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

Colorectal cancer recurrence and its impact on survival after curative surgery: An analysis based on multistate models

AIM

To investigate the usefulness of multistate models (MSM) for determining colorectal cancer (CRC) recurrence rate, to analyse the effect of different factors on tumour recurrence and death, and to assess the impact of recurrence for CRC prognosis.

METHODS

Observational follow-up study of incident CRC cases disease-free after curative resection in 2006-2013 (n = 994). Recurrence and mortality were analyzed with MSM, as well as covariate effects on transition probabilities.

RESULTS

Cumulative incidence of recurrence at 60 months was 13.7%. Five years after surgery, 70.3% of patients were alive and recurrence-free, and 8.4% were alive after recurrence. Recurrence has a negative impact on prognosis, with 5-year CRC-related mortality increasing from 3.8% for those who are recurrence-free 1-year after surgery to 33.6% for those with a recurrence. Advanced stage increases recurrence risk (HR = 1.53) and CRC-related mortality after recurrence (HR = 2.35). CRC-related death was associated with age in recurrence-free patients, and with comorbidity after recurrence. As expected, age≥75 years was a risk factor for non-CRC-related death with (HR = 7.76) or without recurrence (HR = 4.26), while its effect on recurrence risk was not demonstrated.

CONCLUSIONS

MSM allows detailed analysis of recurrence and mortality in CRC. Recurrence has a negative impact on prognosis. Advanced stage was a determining factor for recurrence and CRC-death after recurrence.

Relationship between time from symptom's onset to diagnosis and prognosis in patients with symptomatic colorectal cancer

BACKGROUND

Controversy exists regarding the relationship of the outcome of patients with colorectal cancer (CRC) with the time from symptom onset to diagnosis. The aim of this study is to investigate this association, with the assumption that this relationship was nonlinear and with adjustment for multiple confounders, such as tumor grade, symptoms, or admission to an emergency department.

METHODS

This multicenter study with prospective follow-up was performed in five regions of Spain from 2010 to 2012. Symptomatic cases of incident CRC from a previous study were examined. At the time of diagnosis, each patient was interviewed, and the associated hospital and clinical records were reviewed. During follow-up, the clinical records were reviewed again to assess survival. Cox survival analysis with a restricted cubic spline was used to model overall and CRC-specific survival, with adjustment for variables related to the patient, health service, and tumor.

RESULTS

A total of 795 patients had symptomatic CRC and 769 of them had complete data on diagnostic delay and survival. Univariate analysis indicated a lower HR for death in patients who had diagnostic intervals less than 4.2 months. However, after adjustment for variables related to the patient, tumor, and utilized health service, there was no relationship of the diagnostic delay with survival of patients with colon and rectal cancer, colon cancer alone, or rectal cancer alone. Cubic spline analysis indicated an inverse association of the diagnostic delay with 5-year survival. However, this association was not statistically significant.

CONCLUSIONS

Our results indicated that the duration of diagnostic delay had no significant effect on the outcome of patients with CRC. We suggest that the most important determinant of the duration of diagnostic delay is the biological profile of the tumor. However, it remains the responsibility of community health centers and authorities to minimize diagnostic delays in patients with CRC and to implement initiatives that improve early diagnosis and provide better outcomes.

Characterisation of long-term cancer survivors and application of statistical cure models: a protocol for an observational follow-up study in patients with colorectal cancer

BACKGROUND

Improved colorectal cancer (CRC) survival rates have been reported over the last years, with more than half of these patients surviving more than 5 years after the initial diagnosis. Better understanding these so-called long-term survivors could be very useful to further improve their prognosis as well as to detect other problems that may cause a significant deterioration in their health-related quality of life (HRQoL). Cure models provide novel statistical tools to better estimate the long-term survival rate for cancer and to identify characteristics that are differentially associated with a short or long-term prognosis. The aim of this study will be to investigate the long-term prognosis of CRC patients, characterise long-term CRC survivors and their HRQoL, and demonstrate the utility of statistical cure models to analyse survival and other associated factors in these patients.

METHODS

This is a single-centre, ambispective, observational follow-up study in a cohort of n = 1945 patients with CRC diagnosed between 2006 and 2013. A HRQoL sub-study will be performed in the survivors of a subset of n = 485 CRC patients for which baseline HRQoL data from the time of their diagnosis is already available. Information obtained from interviews and the clinical records for each patient in the cohort is already available in a computerised database from previous studies. This data includes sociodemographic characteristics, family history of cancer, comorbidities, perceived symptoms, tumour characteristics at diagnosis, type of treatment, and diagnosis and treatment delay intervals. For the follow-up, information regarding local recurrences, development of metastases, new tumours, and mortality will be updated using hospital records. The HRQoL for long-term survivors will be assessed with the EORTC QLQ-C30 and QLQ-CR29 questionnaires. An analysis of global and specific survival (competitive risk models) will be performed. Relative survival will be estimated and mixture cure models will be applied. Finally, HRQoL will be analysed through multivariate regression models.

DISCUSSION

We expect the results from this study to help us to more accurately determine the long-term survival of CRC, identify the needs and clinical situation of long-term CRC survivors, and could be used to propose new models of care for the follow-up of CRC patients.

A pathological complete response after neoadjuvant triplet chemotherapy for locally advanced transverse colon cancer

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Perioperative chemotherapy could improve oncological outcome for colon cancer.

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The effectiveness of triplet chemotherapy as neoadjuvant setting is still unknown.

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A pathological complete response after neoadjuvant triplet chemotherapy was described.

Introduction

Perioperative chemotherapy could improve oncological outcomes for patients with advanced colon cancer. However, the effectiveness of triplet chemotherapy in the neoadjuvant setting is still unknown.

Presentation of case

A 61-year-old man was referred to our hospital due to abdominal distention. Abdominal computed tomography showed a huge, 18-cm mass in the right upper abdomen. Biopsy showed well-differentiated adenocarcinoma. Locally advanced transverse colon cancer T4b N2a M0 Stage IIIC was diagnosed. Considering the extensive invasion to surrounding organs and difficulties in achieving margin-negative surgery, an emergency ileostomy was performed first. Then, neoadjuvant chemotherapy (NAC) consisting of a combination of 5-fluorouracil (5-FU), oxaliplatin, irinotecan, and leucovorin (FOLFOXIRI) was planned, followed by primary tumor resection. After 6 courses of treatment, the primary tumor shrank remarkably. Finally, laparoscopic radical extended right hemi-colectomy was performed. There were no residual tumor cells in resected specimens, including the primary tumor and surrounding lymph nodes. The pathological diagnosis was complete response.

Conclusion

A case of pathological complete response after neoadjuvant treatment followed by radical resection was reported. Further research is needed to confirm the appropriate indications for neoadjuvant FOLFOXIRI therapy for patients with LACC.

Factors related to short-term outcomes and delayed systemic treatment following primary tumor resection for asymptomatic stage IV colorectal cancer

BACKGROUND

The effectiveness of primary tumor resection (PTR) for asymptomatic stage IV colorectal cancer patients to continue prolonged and safe systemic chemotherapy has recently been re-evaluated. However, postoperative complications lead to a prolonged hospital stay and delay systemic treatment, which could result in a poor oncologic outcome. The objective of this study was to identify the risk factors for morbidity and delay of systemic chemotherapy in such patients.

METHODS

Between April 2016 and March 2018, 115 consecutive colorectal cancer patients with distant metastasis who had no clinical symptoms and underwent PTR in all participating hospitals were retrospectively reviewed. The patients were divided into two groups according to the presence (CD ≥ 2, n = 23) or absence (CD < 2, n = 92) of postoperative complications.

RESULTS

The proportion of combined resection of adjacent organs was significantly higher in the postoperative complication group (p = 0.014). Complications were significantly correlated with longer hospital stay (p < 0.001) and delay of first postoperative treatment (p = 0.005). Univariate and multivariate analyses showed that combined resection (odds ratio 4.593, p = 0.010) was the independent predictor for postoperative complications. Median survival time was 8.5 months. Postoperative complications were not associated with overall survival, but four patients (3.5%) could not receive systemic chemotherapy because of prolonged postoperative complications.

CONCLUSIONS

Although PTR for asymptomatic stage IV CRC patients showed an acceptable prognosis, appropriate patient selection is needed to obtain its true benefit.

Emergency presentation of colorectal patients in Spain

Background

Colorectal cancer (CRC) is the leading cause of cancer deaths in Europe. Survival is poorer in patients admitted to hospitals through the emergency department than in electively admitted patients. Knowledge of factors associated with a cancer diagnosis through presentation at an emergency department may reduce the likelihood of an emergency diagnosis. This study evaluated factors influencing the diagnosis of CRC in the emergency department.

Methods and findings

This is a cross-sectional study in 5 Spanish regions; subjects were incident cases of CRC diagnosed in 9 public hospitals, between 2006 and 2008. Data were obtained from patient interviews and primary care and hospital clinical records. We found that approximately 40% of CRC patients first contacted a hospital for CRC through an emergency service. Women were more likely than men to be emergency presenters. The type of symptom associated with emergency presentation differed between patients with colon cancer and those with rectal cancer, in that the frequency of “alarm symptoms” was significantly lower in colon than in rectal cancer patients who initially presented to emergency services. Soon after symptom onset, some patients went to a hospital emergency service, whereas others contacted their GP. Lack of contact with a GP for CRC-related symptoms was consistently related to emergency presentation. Among patients who contacted a GP, a higher number of consultations for CRC symptoms and any referral to outpatient consultations reduced the likelihood of emergency presentation. All diagnostic time intervals were shorter in emergency presenters than in elective patients.

Conclusions

Emergency presenters are not a uniform category and can be divided into categories according to their symptoms, help seeking behavior trajectory and interaction with their GPs. Time constraints for testing and delays in obtaining outpatient appointments led patients to visit a hospital service either on their own or after referral by their GP.

Symptom Signatures and Diagnostic Timeliness in Cancer Patients: A Review of Current Evidence

Early diagnosis is an important aspect of contemporary cancer prevention and control strategies, as the majority of patients are diagnosed following symptomatic presentation. The nature of presenting symptoms can critically influence the length of the diagnostic intervals from symptom onset to presentation (the patient interval), and from first presentation to specialist referral (the primary care interval). Understanding which symptoms are associated with longer diagnostic intervals to help the targeting of early diagnosis initiatives is an area of emerging research. In this Review, we consider the methodological challenges in studying the presenting symptoms and intervals to diagnosis of cancer patients, and summarize current evidence on presenting symptoms associated with a range of common and rarer cancer sites. We propose a taxonomy of cancer sites considering their symptom signature and the predictive value of common presenting symptoms. Finally, we consider evidence on associations between symptomatic presentations and intervals to diagnosis before discussing implications for the design, implementation, and evaluation of public health or health system interventions to achieve the earlier detection of cancer.

Evidence of advanced stage colorectal cancer with longer diagnostic intervals: a pooled analysis of seven primary care cohorts comprising 11 720 patients in five countries

BACKGROUND

The benefits from expedited diagnosis of symptomatic cancer are uncertain. We aimed to analyse the relationship between stage of colorectal cancer (CRC) and the primary and specialist care components of the diagnostic interval.

METHODS

We identified seven independent data sets from population-based studies in Scotland, England, Canada, Denmark and Spain during 1997-2010 with a total of 11 720 newly diagnosed CRC patients, who had initially presented with symptoms to a primary care physician. Data were extracted from patient records, registries, audits and questionnaires, respectively. Data sets were required to hold information on dates in the diagnostic interval (defined as the time from the first presentation of symptoms in primary care until the date of diagnosis), symptoms at first presentation in primary care, route of referral, gender, age and histologically confirmed stage. We carried out reanalysis of all individual data sets and, using the same method, analysed a pooled individual patient data set.

RESULTS

The association between intervals and stage was similar in the individual and combined data set. There was a statistically significant convex (∩-shaped) association between primary care interval and diagnosis of advanced (i.e., distant or regional) rather than localised CRC (P=0.004), with odds beginning to increase from the first day on and peaking at 90 days. For specialist care, we saw an opposite and statistically significant concave (∪-shaped) association, with a trough at 60 days, between the interval and diagnosis of advanced CRC (P<0.001).

CONCLUSIONS

This study provides evidence that longer diagnostic intervals are associated with more advanced CRC. Furthermore, the study cannot define a specific 'safe' waiting time as the length of the primary care interval appears to have negative impact from day one.

Factors that influence treatment delay in patients with colorectal cancer

A prospective study was performed of patients diagnosed with colorectal cancer (CRC), distinguishing between colonic and rectal location, to determine the factors that may provoke a delay in the first treatment (DFT) provided.2749 patients diagnosed with CRC were studied. The study population was recruited between June 2010 and December 2012. DFT is defined as time elapsed between diagnosis and first treatment exceeding 30 days.Excessive treatment delay was recorded in 65.5% of the cases, and was more prevalent among rectal cancer patients. Independent predictor variables of DFT in colon cancer patients were a low level of education, small tumour, ex-smoker, asymptomatic at diagnosis and following the application of screening. Among rectal cancer patients, the corresponding factors were primary school education and being asymptomatic.We conclude that treatment delay in CRC patients is affected not only by clinicopathological factors, but also by sociocultural ones. Greater attention should be paid by the healthcare provider to social groups with less formal education, in order to optimise treatment attention.

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.

Colorectal cancer health services research study protocol: the CCR-CARESS observational prospective cohort project

BACKGROUND

Colorectal cancers are one of the most common forms of malignancy worldwide. But two significant areas of research less studied deserve attention: health services use and development of patient stratification risk tools for these patients.

METHODS

DESIGN

a prospective multicenter cohort study with a follow up period of up to 5 years after surgical intervention. Participant centers: 22 hospitals representing six autonomous communities of Spain. Participants/Study population: Patients diagnosed with colorectal cancer that have undergone surgical intervention and have consented to participate in the study between June 2010 and December 2012. Variables collected include pre-intervention background, sociodemographic parameters, hospital admission records, biological and clinical parameters, treatment information, and outcomes up to 5 years after surgical intervention. Patients completed the following questionnaires prior to surgery and in the follow up period: EuroQol-5D, EORTC QLQ-C30 (The European Organization for Research and Treatment of Cancer quality of life questionnaire) and QLQ-CR29 (module for colorectal cancer), the Duke Functional Social Support Questionnaire, the Hospital Anxiety and Depression Scale, and the Barthel Index. The main endpoints of the study are mortality, tumor recurrence, major complications, readmissions, and changes in health-related quality of life at 30 days and at 1, 2, 3 and 5 years after surgical intervention.

STATISTICAL ANALYSIS

In relation to the different endpoints, predictive models will be used by means of multivariate logistic models, Cox or linear mixed-effects regression models. Simulation models for the prediction of discrete events in the long term will also be used, and an economic evaluation of different treatment strategies will be performed through the use of generalized linear models.

DISCUSSION

The identification of potential risk factors for adverse events may help clinicians in the clinical decision making process. Also, the follow up by 5 years of this large cohort of patients may provide useful information to answer different health services research questions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02488161 . Registration date: June 16, 2015.

Identifying the Factors Causing Delayed Presentation of Cancer Patients to a Government Medical College of Central India

BACKGROUND

The incidence of cancer is increasing throughout the world. One of the prime aims of its management is early diagnosis and therapeutic intervention. Factors causing delay to either of these goals should be identified and rectified.

AIM

To identify the factors causing delayed initial diagnosis and subsequent management in patients presenting to the Oncology department.

MATERIALS AND METHODS

Three hundred proven cancer patients were prospectively evaluated for the pattern of presentation to the outpatient Department of Radiation Oncology of a Government Medical College (MC) in Central India.

RESULTS

The mean age of presentation was 51.05 years (range 7 months-77 years). The number of male patients was 168 while females were 132. The duration of symptoms ranged from 20 days to 3 years. The number of patients with little/no education presented mainly in advanced stages as compared to their educated counterpart and this difference was statistically significant (p<0.001). The number of patients presenting directly to the department was 108, those diagnosed outside and referred to us was 84 while those diagnosed and received some form of oncologic treatment outside and referred thereafter was 108. The difference in the primary delay between patients presenting directly to the MC versus those diagnosed outside was significant (p=0.0126). The mean duration of starting definitive treatment after presentation to the outpatient was 4.68 days (range 0-22 days) and was very significantly (p< 0.001) less than the secondary delays caused to the other two subsets of patients.

CONCLUSION

Factors causing delayed presentation are both patient and system related. It is imperative to educate the common people regarding the early signs and symptoms of cancer. At the same time, the system needs to overhaul its efficiency to avoid secondary delays that adversely affect the treatment outcome. An upgradation of the existing oncology facilities in the public sector can achieve this target efficiently.

Surgical outcome in patients with gastrointestinal malignancies; a report from a large referral hospital, 2008-2010

BACKGROUND

A considerable portion of gastrointestinal malignancies undergoes surgerywithout curative resection. This study was conducted to assess surgical outcomein patients with gastrointestinal cancers.

METHODS

We reviewed individuals with esophagus, stomach, colon and rectum cancersadmitted for surgical treatment after initial preoperative evaluations. Surgicaloutcome, stage of tumors and 1 and 5 years survival rate were assessedand analyzed.

RESULTS

Two hundred and fifty five patients with esophagus, stomach and colorectalmalignancies, who were admitted for surgical resection, were reviewed. Twohundred and twenty two patients were underwent surgery but tumor was not resectedin 41 cases (18.6%). Based on pathological assessment, stage of tumorswas III or IV in 108 individuals (48.9%). The proportion of tumor with advancedstage was significantly higher in patients with gastroesophageal cancersthan those with colorectal malignancies (62.6% versus 31.6%), p<0.0001). Theproportion of non-resectable tumor was also significantly higher in patientswith esophageal and gastric cancers (p=0.0001). Palliative surgery was donein 26.1% of patients treated by surgical resection. The proportion of palliativesurgery was significantly lower in patients with gastric cancer (p=0.001). 1 and5-year survival were significantly longer in colorectal cancer and those withcurative surgery (p=0.001). Survival of patients with palliative resection wasthe same as patient without tumor resection.

CONCLUSION

Despite preoperative evaluations, there are still a considerable proportionof patients who are diagnosed as inoperable during surgery. Further researchesseem to be necessary in order to provide more precise preoperative staging.Screening programs should also be considered for GI cancers in high-risk areas.It seems that palliative resection would not improve survival of patientswith advanced GI malignancies.

Diagnostic and treatment delay, quality of life and satisfaction with care in colorectal cancer patients: a study protocol

Background

Due to recent improvements in colorectal cancer survival, patient-reported outcomes, including health-related quality of life and satisfaction with care, have become well-established endpoints to determine the impact of the disease on the lives of patients.

The aim of this study is to determine prospectively, in a cohort of colorectal cancer incident cases: a) health-related quality of life, b) satisfaction with hospital-based care, and c) functional status. A secondary objective is to determine whether diagnostic/therapeutic delay influence quality of life or patients’ satisfaction levels.

Methods/design

Single-centre prospective follow-up study of colorectal cancer patients diagnosed during the period 2011–2012 (n = 375).

This project was approved by the corresponding ethics review board, and informed consent is obtained from each patient. After diagnosis, patients are interviewed by a trained nurse, obtaining information on sociodemographic characteristics, family history of cancer, first symptoms, symptom perception and reaction to early symptoms. Quality of life is assessed with the EORTC QLQ-C30 and QLQ-CR29 questionnaires, and patients’ satisfaction with care is determined using the EORTC IN-PATSAT32. Functional status is measured with the Karnofsky Performance Status Scale.

Clinical records are also reviewed to collect information on comorbidity, tumour characteristics, treatment, hospital consultations and exploratory procedures.

Symptoms-to-diagnosis interval is defined as the time from the date of first symptoms until the cytohistological confirmation of cancer. Treatment delay is defined as the time between diagnosis and surgical treatment.

All the patients will be followed-up for a maximum of 2 years. For survivors, assessments will be re-evaluated at one and two years after the diagnosis.

Multiple linear/logistic regression models will be used to identify variables associated with the patients’ functional status, quality of life and satisfaction with care score. Changes in quality of life over time will be analysed with linear mixed-effects regression models.

Discussion

The results will provide a deeper understanding of the impact of colorectal cancer from a more patient-centred approach, allowing us to identify groups of patients in need of additional attention, as well as areas for improvement. Special attention will be given to the relationship between diagnostic/therapeutic delay and patients’ quality of life and satisfaction with the care received.

Appraisal of emerging symptoms of colorectal cancer: associations with dispositional, demographic, and tumor characteristics

The time it takes for individuals to realize that their emerging colorectal cancer (CRC) symptoms are serious is often an impediment to expeditious help-seeking. Tailored educational efforts to hasten symptom appraisal time would benefit from knowledge of the characteristics of individuals who tend to neglect their symptoms as well as the nature of symptoms that are most often neglected. In a sample of 112 CRC patients, we investigated associations between duration of symptom appraisal and: (1) trait anxiety, and (2) tumor location, which affects symptomatology. Symptom appraisal duration was associated with a sex-by-anxiety interaction (p = 0.007). The longest times (in weeks) were among high anxiety females (Mdn = 26.0) and low anxiety males (Mdn = 17.0), with shorter times among low anxiety females (Mdn = 9.0) and high anxiety males (Mdn = 2.0). Symptom appraisal times were also longer for patients with distal (vs. proximal) tumors (p = 0.036).

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.

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.

Factors associated with late presentation of cancer: a limited literature review

According to the World Health Organization (WHO 2006), cancer is one of the leading causes of death worldwide. Deaths from cancer are projected to continue rising, with an estimated 9 million people dying from cancer in 2015 and 11.4 million dying in 2030 (WHO 2006). Delayed presentation or late diagnosis of cancer is associated with low survival. The aim of this review is to identify factors associated with delayed presentation of cancer that were reported by previous studies. Published studies which identified the most common factors attributed to the late presentation of cancer were reviewed. Publications were identified using MEDLINE (Medical Literature Analysis and Retrieval System Online), the Cochrane Library, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and EMBASE (Excerpta Medica Database) databases. A Critical Appraisal Skills Programme (CASP) was used to assess the methodological quality of the studies. A total of 24 studies met the inclusion criteria. A data extraction sheet was used to systematically record relevant factors. Twenty-four studies met the inclusion criteria which identified factors associated with patients’ delay including patients’ knowledge, stress and fear, and nature of the disease. Other factors were attributed to health providers such as general practitioner (GP) experience, referral delay, and a younger age group being considered as low risk, so symptoms were missed.

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.