Emergency room presentation of colorectal cancer: a consecutive cohort study

Patient outcomes associated with cancer diagnosis through the emergency department: A systematic review

OBJECTIVE

Many patients are initially diagnosed with a new suspected cancer through the emergency department (ED). The objective of this systematic review was to compare stage of cancer and survival of patients diagnosed with cancer through the ED to patients diagnosed elsewhere.

METHODS

Electronic searches of Medline and EMBASE were conducted and reference lists were hand-searched. Studies comparing adult patients diagnosed with any type of cancer through the ED (ED diagnosis) to patients diagnosed elsewhere (non-ED diagnosis) were included. Two reviewers independently screened titles and abstracts, assessed quality of the studies, and extracted data. The risk of bias of included studies was assessed using the Newcastle-Ottawa Scale. Data pertaining to patient outcomes were summarized and pooled using random-effects models and reported as risk ratios (RRs) with 95% confidence intervals (CIs), where applicable.

RESULTS

Fourteen studies were included. There was an increased risk of more advanced/later stage cancer (Stage III/IV or late-stage vs. earlier stage) among patients with an ED diagnosis of cancer compared to a non-ED diagnosis of cancer (RR 1.30, 95% CI 1.39-1.58). Survival was lower for patients with an ED diagnosis of cancer compared to those diagnosed elsewhere (RR 0.61, 95% CI 0.49-0.75).

CONCLUSIONS

Patients with an ED diagnosis of cancer had more advanced/late stage of cancer at diagnosis and worse survival compared to patients diagnosed elsewhere. Future research examining patients diagnosed with cancer through the ED is required.

Presentation Patterns and Outcomes in Patients with Colorectal Cancer Seeking the Emergency Department for Consultation

Background Patients with colorectal cancer may seek the emergency department for symptoms related to chemotherapy and radiotherapy side effects as well as those from the disease itself and from surgery complications.

Objectives To establish the epidemiological and clinical profile of colorectal cancer patients that look for consultations in the emergency department.

Methods Retrospective study of emergency room charts from colorectal cancer patients that consulted in a single oncological hospital for the period of 1 year.

Results Four hundred and forty-six consultations were identified (49.5% males and 50.5% females) with a mean age of 63 years and with advanced disease (most with tumor, node, metastases [TNM] stages III and IV). The most common complaint was abdominal pain (27.5%), followed by nausea (4.7%; more commonly seen in females with p = 0.03) and bladder symptoms (4.7%; more commonly seen in males, with p = 0.003). Infections (10.3%) and acute abdominal pain (9.1%) were the most frequent diagnoses. About 18% of them were admitted to the hospital and 80% were discharged home.

Conclusion The profile of patients with colorectal cancer seeking the emergency department comprises patients with advanced disease and a similar proportion of males and females. Symptom-driven complaints were the most frequent reason for consultations.

Real-world colorectal cancer diagnostic pathways in Ontario, Canada: A population-based study

OBJECTIVE

This study aimed to identify colorectal cancer (CRC) diagnostic pathways and describe patients in those pathway groups.

METHODS

This was a cross-sectional study of CRC patients in Ontario, Canada, diagnosed 2009-2012 that used linked administrative data at ICES. We used cluster analysis on 11 pathway variables characterising patient presentation, symptoms, procedures and referrals. We assessed associations between patient- and disease-related characteristics and diagnostic pathway group. We further characterised the pathways by diagnostic interval and number of related physician visits.

RESULTS

Six diagnostic pathways were identified, with three adhering to provincial diagnostic guidelines: screening (N = 4494), colonoscopy (N = 10,066) and imaging plus colonoscopy (N = 3427). Non-adherent pathways were imaging alone (N = 2238), imaging and emergency presentation (N = 2849) and no pre-diagnostic workup (N = 887). Patients in adherent pathways were younger, had fewer comorbidities, lived in less deprived areas and had earlier stage disease. The median diagnostic interval length varied across pathways from 12 to 126 days, correlating with the number of CRC-related visits.

CONCLUSIONS

This study demonstrated substantial variations in real-world CRC diagnostic pathways and 25% were diagnosed through non-adherent pathways. Those patients were older, had more comorbid disease and had higher stage cancer. Further research needs to identify and describe the reasons for divergent diagnostic processes.

Determinants of emergency presentation in patients with colorectal cancer: a systematic review and meta-analysis

Colorectal cancer remains a significant cause of morbidity and mortality, even despite curative treatment. A significant proportion of patients present emergently and have poorer outcomes compared to elective presentations, independent of TNM stage. In this systematic review and meta-analysis, differences between elective/emergency presentations of colorectal cancer were examined to determine which factors were associated with emergency presentation. A literature search was carried out from 1990 to 2018 comparing elective and emergency presentations of colon and/or rectal cancer. All reported clinicopathological variables were extracted from identified studies. Variables were analysed through either systematic review or, if appropriate, meta-analysis. This study identified multiple differences between elective and emergency presentations of colorectal cancer. On meta-analysis, emergency presentations were associated with more advanced tumour stage, both overall (OR 2.05) and T/N/M/ subclassification (OR 2.56/1.59/1.75), more: lymphovascular invasion (OR 1.76), vascular invasion (OR 1.92), perineural invasion (OR 1.89), and ASA (OR 1.83). Emergencies were more likely to be of ethnic minority (OR 1.58). There are multiple tumour/host factors that differ between elective and emergency presentations of colorectal cancer. Further work is required to determine which of these factors are independently associated with emergency presentation and subsequently which factors have the most significant effect on outcomes.

Definition of large bowel obstruction by primary colorectal cancer: A systematic review

AIM

Controversies on therapeutic strategy for large bowel obstruction by primary colorectal cancer mainly concern acute conditions, being essentially different from subacute obstruction. Clearly defining acute obstruction is important for design and interpretation of studies as well as for guidelines and daily practice. This systematic review aimed to evaluate definitions of obstruction by colorectal cancer in prospective studies.

METHOD

A systematic search was performed in PubMed, Embase and the Cochrane Library. Eligibility criteria included randomized or prospective observational design, publication between 2000 and 2019, and the inclusion of patients with an obstruction caused by colorectal cancer. Provided definitions of obstruction were extracted with assessment of common elements.

RESULTS

A total of 16 randomized controlled trials (RCTs) and 99 prospective observational studies were included. Obstruction was specified as acute in 28 studies, complete/emergency in five, (sub)acute or similar terms in four and unspecified in 78. Five of 16 RCTs (31%) and 37 of 99 cohort studies (37%) provided a definition. The definitions included any combination of clinical symptoms, physical signs, endoscopic features and radiological imaging findings in 25 studies. The definition was only based on clinical symptoms in 11 and radiological imaging in six studies. Definitions included a radiological component in 100% of evaluable RCTs (5/5) vs. 54% of prospective observational studies (20/37, P = 0.07).

CONCLUSION

In this systematic review, the majority of prospective studies did not define obstruction by colorectal cancer and its urgency, whereas provided definitions varied hugely. Radiological confirmation seems to be an essential component in defining acute obstruction.

Diagnosis Setting and Colorectal Cancer Outcomes: The Impact of Cancer Diagnosis in the Emergency Department

BACKGROUND

The rate of diagnosis of colorectal cancer (CRC) in the emergency department (ED), its characteristics, and its effect on outcomes have been poorly described.

MATERIALS AND METHODS

Chart review was conducted to identify presenting clinical setting leading to diagnosis, symptoms, and history of colonoscopy for patients diagnosed with CRC at a single institution from 2012-2014. Patients diagnosed with CRC as a result of an ED visit (EDDx) were compared with those diagnosed after presentation to other settings (non-EDDx).

RESULTS

Of 638 patients meeting inclusion criteria, 271 (42.4%) were EDDx patients. These patients were more likely to be older than 80 y (29.89% versus 19.35%), have Medicare (59.78% versus 42.78%) or Medicaid (23.62% versus 12.81%) insurance, have stage IV cancer (45.02% versus 18.26%), and were symptomatic at the time of presentation (94.83% versus 64.03%). EDDx patients were less likely to ever have had a colonoscopy (21.77% versus 41.69%). In a model adjusted for patient demographics, cancer stage, presence of symptoms, and history of prior colonoscopy, EDDx was associated with increased mortality (hazard ratio, 1.89; 95% confidence interval, 1.3-2.8). On stratifying survival by stage, it was found that for all stages, EDDx was associated with decreased survival.

CONCLUSIONS

More than 40% of patients with CRC received their diagnosis through the ED. EDDx was associated with a nearly twofold mortality risk increase. EDDx should be considered a marker of poor outcomes for CRC and may be related to unaccounted patient-level or systems-level factors. Efforts should be made to identify modifiable risks of cancer diagnosis in the ED to improve cancer outcomes.

Comorbid chronic diseases and cancer diagnosis: disease-specific effects and underlying mechanisms

An earlier diagnosis is a key strategy for improving the outcomes of patients with cancer. However, achieving this goal can be challenging, particularly for the growing number of people with one or more chronic conditions (comorbidity/multimorbidity) at the time of diagnosis. Pre-existing chronic diseases might affect patient participation in cancer screening, help-seeking for new and/or changing symptoms and clinicians' decision-making on the use of diagnostic investigations. Evidence suggests, for example, that pre-existing pulmonary, cardiovascular, neurological and psychiatric conditions are all associated with a more advanced stage of cancer at diagnosis. By contrast, hypertension and certain gastrointestinal and musculoskeletal conditions might be associated with a more timely diagnosis. In this Review, we propose a comprehensive framework that encompasses the effects of disease-specific, patient-related and health-care-related factors on the diagnosis of cancer in individuals with pre-existing chronic illnesses. Several previously postulated aetiological mechanisms (including alternative explanations, competing demands and surveillance effects) are integrated with newly identified mechanisms, such as false reassurances, or patient concerns about appearing to be a hypochondriac. By considering specific effects of chronic diseases on diagnostic processes and outcomes, tailored early diagnosis initiatives can be developed to improve the outcomes of the large proportion of patients with cancer who have pre-existing chronic conditions.

First hospital contact via the Emergency Department is an independent predictor of overall survival and disease-free survival in patients with colorectal cancer

AIMS

the aim of this study was to examine the possible association between the type of hospital admission and subsequent survival of the patient, as well as the pathological features recorded in a large population of patients with colorectal cancer.

METHODS

the study included 1,079 patients diagnosed with colon or rectal cancer in the Hospital Costa del Sol (Marbella, Spain). The relationship between patient survival rate and type of first admission to the hospital (elective or emergency admission) was assessed. The following variables were studied: age, gender, tumor location, pathological stage, differentiation grade, chemotherapy before surgery and survival.

RESULTS

colon tumors are more common in patients admitted to hospital for the first time via the emergency service (63.7%) and the tumors tend to be poorly differentiated (64.2%) and metastatic (70%). These patients also present a more aggressive disease and a poorer prognosis than patients with an elective admission. With regard to patients from the Emergency Department, a Cox regression analysis showed a risk-ratio (RR) of 1.36 (confidence interval [CI] 95%: 1.11-1.66) for disease-free survival and of 1.41 (95% CI: 1.14-1.76) for overall survival.

CONCLUSIONS

hospital admission via the Emergency Department is an indicator of aggressiveness and poorer prognosis compared to patients who enter via programmed routes.

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.

Emergency presentation of colorectal cancer in Northwestern Saudi Arabia

Objectives:

To investigate the frequency and clinical characteristics of emergency presentation of colorectal carcinoma (CRC) in Tabuk Region of Saudi Arabia.

Methods:

This is a retrospective, descriptive hospital-based study. All cases with CRC that presented to the main referral hospitals in Tabuk, Saudi Arabia between 2010 and 2015 were retrieved. The relevant hospitals are: King Salman Military Hospital, King Khalid Hospital, and King Fahad Hospital.

Results:

Seventy-three patients were included in the study. Twenty-two patients presented emergency constituting 30.6% of the total. Emergency CRC presentation was more common in elderly patients (81.8%), but a greater proportion of young patients was also affected (40% versus 29% in elderly patients). The disease is more common in females (37%) than males (26.7%) and intestinal obstruction was the sole form of presentation. Patients presenting emergency had more right-sided (61.9%) than left-sided tumors (30.2%). Advanced presentation with metastasis was noted in 40% of the patients presenting acutely.

Conclusion:

Emergency CRC presentation is common in the Tabuk region. Patients tend to present at an advanced stage, which necessitates an endeavor to detect the disease in its early stages, possibly through initiation of health education programs and suitable screening projects.

Causes and outcomes of emergency presentation of rectal cancer

Emergency presentation of rectal cancer carries a relatively poor prognosis, but the roles and interactions of causative factors remain unclear. We describe an innovative statistical approach which distinguishes between direct and indirect effects of a number of contextual, patient and tumour factors on emergency presentation and outcome of rectal cancer. All patients diagnosed with rectal cancer in Ireland 2004-2008 were included. Registry information, linked to hospital discharge data, provided data on patient demographics, comorbidity and health insurance; population density and deprivation of area of residence; tumour type, site, grade and stage; treatment type and optimality; and emergency presentation and hospital caseload. Data were modelled using a structural equation model with a discrete-time survival outcome, allowing us to estimate direct and mediated effects of the above factors on hazard, and their inter-relationships. Two thousand seven hundred and fifty patients were included in the analysis. Around 12% had emergency presentations, which increased hazard by 80%. Affluence, private patient status and being married reduced hazard indirectly by reducing emergency presentation. Older patients had more emergency presentations, while married patients, private patients or those living in less deprived areas had fewer than expected. Patients presenting as an emergency were less likely to receive optimal treatment or to have this in a high caseload hospital. Apart from stage, emergency admission was the strongest determinant of poor survival. The factors contributing to emergency admission in this study are similar to those associated with diagnostic delay. The socio-economic gradient found suggests that patient education and earlier access to endoscopic investigation for public patients could reduce emergency presentation.

Cancer diagnosed in the Emergency Department of a Regional Health Service

OBJECTIVE

Patients diagnosed with cancer in the Emergency Department (ED) have more advanced disease at diagnosis and poorer outcomes. High rates of initial presentation to ED suggest potential problems with access to care. The aim of this project was to interpret findings in regional/rural Victoria and explore implications for practice.

DESIGN

Cross-sectional study linking two independent data sets.

SETTING

Regional city of Geelong and surrounding rural areas in south-west Victoria.

PARTICIPANTS

All newly diagnosed cancer patients in 2009.

MAIN OUTCOME MEASURES

Number of cancer patients diagnosed in the ED.

RESULTS

One in five newly diagnosed cancer patients present to ED 6 months prior to cancer diagnosis. One in 10 is diagnosed as a result of their ED visit. Patients presenting to ED were older, more often men and from disadvantaged areas. Symptoms on presentation included chest complaints, bowel obstruction, abdominal pain, anaemia and generalised weakness. Cancer diagnosed in the ED is associated with advanced stage and shorter survival.

CONCLUSION

Reasons for presentation to ED would be multifactorial and include complex cases with coexisting symptoms making diagnosis difficult. The general public appear to have a low level of awareness of alternative primary care services or difficulty accessing such information. Some of the changes towards reducing the number of patients presenting to ED will include patient education.

Risk factors for emergency presentation with lung and colorectal cancers: a systematic review

OBJECTIVE

To identify patient and practitioner factors that influence cancer diagnosis via emergency presentation (EP).

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, EBM Reviews, Science and Social Sciences Citation Indexes, Conference Proceedings Citation Index-Science and Conference Proceedings Citation Index-Social Science and Humanities. Searches were undertaken from 1996 to 2014. No language restrictions were applied.

STUDY SELECTION

Studies of any design assessing factors associated with diagnosis of colorectal or lung cancer via EP, or describing an intervention to impact on EP, were included. Studies involving previously diagnosed cancer patients, assessing only referral pathway effectiveness, outcomes related to diagnosis or post-EP management were excluded. The population was individual or groups of adult patients or primary care practitioners. Two authors independently screened studies for inclusion.

RESULTS

22 studies with over 200,000 EPs were included, most providing strong evidence. Five were graded 'insufficient', primarily due to missing information rather than methodological weakness. Older patient age was associated with EP for lung and colorectal cancers (OR 1.11-11.03 and 1.19-5.85, respectively). Women were more at risk of EP for lung but not colorectal cancer. Higher deprivation increased the likelihood of lung cancer EP, but evidence for colorectal was less conclusive. Being unmarried (or divorced/widowed) increased the likelihood of EP for colorectal cancer, which was also associated with pain, obstruction and weight loss. Lack of a regular source of primary care, and lower primary care use were positively associated with EP. Only three studies considered practitioner factors, two involving diagnostic tests. No conclusive evidence was found.

CONCLUSIONS

Patient-related factors, such as age, gender and deprivation, increase the likelihood of cancer being diagnosed as the result of an EP, while cancer symptoms and patterns of healthcare utilisation are also relevant. Further work is needed to understand the context in which risk factors for EP exist and influence help-seeking.

Emergency presentation of cancer and short-term mortality

Background:

The short-term survival following a cancer diagnosis in England is lower than that in comparable countries, with the difference in excess mortality primarily occurring in the months immediately after diagnosis. We assess the impact of emergency presentation (EP) on the excess mortality in England over the course of the year following diagnosis.

Methods:

All colorectal and cervical cancers presenting in England and all breast, lung, and prostate cancers in the East of England in 2006–2008 are included. The variation in the likelihood of EP with age, stage, sex, co-morbidity, and income deprivation is modelled. The excess mortality over 0–1, 1–3, 3–6, and 6–12 months after diagnosis and its dependence on these case-mix factors and presentation route is then examined.

Results:

More advanced stage and older age are predictive of EP, as to a lesser extent are co-morbidity, higher income deprivation, and female sex. In the first month after diagnosis, we observe case-mix-adjusted excess mortality rate ratios of 7.5 (cervical), 5.9 (colorectal), 11.7 (breast ), 4.0 (lung), and 20.8 (prostate) for EP compared with non-EP.

Conclusion:

Individuals who present as an emergency experience high short-term mortality in all cancer types examined compared with non-EPs. This is partly a case-mix effect but EP remains predictive of short-term mortality even when age, stage, and co-morbidity are accounted for.

Impact of comorbidity and healthcare utilization on colorectal cancer stage at diagnosis: literature review

PURPOSE

Individuals diagnosed with cancer close to death have low access to enrollment in palliative care programs. The purpose of this literature review was to assess the usefulness of pre-diagnostic comorbidity and healthcare utilization as indicators of late-stage colorectal cancer (CRC) diagnosis, to help with early identification of individuals who may benefit from palliative care.

METHODS

A literature search was conducted in relevant databases using title/abstract terms which included "cancer," "stage," "diagnosis," "determinants," "predictors," and "associated." Included studies examined whether comorbidity and/or healthcare utilization had an impact on the stage at which CRC was diagnosed. A standardized data abstraction form was used to assess the eligibility of each study. Thirteen articles were included in the literature review. These studies were assessed and synthesized using qualitative methodology.

RESULTS

We found much heterogeneity among study variables. The findings of this literature review point to the presence of comorbidity and non-emergent healthcare utilization as having no association with late-stage diagnosis. Conversely, emergency room presentation (ERP) was associated with late-stage diagnosis.

CONCLUSIONS

The results of this literature review did not find strong evidence to suggest that comorbidity and healthcare utilization are potential indicators of late-stage diagnosis. However, ERP may be useful as a flag for consideration of prompt referral to palliative care. Additional research is required to identify potential indicators of late-stage diagnosis that may be available in administrative databases, particularly in the area of healthcare utilization.

Acuity and survival in colon cancer surgery

PURPOSE

Reports indicate that up to 40% of patients with colon cancer require nonelective resection, which has been shown to portend worse long-term prognosis compared with elective resection. We used a national database to identify specific preoperative, perioperative, and postoperative factors mediating the acuity-survival relationship in an effort to identify areas of medical practice that can serve as targets for improvement in cancer care.

METHODS

We used the Surveillance, Epidemiology and End Results-Medicare-linked database to identify non-health maintenance organization-enrolled people aged 66 years and older who were diagnosed with stages I to III colon cancer between 1996 and 2003 (N = 30,685). Using stepwise, multivariate Cox regression, disease-specific survival was compared in patients undergoing elective vs nonelective resection. Adjustment for preoperative, perioperative, and postoperative variables was performed to identify factors contributing to the acuity-survival relationship.

RESULTS

Five-year disease-specific survival was 86.3% after elective and 75.4% after nonelective colon resection (hazard ratio, 1.92; P < .001). A significant proportion of this disparity was the result of differences in stage and patient characteristics, particularly age and comorbidity burden, at the time of resection. Differences in adequacy of nodal assessment and the use of surveillance colonoscopy and adjuvant chemotherapy, however, also contributed to the disparity. After adjustment for these factors, the hazard ratio for nonelective resection was 1.30 (P < .001).

CONCLUSION

Nonelective resection of colon cancer is associated with poor long-term prognosis compared with elective resection. Disease-specific survival among patients undergoing nonelective surgery may be improved by addressing insufficient nodal assessment, inadequate follow-up care, and underutilization of appropriate, adjuvant chemotherapy.

Emergency first presentation of colorectal cancer predicts significantly poorer outcomes: a review of 356 consecutive Irish patients

PURPOSE

Colorectal cancer commonly presents first as an emergency and is likely to be complicated by bowel obstruction/perforation requiring more difficult procedures, with poorer outcomes. Analysis of all of the procedures performed on patients diagnosed in Wexford General Hospital, Ireland, during the period 2000 to 2006 was carried out to validate this hypothesis in our western European population.

METHODS

Retrospective analysis of a prospectively maintained database of patient demographics, diagnosis, procedures, and mode of presentation (elective, emergency) was undertaken.

RESULTS

A total of 356 patients with colorectal cancer underwent 498 procedures during the years 2000 to 2006. Eighty-four emergency endoscopies and 100 emergency bowel resections were performed. Obstructive lesions were more likely to require emergency resection (P < 0.001). Median survival time for patients treated electively was 82 months vs. 59 months for patients treated on an emergency basis.

CONCLUSIONS

Of all colonic resections, 34 percent were carried out as emergencies and were significantly more likely to be complicated by obstruction or perforation (P < 0.001). Emergency resections were associated with a significantly poorer perioperative mortality and five-year survival rate (P < 0.001). Forty-one percent of colorectal cancers diagnosed at endoscopy were first seen emergently. These data raise concerns regarding public awareness of colorectal cancer and resource allocation and reemphasize the need for a national colorectal screening program.

Retrospective analysis of pre- and peri-operative imaging in confirmed proximal colonic cancers--possible implications for screening flexible sigmoidoscopy

OBJECTIVE

Faecal occult blood testing is being introduced for population screening in the United Kingdom. Flexible sigmoidoscopy may provide a viable alternative. The outcomes of the flexible sigmoidoscopy trial are awaited but the most obvious disadvantage is that only the lower third of the colon is examined and proximal pathology cannot be excluded. The relationship between proximal pathology and distal findings at flexible sigmoidoscopy is uncertain. The aim of this study was to determine the incidence of distal neoplasia in patients with confirmed proximal cancers of the colon.

METHOD

All confirmed proximal colonic cancers (defined as those proximal to the splenic flexure) were identified from a database of pathology specimens at a single centre between January 1999 and August 2006. A retrospective analysis of preoperative and peri-operative mucosal imaging (contrast enema, colonoscopy and CT colonography) was conducted to identify any distal neoplasia in these patients.

RESULTS

A total of 348 patients were identified. Pre- or peri-operative mucosal imaging was identified in 231 (66%) and 49 (21%) had distal neoplasia. Nineteen (8%) of these patients would have gone on to have a colonoscopy based on the UK flexible sigmoidoscopy trial protocol and 92% of the cohort would not have had a colonoscopy.

CONCLUSION

Nearly 80% of confirmed proximal cancers in our series did not have any demonstrable distal neoplasia. Only 8% of our cohort would have proceeded to colonoscopy. A very significant number of proximal cancers would not have been detected.