Delayed treatment for rectal cancer

Rectal cancer survival and prognostic factors in Iranian population: A retrospective cohort study

BACKGROUND

Rectal cancer (RC) poses a significant global health challenge, causing substantial morbidity and mortality. This study aims to investigate the survival rates of RC patients and identify the factors that influence their survival. The study considers demographic characteristics, tumor features, and treatment received as the factors under consideration.

METHODS

A retrospective analysis was conducted on the medical records of 593 RC patients. Data were collected through a comprehensive review of medical records and conducting telephone interviews. Survival rates were estimated using the life table method, and subgroup comparisons were performed using the log-rank test. Cox regression analysis was utilized to assess the independent associations between RC survival time and various covariates.

RESULTS

The study cohort comprised 593 RC patients, with a predominantly male representation. The mean age at diagnosis was 58.18 years, and the majority of patients (78.6 %) underwent surgical interventions. The median age at symptom onset and diagnosis were 58 and 59 years, respectively. Survival rates at 1st, 3rd, 5th, and 10th years were estimated to be 85 %, 59 %, 47 %, and 36 %, respectively. Statistical analysis revealed several significant prognostic factors, including age, education, symptoms, and cancer stage. In the multivariate Cox proportional-hazards analysis, advanced regional stage (HR = 1.54, 95 % CI, 1.13-2.08), presence of metastasis (HR = 3.73, 95 % CI, 2.49-5.58), and age over 70 (HR = 1.65) were associated with a higher risk of mortality.

CONCLUSION

Given the alarming prognosis of RC observed in the study area and the significant delay between symptom onset and diagnosis, it is crucial to address this issue and potentially improve the survival rates of RC patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

REGISTRATION

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

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

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

Patient-reported and doctor-reported symptoms when faecal immunochemical tests are requested in primary care in the diagnosis of colorectal cancer and inflammatory bowel disease: a prospective study

BACKGROUND

Rectal bleeding and a change in bowel habits are considered to be alarm symptoms for colorectal cancer and they are also common symptoms for inflammatory bowel disease. However, most patients with these symptoms do not have any of these diseases. Faecal immunochemical tests (FITs) for haemoglobin are used as triage tests in Sweden and other countries but little is known about the symptoms patients have when FITs are requested.

OBJECTIVE

Firstly, to determine patients' symptoms when FITs are used as triage tests in primary care and whether doctors record the symptoms that patients report, and secondly to evaluate the association between symptoms, FIT results and possible prediction of colorectal cancer or inflammatory bowel disease.

METHODS AND MATERIALS

This prospective study included 364 consecutive patients for whom primary care doctors requested a FIT. Questionnaires including gastrointestinal symptoms were completed by patients and doctors.

RESULTS

Concordance between symptoms reported from patients and doctors was low. Rectal bleeding was recorded by 43.5% of patients versus 25.6% of doctors, FITs were negative in 58.3 and 52.7% of these cases respectively. The positive predictive value (PPV) of rectal bleeding recorded by patients for colorectal cancer or inflammatory bowel disease was 9.9% (95% confidence interval [CI] 5.2-14.7); for rectal bleeding combined with a FIT the PPV was 22.6% (95% CI 12.2-33.0) and the negative predictive value (NPV) was 98.9% (95% CI 96.7-100). For patient-recorded change in bowel habits the PPV was 6.1% (95% CI 2.4-9.8); for change in bowel habits combined with a FIT the PPV was 18.2% (95% CI 9.1-30.9) and the NPV 100% (95% CI 90.3-100).

CONCLUSIONS

Doctors should be aware that, during consultations, they do not record all symptoms experienced by patients. FITs requested in primary care, when found positive, may potentially be of help in prioritising referrals, also when patients present with rectal bleeding or change in bowel habits.

Threat sensitivity is associated with the healthcare source used most often: doctor's office, emergency room, or none at all

A significant proportion of American adults do not have a regular source of healthcare and the reasons for this shortfall are not fully understood. The objective of this study was to examine the relationship between individual differences in threat sensitivity and healthcare utilization in a survey of 483 African American men. Demographics, psychological characteristics, and health behaviors were assessed. The primary outcomes were: 1) most frequent source of healthcare utilization (doctor's office or clinic vs. emergency room vs. no place), and 2) frequency of healthcare utilization (one or more vs. no healthcare visits in the previous year). Data were analyzed with multivariable logistic regression. Results showed that threat sensitivity, insurance status, and age were associated with the most frequent source of healthcare utilization. Compared to men who most commonly used a doctor's office or clinic, men who tended to use an emergency room had higher levels of threat sensitivity and those with no usual healthcare source had lower levels of threat sensitivity. These findings fit with leading neurobiological theories of personality regarding threat sensitivity. From a pragmatic standpoint, these findings may also lend insight to the tailoring of health marketing messages designed to optimize utilization of healthcare resources.

Quality improvement measures: effects on rectal cancer tissue biopsy process

PURPOSE

Delay in histologically confirming rectal cancer may lead to late treatment as histological confirmation is required prior to chemo-radiotherapy or surgical intervention. Multidisciplinary colorectal meetings indicate that there are patients who require multiple tissue biopsy episodes prior to histologically confirming rectal cancer. The purpose of this paper is to examine a quality improvement (QI) measure's impact on tissue biopsy process diagnostic yield.

DESIGN/METHODOLOGY/APPROACH

The authors performed the study in two phases (pre- and post-QI), between February 2012 and April 2014 in a district general hospital. The QI measures were derived from process mapping a rectal cancer diagnostic pathway. The primary outcome was to assess the tissue biopsy process diagnostic yield. The secondary outcome included total breaches for a 62-day target in the pre- and post-QI study phases.

FINDINGS

There was no significant difference in demographics or referral mode in both study phases. There were 81 patients in the pre-QI phase compared to 38 in the post-QI phase, 68 per cent and 74 per cent were referred via the two-week wait urgent pathway, respectively. Diagnostic tissue biopsy process yield improved from 58.1 to 77.6 per cent after implementing the QI measure ( p=0.02). The 62-day target breach was reduced from 14.8 to 3.5 per cent ( p=0.42).

PRACTICAL IMPLICATIONS

Simple QI measures can achieve significant improvements in rectal cancer diagnostic tissue biopsy process yields. A multidisciplinary approach, involving process mapping and cause and effect modelling, proved useful tools.

ORIGINALITY/VALUE

A process mapping exercise and QI measures resulted in significant improvements in diagnostic yield, reducing the episodes per patient before histological diagnosis was confirmed.

Anal Neoplasia in Inflammatory Bowel Disease: Classification Proposal, Epidemiology, Carcinogenesis, and Risk Management Perspectives

Patients with inflammatory bowel disease [IBD] may develop, similarly to individuals from general population, rare cases of human papilloma virus [HPV]-related anal canal squamous cell carcinoma [SCC] and intra-epithelial precursor lesions, as well as very rare cases of anal canal adenocarcinoma. Patients with chronic perianal Crohn's disease [CD] are at substantial risk of developing SCC or adenocarcinoma from the fistula-lining epithelium, as well as SCC or adenocarcinoma arising from chronic anorectal ulcerations or strictures. Based on this lesion stratification, we provide in this review tailored incidence estimates and we propose an IBD-specific classification of all types of anal neoplasia that may occur in patients with IBD. After reviewing putative carcinogenesis of all types of neoplasia, we conclude that HPV vaccination could reduce the incidence of HPV-related lesions, although an anal screening programme related to these lesions is not mandatory on the sole basis of IBD. By contrast, we point out that all patients with chronic perianal CD should be explored in depth, including biopsies under anaesthesia and fistula curettage when necessary, in case of any change in anal symptoms ─in particular new, increasing, unexplained pain. Finally, we conclude that there is an urgent need for elaborating and evaluating surveillance algorithms in patients with chronic perianal CD, in order to avoid cancers with late diagnosis and poor prognosis.

Delayed Workup of Rectal Bleeding in Adult Primary Care: Examining Process-of-Care Failures

BACKGROUND

Although delayed colorectal cancer diagnoses figure prominently in medical malpractice claims, little is known about the quality of primary care clinicians' workup of rectal bleeding.

METHODS

In this study, 438 patients were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for rectal bleeding, hemorrhoids, and blood in the stool at 10 Boston adult primary care practices. Following nurse chart abstraction, physician reviewers assessed the overall quality of care and key care processes. Subjects' characteristics and physician reviewers' processes-of-care assessments were tabulated, and logistic regression models were used to examine the association of process failures with overall quality and guideline concordance.

RESULTS

Although reviewers judged the overall quality of care to be good or excellent in 337 (77%) of 438 cases, 312 (71%) patients experienced at least one process-of-care failure in the workup of rectal bleeding. Clinicians failed to obtain an adequate family history in 38% of cases, complete a pertinent physical exam in 23%, and order laboratory tests in 16%. Failure to order or perform tests, or to make follow-up plans were associated with increased odds of poor or fair care. Guideline concordance bore little relationship with quality judgments. Reviewers judged that 128 delays could have been reduced or prevented.

CONCLUSION

Process-of-care failures among adult primary care patients with rectal bleeding were frequent and associated with fair or poor quality. Educating practitioners and creating systems to ensure adequate history taking, physical examination, and processes for ordering, performing, and interpreting diagnostic tests may improve performance.

Factors associated with late stage at diagnosis among Puerto Rico's government health plan colorectal cancer patients: a cross-sectional study

Background

Late stage at diagnosis of cancer is considered a key predictor factor for a lower survival rate. Knowing and understanding the barriers to an early diagnosis of colorectal cancer is critical in the fight to reduce the social and economic burden caused by cancer in Puerto Rico. This study evaluates factors associated to colorectal cancer stage at diagnosis among Puerto Rico’s Government Health Plan (GHP) patients.

Methods

We conducted a cross-sectional study based on a secondary data analysis using information from the Puerto Rico Central Cancer Registry (PRCCR) and the Puerto Rico Health Insurance Administration (PRHIA). Logistic regression models were used to estimate the unadjusted odds ratio (ORs) and adjusted odds ratio (AORs), and their 95 % confidence intervals (CIs). Colorectal cancer cases diagnosed between January 1, 2012 and December 31, 2012, among persons 50 to 64 years of age, participants of the GHP and with a cancer diagnosis reported to the PRCCR were included in the study.

Results

There were 68 (35.79 %) colorectal cancer patients diagnosed at early stage while 122 (64.21 %) where diagnosed at late stage. In the multivariate analysis having a diagnostic delay of more than 59 days (AOR 2.94, 95 % CI: 1.32 to 6.52) and having the first visit through the emergency room (AOR 3.48, 95 % CI: 1.60 to 7.60) were strong predictors of being diagnosed with colorectal cancer at a late stage.

Conclusions

These results are relevant to understand the factors that influence the outcomes of colorectal cancer patients in the GHP. Therefore, it is important to continue developing studies to understand the Government Health Plan patient’s pathways to a cancer diagnosis, in order to promote assertive decisions to improve patient outcomes.

Symptom attributions in patients with colorectal cancer

Background

Symptoms of cancer may be interpreted differently by different patients before the diagnosis. This study investigated symptom attributions in Danish patients with colorectal cancer and the potential associations with symptom type, socio-demographic characteristics and patient interval.

Methods

Data were collected among incident colorectal cancer patients (n = 577, response rate 64.2 %), who were asked to think back on the time before their diagnosis when completing the questionnaire. The questionnaire comprised a Danish version of the revised Illness Perception Questionnaire (IPQ-R) with questions on 19 symptom attributions. These 19 attribitutions were categorised into five causal groups for statistical analyses. The patient interval (i.e. the time from the patient’s first symptom experience to presentation to the healthcare system) was assessed in the same questionnaire. Data on socio-demographic characteristics were obtained by using nationwide registers from Statistics Denmark.

Results

Patients who experienced ‘blood in stool’ as the most important symptom were more likely to attribute this to cancer (PR_ad 1.90, 95 % CI 1.43-2.54) and benign somatic causes (PR_ad 1.33, 95 % CI 1.02-1.72), such as haemorrhoids, compared to patients who did not perceive this symptom as the most important. Socio-demographic characteristics were also associated with symptom attribution. Patients with higher educational levels were less likely to attribute their most important symptom to psychological causes (PR_ad 0.57, 95 % CI 0.35–0.94) than patients with lower educational levels. Patients with rectal cancer attributed their most important symptom to a benign somatic cause more often than patients with colon cancer (PR_ad 1.39, 95 % CI 1.07–1.80).

Conclusions

Symptom attribution in patients was associated with aspects of socio-demography and with the symptom type perceived by the patient as the most important. No significant associations were found between symptom attributions and patient interval. These results have implications for general practice as symptom attributions may prompt patients to present symptoms in a certain way and thereby influence the general practitioner’s assessment of presented symptoms.

Help seeking behavior of women with self-discovered breast cancer symptoms: a meta-ethnographic synthesis of patient delay

BACKGROUND AND OBJECTIVE

Patient delay makes a critical contribution to late diagnosis and poor survival in cases of breast cancer. Identifying the factors that influence patient delay could provide information for adopting strategies that shorten this delay. The aim of this meta-ethnography was to synthesize existing qualitative evidence in order to gain a new understanding of help seeking behavior in women with self-discovered breast cancer symptoms and to determine the factors that influence patient delay.

METHODS

The design was a meta-ethnography approach. A systematic search of the articles was performed in different databases including Elsevier, PubMed, ProQuest and SCOPUS. Qualitative studies with a focus on help seeking behaviors in women with self-discovered breast cancer symptoms and patient delay, published in the English language between 1990 and 2013 were included. The quality appraisal of the articles was carried out using the Critical Appraisal Skills Programme qualitative research checklist and 13 articles met the inclusion criteria. The synthesis was conducted according to Noblit and Hare's meta-ethnographic approach (1988), through reciprocal translational analysis and lines-of-argument.

FINDINGS

The synthesis led to identification of eight repeated key concepts including: symptom detection, initial symptom interpretation, symptom monitoring, social interaction, emotional reaction, priority of medical help, appraisal of health services and personal-environmental factors. Symptom interpretation is identified as the important step of the help seeking process and which changed across the process through active monitoring of their symptoms, social interactions and emotional reactions. The perceived seriousness of the situation, priority to receive medical attention, perceived inaccessibility and unacceptability of the health care system influenced women's decision-making about utilizing health services.

CONCLUSION

Help seeking processes are influenced by multiple factors. Educational programs aimed at correcting misunderstandings, erroneous social beliefs and improving self-awareness could provide key strategies to improve health policy which would reduce patient delay.

Breast cancer patients' experiences within and outside the safety net

BACKGROUND

Following reforms to the breast-cancer referral process for our city's health Safety Net (SN), we compared the experiences from first abnormality to definitive diagnosis of breast-cancer patients referred to Siteman Cancer Center from SN and non-SN (NSN) providers.

MATERIALS AND METHODS

SN-referred patients with any stage (0-IV) and NSN-referred patients with late-stage (IIB-IV) breast cancer were prospectively identified after diagnosis during cancer center consultations conducted between September 2008 and June 2010. Interviews were taped and transcribed verbatim; transcripts were independently coded by two raters using inductive methods to identify themes.

RESULTS

Of 82 eligible patients, 57 completed interviews (33/47 SN [70%] and 24/35 NSN [69%]). Eighteen SN-referred patients (52%) had late-stage disease at diagnosis, as did all NSN patients (by design). A higher proportion of late-stage SN patients (67%) than either early-stage SN (47%) or NSN (33%) patients reported feelings of fear and avoidance that deterred them from pursuing care for concerning breast findings. A higher proportion of SN late-stage patients than NSN patient reported behaviors concerning for poor health knowledge or behavior (33% versus 8%), but reported receipt of timely, consistent communication from health care providers once they received care (50% versus 17%). Half of late-stage SN patients reported improper clinical or administrative conduct by health care workers that delayed referral and/or diagnosis.

CONCLUSIONS

Although SN patients reported receipt of compassionate care once connected with health services, they presented with higher-than-expected rates of late-stage disease. Psychological barriers, life stressors, and provider or clinic delays affected access to and navigation of the health care system and represent opportunities for intervention.

Medical malpractice claims in relation to colorectal malignancy in the national health service

AIM

Under the current increased financial constraints affecting the National Health Service (NHS), clinical negligence claims and associated compensations are constantly rising. Our aim was to identify the magnitude, trends and causes of malpractice claims in relation to a common pathology such as colorectal malignancy in the NHS.

METHOD

Data requests were submitted to the NHS Litigation Authority (NHSLA) and to the Medical Defence Union (MDU) and Medical Protection Society (MPS). Data were reviewed, categorized clinically and analysed in terms of causes and costs behind claims.

RESULTS

Data from the MPS and MDU were unavailable. In all, 169 claims were identified from the NHSLA database between 2003 and 2012; 123 (73%) cases had been closed, 80 (65%) of which were successful. An increasing overall claim frequency and success rate were found over the last few years. Total litigation expenses were £8.6 million, with 39% paid out as legal expenses. The commonest cause of complaint in successful claims was in relation to diagnostic delays or failures (58%, £5.1 million), with a delay or failure by the clinician to take action in response to an abnormal investigation result being a major factor. The occurrence of peri-operative complications (20%, £1.6 million) was the second commonest cause.

CONCLUSION

Average frequency and success rates of malpractice claims in secondary care in the NHS are rising, leading to significant overall payouts. The failure or delay in diagnosing colorectal malignancy or its postoperative complications is a common cause behind malpractice claims. Improvement in these areas could enhance patient care and reduce future claims.

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.

Patient and process factors associated with late-stage breast cancer diagnosis in Safety-Net patients: a pilot prospective study

BACKGROUND

Following reforms to our city's Safety-Net (SN) breast cancer referral process, we investigated whether factors often associated with late-stage diagnosis would differ by referral source--SN versus non-Safety-Net (NSN)--or, among SN patients, by stage at diagnosis.

METHODS

From September 2008 to June 2010, SN patients with any-stage (0-IV) and NSN patients with late-stage (IIB-IV) breast cancer were identified prospectively during initial cancer-center consultations. Data were analyzed using logistic regression, chi-square, and t tests; two-tailed P < 0.05 was considered significant.

RESULTS

Fifty-seven women completed interviews (33 SN, 24 NSN); 52% of SN-referred patients were diagnosed with late-stage disease. Compared with NSN late-stage patients, SN late-stage patients were more likely to be African-American (83% vs. 21%, P < 0.001), to have an annual household income <$25,000 (89% vs. 38%, P < 0.001), and to report having a health problem in the preceding year but not being able to see a doctor because of cost (67% vs. 25%, P = 0.012); they were less likely to be married/partnered (22% vs. 79%, P < 0.001) and to have post-college education (0% vs. 25%, P < 0.03), any insurance (61% vs. 96%, P < 0.005), and to have sought medical attention within 1 week of realizing they had concerning breast findings (50% vs. 79%, P = 0.047). Married/partnered patients were more likely to delay medical care by >1 week (odds ratio = 9.9, P = 0.038).

CONCLUSIONS

SN patients presented with higher-than-expected rates of late-stage disease despite improvements in mammography rates and the referral process. Efforts to further facilitate access to care for this vulnerable SN patient population are needed.

Invasive cancer in a diminutive rectal polyp amidst internal hemorrhoids detected by rectal retroflexion

A diminutive rectal polyp amidst internal hemorrhoids, detected by rectal retroflexion during colonoscopy, was shown to harbor invasive rectal adenocarcinoma by colonoscopic biopsy. Initially this lesion had appeared to be a relatively innocuous prominent anorectal mucosal fold and was recognized as a diminutive polyp only after careful rectal retroflexion during colonoscopy. This report emphasizes that lesions just above the anorectal junction with atypical endoscopic features for internal hemorrhoids should be carefully examined at rectal retroflexion and that polyps or suspicious lesions amidst internal hemorrhoids identified during colonoscopy should be snared or at least biopsied, even if small. This case report also illustrates how easily an early cancer in a diminutive colonic polyp can be missed when in difficult areas of colonoscopic inspection, such as behind a colonic fold or immediately above the anus.

Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Interval from diagnosis to treatment onset for six major cancers in Catalonia, Spain

BACKGROUND

Targets set by health care organizations on time intervals between cancer diagnosis and treatment often go unmet. The objective of the study was to analyse the interval from diagnosis to treatment onset, and related factors, in the six most incident cancers in Catalonia (Spain), a developed European region with universal free access to health care.

METHODS

Twenty-two hospitals contributed 1023 incident cancer patients (198 lung, 253 colorectal, 95 prostate, 109 urinary bladder, 266 breast, 102 endometrial). Information was gathered from hospital medical records. The dependent variable was the length of the diagnosis to treatment interval (DTI). Independent variables were age, sex, disease stage, hospital level, mode of admission to hospital, and type of physician seen before admission. Multivariate-adjusted odds ratios were calculated by unconditional logistic regression for each cancer site.

RESULTS

The median DTI (in days) was 39 for lung cancer, 25 for colorectal, 108 for prostate, 69 for bladder, 35 for breast and 40 for endometrial cancer. In prostate and bladder cancers, over 78% of patients showed a DTI >30 days, while in colorectal the figure was 42%. Disseminated stage (distant metastases) was associated with a lower DTI in all sites. Patients admitted to third-level hospitals and with an elective admission were more likely to have a DTI >30 days.

CONCLUSIONS

In Catalonia, a substantial proportion of cancer patients experience treatment delays that may impact negatively on psychological well-being, quality of life, and probably survival as well.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Reported symptoms, diagnostic delay and stage of colorectal cancer: a population-based study in Denmark

OBJECTIVE

The primary prognostic factor for colorectal cancer (CRC) is stage. Any association between symptoms, diagnostic delay and stage may have implications for the clinical course of the disease. We examined the association between symptoms and diagnostic delay and between symptoms and stage, and assessed whether the associations differed for colon cancer (CC) and rectal cancer (RC).

PATIENTS AND METHODS

Population-based prospective observational study based on 733 Danish CRC patients. Diagnostic delay and patients' reported symptoms were determined through questionnaire-interviews. Dukes' stage was obtained from medical records and pathology forms. Diagnostic delay was categorized into three delay groups: < or = 60, 61-150 and > 150 days. Stage was classified into nonadvanced (Dukes' A and B) or advanced (Dukes' C and D) cancers. We calculated the frequency of the most frequently reported initial symptom or symptom complex for CC and RC patients, and evaluated the frequency of patients with different initial symptoms/symptom complexes in the three delay groups. For the most frequent initial symptoms/symptom complexes, we calculated the frequencies according to stage, and estimated the relative risk of having an advanced stage, with 95% confidence intervals.

RESULTS

The most frequent initial symptoms/symptom complexes were very vague symptoms for CC and rectal bleeding for RC. For both CC and RC, rectal bleeding was significantly associated with nonadvanced stage. The relative risk of having an advanced cancer was 0.6 for monosymptomatic rectal bleeding and 0.7 for rectal bleeding combined with other symptoms.

CONCLUSIONS

Initial symptoms of CC were often very vague, making it difficult to identify a precise start date. The most frequent initial symptom/symptom complex for RC - rectal bleeding - was better defined. Rectal bleeding was significantly associated with nonadvanced CC and RC and a significantly decreased relative risk of having an advanced cancer.