Rectal bleeding. Patient delay in presentation

Psychological factors related to time to help-seeking for cancer symptoms: a meta-analysis across cancer sites

The time patients wait before seeking help for cancer symptoms is among the most important factors contributing to diagnostic delays in cancer. We reviewed the association between time to help-seeking and three psychological factors: symptom knowledge, symptom interpretation, and beliefs about cancer. Forty-seven studies met the inclusion criteria, providing data from 22 countries concerning seven cancer sites. Better symptom knowledge was related to lower odds of a long help-seeking interval in both studies with healthy populations (OR = .73, 95% CI [.63, .84], k = 19) and patients (OR = .40, 95% CI [.23, .69], k = 12), and so was interpreting experienced symptoms as cancer-related (OR = .52, 95% CI [.36, .75], k = 13 studies with patients). More positive beliefs about cancer (i.e., that cancer is treatable) were associated with lower odds of a long help-seeking interval in both studies with healthy populations (OR = .70, 95% CI [.52, .92], k = 11) and with patients (OR = .51, 95% CI [.32, .82], k = 7). Symptom knowledge, interpretation, and beliefs about cancer are likely to be universal predictors of help-seeking and should be incorporated into theoretical models of patient help-seeking and interventions aiming to reduce delays.

Awareness of Colorectal Cancer among the Urban Population in the Klang Valley

BACKGROUND

Colorectal cancer (CRC) is the second most common cancer in Malaysia. Awareness of risk factors, symptoms and warning signs of CRC will help in early detection. This paper presents the level of CRC awareness among the urban population in Malaysia.

METHOD

A cross-sectional study was conducted from November 2015 till December 2016 at three government clinics in the Klang Valley. The validated Bowel Cancer Awareness Measure questionnaire in both English and Malay was used. The mean knowledge scores for the warning signs and risk factors of CRC in different socio-demographic groups were compared using ANOVA in SPSS version 23. Statistical significance was set at p<0.05 and a 95% confidence level.

RESULTS

Of the 426 respondents, 29.1% were unable to recall the warning signs and symptoms of CRC. Average recall was less than two warning signs and symptoms (mean 1.62, SD 1.33). The mean total knowledge score for CRC was 9.91 (SD 4.78), with a mean knowledge scores for warning signs and risk factors at 5.27 (SD 2.74) and 4.64 (SD 2.78), respectively. Respondents with a higher level of education were found to have higher level of knowledge regarding the warning signs of CRC. There was a significant positive association between knowledge score for warning signs and level of confidence in detecting warning signs. Regarding the total knowledge score for CRC, 3.3% of respondents scored zero. For warning signs and risk factors, 8.2% and 8.5% of respondents had zero knowledge scores, respectively.

CONCLUSIONS

Generally, awareness of CRC is poor among the urban population of Klang Valley. Greater education and more confidence in detecting warning signs are significantly associated with better knowledge of warning signs. CRC awareness programs should be increased to improve awareness.

Knowledge and Awareness of Colorectal Cancer Early Warning Signs and Risk Factors among University Students in Jordan

In the present study, we aimed to assess the level of awareness regarding CRC warning signs and risk factors among undergraduate students. A cross-sectional survey using standardized questionnaire developed by the Cancer Research Center in the UK was carried out in three different public universities in Jordan including Jordan University of Science and Technology, Yarmouk University, and AL al-Bayt University over a 5-month period. Volunteers were asked about their knowledge regarding CRC symptoms, risk factors, and their behaviors regarding seeking medical advice. Findings revealed that response rate was 80.1%. Vast majority of responders were female (70.9%) and 18.2% of them were studying medical-related specialties. Regarding CRC symptoms, 14.3% of responders experienced poor knowledge, 52.9% have fair knowledge, and 32.8% have good knowledge. Abdominal pain was the most recognized warning signs where 70.8% of responders could recall it. In addition, risk factors awareness was lower than warning signs awareness. About 36.1% of responders have poor knowledge, 47.4% had fair knowledge, and 16.5% had good knowledge. Unhealthy diet was the most recognized risk factor where 32.3% of responders could recall it. Moreover, females were more aware regarding CRC symptoms. Similar findings were obtained for participants who were aged 20 years or more and for those who had previous experience of cancer. Students who were studying medical-related specialties were more aware of both CRC symptoms and risk factors than those who studying other specialties. Furthermore, regarding time to seek medical attention we found that 60.6% of volunteers would seek medical advice within 1 week of noticing CRC symptoms and 12% would seek it within 2 weeks. The mean duration for seeking medical advice was found to be 1.9 weeks. University students' awareness level of CRC is poor, and therefore, extended attention should be attempted to enhance the awareness of CRC via continuous education programs, lectures, or campaigns to encourage the early detection CRC.

Patient delay in cancer diagnosis: what do we really mean and can we be more specific?

Background

Early diagnosis is a key focus of cancer control because of its association with survival. Delays in diagnosis can occur throughout the diagnostic pathway, within any one of its three component intervals: the patient interval, the primary care interval and the secondary care interval.

Discussion

A key focus for help-seeking research in patients with symptoms of cancer has been the concept of ‘delay’. The literature is plagued by definitional and semantic problems, which serve to hinder comparison between studies. Use of the word ‘delay’ has been criticised as judgemental and potentially stigmatising, because of its implications of intent. However, the suggested alternatives (time to presentation, appraisal interval, help-seeking interval and postponement of help-seeking) still fail to accurately define the concept in hand, and often conflate three quite separate ideas; that of an interval, that of an unacceptably long interval, and that of a specific event which caused delay in the diagnostic process. We discuss the need to disentangle current terminology and suggest the term ‘prolonged interval’ as a more appropriate alternative. Most studies treat the patient interval as a dichotomous variable, with cases beyond a specified time point classified as ‘delay’. However, there are inconsistencies in both where this line is drawn, ranging from one week to three months, and how, with some studies imposing seemingly arbitrary time points, others utilising the median as a divisive tool or exploring quartiles within their data. This not only makes comparison problematic, but, as many studies do not differentiate between cancer site, also imposes boundaries which are not necessarily site-relevant. We argue that analysis of the patient interval should be based on presenting symptom, as opposed to pathology, to better reflect the context of the help-seeking interval, and suggest how new definitional boundaries could be developed.

Summary

The word ‘delay’ is currently (conf)used to describe diverse conceptualisations of ‘delay’ and more mindful, and discerning language needs to be developed to enable a more sophisticated discussion. By stratifying help-seeking by presenting symptom(s), more accurate and informative analyses could be produced which, in turn, would result in more accurately targeted early diagnosis interventions.

Level of colorectal cancer awareness: a cross sectional exploratory study among multi-ethnic rural population in Malaysia

Background

This paper presents the level of colorectal cancer awareness among multi-ethnic rural population in Malaysia.

Methods

A rural-based cross sectional survey was carried out in Perak state in Peninsular Malaysia in March 2011. The survey recruited a population-representative sample using multistage sampling. Altogether 2379 participants were included in this study. Validated bowel/colorectal cancer awareness measure questionnaire was used to assess the level of colorectal cancer awareness among study population. Analysis of variance (ANOVA) was done to identify socio-demographic variance of knowledge score on warning signs and risk factors of colorectal cancer.

Results

Among respondents, 38% and 32% had zero knowledge score for warning signs and risk factors respectively. Mean knowledge score for warning signs and risk factors were 2.89 (SD 2.96) and 3.49 (SD 3.17) respectively. There was a significant positive correlation between the knowledge score of warning signs and level of confidence in detecting a warning sign. Socio-demographic characteristics and having cancer in family and friends play important role in level of awareness.

Conclusions

Level of awareness on colorectal cancer warning signs and risk factors in the rural population of Malaysia is very low. Therefore, it warrants an extensive health education campaign on colorectal cancer awareness as it is one of the commonest cancer in Malaysia. Health education campaign is urgently needed because respondents would seek medical attention sooner if they are aware of this problem.

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

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

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

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

Determining patient and primary care delay in the diagnosis of cancer - lessons from a pilot study of patients referred for suspected cancer

BACKGROUND

There is no validated way of measuring diagnostic delay in cancer, especially covering patient and primary care delays. An instrument is needed in order to determine the effect of potential interventions to reduce delay and improve cancer morbidity and mortality.

METHODS

Development of a postal questionnaire tool to measure patient and primary care time responses to key symptoms and signs. The pilot questionnaire was sent to 184 patients with suspected cancer.

RESULTS

The response rate was only 85/184 (46.2%). Anxiety was cited as one reason for this low response. Patients returning questionnaires were more likely to be women and more likely to be younger. 84/85 (98.8%) provided consent to access medical records, and questions regarding health profile, smoking and socio-economic profile were answered adequately. Outcome data on their cancer diagnosis was linked satisfactorily and the question about GP-initiated investigations was answered well. Estimated dates for symptom duration were preferred for patient delays, but exact dates were preferred for primary care delays; however there was a significant amount of missing data.

CONCLUSION

A more personal approach to the collection of data about the duration of symptoms in this group of people is needed other than a postal questionnaire. However elements of this piloted questionnaire are likely to figure strongly in future development and evaluation of this tool.

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

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

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

Background

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

Methods/Design

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

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

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

Discussion

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

Can early diagnosis of symptomatic colorectal cancer improve the prognosis?

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

Predictive value of rectal bleeding for distal colonic neoplastic lesions in a screened population

The aim of this study was to determine the diagnostic value of rectal bleeding for distal colorectal cancer (CRC), or large (> or =10 mm) adenomas among an average-risk population. A cross-sectional survey was conducted among individuals aged 55-64 years, who attended sigmoidoscopy (FS) screening in the context of a multicentre randomised trial of FS screening for CRC. Sensitivity, specificity and positive predictive value (PPV) of rectal bleeding for large distal adenomas or CRC were calculated. Rectal bleeding was reported by 8.8% of 8507 patients examined (15% of those with large adenomas and 29% of those with CRC). The risk of CRC was increased when bleeding was associated with an altered bowel habit: odds ratio (OR)=10.42; 95% Confidence Interval (CI): 4.08-26.59; the corresponding OR for isolated bleeding was 5.29 (95% CI: 2.28-12.30). Rectal bleeding carries an increased risk of distal neoplastic lesions. However, most lesions are detected among asymptomatic subjects. This finding suggests that screening represents the optimal strategy to detect CRC or large adenomas in the distal colon in the targeted age range.

Factors associated with the frequency of stool examination: effect on incidence of reported rectal bleeding

BACKGROUND

Rectal bleeding is an important presenting symptom of colorectal cancer. The presentation and investigation of patients with rectal bleeding may be delayed if people do not regularly inspect their stool or toilet paper.

AIM

To determine how frequently stool or toilet paper is inspected, factors associated with the frequency of inspection, and whether this affects the reported prevalence of rectal bleeding.

METHODS

A questionnaire on the frequency of stool inspection and the occurrence of various gastrointestinal symptoms and diseases was developed, validated and sent to 2149 subjects chosen from four general practice lists in south-west London.

RESULTS

There was a 79% response rate. Four hundred and forty-two of 1611 subjects (27%) examined both their stool and toilet paper every time. One hundred and two (6%) never examined either. Those who always examined their stool and toilet paper were more likely to report rectal bleeding compared to those who never examined either (23% vs 4%). They were also more likely to be male, to open their bowels more than three times per day, to have watery stools, to experience urgency, and have a history of piles.

CONCLUSION

Many people examine their stools and toilet paper infrequently. The possibility that this may contribute to delayed diagnosis of colorectal cancer deserves further evaluation.

Knowledge of cancer symptoms among patients attending one-stop breast and rectal bleeding clinics

AIM AND METHOD

The aim of this questionnaire study was to identify knowledge of breast and colorectal cancer symptoms among 100 patients attending one-stop breast clinics and rectal bleeding clinics and to determine the source of the information.

RESULTS

Seventy-five breast clinic (mean age 46 years, all female) and 78 colorectal clinic patients (mean age 59 years, 51% male) responded. Knowledge of breast was significantly greater than bowel cancer in both groups (P<0.0001, McNemar's chi(2)). There was no difference in knowledge of symptoms of breast cancer or bowel cancer between patients attending either clinic. There was a positive association between cancer knowledge, family history and female gender but no association with age. Knowledge of Bowel Cancer Awareness Week was positively associated with colorectal cancer knowledge.

CONCLUSION

Knowledge of colorectal cancer is much less than breast cancer in clinic attenders. Seventy-five per cent of women attending breast clinic could name a breast cancer symptom whereas only 37% of patients attending colorectal clinic could name a bowel cancer symptom. These findings have implications when considering patients' anxiety, expectations of a cancer diagnosis and breaking bad news.

Implications of delayed diagnosis in colorectal cancer

BACKGROUND

Delayed diagnosis of colorectal cancer (CRC) continues to produce anxiety and is associated with the assumption that disease stage and survival will be worse. The aims of the present study were to assess the prevalence and reasons for delay in the diagnosis of CRC, and the effects of delay, gender, age and tumour site on the stage of disease.

METHODS

A retrospective study of 100 patients presenting with CRC during a 1-year period was performed. Delay was defined to have occurred if more than a 3-month period had lapsed from the time when initial symptoms were clearly established to the time of operation. Data were collected on principal presenting symptoms, time to first presentation to a doctor, time to diagnosis and treatment, reasons for delay, diagnostic procedures, tumour site, operation, and Australian clinicopathological (ACP) stage of the tumour.

RESULTS

Thirty-four patients had a delay in diagnosis of their cancer. In 18 patients (53%) delay was attributable to patient reasons; in 13 patients (38%) delay was attributable to doctor-related delay and in three patients (9%) it was attributable to both. Male patients were more likely to have patient-related delay (31% for male patients vs 10% for female patients; P = 0.011). Patients with delay were less likely to have a stage A tumour (6% for delay group vs 21% for non-delay group; P = 0.04). Male patients were less likely to have a stage A tumour than female patients (8% for male patients vs 25% for female patients; P = 0.018), but the effect of delay on stage disappeared when gender and tumour site were controlled in a logistic regression model.

CONCLUSIONS

The present study suggests some areas where improvements may be made concerning early diagnosis and treatment of patients with CRC.

Delay in the diagnosis and outcome of colorectal cancer: a prospective study

AIMS

The aim of this study was to examine the incidence of the delay in the diagnosis of colorectal carcinoma, possible causes of this delay and its effects on outcome.

METHODS

A prospective study was performed on 100 patients affected by colorectal cancer. Duration of symptoms was calculated from the date of onset of symptoms to the date of surgery.

RESULTS

Sixty-nine patients suffered delays in treatment of more than 12 weeks from the onset of symptoms. In patients with symptoms of less than 12 weeks' duration there was a higher incidence of radical surgery and none of these patients presented, at the time of surgery, a neoplastic dissemination. Multivariate analysis, however, showed that the only factors with an independent effect on 5-year survival and disease-free survival were Dukes' stage and the presence of pre-operative complications.

CONCLUSIONS

The results of this study suggest that, independent of the diagnostic delay, the outcome of the colorectal cancer is only conditioned by tumour stage and by complicated cancer.

Self-reported rectal bleeding in a United States community: prevalence, risk factors, and health care seeking

OBJECTIVE

Little data on rectal bleeding in the U.S. population are available. We therefore sought to assess the prevalence of different types of rectal bleeding, their association with potential risk factors including other colonic symptoms, and predictors of health care seeking in a U.S. community.

METHODS

We used a crossectional survey by mail, applying a previously validated self-report symptom questionnaire. Our population comprised an age- and gender-stratified random sample of Olmsted County, Minnesota residents aged 20-64 yr.

RESULTS

In total, 1643 responded (77%). Rectal bleeding was reported by 235 subjects (age- and gender-adjusted prevalence, 15.5 per 100; 95% confidence interval [CI], 13.6-17.4); 218 found blood on wiping, 74 noted blood coating the stools, and 46 reported dark blood mixed in the stools. The prevalence of rectal bleeding was significantly higher in younger persons (18.9%, 20-40 yr vs 11.3% > 40 yr; p < 0.001). By stepwise logistic regression analysis, constipation (odds ratio [OR] = 3.03; 95% CI, 2.09-4.41) and diarrhea (OR = 1.90; 95% CI, 1.25-2.84) were independent predictors of rectal bleeding. Among those with rectal bleeding, 13.9% (95% CI, 9.6-19.1%) had visited a physician for bowel problems in the prior yr; only a history of abdominal surgery was an independent predictor of physician visits but this explained just 15.9% of the deviance.

CONCLUSIONS

In otherwise healthy young and middle-aged persons, approximately one in seven have a history of rectal bleeding and this is more frequent in younger people; only a minority seek health care and this is not related to symptom status.

European School of Oncology Advisory report to the European Commission for the "Europe Against Cancer Programme" European Code Against Cancer

A European School of Oncology Advisory Group has reviewed the European Code Against Cancer after its initial use over a 6-year period. With minor modifications, the original ten recommendations were found to be adequate, although it was agreed that an Annex was necessary to explain the scientific evidence supporting each point, and is presented herewith. Tobacco smoking clearly remains the most important cause of cancer, and now it can be quantified better than ever before. It is also clear that it is never too late to stop smoking: stopping even in middle age, prior to the onset of serious illness has a beneficial effect on life expectancy. Alcohol drinking is an important cause of cancer, and yet modest consumption levels protect against cardiovascular disease mortality. The optimal strategy seems to be a consumption not exceeding 2-3 drinks per day, although this limit may be lower for women. Increased consumption of fruits and vegetables, reduction in consumption of fatty foods, reduction of obesity and increased physical activity can all be recommended to reduce cancer risk. Exposure to excessive sunlight remains a problem which should be limited. Control of occupational cancer is a three-way partnership: legislation identifies and limits exposure to known carcinogens, employers enact the legislation and workers should respect the measures introduced. There are a number of signs and symptoms which may lead to cancer being diagnosed earlier, and patients with these should be referred to a doctor. For women, participation in organised programmes of cervical cancer and breast cancer (after 50 years of age) should lead to a reduction in mortality from these forms of cancer. The key element is organised programmes, where quality control and quality assurance are in force. These revised recommendations are the result of an agreement following advice, review and dialogue with cancer experts throughout Europe. They were approved by the European Community Cancer Experts at their meeting in Bonn on 28-29 November 1994. Their implementation by the European population should greatly reduce cancer incidence and mortality.

Rectal bleeding: prevalence and consultation behaviour

OBJECTIVES

To determine prevalence of rectal bleeding in the community and to examine factors that lead some patients to consult their general practitioner about rectal bleeding while others do not.

DESIGN

Questionnaire survey followed by semistructured interviews of sample of respondents with rectal bleeding.

SETTING

Two general practices on Tyneside.

SUBJECTS

2000 adult patients registered with the general practices were sent a validated questionnaire. Respondents with rectal bleeding were divided into consulters and non-consulters, and 30 patients from each group (matched for age, sex, and characteristics of bleeding) were interviewed.

MAIN OUTCOME MEASURES

Prevalence of rectal bleeding, proportion of subjects with rectal bleeding who sought medical advice, and reasons for consulting or not consulting a doctor about rectal bleeding.

RESULTS

287 of the 1200 respondents to the questionnaire had noticed rectal bleeding at some time in their lives, and 231 had noticed it within previous 12 months. Only 118 (41%) of all respondents with rectal bleeding had ever sought medical advice for the problem. Those aged over 60 were most likely to have consulted, as were those who reported blood mixed with their stools. Main difference between those who had sought medical advice and those who had not was that consulters were more likely than non-consulters to perceive their symptoms as serious.

CONCLUSIONS

Although rectal bleeding is common, only minority of patients seek medical of symptoms seems to be most important factor in deciding whether to consult a doctor for rectal bleeding.

Time lag to diagnosis of bladder cancer--influence of psychosocial parameters and level of health-care provision

Delay in diagnosis of carcinoma of the urinary bladder was studied in 343 patients. The median patient's delay (time from first symptom to first consultation) was 15 days, and was longer when the only presenting symptom was urgency of micturition than when it was haematuria (45 vs. 5 days, p < 0.001). In advanced (T2-T4) tumour, patient's delay was 21 days and in Ta-T1 it was 13 days (NS). The median doctor's delay (time from first consultation to diagnosis) was 62 days. It comprised two phases: A from consultation to first referral and B from first referral to diagnosis-respective medians 6 and 47 days. Median doctor's delay (A+B) was longer when the initial consultation was with a general practitioner than with a urologist (78 vs. 21 days, p < 0.001) and longer in patients older than 70 years (69 vs. 54 days, p < 0.01). Doctor's delay correlated with symptoms, being longest in cases with only urgency and shortest in haematuria plus pain (114 vs. 44 days, p < 0.001), and also with number of referrals (33, 63, 230 and 117 days, respectively, for 0, 1, 2 and 3 referrals). More women than men were referred a second or third time (25.6% vs. 8.6%, p < 0.001), and doctor's delay was longer for women (76 vs. 59 days, p < 0.05). A questionnaire completed by 203 of the 229 surviving patients revealed no significant correlation between psychosocioeconomic factors and patient's delay.

General practitioner databases in Australia

OBJECTIVE

General practitioner-based research has been hampered by the poorly defined database and the cost of continuous updating of lists of practitioners. Little is known about the general practitioner workforce. Fresh awareness by health planners of the serious maldistribution of general practitioners has heightened the need for workforce planning. Integral to this is the availability of an accurate listing of general practitioners.

DATA SOURCES

A CD-ROM Medline review of all surveys involving general practitioners which were conducted in Australia in the period 1983-1990 was performed. All general practitioner listings still existing at the end of the decade were identified.

STUDY SELECTION

Nine listings considered for use as general practitioner databases.

DATA EXTRACTION

Each listing was assessed in six ways--quality of information provided, availability for research purposes, cost, potential to provide the correct postal address, ability to identify general practitioners in active practice and comparative advantage over other lists.

DATA SYNTHESIS

Each listing has limitations and advantages, with individual peculiarities and variable information relating to identifying characteristics of general practitioners. None was specifically created for research or workforce planning purposes. The Medical Provider File (formerly called the Central Register of Medical Practitioners) was the most used list.

CONCLUSIONS

We propose a framework for the ideal database and avenues for its development.