effect of tumour stage on the relationship between delay and survival in CRC should be clarified. We review here the evidence on the relationship between diagnostic and therapeutic delays and stage in colorectal cancer.

METHODS

We conducted a systematic review of Medline, Embase, Cancerlit and the Cochrane Database of Systematic Reviews to identify publications published between 1965 and 2006 dealing with delay, stage and colorectal cancer. A meta-analysis was performed based on the estimation of the odds ratios (OR) and on a random effects model.

RESULTS

We identified 50 studies, representing 18,649 patients. Thirty studies were excluded due to excessively restricted samples (e.g. exclusion of patients with intestinal obstruction or who died 1-3 months after surgery) or because they studied only a portion of the delay. Of the 37 remaining studies, great variability was noted in connection with the type of classification used for disease stage and the type of measurement used for the delay. Meta-analysis was performed based on 17 studies that included 5209 patients. The combined OR was 0.98 (95% confidence interval (CI): 0.76-1.25), suggesting a lack of association between delay and disease stage. In four studies, cancers of the colon and rectum were dealt with separately, and a meta-analysis was performed using the data for colon cancer (1001 patients) and for rectal cancer (799 patients). In both cases, the combined ORs overlapped 1.0, and showed opposite associations when studied separately: 0.86 (95% CI: 0.63-1.19) for the colon (i.e. more delay is associated with the earlier stage at diagnosis) and 1.93 (95% CI: 0.89-4.219) for the rectum (i.e. less delay is associated with the earlier stage).

CONCLUSIONS

When colorectal cancers are taken as a whole, there appears to be no association between diagnostic delay and disease stage when diagnosis is made. However, when cancers of the colon and the rectum are studied separately, there may be an opposite association. More studies about this issue are needed with larger and unrestricted samples.

Influences on pre-hospital delay in the diagnosis of colorectal cancer: a systematic review

Colorectal cancer is a major global health problem, with survival varying according to stage at diagnosis. Delayed diagnosis can result from patient, practitioner or hospital delay. This paper reports the results of a review of the factors influencing pre-hospital delay - the time between a patient first noticing a cancer symptom and presenting to primary care or between first presentation and referral to secondary care. A systematic methodology was applied, including extensive searches of the literature published from 1970 to 2003, systematic data extraction, quality assessment and narrative data synthesis. Fifty-four studies were included. Patients' non-recognition of symptom seriousness increased delay, as did symptom denial. Patient delay was greater for rectal than colon cancers and the presence of more serious symptoms, such as pain, reduced delay. There appears to be no relationship between delay and patients' age, sex or socioeconomic status. Initial misdiagnosis, inadequate examination and inaccurate investigations increased practitioner delay. Use of referral guidelines may reduce delay, although evidence is currently limited. No intervention studies were identified. If delayed diagnosis is to be reduced, there must be increased recognition of the significance of symptoms among patients, and development and evaluation of interventions that are designed to ensure appropriate diagnosis and examination by practitioners.

Need for a paradigm shift in cancer prevention and clinical oncology

Every year approximately 3 million Europeans develop a cancer. Of these patients, 20-25% will suffer from cancer of the hepatogastrointestinal tract (the largest cancer group) and most of these individuals will die from the disease. Recent analysis from the American Cancer Society indicates that disease-related mortality from heart, cerebrovascular and infectious disease has decreased dramatically in the last 60 years, whereas the mortality of cancer remains unchanged. Despite recent improvements in the understanding of the biology, development and progression of human cancers, and the development of novel diagnostic and therapeutic approaches, most cancer patients are diagnosed in an advanced stage with a limited chance of cure. We hypothesize that there has been a dramatic shift in the treatment and, more importantly, prevention of heart, cerebrovascular and infectious diseases that has not yet reached oncology practice. We think that the shift from local to systemic therapy in combination with biomarker-guided detection of patients at risk leads to a reversion of current medical management: we do not treat the end-stage disease but rather follow the course of cancer development starting with risk assessment, followed by disease treatment and prevention of disease progression. Thus, we can prevent end-stage disease that cannot be treated curatively. Our two-step hypothesis should lead to a dramatic improvement of the prognosis of cancer patients.

Relationship of diagnostic and therapeutic delay with survival in colorectal cancer: a review

BACKGROUND

Early diagnosis of colorectal cancer before the onset of symptoms improves survival. Once symptoms have occurred, however, the effect of delay on survival is unclear. We review here evidence on the relationship of diagnostic and therapeutic delay with survival in colorectal cancer.

METHODS

We conducted a systematic of Medline, Embase, Cancerlit and the Cochrane Database of Systematic Reviews to identify publications published between 1962 and 2006 dealing with delay, survival and colon cancer. A meta-analysis was performed based on the calculation of the relative risk (RR) and on a model of random effects.

RESULTS

We identified 40 studies, representing 20,440 patients. Fourteen studies were excluded due to excessively restricted samples (e.g. exclusion of patients with intestinal obstruction, with tumours at stage C or D at the time of diagnosis, or who died 1-3 months after surgery); or because they studied only a portion of the delay. Of the 26 remaining studies, 20 showed no association between delay and survival. In contrast, four studies showed that delay was a factor contributing to better prognosis, and two showed that it contributed to poorer prognosis. There was no association between delay and survival when the colon and rectum were considered separately, when a multivariate analysis was performed, and when the effects of tumour stage and degree of differentiation were taken into account. To perform a meta-analysis, 18 additional studies were excluded, since the published articles did not specify the absolute numbers. In the remaining eight studies, the combined relative risk (RR) of delay was 0.92 (confidence interval (CI) 95%: 0.87-0.97).

CONCLUSIONS

The results of the review suggest that there is no association between diagnostic and therapeutic delay and survival in colorectal cancer patients. Colon and rectum should be assessed separately, and it is necessary to adjust for other relevant variables such as tumour stage.

Factors influencing delay in the diagnosis of colorectal cancer: a study protocol

Background

Colorectal cancer (CRC) is the second most frequent tumor in developed countries. Since survival from CRC depends mostly on disease stage at the time of diagnosis, individuals with symptoms or signs suspicious of CRC should be examined without delay. Many factors, however, intervene between symptom onset and diagnosis. This study was designed to: 1) Describe the diagnostic process of CRC from the onset of first symptoms to diagnosis and treatment. 2) Establish the time interval from initial symptoms to diagnosis and treatment, globally and considering patient's and doctors' delay, with the latter due to family physician and/or hospital services. 3) Identify the factors related to defined types of delay. 4) Assess the concordance between information included in primary health care and hospital clinical records regarding onset of first symptoms.

Methods/Design

Descriptive study, coordinated, with 5 participant groups of 5 different Spanish regions (Balearic Islands, Galicia, Catalunya, Aragón and Valencia Health Districts), with a total of 8 acute public hospitals and 140 primary care centers.

Incident cases of CRC during the study period, as identified from pathology services at the involved hospitals. A sample size of 896 subjects has been estimated, 150 subjects for each participant group.

Information will be collected through patient interviews and primary health care and hospital clinical records. Patient variables will include sociodemographic variables, family history of cancer, symptom perception, and confidence in the family physician; tumor variables will include tumor site, histological type, grade and stage; symptom variables will include date of onset, type and number of symptoms; health system variables will include number of patient contacts with family physician, type and content of the referral, hospital services attending the patient, diagnostic modalities and results; and delay intervals, including global delays and delays attributed to the patient, family physician and hospital.

Discussion

To obtain a nonrestricted sample of patients with CRC we have minimized selection risk by identifying the patients from pathology services. A greater constraint may be associated with information sources based on clinical records. Due to inherent features of coordinated studies, it is important to standardize the collection of information.

The mortality of colorectal cancer in relation to the initial symptom at presentation to primary care and to the duration of symptoms: a cohort study using medical records

The association between the staging of colorectal cancer and mortality is well known. Much less researched is the relationship between the duration of symptoms and outcome, and whether particular initial symptoms carry a different prognosis. We performed a cohort study of 349 patients with primary colorectal cancer in whom all their prediagnostic symptoms and investigation results were known. Survival data for 3–8 years after diagnosis were taken from the cancer registry. Six features were studied: rectal bleeding, abdominal pain, diarrhoea, constipation, weight loss, and anaemia. Two of these were significantly associated with different staging and mortality. Rectal bleeding as an initial symptom was associated with less advanced staging (odds ratio from one Duke's stage to the next 0.50, 95% confidence interval 0.31, 0.79; P=0.003) and with reduced mortality (Cox's proportional hazard ratio (HR) 0.56 (0.41, 0.79); P=0.001. Mild anaemia, with a haemoglobin of 10.0–12.9 g dl⁻¹, was associated with more advanced staging (odds ratio 2.2 (1.2, 4.3); P=0.021) and worse mortality (HR 1.5 (0.98, 2.3): P=0.064). When corrected for emergency admission, sex, and the site of the tumour, the HR for mild anaemia was 1.7 (1.1, 2.6); P=0.015. No relationship was found between the duration of symptoms and staging or mortality.

Colorectal cancer--a prospective evaluation of symptom duration and GP referral patterns in an inner city teaching hospital

OBJECTIVE

A high percentage of colorectal cancer patients (CRC) present as an emergency. Our aim was to evaluate delays in referral based on patient and general practitioner (GP) factors to see if there was any difference between elective and emergency patients.

METHOD

Symptom questionnaires were prospectively collected from 101 consecutive patients presenting to a single colorectal unit (58 male, 43 female; median age 72 years) and entered into a database. Questionnaires assessed time from symptom onset until first GP visit, time for GP to refer, and type of admission. Symptoms and Dukes stage were noted.

RESULTS

Fifty-eight (57%) patients presented electively and 43 (43%) as an emergency. Eighty-eight patients (87%) saw their GP of which 34 (39%) later presented as emergency; 13 (13%) did not see their GP. The median time before patients first sought medical advice was 30 days (0-1095 days). Median delay until treatment was 90 days (range 0-1460 days). Emergency patients waited a median of 11.5 days before visiting the GP, and elective a median of 49.5 days (P = 0.04) (Mann-Whitney U). Nine of 13 patients who did not see their GP presented as an emergency (median wait 44 days). The median time taken for a GP to refer to a hospital specialist was 28 days in elective patients and 14 days in the emergency group. (P = ns) Thirty (38%) patients took longer than six weeks to be referred (33% as an emergency). Thirty-six patients had Dukes A or B and took a median of 30 days to first presentation. Sixty-five had Dukes C or D and took a median of 32 days to first presentation. (P = ns)

CONCLUSION

Emergency patients have symptoms for less time before seeking medical advice compared to elective patients. The duration of these symptoms is unrelated to the histological stage at diagnosis. Although the majority of GPs referred CRC patients within six weeks, there was no association between time taken to refer and mode of presentation. The factors that relate to disease stage occur before symptoms are acted on.

Pathways to the diagnosis of colorectal cancer: an observational study in three UK cities

BACKGROUND

Colorectal cancer can present in a variety of ways, and with any of several symptoms. Different referral routes from primary to secondary care cater for these different presentations. The route that has received most investment in the UK National Health Service is the 2-week clinic, but the proportions of patients taking this and other routes to diagnosis are largely unknown.

METHODS

We designed an observational audit in Exeter, Oxford and Sheffield, UK. Colorectal cancers diagnosed in 2002 from participating practices were identified and the presence and timing of seven important clinical features noted: diarrhoea, constipation, rectal bleeding, abdominal pain, the finding of an abdominal or rectal mass on examination, anaemia and positive faecal occult blood tests. The referral pathways to secondary care were identified.

RESULTS

Of the 151 patients studied, 112 (74%) were referred with at least one clinical feature of colorectal cancer to a specialist. Only 43 of these (28% of the total) were referred to a 2-week clinic; 39 patients (26% of the total) had an emergency admission, of whom 10 (7%) had their emergency admission after referral to a specialist for investigation but before a diagnosis had been established. The time intervals between the first consultation with a symptom of cancer and referral were mostly short.

CONCLUSION

Patients with colorectal cancer travel several different pathways to diagnosis. The pathway with the most resources-the 2-week clinic-is used by a minority of patients.

How has the 'two-week wait' rule affected the presentation of colorectal cancer?

OBJECTIVE

To assess the impact of the 'two-week wait' rule on the presentation of colorectal cancer.

METHODS

A retrospective study of all patients referred to a fast-track clinic in a colorectal cancer centre over an 18-month period, documenting outcome, especially colorectal cancer diagnosis. Comparison was made with patients diagnosed with colorectal cancer presenting via other routes in the same time period.

RESULTS

Over an 18-month period, 462 patients were seen in the fast-track clinic and 64 (13.8%) were diagnosed with colorectal cancer. A further 131 patients with colorectal cancer presented to the department in the same time period through other means; 66 via standard out-patient letters, 26 from other departments and 39 (20%) as emergency admissions. Median (range) time to first clinic was 12 (2-28) days for fast-track and 24 (1-118) days for standard referrals (P < 0.0001); median time to first treatment was a further 36 (9-134) and 36.5 (1-226) days, respectively. The fast-track cohort had more advanced staging than those referred by standard letter. There were 19 Dukes' B, 22 Dukes' C and 14 Dukes' D cancers in the fast-track group compared with 28 Dukes' B, 25 Dukes' C and 6 Dukes' D in the standard referral group. After patient interview, only 337 (73%) of 462 fast-track patients appeared to fulfil the referral criteria but of the 64 diagnosed with cancer, 59 (92%) satisfied the criteria. Of the 66 patients with cancer referred by standard letter, 61 (92%) fulfilled the criteria.

CONCLUSION

Patients referred to the fast-track clinic were seen quicker than those referred by standard letter, but they tended to have more advanced disease. The fast-track referral criteria were fulfilled by most patients with cancer (whether or not they were referred to the fast track clinic), confirming their validity. After detailed interview in the clinic, a quarter of fast-track referrals were found not to satisfy referral criteria, suggesting that prioritization in primary care could be improved.

Can early diagnosis of symptomatic colorectal cancer improve the prognosis?

Patients with colorectal cancer continue to present with relatively advanced tumors. Delay in diagnosis is often believed to have been a contributing factor, and the validity of this hypothesis has seldom been questioned. The aim of this study was to establish whether a delay in diagnosis is related to long-term survival and if the most frequent symptoms were related to the stage or time at which the carcinoma was diagnosed. Data from 660 patients surgically treated for uncomplicated colorectal carcinoma in our institution between 1985 and 2000 were analyzed retrospectively. Age, sex, initial symptoms, duration of symptoms, neoplasm location, curative surgery, TNM stage, and survival time were the variables recorded. Patients were classified into two groups according to symptom duration: < 3 months versus >/= 3 months. Comparative statistical analysis was performed for the two groups as well as the initial symptom, TNM stage, and survival time. Also, the initial symptoms most frequently reported were compared with the TNM stage. The two groups were found to be equal with regard to distribution of age, gender, location of the neoplasm, type of surgery performed, and TNM stage. We found that symptom duration was shortened in the presence of abdominal pain ( p = 0.002) [odds ratio (OR) 0.53; 95% confidence interval (CI) 0.35-0.80] and was delayed in the presence of an anemic syndrome ( p = 0.006) (OR 2.4; 95% CI 1.27-4.56). Also, the stage of the neoplasm was related to rectal bleeding ( p < 0.001) and abdominal pain ( p = 0.008). The log-rank test indicated that duration of symptoms was not related to long-term survival ( p = 0.90). We concluded that the duration of colorectal cancer symptoms is not related to the stage or prognosis of tumors.

Factors influencing time from presentation to treatment of colorectal and breast cancer in urban and rural areas

Stage at diagnosis and survival from cancer vary according to where people live, suggesting some may have delays in diagnosis. The aim of this study was to determine if time from presentation to treatment was longer for colorectal and breast cancer patients living further from cancer centres, and identify other important factors in delay. Data were collected on 1097 patients with breast and 1223 with colorectal cancer in north and northeast Scotland. Women with breast cancer who lived further from cancer centres were treated more quickly than those living closer to cancer centres (P=0.011). Multilevel modelling found that this was largely due to them receiving earlier treatment at hospitals other than cancer centres. Breast lump, change in skin contour, lymphadenopathy, more symptoms and signs, and increasing age predicted faster treatment. Screen detected cancers and private referrals were treated more quickly. For colorectal cancer, time to treatment was similar for people in rural and urban areas. Quicker treatment was associated with palpable rectal or abdominal masses, tenesmus, abdominal pain, frequent GP consultations, age between 50 and 74 years, tumours of the transverse colon, and iron medication at presentation. Delay was associated with past anxiety or depression. There was variation between general practices and treatment appeared quicker at practices with more female general practitioners.

Factors influencing time from presentation to treatment of colorectal and breast cancer in urban and rural areas

Stage at diagnosis and survival from cancer vary according to where people live, suggesting some may have delays in diagnosis. The aim of this study was to determine if time from presentation to treatment was longer for colorectal and breast cancer patients living further from cancer centres, and identify other important factors in delay. Data were collected on 1097 patients with breast and 1223 with colorectal cancer in north and northeast Scotland. Women with breast cancer who lived further from cancer centres were treated more quickly than those living closer to cancer centres (P=0.011). Multilevel modelling found that this was largely due to them receiving earlier treatment at hospitals other than cancer centres. Breast lump, change in skin contour, lymphadenopathy, more symptoms and signs, and increasing age predicted faster treatment. Screen detected cancers and private referrals were treated more quickly. For colorectal cancer, time to treatment was similar for people in rural and urban areas. Quicker treatment was associated with palpable rectal or abdominal masses, tenesmus, abdominal pain, frequent GP consultations, age between 50 and 74 years, tumours of the transverse colon, and iron medication at presentation. Delay was associated with past anxiety or depression. There was variation between general practices and treatment appeared quicker at practices with more female general practitioners.

A prospective, controlled assessment of factors influencing acceptance of screening colonoscopy

OBJECTIVES

Medicare beneficiaries now have access to screening colonoscopy (SC). For colon cancer screening to be fruitful, SC must become more acceptable to a broad segment of this population. However, we currently lack knowledge of which aspects of SC have an impact on patient acceptance. The aims of this study were: 1) to identify the features of SC that are most important in deterring participation, and 2) to prioritize and to compare the perceptions of never-screened individuals with those of individuals previously screened for colon cancer.

METHODS

Questionnaires were distributed to 300 outpatients at Mayo Clinic, Rochester (150 never-screened patients; 150 previously screened patients). The survey instrument addressed domains of the Health Belief Model and colon cancer risk perception. Patients ranked the three most important barriers to SC and answered general knowledge questions on colon cancer.

RESULTS

Response rates of never-screened (84%) and screened (88%) patients were similar. Never-screened patients were less likely to have a regular primary physician (80% vs 95%, p = 0.0003) and were less likely to have undergone a prior screening mammography (87% vs 96% of women, p = 0.02) compared with screened patients. The four most reported deterrents to SC ("volume of bowel preparation," "adequate analgesia," "no recommendation from primary physician," and "embarrassment") were ranked similarly by both groups. Never-screened patients had less understanding of the incidence and treatment outcomes of colon cancer.

CONCLUSION

Colon cancer screening behavior seems to be associated with having a regular primary physician, as well as other cancer screening behaviors. Knowledge of colon cancer is the most reliable discriminator of prior screening status. There does not seem to be any difference in the preferences expressed by never-screened and screened patients with respect to the aspects of colonoscopy that they find objectionable.

Emergency admission for surgery predicts disease progression during adjuvant 5-Fluouracil (5-FU)-based chemotherapy

OBJECTIVE

To determine the prognostic significance of a number of variables in patients that receive adjuvant chemotherapy for colorectal cancer.

PATIENTS AND METHODS

We reviewed the Cancer Centre records of 194 patients who received adjuvant chemotherapy following potentially curative resection of Dukes' B or C colorectal cancer. Eight variables were examined to determine which factor(s) predicted disease progression during the 6-month chemotherapy period.

RESULTS

Admission for emergency resection (due to bowel obstruction or perforation) rather than elective resection, and a poorly differentiated tumour rather than moderately/well differentiated were independent significant factors in predicting disease progression (P < 0.001 and P=0.011, respectively). However, sex, age, Dukes' stage, number of involved lymph nodes, delays in starting chemotherapy and compliance with chemotherapy regime had no significant effect on 6-month tumour progression.

CONCLUSION

These preliminary findings confirm data which suggest that emergency admission patients may suffer from intrinsically more aggressive disease than the average population with colorectal cancer.

How does colorectal cancer present? Symptoms, duration, and clues to location

OBJECTIVE

Most colorectal cancers still present with symptoms because screening, although effective, is not yet widely practiced. A careful history and physical examination are still the usual methods for suspecting colorectal cancer and ordering appropriate investigation. Therefore, we studied the symptoms, duration, and clues to location of colorectal cancer.

METHODS

We reviewed both hospital and office records for 204 consecutive patients with colorectal cancer, first diagnosed after symptoms, at one regional referral center from 1983-87. We abstracted data on demographic characteristics, presence and duration of 15 symptoms, and characteristics of the tumors.

RESULTS

The 194 patients included in the study were similar to those with colorectal cancer described elsewhere in terms of age, gender, and tumor location (58% distal to the splenic flexure), and stage (56% stage A or B). The most common symptoms were rectal bleeding (58%), abdominal pain (52%), and change in bowel habits (51%); the majority had anemia (57%) and occult bleeding (77%). The median duration of symptoms (from onset to diagnosis) was 14 wk (interquartile range 5-43). We found no association between overall duration of symptoms and the stage of the tumor. Patient age, gender, and proximal cancer location were also not associated with a longer duration of symptoms before diagnosis. We developed a rule for predicting a distal location of cancer using multiple logistic regression. Independent predictors were (odds ratio [95% CI]): Hb (1.34 for each g/dl [1.16-1.54]); rectal bleeding (3.45 [1.71-6.95]); constipation (3.16 [1.38-7.24]); and proximal symptoms (at least one of anorexia, nausea, vomiting, abdominal pain, or fatigue) (0.48 [0.20-1.02]). The rule had sensitivity of 93% and a specificity of 47%, with an area under the ROC curve of 0.79.

CONCLUSIONS

Until prevention of colorectal cancer is more common, we must continue to rely on clinical findings for detecting this cancer. Our results will remind physicians to keep colorectal cancer on the differential diagnosis of "chronic" gastrointestinal symptoms, and our decision rule may prompt earlier investigation with colonoscopy.