Risk of colorectal cancer in general practice patients presenting with rectal bleeding, change in bowel habit or anaemia

Management of blood thinning medications in elderly populations presenting with rectal bleeding: Are we doing right?

Introduction

Rectal bleeding commonly occurs in elderly patients using blood thinners, posing management challenges due to limited guidance on reversal agents and medication restart criteria. This study aims to review the demographics and management of elderly patients with rectal bleeding while on blood thinners.

Methods

A retrospective analysis of patients aged 60 or older presenting with rectal bleeding at West Suffolk Hospital's emergency department was conducted from January 2018 to December 2020. Data were extracted from electronic records, focusing on patients using blood thinners and adhering to British Society of Gastroenterology guidelines. All patients ceased blood-thinning medications upon admission. The hospital's ethics committee approved the study, which focused on demographics, diagnosis, and management, particularly regarding re-initiation of blood-thinning medicines.

Results

During the study period, 170 patients were admitted to the emergency department of West Suffolk Hospital. 93 (54.71%) patients were included in the study. The average age of the participants was 82 years, and 62.3% were male. All patients were followed up for three months. Atrial fibrillation accounted for 52% of patients, while previous strokes accounted for 20%. The most typical pathology was diverticulosis.Regarding restarting of anticoagulants, Among patients on DOAC (Direct oral anticoagulant), 39% were restarted on discharge, 23% were switched to warfarin, and another 23% were not restarted; 15% planned to restart after seven days. For those on Warfarin, 62% were restarted on discharge, 22% stopped the medication, and the rest were switched to Dual Oral Anticoagulant. Among aspirin patients, 60% were restarted at discharge, while the remaining discontinued. All patients receiving clopidogrel and dual antiplatelet therapy were started at discharge. None of the patients were readmitted during the follow-up period of 3 months.

Conclusion

Restarting of blood-thinning drugs in patients with rectal bleeding is subject to individual patient variation. Necessitates more extensive trials to achieve greater standardization.

Diagnostic yield from symptomatic lower gastrointestinal endoscopy in the UK: A British Society of Gastroenterology analysis using data from the National Endoscopy Database

BACKGROUND

The value of lower gastrointestinal endoscopy (LGIE; colonoscopy or sigmoidoscopy) relates to its ability to detect clinically relevant findings, predominantly cancers, preneoplastic polyps or inflammatory bowel disease. There are concerns that many LGIEs are performed on low-risk patients with limited benefit.

AIMS

To determine the diagnostic outcomes of LGIE for common symptoms.

METHODS

We performed a cross-sectional study of diagnostic LGIE between March 2019 and February 2020 using the UK National Endoscopy Database. We used mixed-effects logistic regression models, incorporating random (endoscopist) and fixed (symptoms, patient age, and sex) effects upon two dependent variables (large polyp [≥10 mm] and cancer diagnosis). Adjusted positive predictive values (aPPVs) were calculated.

RESULTS

We analysed 384,510 LGIEs; 33.2% were performed on patients aged under 50 and 53.6% on women. Regarding colonoscopies, the unadjusted PPV for cancer was 1.5% (95% CI: 1.4-1.5); higher for men than women (1.9% vs. 1.1%, p < 0.01). The PPV for large polyps was 3.2% (95% CI: 3.1-3.2). The highest colonoscopy cancer aPPVs were in the over 50s (1.9%) and in those with rectal bleeding (2.5%) or anaemia (2.1%). Cancer aPPVs for other symptoms were <1% despite representing 54.3% of activity. In patients under 50, aPPVs were 0.4% for cancer and 1.6% for large polyps. Results were similar for sigmoidoscopy.

CONCLUSIONS

Most colonoscopies were performed on patients with low-risk symptoms, where cancer risk was similar to the general population. Cancer and large polyp yield was highest in elderly patients with rectal bleeding or anaemia, although still fell short of FIT-based screening yields.

A taxonomy of early diagnosis research to guide study design and funding prioritisation

Researchers and research funders aiming to improve diagnosis seek to identify if, when, where, and how earlier diagnosis is possible. This has led to the propagation of research studies using a wide range of methodologies and data sources to explore diagnostic processes. Many such studies use electronic health record data and focus on cancer diagnosis. Based on this literature, we propose a taxonomy to guide the design and support the synthesis of early diagnosis research, focusing on five key questions: Do healthcare use patterns suggest earlier diagnosis could be possible? How does the diagnostic process begin? How do patients progress from presentation to diagnosis? How long does the diagnostic process take? Could anything have been done differently to reach the correct diagnosis sooner? We define families of diagnostic research study designs addressing each of these questions and appraise their unique or complementary contributions and limitations. We identify three further questions on relationships between the families and their relevance for examining patient group inequalities, supported with examples from the cancer literature. Although exemplified through cancer as a disease model, we recognise the framework is also applicable to non-neoplastic disease. The proposed framework can guide future study design and research funding prioritisation.

Anatomical location, risk factors, and outcomes of lower gastrointestinal bleeding in colorectal cancer patients: a national inpatient sample analysis (2009-2019)

PURPOSE

This study aimed to investigate the incidence, predictors, and impact of lower gastrointestinal bleeding (LGIB) on inpatient mortality among colorectal cancer patients, due to its clinical significance and potential influence on patient outcomes.

METHODS

We conducted a retrospective analysis of data from the National Inpatient Sample database between 2009 and 2019, including 2,598,326 colorectal cancer patients with and without LGIB. Univariate and multivariate logistic regression analyses were performed to determine predictors of LGIB and its association with inpatient outcomes.

RESULTS

The highest incidence of LGIB was observed in rectal cancer patients (3.8%), followed by distal colon cancer patients (1.4%) and proximal colon cancer patients (1.2%). Several factors were significantly associated with LGIB, including older age; male sex; certain racial such as Black, Hispanic, and Asia/Pacific Islander patients; or lower socioeconomic status. Multivariate analysis identified independent predictors of LGIB, such as severe sepsis, use of anticoagulants, long-term use of aspirin or antiplatelet drugs, palliative care, malnutrition, cachexia, chemotherapy or immunotherapy, metastasis, alcohol abuse, hypertension, obesity, and family history of digestive cancer. No significant difference in inpatient mortality was observed between patients with and without LGIB.

CONCLUSION

Our study underscores the importance of considering colorectal cancer location and identified risk factors for LGIB assessment. Clinicians should address modifiable risk factors and healthcare disparities. Future research should explore underlying mechanisms, targeted interventions, and long-term outcomes beyond inpatient mortality.

Patient-reported diagnostic intervals to colorectal cancer diagnosis in the Midland region of New Zealand: a prospective cohort study

BACKGROUND AND OBJECTIVES

New Zealand (NZ) has high rates of colorectal cancer (CRC) but low rates of early detection. The majority of CRC is diagnosed through general practice, where lengthy diagnostic intervals are common. We investigated factors contributing to diagnostic delay in a cohort of patients newly diagnosed with CRC.

METHODS

Patients were recruited from the Midland region and interviewed about their diagnostic experience using a questionnaire based on a modified Model of Pathways to Treatment framework and SYMPTOM questionnaire. Descriptive statistics were used to describe the population characteristics. Chi-square analysis and logistic regression were used to analyse factors influencing diagnostic intervals.

RESULTS

Data from 176 patients were analysed, of which 65 (36.9%) experienced a general practitioner (GP) diagnostic interval of >120 days and 96 (54.5%) experienced a total diagnostic interval (TDI) > 120 days. Patients reporting rectal bleeding were less likely to experience a long TDI (odds ratio [OR] 0.34, 95% confidence interval [CI]: 0.14-0.78) and appraisal/help-seeking interval (OR, 0.19, 95% CI: 0.06-0.59). Patients <60 were more likely to report a longer appraisal/help-seeking interval (OR, 3.32, 95% CI: 1.17-9.46). Female (OR, 2.19, 95% CI: 1.08-4.44) and Māori patients (OR, 3.18, 95% CI: 1.04-9.78) were more likely to experience a long GP diagnostic interval.

CONCLUSION

NZ patients with CRC can experience long diagnostic intervals, attributed to patient and health system factors. Young patients, Māori, females, and patients experiencing change of bowel habit may be at particular risk. We need to increase symptom awareness of CRC for patients and GPs. Concentrated efforts are needed to ensure equity for Māori in access to screening, diagnostics, and treatment.

Gastrointestinal bleeding and the risk of colorectal cancer in anticoagulated patients with atrial fibrillation

AIMS

Gastrointestinal bleeding (GI-bleeding) is frequent in patients with atrial fibrillation (AF) treated with oral anticoagulation (OAC) therapy. We sought to investigate to what extent lower GI-bleeding represents the unmasking of an occult colorectal cancer.

METHODS AND RESULTS

A total of 125 418 Danish AF patients initiating OAC therapy were identified using Danish administrative registers. Non-parametric estimation and semi-parametric absolute risk regression were used to estimate the absolute risks of colorectal cancer in patients with and without lower GI-bleeding. During a maximum of 3 years of follow-up, we identified 2576 patients with lower GI-bleeding of whom 140 patients were subsequently diagnosed with colorectal cancer within the first year of lower GI-bleeding. In all age groups, we observed high risks of colorectal cancer after lower GI-bleeding. The absolute 1-year risk ranged from 3.7% [95% confidence interval (CI) 2.2-6.2] to 8.1% (95% CI 6.1-10.6) in the age groups ≤65 and 76-80 years of age, respectively. When comparing patients with and without lower GI-bleeding, we found increased risk ratios of colorectal cancer across all age groups with a risk ratio of 24.2 (95% CI 14.5-40.4) and 12.3 (95% CI 7.9-19.0) for the youngest and oldest age group of ≤65 and >85 years, respectively.

CONCLUSION

In anticoagulated AF patients, lower GI-bleeding conferred high absolute risks of incident colorectal cancer. Lower GI-bleeding should not be dismissed as a benign consequence of OAC therapy but always examined for a potential underlying malignant cause.

Outcomes from colonoscopy following referral from New Zealand general practice: a retrospective analysis

Background

New Zealand has high rates of colorectal cancer (CRC) but poor outcomes. Most patients with CRC are diagnosed following referral from general practice, where a general practitioner (GP) assesses symptoms according to national guidelines. All referred patients are then re-prioritised by the hospital system. The first objective of this study was to identify what proportion of patients referred by general practice to surgical/gastroenterology at Waikato District Health Board (DHB) had a colonoscopy. The second objective was to determine what proportion of these referrals have an underlying CRC and the factors associated with the likelihood of this diagnosis.

Methods

This study is a retrospective analysis of e-referral data for patients aged 30–70+ who were referred from 75 general practices to general surgery, gastroenterology or direct to colonoscopy at Waikato DHB, 01 January 2015–31 December 2017. Primary and secondary outcome measures included the proportion and characteristics of patients who were having colonoscopy, and of those, who were diagnosed with CRC. Data were analysed using chi square and logistic regression.

Results

6718/20648 (32.5%) patients had a colonoscopy and 372 (5.5%) of these were diagnosed with CRC. The probability of having CRC following a colonoscopy increased with age (p value < 0.001). Females (p value < 0.001), non-Māori (p value < 0.001), and patients with a high suspicion of cancer (HSCan) label originating from their GP were more likely to have a colonoscopy, while the odds ratio of Māori having a colonoscopy was 0.66 (95% CI 0.60–0.73). The odds ratio of a CRC diagnosis following colonoscopy was 1.67 (95% CI 1.35–2.07) for men compared to women, and 2.34 (95% CI 1.70–3.22) for those with a GP HSCan label. Of the 585 patients referred with a GP HSCan, 423 (72.3%) were reprioritised by the hospital and 55 patients had their diagnosis unnecessarily delayed.

Conclusions

If a GP refers a patient with an HSCan, and the patient receives a colonoscopy, then the likelihood of having CRC is almost 15.0%. This would suggest that these patients should be routinely prioritised without further triage by the hospital. Further research is needed to understand why Māori are less likely to receive a colonoscopy following referral from general practice.

Conceptual Framework to Guide Early Diagnosis Programs for Symptomatic Cancer as Part of Global Cancer Control

Diagnosing cancer earlier can enable timely treatment and optimize outcomes. Worldwide, national cancer control plans increasingly encompass early diagnosis programs for symptomatic patients, commonly comprising awareness campaigns to encourage prompt help-seeking for possible cancer symptoms and health system policies to support prompt diagnostic assessment and access to treatment. By their nature, early diagnosis programs involve complex public health interventions aiming to address unmet health needs by acting on patient, clinical, and system factors. However, there is uncertainty regarding how to optimize the design and evaluation of such interventions. We propose that decisions about early diagnosis programs should consider four interrelated components: first, the conduct of a needs assessment (based on cancer-site-specific statistics) to identify the cancers that may benefit most from early diagnosis in the target population; second, the consideration of symptom epidemiology to inform prioritization within an intervention; third, the identification of factors influencing prompt help-seeking at individual and system level to support the design and evaluation of interventions; and finally, the evaluation of factors influencing the health systems' capacity to promptly assess patients. This conceptual framework can be used by public health researchers and policy makers to identify the greatest evidence gaps and guide the design and evaluation of local early diagnosis programs as part of broader cancer control strategies.

The Full Blood Count Blood Test for Colorectal Cancer Detection: A Systematic Review, Meta-Analysis, and Critical Appraisal

INTRODUCTION

A full blood count (FBC) blood test includes 20 components. We systematically reviewed studies that assessed the association of the FBC and diagnosis of colorectal cancer to identify components as risk factors. We reviewed FBC-based prediction models for colorectal cancer risk.

METHODS

MEDLINE, EMBASE, CINAHL, and Web of Science were searched until 3 September 2019. We meta-analysed the mean difference in FBC components between those with and without a diagnosis and critically appraised the development and validation of FBC-based prediction models.

RESULTS

We included 53 eligible articles. Three of four meta-analysed components showed an association with diagnosis. In the remaining 16 with insufficient data for meta-analysis, three were associated with colorectal cancer. Thirteen FBC-based models were developed. Model performance was commonly assessed using the c-statistic (range 0.72-0.91) and calibration plots. Some models appeared to work well for early detection but good performance may be driven by early events.

CONCLUSION

Red blood cells, haemoglobin, mean corpuscular volume, red blood cell distribution width, white blood cell count, and platelets are associated with diagnosis and could be used for referral. Existing FBC-based prediction models might not perform as well as expected and need further critical testing.

Assessing patients at risk of symptomatic-but-as-yet-undiagnosed cancer in primary care using information from patient records

Evidence arising from primary care electronic health records can help to assess the risk of symptomatic-but-as-yet-undiagnosed cancer. Existing evidence and methodological innovations in this field of study hold further promise for improving the diagnostic process and achieving earlier diagnosis in cancer patients.

Prediction of advanced colonic neoplasm in symptomatic patients: a scoring system to prioritize colonoscopy (COLONOFIT study)

BACKGROUND

Fast-track colonoscopy to detect patients with colorectal cancer based on high-risk symptoms is associated with low sensitivity and specificity. The aim was to derive a predictive score of advanced colonic neoplasia in symptomatic patients in fast-track programs.

METHODS

All patients referred for fast-track colonoscopy were evaluated. Faecal immunological haemoglobin test (3 samples; positive> 4 μg Hb/g), and a survey to register clinical variables of interest were performed. Colorectal cancer and advanced adenoma were considered as advanced colonic neoplasia. A sample size of 600 and 500 individuals were calculated for each phase 1 and phase 2 of the study, respectively (Phase 1, derivation and Phase 2, validation cohort). A Bayesian logistic regression analysis was used to derive a predictive score.

RESULTS

1495 patients were included. Age (OR, 21), maximum faecal-Hb value (OR, 2.3), and number of positive samples (OR, 28) presented the highest ORs predictive of advanced colonic neoplasia. The additional significant predictive variables adjusted for age and faecal-Hb variables in Phase 1 were previous colonoscopy (last 5 years) and smoking (no, ex/active). With these variables a predictive score of advanced colonic neoplasia was derived. Applied to Phase 2, patients with a Score > 20 had an advanced colonic neoplasia probability of 66% (colorectal cancer, 32%), while those with a Score ≤ 10, a probability of 10% (colorectal cancer, 1%). Prioritizing patients with Score > 10, 49.4% of patients would be referred for fast-track colonoscopy, diagnosing 98.3% of colorectal cancers and 77% of advanced adenomas.

CONCLUSIONS

A scoring system was derived and validated to prioritize fast-track colonoscopies according to risk, which was efficient, simple, and robust.

A review of sex-related differences in colorectal cancer incidence, screening uptake, routes to diagnosis, cancer stage and survival in the UK

Background

Colorectal cancer (CRC) is an illness strongly influenced by sex and gender, with mortality rates in males significantly higher than females. There is still a dearth of understanding on where sex differences exist along the pathway from presentation to survival. The aim of this review is to identify where actions are needed to improve outcomes for both sexes, and to narrow the gap for CRC.

Methods

A cross-sectional review of national data was undertaken to identify sex differences in incidence, screening uptake, route to diagnosis, cancer stage at diagnosis and survival, and their influence in the sex differences in mortality.

Results

Overall incidence is higher in men, with an earlier age distribution, however, important sex differences exist in anatomical site. There were relatively small differences in screening uptake, route to diagnosis, cancer staging at diagnosis and survival. Screening uptake is higher in women under 69 years. Women are more likely to present as emergency cases, with more men diagnosed through screening and two-week-wait. No sex differences are seen in diagnosis for more advanced disease. Overall, age-standardised 5-year survival is similar between the sexes.

Conclusions

As there are minimal sex differences in the data from routes to diagnosis to survival, the higher mortality of colorectal cancer in men appears to be a result of exogenous and/or endogenous factors pre-diagnosis that lead to higher incidence rates. There are however, sex and gender differences that suggest more targeted interventions may facilitate prevention and earlier diagnosis in both men and women.

Diagnostic profile characteristics of cancer patients with frequent consultations in primary care before diagnosis: a case-control study

BACKGROUND

Many patients with common cancers are late diagnosed.

OBJECTIVES

Identify consultation profiles and clinical features in patients with the seven most common cancers, who had consulted a general practitioner (GP) frequently before their cancer diagnosis.

METHODS

A case-control study was conducted in Region Västra Götaland, Sweden. A total of 2570 patients, diagnosed in 2011 with prostate, breast, colorectal, lung, gynaecological and skin cancers including malignant melanoma, and 9424 controls were selected from the Swedish Cancer Register and a regional health care database. Diagnostic codes [International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10)] from primary care for patients with ≥4 GP consultations registered in the year before cancer diagnosis were collected. Likelihood ratios (LRs) were calculated for variables associated with the different cancers.

RESULTS

Fifty-six percent of the patients had consulted a GP four or more times in the year before cancer diagnosis. Alarm symptoms or signs represented 60% of the codes with the highest LR, but only 40% of the 10 most prevalent codes. Breast lump had the highest LR, 11.9 [95% confidence interval (CI) 8.0-17.8]; abnormalities of plasma proteins had an LR of 5.0 (95% CI 3.0-8.2) and abnormal serum enzyme levels had an LR of 4.6 (95% CI 3.6-5.9). Early clinical features associated with cancer had been registered already at the first two GP consultations.

CONCLUSION

One out of six clinical features associated with cancer were presented by cancer patients with four or more pre-referral consultations already at the two first consultations. These early clinical features that were focal and had benign characteristics might have been missed diagnostic opportunities.

Abdominal symptoms and cancer in the abdomen: prospective cohort study in European primary care

BACKGROUND

Different abdominal symptoms may signal cancer, but their role is unclear.

AIM

To examine associations between abdominal symptoms and subsequent cancer diagnosed in the abdominal region.

DESIGN AND SETTING

Prospective cohort study comprising 493 GPs from surgeries in Norway, Denmark, Sweden, Scotland, Belgium, and the Netherlands.

METHOD

Over a 10-day period, the GPs recorded consecutive consultations and noted: patients who presented with abdominal symptoms pre-specified on the registration form; additional data on non-specific symptoms; and features of the consultation. Eight months later, data on all cancer diagnoses among all study patients in the participating general practices were requested from the GPs.

RESULTS

Consultations with 61 802 patients were recorded and abdominal symptoms were documented in 6264 (10.1%) patients. Malignancy, both abdominal and non-abdominal, was subsequently diagnosed in 511 patients (0.8%). Among patients with a new cancer in the abdomen (n = 251), 175 (69.7%) were diagnosed within 180 days after consultation. In a multivariate model, the highest sex- and age-adjusted hazard ratio (HR) was for the single symptom of rectal bleeding (HR 19.1, 95% confidence interval = 8.7 to 41.7). Positive predictive values of >3% were found for macroscopic haematuria, rectal bleeding, and involuntary weight loss, with variations according to age and sex. The three symptoms relating to irregular bleeding had particularly high specificity in terms of colorectal, uterine, and bladder cancer.

CONCLUSIONS

A patient with undiagnosed cancer may present with symptoms or no symptoms. Irregular bleeding must always be explained. Abdominal pain occurs with all types of abdominal cancer and several symptoms may signal colorectal cancer. The findings are important as they influence how GPs think and act, and how they can contribute to an earlier diagnosis of cancer.

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.

Disparities in evaluation of patients with rectal bleeding 40 years and older

BACKGROUND & AIMS

Rectal bleeding is associated with colorectal cancer. We characterized the evaluation of patients aged 40 years and older with rectal bleeding and identified characteristics associated with inadequate evaluation.

METHODS

We conducted a retrospective review of records of outpatient visits that contained reports of rectal bleeding for patients aged 40 years and older (N = 480). We studied whether patient characteristics affected whether or not they received a colonoscopy examination within 90 days of presentation with rectal bleeding. Patient characteristics included demographics; family history of colon cancer and polyps; and histories of screening colonoscopies, physical examinations, referrals to specialists at the index visit, and communication of laboratory results. Data were collected from medical records, and patient income levels were estimated based on Zip codes.

RESULTS

Nearly half of the patients presenting with rectal bleeding received colonoscopies (48.1%); 81.7% received the procedure within 90 days. A history of a colonoscopy examination was more likely to be reported in white patients compared with Hispanic or Asian patients (P = .012 and P = .006, respectively), and in high-income compared with low-income patients (P = .022). A family history was more likely to be documented among patients with private insurance than those with Medicaid or Medicare (P = .004). A rectal examination was performed more often for patients who were white or Asian, male, and with high or middle incomes, compared with those who were black, Hispanic, female, or with low incomes (P = .027). White patients were more likely to have their laboratory results communicated to them than black patients (P = .001).

CONCLUSIONS

Sex, race, ethnicity, patient income, and insurance status were associated with disparities in evaluation of rectal bleeding. There is a need to standardize the evaluation of patients with rectal bleeding.

The increasing incidence of young-onset colorectal cancer: a call to action

In the United States, colorectal cancer (CRC) is the third most common and second most lethal cancer. More than one-tenth of CRC cases (11% of colon cancers and 18% of rectal cancers) have a young onset (ie, occurring in individuals younger than 50 years). The CRC incidence and mortality rates are decreasing among all age groups older than 50 years, yet increasing in younger individuals for whom screening use is limited and key symptoms may go unrecognized. Familial syndromes account for approximately 20% of young-onset CRCs, and the remainder are typically microsatellite stable cancers, which are more commonly diploid than similar tumors in older individuals. Young-onset CRCs are more likely to occur in the distal colon or rectum, be poorly differentiated, have mucinous and signet ring features, and present at advanced stages. Yet, stage-specific survival in patients with young-onset CRC is comparable to that of patients with later-onset cancer. Primary care physicians have an important opportunity to identify high-risk young individuals for screening and to promptly evaluate CRC symptoms. Risk modification, targeted screening, and prophylactic surgery may benefit individuals with a predisposing hereditary syndrome or condition (eg, inflammatory bowel disease) or a family history of CRC or advanced adenomatous polyps. When apparently average-risk young adults present with CRC-like symptoms (eg, unexplained persistent rectal bleeding, anemia, and abdominal pain), endoscopic work-ups can expedite diagnosis. Early screening in high-risk individuals and thorough diagnostic work-ups in symptomatic young adults may improve young-onset CRC trends.

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.

Clinical features of bladder cancer in primary care

BACKGROUND

Bladder cancer accounts for over 150,000 deaths worldwide. No screening is available, so diagnosis depends on investigations of symptoms. Of these, only visible haematuria has been studied in primary care.

AIM

To identify and quantify the features of bladder cancer in primary care.

DESIGN AND SETTING

Case-control study, using electronic medical records from UK primary care.

METHOD

Participants were 4915 patients aged ≥40 years, diagnosed with bladder cancer January 2000 to December 2009, and 21,718 age, sex, and practice-matched controls, were selected from the General Practice Research Database, UK. All clinical features independently associated with bladder cancer using conditional logistic regression were identified, and their positive predictive values for bladder cancer, singly and in combination, were estimated.

RESULTS

Cases consulted their GP more frequently than controls before diagnosis: median 15 consultations (interquartile range 9-22) versus 8 (4-15): P<0.001. Seven features were independently associated with bladder cancer: visible haematuria, odds ratio 34 (95% confidence interval [CI] = 29 to 41), dysuria 4.1 (95% CI = 3.4 to 5.0), urinary tract infection 2.2 (95% CI = 2.0 to 2.5), raised white blood cell count 2.1 (95% CI = 1.6 to 2.8), abdominal pain 2.0 (95% CI = 1.6 to 2.4), constipation 1.5 (95% CI = 1.2 to 1.9), raised inflammatory markers 1.5 (95% CI = 1.2 to 1.9), and raised creatinine 1.3 (95% CI = 1.2 to 1.4). The positive predictive value for visible haematuria in patients aged ≥60 years was PPV of 2.6% (95% CI = 2.2 to 3.2).

CONCLUSION

Visible haematuria is the commonest and most powerful predictor of bladder cancer in primary care, and warrants investigation. Most other previously reported features of bladder cancer were associated with the disease, but with low predictive values. There is a need for improved diagnostic methods, for those patients whose bladder cancer presents without visible haematuria.

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).

Criteria for Referring Patients With Outpatient Gastroenterological Disease for Specialist Consultation: A Review of the Literature

Background

Demands on gastroenterology are growing, as a result of the high prevalence of digestive diseases, the impact of colon cancer screening programs and an aging population. Prioritizing referrals to gastroenterology would assist in managing wait times. Our objectives were (1) to assess whether there were consistent criteria to guide referrals from family physicians for gastroenterological outpatient consultation and (2) to determine if there were different levels of urgency or priority in referral criteria.

Methods

We conducted a scoping review, searching Medline, Embase and Cochrane databases from 1997 to 2009, using the terms referral, triage, consultation and at least one from a list of gastroenterology-specific search terms. Of 2978 initial results, 51 papers were retrieved, and 20 were retained after review by two reviewers. Additional publications were identified through hand searches of retained papers, website searches and nomination by a panel of specialists.

Results

Thirty-four papers, reports or websites were retained. No referral criteria covered the spectrum of disorders that might be referred by family physicians to gastroenterologists. Criteria for referral were most commonly listed for suspected colorectal cancer, followed by suspected upper GI cancer, hepatitis, and functional disorders.

Conclusions

A clinical panel comprised of gastroenterologists and primary care providers, informed by this literature review, are completing the work of formulating a Gastroenterology Priority Referral Score, and plan to test the reliability and validity of the tool for determining the relative urgency for referral from primary care to gastroenterology.

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.

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.

Rectal bleeding in patients with haemorrhoids. Coincidental findings in colon and rectum

INTRODUCTION

Rectal bleeding is a very common clinical sign. It is often caused by haemorrhoids. However, it can be a symptom of other pathology in the rectum or colon. There are little data coincidental pathology in patients with haemorrhoids and rectal bleeding.

OBJECTIVE

To examine coincidental pathology in patients with rectal bleeding and haemorrhoids, especially with respect to age.

METHODS

Prospectively, 290 consecutive patients presenting with bleeding and haemorrhoids were analysed. All patients had an endoscopic examination. All significant endoscopic findings (diverticuli, polyps, cancer, angiodysplasia and varices or colitis) were recorded.

RESULTS

The patients were divided into two groups. Group 1 consisted of patients with only haemorrhoids (n = 129, % male: 41.1, mean age: 53.6 +/- 12.7 years). Group 2 consisted of patients with haemorrhoids and coincidental pathology (n = 161, % male: 46.6, mean age: 67.3 +/- 13.7 years). There was no difference in gender or in the type of endoscopy. However, patients in Group 2 were significantly older.

CONCLUSION

It can be concluded that in cases of rectal bleeding and haemorrhoids, coincidental pathology occurs in a large proportion of patients, especially the elderly. Omitting endoscopy in these patients can lead to major doctors delay.

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.

Alarm symptoms and identification of non-cancer diagnoses in primary care: cohort study

OBJECTIVE

To evaluate the predictive value of alarm symptoms for specified non-cancer diagnoses and cancer diagnoses in primary care.

DESIGN

Cohort study using the general practice research database.

SETTING

128 general practices in the UK contributing data, 1994-2000.

PARTICIPANTS

762 325 patients aged 15 or older.

MAIN OUTCOME MEASURES

Up to 15 pre-specified, non-cancer diagnoses associated with four alarm symptoms (haematuria, haemoptysis, dysphagia, rectal bleeding) at 90 days and three years after the first recorded alarm symptom. For each outcome analyses were implemented separately in a time to event framework. Data were censored if patients died, left the practice, or reached the end of the study period.

RESULTS

We analysed data on first episodes of haematuria (11 108), haemoptysis (4812), dysphagia (5999), or rectal bleeding (15 289). Non-cancer diagnoses were common in patients who presented with alarm symptoms. The proportion diagnosed with either cancer or non-cancer diagnoses generally increased with age. In patients presenting with haematuria, the proportions diagnosed with either cancer or non-cancer diagnoses within 90 days were 17.5% (95% confidence interval 16.4% to 18.6%) in women and 18.3% (17.4% to 19.3%) in men. For the other symptoms the proportions were 25.7% (23.8% to 27.8%) and 24% (22.5% to 25.6%) for haemoptysis, 17.2% (16% to 18.5%) and 22.6% (21% to 24.3%) for dysphagia, and 14.5% (13.7% to 15.3%) and 16.7% (15.8% to 17.5%) for rectal bleeding.

CONCLUSION

Clinically relevant diagnoses are made in a high proportion of patients presenting with alarm symptoms. For every four to seven patients evaluated for haematuria, haemoptysis, dysphagia, or rectal bleeding, relevant diagnoses will be identified in one patient within 90 days.

Determining the date of diagnosis--is it a simple matter? The impact of different approaches to dating diagnosis on estimates of delayed care for ovarian cancer in UK primary care

Background

Studies of cancer incidence and early management will increasingly draw on routine electronic patient records. However, data may be incomplete or inaccurate. We developed a generalisable strategy for investigating presenting symptoms and delays in diagnosis using ovarian cancer as an example.

Methods

The General Practice Research Database was used to investigate the time between first report of symptom and diagnosis of 344 women diagnosed with ovarian cancer between 01/06/2002 and 31/05/2008. Effects of possible inaccuracies in dating of diagnosis on the frequencies and timing of the most commonly reported symptoms were investigated using four increasingly inclusive definitions of first diagnosis/suspicion: 1. "Definite diagnosis" 2. "Ambiguous diagnosis" 3. "First treatment or complication suggesting pre-existing diagnosis", 4 "First relevant test or referral".

Results

The most commonly coded symptoms before a definite diagnosis of ovarian cancer, were abdominal pain (41%), urogenital problems(25%), abdominal distension (24%), constipation/change in bowel habits (23%) with 70% of cases reporting at least one of these. The median time between first reporting each of these symptoms and diagnosis was 13, 21, 9.5 and 8.5 weeks respectively. 19% had a code for definitions 2 or 3 prior to definite diagnosis and 73% a code for 4. However, the proportion with symptoms and the delays were similar for all four definitions except 4, where the median delay was 8, 8, 3, 10 and 0 weeks respectively.

Conclusion

Symptoms recorded in the General Practice Research Database are similar to those reported in the literature, although their frequency is lower than in studies based on self-report. Generalisable strategies for exploring the impact of recording practice on date of diagnosis in electronic patient records are recommended, and studies which date diagnoses in GP records need to present sensitivity analyses based on investigation, referral and diagnosis data. Free text information may be essential in obtaining accurate estimates of incidence, and for accurate dating of diagnoses.

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

BACKGROUND

Colorectal cancer is generally diagnosed following a symptomatic presentation to primary care. Although the presenting features of the cancer are well described, the risks they convey are less well known. This study aimed to quantify the risk of cancer for different symptoms, across age groups and in both sexes.

METHODS

This was a case-control study using pre-existing records in a large electronic primary care database. Cases were patients aged 30 years or older with a diagnosis of colorectal cancer between January 2001 and July 2006, matched to seven controls by age, sex and practice. All features of colorectal cancer recorded in the 2 years before diagnosis were identified. Features independently associated with cancer were identified using multivariable conditional logistic regression, and their risk of cancer quantified.

RESULTS

We identified 5477 cases, with 38,314 age, sex and practice-matched controls. Six symptoms and two abnormal investigations (anaemia and microcytosis) were independently associated with colorectal cancer. The positive predictive values of symptoms were: rectal bleeding, positive predictive value for a male aged > or = 80 years 4.5% (95% confidence interval 3.5, 5.9); change in bowel habit 3.9% (2.8, 5.5); weight loss 0.8% (0.5, 1.3); abdominal pain 1.2% (1.0, 1.4); diarrhoea 1.2% (1.0, 1.5) and constipation 0.7% (0.6, 0.8). Positive predictive values were lower in females and younger patients. Only 27% of patients had reported either of the two higher risk symptoms.

CONCLUSION

Most symptomatic colorectal cancers present with only a low-risk symptom. There is a need to find a method of identifying those at highest risk of cancer from the large number presenting with such symptoms.

Validation of the Lower Gastrointestinal Electronic Referral Protocol

Background

Recognition of people presenting to the general practitioner with symptoms suggestive of colorectal cancer varies considerably, as do the subsequent patterns of referral and treatment. The Lower Gastrointestinal Electronic Referral Protocol (e-RP) was developed to be used alongside the national Choose and Book programme. This paper addresses the validation of the e-RP.

Methods

The e-RP was validated using three datasets: 100 consecutive patients with colorectal cancer, 100 2-week wait (TWW) suspected cancer referrals and 100 routine referrals. The actual destination of referred patients, their clinical diagnosis and referral urgency were compared with destination and referral urgency assigned by the e-RP.

Results

Some 43·0 per cent of patients with colorectal cancer were actually referred through the TWW system and the e-RP successfully upgraded 85·0 per cent of these patients as TWW referrals (Pearson χ2 = 9·76, 1 d.f., P = 0·002). The e-RP also redirected three of four patients with colorectal cancer in routine referrals to TWW clinics. Right-sided cancers were appropriately directed to colonoscopy as the first contact in secondary care or to outpatients for investigation of a palpable mass. Most patients with left-sided cancers were directed to flexible sigmoidoscopy clinics.

Conclusion

A dedicated referral protocol addressing all colorectal symptoms would significantly improve the overall yield of colorectal cancers through the TWW route and reduce delays in patient pathways with ‘straight to test’ in secondary care.

Alarm symptoms in early diagnosis of cancer in primary care: cohort study using General Practice Research Database

OBJECTIVE

To evaluate the association between alarm symptoms and the subsequent diagnosis of cancer in a large population based study in primary care.

DESIGN

Cohort study.

SETTING

UK General Practice Research Database. Patients 762 325 patients aged 15 years and older, registered with 128 general practices between 1994 and 2000. First occurrences of haematuria, haemoptysis, dysphagia, and rectal bleeding were identified in patients with no previous cancer diagnosis.

MAIN OUTCOME MEASURE

Positive predictive value of first occurrence of haematuria, haemoptysis, dysphagia, or rectal bleeding for diagnoses of neoplasms of the urinary tract, respiratory tract, oesophagus, or colon and rectum during three years after symptom onset. Likelihood ratio and sensitivity were also estimated.

RESULTS

11.108 first occurrences of haematuria were associated with 472 new diagnoses of urinary tract cancers in men and 162 in women, giving overall three year positive predictive values of 7.4% (95% confidence interval 6.8% to 8.1%) in men and 3.4% (2.9% to 4.0%) in women. After 4812 new episodes of haemoptysis, 220 diagnoses of respiratory tract cancer were made in men (positive predictive value 7.5%, 6.6% to 8.5%) and 81 in women (4.3%, 3.4% to 5.3%). After 5999 new diagnoses of dysphagia, 150 diagnoses of oesophageal cancer were made in men (positive predictive value 5.7%, 4.9% to 6.7%) and 81 in women (2.4%, 1.9 to 3.0%). After 15 289 episodes of rectal bleeding, 184 diagnoses of colorectal cancer were made in men (positive predictive value 2.4%, 2.1% to 2.8%) and 154 in women (2.0%, 1.7% to 2.3%). Predictive values increased with age and were strikingly high, for example, in men with haemoptysis aged 75-84 (17.1%, 13.5% to 21.1%) and in men with dysphagia aged 65-74 (9.0%, 6.8% to 11.7%).

CONCLUSION

New onset of alarm symptoms is associated with an increased likelihood of a diagnosis of cancer, especially in men and in people aged over 65. These data provide support for the early evaluation of alarm symptoms in an attempt to identify underlying cancers at an earlier and more amenable stage.