Rectal bleeding and colorectal cancer in general practice: diagnostic study

Possible Value of Faecal Immunochemical Test (FIT) When Added in Symptomatic Patients Referred for Colonoscopy: A Systematic Review

If Colorectal cancer (CRC) is detected and treated early, the survival rate is high. This is one of the reasons that population-based screening programs for the early detection of CRC using the faecal immunochemical test (FIT) started worldwide. These programs compete with regular colonoscopy programs and increase the waiting time for symptomatic patients. However, the literature has shown that the correlation between intestinal complaints and the gain of colonoscopy is poor. The aim of this study is to assess the diagnostic utility of symptoms for the yield (CRC) of colonoscopy and to compare this with the diagnostic utility of FIT when offered to symptomatic patients. Methods: We performed a systematic review search for CRC as an outcome of colonoscopy in referred symptomatic patients and separately for CRC as an outcome in symptomatic patients with a positive FIT. We searched systematically for clinical trials or observational studies in databases, followed by hand-searching of reference lists. We used random Meta-Disc to evaluate the diagnostic performance, using the exploration of heterogeneity with a variety of test statistics and by computing the pooled estimates. Results: We included 35 studies, with almost 5 million symptomatic patients. In addition, we included nine prospective studies with a positive FIT in symptomatic patients, with more than 5000 patients. Significant heterogeneity was found for every symptom and the outcome of colonoscopy in the effect size of sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio. In a random effect model, the pooled sensitivity of colonoscopy in symptomatic patients was very low (25%). However, the pooled sensitivity in symptomatic patients with a positive FIT was 83% and the pooled specificity 77%. A total of 75 symptomatic patients (1.4%) had a false-negative FIT. Conclusion: Adding FIT in symptomatic patients seems useful for predicting CRC as an outcome of colonoscopy. FIT seems a potential tool for an improved triage of colonoscopy in symptomatic patients.

A pilot study for colorectal carcinoma screening by instant metabolomic profiles using conductive polymer spray ionization mass spectrometry

BACKGROUND

The rapid and accurate discrimination of colorectal carcinoma (CRC) and polyps at the molecular level enables early intervention of CRC, which can greatly improve the 5-year survival rate of patients. Here we reported the potential of conductive polymer spray ionization mass spectrometry (CPSI-MS) in successfully screening CRC according to the serum metabolic profile.

METHODS

Trace intravenous blood (50 μL) was collected from 60 colorectal carcinoma (CRC) and 60 polyp patients, respectively. After centrifugation, serum (2 μL) was loaded onto the tip of conductive polymer to form a dried serum spot. When the 5 μL methanol-water (1:1, v/v) extraction solvent was spiked onto the dried serum spot followed with +4.5 kV high voltage applied on the polymer tip, the extracted components will be ionized and carried into the MS system for direct metabolic profiling.

FINDINGS

There were 51 metabolites discovered to be significantly changed in CRC serum compared to polyps. Combining these metabolites as the characteristic panel, the ideal diagnostic performance was achieved by Lasso regression model with the accuracy of 88.3%.

INTERPRETATION

This pilot study demonstrated the potential of CPSI-MS as a cost-effective tool in large-scale CRC screening in the high-risk population.

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

BACKGROUND

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

AIM

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

DESIGN AND SETTING

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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.

Can the colour of per-rectal bleeding estimate the risk of lower gastrointestinal bleeding caused by malignant lesion?

PURPOSE

To estimate the risk of lower gastrointestinal bleeding (LGIB) caused by malignant lesion in patients presenting with per-rectal bleeding (PRB), by using visual aid as an objective measurement of PRB colour.

METHODS

This was a prospective observational study on patients presented with PRB to Family Medicine Specialty Clinic, who undergo flexible sigmoidoscopy (FS) or colonoscopy (CLN) from December 2012 to September 2013. Patients aged 40 years old or above, haemodynamically stable, with normal haemoglobin level were included. Patients with a history of previous colonic surgery, refused to have FS or CLN, with ophthalmologic diseases such as colour blindness were excluded. Parameters including subjective description of PRB colour, number of chosen red colour by patients, source and distance of bleeding from anal verge were recorded for analysis. Receiver operating characteristic (ROC) curve was used to identify the optimal cutoff level of colour for diagnosing colonic lesion. Diagnostic accuracy was assessed by area under the ROC curve (AUC). Accountability of this model was assessed by logistic regression.

RESULTS

The dark PRB colour was associated with diagnosis of tumour (p < 0.001) and advanced neoplastic polyp (p < 0.001). The light PRB colour was associated with the diagnosis of piles (p < 0.001). The performance of our model to predict tumour or advanced neoplastic polyps by colour (AUC, 0.798) had a better discriminative power than that to predict colonic lesion alone (AUC, 0.610) by ROC curve analysis.

CONCLUSION

Objective measurement of PRB colour accurately estimated the risk of LGIB caused by malignant lesion in patients presenting with PRB.

Symptoms, signs, and tests: The general practitioner's comprehensive approach towards a cancer diagnosis

OBJECTIVE

To study the relative importance of different tools a GP can use during the diagnostic process towards cancer detection.

DESIGN

Retrospective cohort study with prospective registration of cancer in general practice.

SETTING AND SUBJECTS

One hundred and fifty-seven Norwegian general practitioners (GPs) reported 261 cancer patients.

METHOD

During 10 consecutive days, GPs registered all patient consultations and recorded any presence of seven focal symptoms and three general symptoms, commonly considered as warning signs of cancer (WSC). Follow-up was done six to 11 months later. For each patient with new or recurrent cancer, the GP completed a questionnaire with medical-record-based information concerning the diagnostic procedure.

RESULTS

In 78% of cancer cases, symptoms, signs, or tests helped diagnose cancer. In 90 cases, there were 131 consultation-recorded WSC that seemed related to the cancer. Further symptoms were reported for another 74 cases. Different clinical signs were noted in 41 patients, 16 of whom had no previous recording of symptoms. Supplementary tests added information in 59 cases; in 25 of these there were no recordings of symptoms or signs. Sensitivity of any cancer-relevant symptom or clinical finding ranged from 100% for patients with uterine body cancer to 57% for patients with renal cancer.

CONCLUSION

WSC had a major role as initiator of a cancer diagnostic procedure. Low-risk-but-not-no-risk symptoms also played an important role, and in 7% of patients they were the only symptoms. Clinical findings and/or supplementary procedures were sometimes decisive for rapid referral.

Diagnostic value of rectal bleeding in predicting colorectal cancer: a systematic review

This study aimed at summarizing published study findings on the diagnostic value of rectal bleeding (RB) and informing clinical practice, preventive interventions and future research areas. We searched Medline and Embase for studies published by September 13, 2013 examining the risk of colorectal cancer in patients with RB using highly inclusive algorithms. Data for sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and positive predictive value (PPV) of RB were extracted by two researchers and analyzed applying Meta-Disc (version 1.4) and Stata (version 11.0). Methodological quality of studies was assessed according to QUADAS. A total of 38 studies containing 5,626 colorectal cancer patients and 73,174 participants with RB were included. The pooled sensitivity and specificity were 0.47 (95% CI: 0.45-0.48) and 0.96 (95% CI: 0.96-0.96) respectively. The overall PPVs ranged from 0.01 to 0.21 with a pooled value of 0.06 (95% CI: 0.05-0.08). Being over the age of 60 years, change in bowel habit, weight loss, anaemia, colorectal cancer among first-degree relatives and feeling of incomplete evacuation of rectum appeared to increase the predictive value of RB. Although RB greatly increases the probability of diagnosing colorectal cancer, it alone may not be sufficient for proposing further sophisticated investigations. However, given the high specificity, subjects without RB may be ruled out of further investigations. Future studies should focus on strategies using RB as an "alarm" symptom and finding additional indications to justify whether there is a need for further investigations.

Guideline for referral of patients with suspected colorectal cancer by family physicians and other primary care providers

OBJECTIVE

The aim of this guideline is to assist FPs and other primary care providers with recognizing features that should raise their suspicions about the presence of colorectal cancer (CRC) in their patients.

COMPOSITION OF THE COMMITTEE

Committee members were selected from among the regional primary care leads from the Cancer Care Ontario Provincial Primary Care and Cancer Network, the members of the Ontario Colorectal Cancer Screening Advisory Committee, and the members of the Cancer Care Ontario Gastrointestinal Cancer Disease Site Group.

METHODS

This guideline was developed through systematic review of the evidence base, synthesis of the evidence, and formal external review involving Canadian stakeholders to validate the relevance of recommendations.

REPORT

Evidence-based guidelines were developed to improve the management of patients presenting with clinical features of CRC within the Canadian context.

CONCLUSION

The judicious balancing of suspicion of CRC and level of risk of CRC should encourage timely referral by FPs and primary care providers. This guideline might also inform indications for referral to CRC diagnostic assessment programs.

Systematic review of clinical features of suspected colorectal cancer in primary care

OBJECTIVE

To systematically review the diagnostic accuracy of clinical features associated with colorectal cancer (CRC) presenting in primary care.

DATA SOURCES

MEDLINE and EMBASE were searched for studies in primary care that provided information on clinical features predictive of CRC. Positive predictive values were used to guide the determination of clinical features associated with increased risk of CRC.

STUDY SELECTION

Systematic reviews or primary studies that provided possible clinical features predictive of CRC were included.

SYNTHESIS

Clinical features of patients presenting in primary care that are associated with increased risk of CRC, listed in descending order of association, included palpable rectal or abdominal mass; rectal bleeding combined with weight loss; iron deficiency anemia; rectal bleeding mixed with stool; rectal bleeding in the absence of perianal symptoms; rectal bleeding combined with change in bowel habits; dark rectal bleeding; rectal bleeding and diarrhea; and change in bowel habits. Being male and increasing age were also, in general, associated with increased risk of CRC.

CONCLUSION

Recognition of clinical features associated with increased risk of CRC by FPs might help with earlier identification and referral among patients presenting in primary care. This review might help inform providers and CRC diagnostic assessment programs about indications for assessment and further investigation.

Frequency of 'warning signs of cancer' in Norwegian general practice, with prospective recording of subsequent cancer

BACKGROUND

Early diagnosis of cancer is an important challenge in general practice. Symptoms are the most common starting points.

OBJECTIVE

To assess the association between symptoms presented and subsequent cancer.

DESIGN

A cohort study of all patients seen consecutively by GPs. Prospective recording of cancer diagnosis, new cancer or new recurrence.

SETTING

Two hundred and eighty-three general practice surgeries and 10 working days.

METHOD

During patient consultations, GPs registered seven focal symptoms and three general symptoms, commonly considered as warning signs of cancer (WSC). Follow-up 6-11 months later with registration of any subsequent diagnosis of cancer was done.

RESULTS

Of 51 073 patients, 6321 (12.4%) had recordings of 7704 WSC. During a median follow-up period of 8 months, 263 patients were diagnosed with cancer and 59 of them with recurrence of a previously diagnosed cancer. Of the cancer patients, 106 (40%) had presented one or more WSC during a preceding consultation. Examined symptoms had likelihood ratios for cancer from 1.5 to 8.2 and positive predictive values (PPVs) from 0.8% to 3.8%. Limited to older age groups, PPVs were a little higher. General symptoms were rarely associated with cancer unless a focal symptom had been recorded as well. Multiple symptoms increased the probability of cancer.

CONCLUSION

12.4% of GP patients presented with WSC. A general symptom may have cancer diagnostic value, but usually, only when it occurs along with a focal symptom. PPV of any single symptom is low, and decisions about referral require additional information.

Incidence, patient characteristics and treatment initiated for GP-diagnosed depression in general practice: results of a 1-year nationwide surveillance study

BACKGROUND

Despite its public health significance, data about depression in general practice are often unavailable.

OBJECTIVE

To study (i) the incidence of GP-diagnosed depression during 2008, (ii) associations between patient characteristics, appraised severity and initiated treatment, (iii) GPs' usual care compared to diagnostic criteria from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition guidelines and the newly developed practice guideline of the Society of Flemish GPs (2008) and (iv) GPs' initiated treatments compared to the Flemish Guideline.

METHODS

General practice-based data were collected on all patients of ≥18 years who were diagnosed by their GP with a new episode of depression in Belgian sentinel general practices (SGP) during 2008.

RESULTS

Data on 1739 persons were recorded by 172 sentinel general practices. Incidence rates for GP-diagnosed depression were estimated at 719/100 000 men and 1440/100 000 women. Thirty-one per cent of patients had mild, 50% had moderate and 19% had severe GP-diagnosed depression. Although only 43% of the patients at risk for suicide were considered to have severe depression, having thoughts of death or suicide was the main factor associated with increased severity of depression. Seventy-five per cent of patients received a prescription for an antidepressive agent; 29% received a prescription for another psychoactive agent; in 36%, non-pharmaceutical support was initiated by the GP and 25% received a referral. In contrast with the Flemish GP guideline criteria: (i) 69% of patients with a new episode of mild or a first episode of moderate depression were prescribed an antidepressive agent and (ii) only 39% of the patients with severe depression were both prescribed an antidepressive agent and referred to a mental health service.

CONCLUSIONS

This study has yielded original data on the incidence and management of depression in Belgian general practice. Our findings show that efforts are needed to improve depression management in Belgian general practice.

Incidence and management of presumption of Lyme borreliosis in Belgium: recent data from the sentinel network of general practitioners

An increasing incidence of tick bites and Lyme disease has been noticed internationally. The aims of this study are threefold: to estimate the incidence of tick bites and erythema migrans, to assess the compliance of the general practitioners (GPs) with the recommendations about the management of tick bites and erythema migrans, and finally, to have a look at the evolution over time, both on incidence and management. We used data of the Belgian network of sentinel general practitioners (SGP) to study the incidence rates in Belgium, the trend over time, and the degree of compliance of the SGP. The overall Belgian incidence rates in the SGP practice in 2008-2009 were 18.65 (95% CI 17.29-20.08) per 10,000 persons for tick bites and 9.02 (95% CI 8.08-10.03) for erythema migrans. The diagnostic management of patients with an asymptomatic tick bite has worsened over time, while the therapeutic management of erythema migrans has improved over time. The international increasing trend of the incidence was not observed in the SGP. There is still room for improvement concerning the approach of the GPs. Recommendations could help to improve their approach.

Portal hypertensive colopathy and haematochezia in cirrhotic patients: an endoscopic study

BACKGROUND AND STUDY AIMS

In patients with liver cirrhosis, portal hypertensive colopathy (PHC) and anorectal varices (ARVs) are thought to cause lower gastrointestinal (GI) bleeding. In the present work, we studied the diagnostic yield of colonoscopy in cirrhotic patients and haematochezia.

PATIENTS AND METHODS

The current study was conducted on 77 consecutive cirrhotic patients who underwent colonoscopy at Mansoura Emergency Hospital, Egypt, between May 2007 and May 2011. Following rapid evaluation and adequate resuscitation, a thorough history was obtained with complete physical examination including digital rectal examination and routine laboratory investigations. Colonoscopic evaluation was performed for the included patients by recording endoscopic abnormalities and obtaining biopsies from lesions.

RESULTS

There was no significant difference between the PHC-positive group when compared with the PHC-negative group regarding patients' age, sex, severity of haematochezia, positive family history and the history of intake of non-steroidal anti-inflammatory drugs (NSAIDs). Significant difference was noted regarding the Child-Pugh class (p<0.05), history of splenectomy (p<0.05), prior history of endoscopic sclerotherapy (EST) or endoscopic variceal ligation (EVL) (p<0.05), prior history of upper gut bleeding (p<0.05), the presence of gastric varices (GVs) (p<0.05), presence of portal hypertensive gastropathy (PHG) (p<0.05), presence of haemorrhoids (p<0.05) and rectal varices (<0.05) and therapy with β-blockers (p<0.05). Regarding the laboratory parameters, the platelet count only was markedly reduced in the PHC-positive group (p<0.05). All the PHC-related sources of bleeding (7/32 cases (21.87%)) were successfully managed with argon plasma coagulation. Regarding the laboratory parameters, the platelet count only was markedly reduced in the PHC-positive group (p<0.05). All the PHC-related sources of bleeding (7/32 cases (21.87%)) were successfully managed with argon plasma coagulation.

CONCLUSION

Our data revealed that it is not only PHC which is involved in haematochezia in cirrhotic patients despite the significant association. Instead, a high prevalence of inflammatory lesions came on the top of the list. Complete colonoscopy is highly advocated to detect probable proximal neoplastic lesions.

End-of-Life Care and Circumstances of Death in Patients Dying As a Result of Cancer in Belgium and the Netherlands: A Retrospective Comparative Study

Purpose

To examine and compare end-of-life care in patients with cancer dying in Belgium and the Netherlands.

Patients and Methods

A mortality follow-back study was undertaken in 2008 via representative nationwide sentinel networks of general practitioners (GPs) in Belgium and the Netherlands. By using similar standardized procedures, GPs reported on aspects of end-of-life care and the circumstances of nonsudden death of patients with cancer in their practice.

Results

Of the 422 reported patients with cancer, most resided at home during the last year of life (Belgium, 91%; the Netherlands, 95%). Death occurred at home in 34% (Belgium) and 61% (the Netherlands) and in the hospital in 29% (Belgium) and 19% (the Netherlands). In the last month of life, end-of-life issues were more often discussed in the Netherlands (88%) than in Belgium (68%). In both countries, physical problems were discussed most often (Belgium, 49%; the Netherlands, 78%) and spiritual issues least often (Belgium, 20%; the Netherlands, 32%). Certain end-of-life treatment preferences were known for 43% (Belgium) and 67% (the Netherlands) of patients. In the last week of life, treatment was most often focused on palliation (Belgium, 94%; the Netherlands, 91%). Physical distress was reported in 84% (Belgium) and 76% (the Netherlands) of patients and psychological distress in 59% and 36%. Most distressing was lack of energy (Belgium, 73%; the Netherlands, 71%) and lack of appetite (Belgium, 61%; the Netherlands, 53%). Two thirds of patients were bedridden (Belgium, 67%; the Netherlands, 69%).

Conclusion

Although place of death and communication about end-of-life issues differ substantially, a palliative treatment goal is adopted for the vast majority of patients in both countries. However, GPs reported that the majority of patients experienced symptom distress at the end of life, which suggests important challenges remain for improving end-of-life care.

Advance care planning in Belgium and The Netherlands: a nationwide retrospective study via sentinel networks of general practitioners

CONTEXT

Advance care planning (ACP) is an important part of patient-centered palliative care. There have been few nationwide studies of ACP, especially in Europe.

OBJECTIVES

To investigate the prevalence and characteristics of ACP in two European countries and identify the associated factors.

METHODS

A mortality follow-back study was undertaken in 2007 via representative nationwide Sentinel Networks of general practitioners (GPs) in Belgium and The Netherlands using similar standardized procedures. All GPs reported on each non-suddenly deceased patient in their practice. Our main outcome measure was whether or not ACP, that is, an agreement for medical treatment and/or medical decisions in the last phase of life in the case of the patient losing competence, was present.

RESULTS

Among 1072 non-sudden deaths, ACP was done with 34% of patients and most often related to the forgoing of potential life-prolonging treatments in general (24%). In 8% of cases, ACP was made in consultation with the patient and in writing. In 23% of cases, care was planned with the patient's family only. Multivariate analysis revealed that ACP was more often made with patients if they were capable of decision making during the last three days of life (odds ratio [OR] 3.86; 95% confidence interval [CI] 2.4-6.1), received treatment aimed at palliation in the last week (OR 2.57; 95% CI 1.6-4.2), had contact with a GP in the last week (OR 2.71; 95% CI 1.7-4.1), died of cancer (OR 1.46; 95% CI 1.1-2.0), or died at home (OR 2.16; 95% CI 1.5-3.0).

CONCLUSION

In these countries, ACP is done with approximately one-third of the studied terminally ill patient population. Most agreements are made only verbally, and care also is often planned with family only. ACP relates strongly both to patient factors and to health care measures performed at the very end of life.

The diagnostic value of symptoms for colorectal cancer in primary care: a systematic review

BACKGROUND

Over 37,000 new colorectal cancers are diagnosed in the UK each year. Most present symptomatically to primary care.

AIM

To conduct a systematic review of the diagnostic value of symptoms associated with colorectal cancer.

DESIGN

Systematic review.

METHOD

MEDLINE, Embase, Cochrane Library, and CINAHL were searched to February 2010, for diagnostic studies of symptomatic adult patients in primary care. Studies of asymptomatic patients, screening, referred populations, or patients with colorectal cancer recurrences, or with fewer than 100 participants were excluded. The target condition was colorectal cancer. Data were extracted to estimate the diagnostic performance of each symptom or pair of symptoms. Data were pooled in a meta-analysis. The quality of studies was assessed with the QUADAS tool.

RESULTS

Twenty-three studies were included. Positive predictive values (PPVs) for rectal bleeding from 13 papers ranged from 2.2% to 16%, with a pooled estimate of 8.1% (95% confidence interval [CI] = 6.0% to 11%) in those aged ≥ 50 years. Pooled PPV estimates for other symptoms were: abdominal pain (three studies) 3.3% (95% CI = 0.7% to 16%); and anaemia (four studies) 9.7% (95% CI = 3.5% to 27%). For rectal bleeding accompanied by weight loss or change in bowel habit, pooled positive likelihood ratios (PLRs) were 1.9 (95% CI = 1.3 to 2.8) and 1.8 (95% CI = 1.3 to 2.5) respectively, suggesting higher risk when both symptoms were present. Conversely, the PLR was one or less for abdominal pain, diarrhoea, or constipation accompanying rectal bleeding.

CONCLUSION

The findings suggest that investigation of rectal bleeding or anaemia in primary care patients is warranted, irrespective of whether other symptoms are present. The risks from other single symptoms are lower, though multiple symptoms also warrant investigation.

Most bowel cancer symptoms do not indicate colorectal cancer and polyps: a systematic review

BACKGROUND

Bowel symptoms are often considered an indication to perform colonoscopy to identify or rule out colorectal cancer or precancerous polyps. Investigation of bowel symptoms for this purpose is recommended by numerous clinical guidelines. However, the evidence for this practice is unclear. The objective of this study is to systematically review the evidence about the association between bowel symptoms and colorectal cancer or polyps.

METHODS

We searched the literature extensively up to December 2008, using MEDLINE and EMBASE and following references. For inclusion in the review, papers from cross sectional, case control and cohort studies had to provide a 2×2 table of symptoms by diagnosis (colorectal cancer or polyps) or sufficient data from which that table could be constructed. The search procedure, quality appraisal, and data extraction was done twice, with disagreements resolved with another reviewer. Summary ROC analysis was used to assess the diagnostic performance of symptoms to detect colorectal cancer and polyps.

RESULTS

Colorectal cancer was associated with rectal bleeding (AUC 0.66; LR+ 1.9; LR- 0.7) and weight loss (AUC 0.67, LR+ 2.5, LR- 0.9). Neither of these symptoms was associated with the presence of polyps. There was no significant association of colorectal cancer or polyps with change in bowel habit, constipation, diarrhoea or abdominal pain. Neither the clinical setting (primary or specialist care) nor study type was associated with accuracy.Most studies had methodological flaws. There was no consistency in the way symptoms were elicited or interpreted in the studies.

CONCLUSIONS

Current evidence suggests that the common practice of performing colonoscopies to identify cancers in people with bowel symptoms is warranted only for rectal bleeding and the general symptom of weight loss. Bodies preparing guidelines for clinicians and consumers to improve early detection of colorectal cancer need to take into account the limited value of symptoms.

Dealing with low-incidence serious diseases in general practice

Cost-effective health care depends on high-quality triage. The most challenging aspect of triage, which GPs confront on a regular basis, is diagnosing rare but serious disease. Failure to shoulder any risk in this situation overloads the health system and subjects patients to unnecessary investigation. Adopting too high a risk threshold leads to missed cases, late diagnosis, and sometimes avoidable death. It also undermines the credibility of primary care practitioners. Quantification of diagnostic risk suggests there is a potential risk gap between the maximum certainty with which GPs can assess the risk of serious disease at presentation and the minimum certainty required by many health systems for further investigation or hospital referral. Physician gut-feeling and diagnostic safety netting are often employed to fill the gap. Neither strategy is well defined or well supported by evidence. It should be possible to reduce the diagnostic risk gap cost-effectively by adopting more explicit diagnostic algorithms and providing better GP access to new diagnostic technologies. It is also essential, given the decreasing experience of triage clinicians employed in a number of countries, that a teachable evidence base is constructed for gut feeling and diagnostic safety netting. However, this construction of an evidence base requires very large-scale studies, and the global primary care research community remains small. The challenge therefore needs to be met by urgent and effective international collaboration.

Positive predictive values of ≥5% in primary care for cancer: systematic review

BACKGROUND

The positive predictive value (PPV) for cancer of symptoms, signs, and non-diagnostic test results of patients routinely consulting a GP (unselected primary care populations) can help to determine when malignancy should be excluded. Comparisons with other illness indicate that a value of 5% or more may be regarded as highly predictive.

AIM

To identify symptoms, signs, and non-diagnostic test results in unselected primary care populations that are highly predictive of cancer.

DESIGN OF STUDY

Systematic review.

SETTING

Primary care.

METHOD

Fourteen bibliographic databases were searched, using terms for primary care, cancer, and predictive values. Reference lists of relevant papers were hand-searched. Data were extracted and the quality of each paper was assessed using predefined criteria, and checked by a second reviewer.

RESULTS

Twenty-five studies were identified. PPVs of 5% or more in specific age and sex groups were reported for: rectal bleeding, change in bowel habit, and iron deficiency anaemia and colorectal cancer; haematuria and urological cancer; malignant rectal examination and prostate cancer; haemoptysis and lung cancer; dysphagia and oesophageal cancer; breast lump and breast cancer; and postmenopausal bleeding and gynaecological cancer.

CONCLUSION

Robust evidence was found for eight symptoms, signs, and non-diagnostic test results as strongly indicative of cancer for specific age and sex groups in unselected primary care populations. These have the potential to improve the early diagnosis of some cancers in primary care by the use of computer warning flags, improved guidelines, audit, and appraisal.

Symptoms and signs in patients with colorectal cancer

The symptoms and signs of colorectal cancer vary from the general population to primary care and in the referred population to secondary care. This review aims to address the diverse symptoms, signs and combinations with relevance to colorectal cancer at various points in the diagnostic pathway and tries to shed light on this complex and confusing area. A move towards a lower threshold for referral and increased use of diagnostics might be a more reliable option for early diagnosis.

Who needs colonoscopy to identify colorectal cancer? Bowel symptoms do not add substantially to age and other medical history

BACKGROUND

Many bodies advise that people with bowel symptoms undergo colonoscopy to detect colorectal cancer.

AIM

To determine which bowel symptoms predict cancer on colonoscopy.

METHODS

Information was collected on symptoms, demographics and medical history from patients subsequently undergoing colonoscopy. Multiple logistic regression modelling was used to identify predictors of colorectal cancer. An ROC curve was estimated for each model, and the area under the curve (AUC) was computed.

RESULTS

Cancer was found in 159 patients and no cancer or adenoma in 7577 patients. Bowel symptoms that predicted cancer were rectal bleeding, change in bowel habit and rectal mucus. Prediction was the strongest in patients who had symptoms at least weekly and commencing within the previous 12 months; abdominal pain was predictive only in such patients. The odds ratios never exceeded 4.27. A model based on age, gender, and medical history was highly predictive (AUC = 0.79). Adding symptoms to this model increased the AUC to 0.85.

CONCLUSIONS

This model predicts patients in whom colonoscopy will have the highest yield. Conversely, colonoscopy can be avoided in people at low risk: in our study, 95% of cancers could have been detected by doing only 60% of the colonoscopies.

Cancer diagnosis in primary care

Around a quarter of those in the developed world die of cancer. Most cancers present to primary care with symptoms, even when there is a screening test for the particular cancer. However, the symptoms of cancer are also symptoms of benign disease, and the GP has to judge whether cancer is a possible explanation. Very little research examined this process until relatively recently. This review paper examines the process of primary care diagnosis, especially the selection of patients for rapid investigation. It concentrates on the four commonest UK cancers: breast, lung, colon, and prostate as these have been the subject of most recent studies.

Value of symptoms and additional diagnostic tests for colorectal cancer in primary care: systematic review and meta-analysis

OBJECTIVE

To summarise available evidence on diagnostic tests that might help primary care physicians to identify patients with an increased risk for colorectal cancer among those consulting for non-acute lower abdominal symptoms.

DATA SOURCES

PubMed, Embase, and reference screening. Study eligibility criteria Studies were selected if the design was a diagnostic study; the patients were adults consulting because of non-acute lower abdominal symptoms; tests included signs, symptoms, blood tests, or faecal tests. Study appraisal and synthesis methods Two reviewers independently assessed quality with a modified version of the QUADAS tool and extracted data. We present diagnostic two by two tables and pooled estimates of sensitivity and specificity. We refrained from pooling when there was considerable clinical or statistical heterogeneity.

RESULTS

47 primary diagnostic studies were included. Sensitivity was consistently high for age >or=50 (range 0.81-0.96, median 0.91), a referral guideline (0.80-0.94, 0.92), and immunochemical faeces tests (0.70-1.00, 0.95). Of these, only specificity of the faeces tests was good. Specificity was consistently high for family history (0.75-0.98, 0.91), weight loss (0.72-0.96, 0.89), and iron deficiency anaemia (0.83-0.95, 0.92), but all tests lacked sensitivity. None of these six tests was (sufficiently) studied in primary care.

CONCLUSIONS

Although combinations of symptom and results of immunochemical faeces tests showed good diagnostic performance for colorectal cancer, evidence from primary care is lacking. High quality studies on their role in the diagnostic investigation of colorectal cancer in primary care are urgently needed.

Two week rule referral for patients with colorectal cancer below the age of 50; are we being ageist?

OBJECTIVES

The TWR system was introduced in July 2000. The purpose of this study was to investigate whether patients below the age of 50 years with colorectal cancer (CRC) are experiencing delays in treatment.

METHODS

The CRC database was searched for all newly diagnosed colorectal cancers between January 2001 and December 2005 in patients who were aged less than 50 years.

RESULTS

There were 911 patients with CRC during the study period. Of these, 41 patients (4.5%) were aged under 50. Thirty-eight case notes were retrieved and reviewed; the median age was 47 years. Fourteen (37%) presented as an emergency, 9 (24%) via the TWR, 8 (21%) were non-TWR referrals to outpatients and the remainder were referred via miscellaneous routes. The median time from referral to initial consultation was 11 days (range 8-14 days) in the TWR group, 24 days (range 14-135 days) in the surgical outpatients group and 44 days (range 11-93 days) in the miscellaneous (direct endoscopy, in-hospital physician's referral) group. The median time from referral to initiation of treatment was 51 days (range 15-116 days) in the TWR group, 103 days (range 43-174 days) in the outpatient group and 96 days (range 27-270 days) in the miscellaneous group. Excluding age as a factor, 73% of the non-TWR referrals met the TWR criteria.

CONCLUSION

Patients with symptoms of CRC below the age of 50 years may face referral and diagnostic delay if not referred via the TWR system; many of these would be eligible if age was not a deciding factor.

Diagnostic accuracy systematic review of rectal bleeding in combination with other symptoms, signs and tests in relation to colorectal cancer

Background:

Rectal bleeding is a recognised early symptom of colorectal cancer. This study aimed to assess the diagnostic accuracy of symptoms, signs and diagnostic tests in patients with rectal bleeding in relation to risk of colorectal cancer in primary care.

Methods:

Diagnostic accuracy systematic review. Medline (1966 to May 2009), Embase (1988 to May 2009), British Nursing Index (1991 to May 2009) and PsychINFO (1970 to May 2009) were searched. We included cohort studies that assessed the diagnostic utility of rectal bleeding in combination with other symptoms, signs and diagnostic tests in primary care. An eight-point quality assessment tool was produced to assess the quality of included studies. Pooled positive likelihood ratios (PLRs), sensitivities and specificities were calculated.

Results:

Eight studies incorporating 2323 patients were included. Average weighted prior probability of colorectal cancer was 7.0% (range: 3.3–15.4%, median: 8.1%). Age ⩾60 years (pooled PLR: 2.79, 95% confidence interval (CI) 2.00–3.90), weight loss (pooled PLR: 1.89, 95% CI: 1.03–3.07) and change in bowel habit (pooled PLR: 1.92, 95% CI: 0.54–3.57) raise the probability of colorectal cancer into the range of referral to secondary care but do not conclusively ‘rule in’ the diagnosis. Presence of severe anaemia has the highest diagnostic value (pooled PLR: 3.67, 95% CI: 1.30–10.35), specificity 0.95 (95% CI: 0.93–0.96), but still only generates a post-test probability of 21.6%.

Conclusions:

In patients with rectal bleeding who present to their general practitioner, additional ‘red flag’ symptoms have modest diagnostic value. These findings have implications in relation to recommendations contained in clinical practice guidelines.

A self administered reliable questionnaire to assess lower bowel symptoms

Background

Bowel symptoms are considered indicators of the presence of colorectal cancer and other bowel diseases. Self administered questionnaires that elicit information about lower bowel symptoms have not been assessed for reliability, although this has been done for upper bowel symptoms. Our aim was to develop a self administered questionnaire for eliciting the presence, nature and severity of lower bowel symptoms potentially related to colorectal cancer, and assess its reliability.

Methods

Immediately before consulting a gastroenterologist or colorectal surgeon, 263 patients likely to have a colonoscopy completed the questionnaire. Reliability was assessed in two ways: by assessing agreement between patient responses and (a) responses given by the doctor at the consultation; and (b) responses given by patients two weeks later.

Results

There was more than 75% agreement for 78% of the questions for the patient-doctor comparison and for 92% of the questions for the patient-patient comparison. Agreement for the length of time a symptom was present, its severity, duration, frequency of occurrence and whether or not medical consultation had been sought, all had agreement of greater than 70%. Over all questions, the chance corrected agreement for the patient-doctor comparison had a median kappa of 65% (which represents substantial agreement), interquartile range 57–72%. The patient-patient comparison also showed substantial agreement with a median kappa of 75%, interquartile range 68–81%.

Conclusion

This self administered questionnaire about lower bowel symptoms is a useful way of eliciting details of bowel symptoms. It is a reliable instrument that is acceptable to patients and easily completed. Its use could guide the clinical consultation, allowing a more efficient, comprehensive and useful interaction, ensuring that all symptoms are assessed. It will also be a useful tool in research studies on bowel symptoms and their predictive value for colorectal cancer and other diseases. Studies assessing whether bowel symptoms predict the presence of colorectal cancer should provide estimates of the reliability of the symptom elicitation.

Validation of the Lower Gastrointestinal Electronic Referral Protocol

Background

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

Methods

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

Results

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

Conclusion

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

Nationwide monitoring of end-of-life care via the Sentinel Network of General Practitioners in Belgium: the research protocol of the SENTI-MELC study

Background

End-of-life care has become an issue of great clinical and public health concern. From analyses of official death certificates, we have societal knowledge on how many people die, at what age, where and from what causes. However, we know little about how people are dying. There is a lack of population-based and nationwide data that evaluate and monitor the circumstances of death and the care received in the final months of life. The present study was designed to describe the places of end-of-life care and care transitions, the caregivers involved in patient care and the actual treatments and care provided to dying patients in Belgium. The patient, residence and healthcare characteristics associated with these aspects of end-of-life care provision will also be studied. In this report, the protocol of the study is outlined.

Methods/Design

We designed a nationwide mortality follow-back study with data collection in 2005 and 2006, via the nationwide Belgian Sentinel Network of General Practitioners (GPs) i.e. an existing epidemiological surveillance system representative of all GPs in Belgium, covering 1.75% of the total Belgian population. All GPs were asked to report weekly, on a standardized registration form, every patient (>1 year) in their practice who had died, and to identify patients who had died "non-suddenly." The last three months of these patients' lives were surveyed retrospectively. Several quality control measures were used to ensure data of high scientific quality.

Discussion

In 2005 and 2006, respectively 1385 and 1305 deaths were identified of which 66% and 63% died non-suddenly. The first results are expected in 2007. Via this study, we will build a descriptive epidemiological database on end-of-life care provision in Belgium, which might serve as baseline measurement to monitor end-of-life care over time. The study will inform medical practice as well as healthcare authorities in setting up an end-of-life care policy. We publish the protocol here to inform others, in particular countries with analogue GP surveillance networks, on the possibilities of performing end-of-life care research. A preliminary analysis of the possible strengths, weaknesses and opportunities of our research is outlined.

Predictive value of common symptom combinations in diagnosing colorectal cancer

Background

This study compared the diagnostic values of age and single symptoms of colorectal cancer with those of age and symptom combinations.

Methods

Consecutive patients with lower gastrointestinal symptoms referred to a surgical clinic over a 12-year period were studied prospectively. The diagnostic value of age and common symptoms of bowel cancer, individually and in combination, was determined by measuring positive predictive value, sensitivity and specificity.

Results

In total, 467 (5·5 per cent) of 8529 patients had colorectal cancer. Symptom combination analyses showed that patients presenting with rectal bleeding and change in bowel habit without anal symptoms had the highest risk of cancer. Those with rectal bleeding and perianal symptoms without change in bowel habit were at the lowest risk of having cancer. Symptom subgroups defined by age had positive predictive values for cancer that varied from less than 1 to 35 per cent.

Conclusion

Symptom combinations defined by age have greater diagnostic value than single symptoms alone.

Diagnostic value of self-reported symptoms in Danish outpatients referred with symptoms consistent with colorectal cancer

OBJECTIVE

To assess the association between self-reported symptoms and a diagnosis of colorectal cancer (CRC) in symptomatic outpatients without CRC risk factors, defined by a Danish expert group.

METHOD

A cross-sectional study of patients aged 40 years and older referred by general practitioners to two Danish surgical outpatient clinics for symptoms consistent with CRC during a 16-month period. CRC was diagnosed at endoscopy and through follow up. Before their first appointment, participants completed a questionnaire about symptoms.

RESULTS

The study included 2172 patients. Of these, 122 were diagnosed with CRC (5.6%). Median age was 61 years (range: 40-97) and 44.0% were men. All symptoms had high (93.4-96.8%) negative predictive values for CRC. The highest positive predictive values (PPV) were found for dark rectal bleeding (PPV: 20.6%) and CRC was diagnosed in a first-degree relative over the age of 50 years (PPV: 11.2%). At multiple logistic regression analysis dark rectal blood was the most important predictor of CRC (OR: 7.4). Other predictors were age 60 years or older (OR: 3.0), change in frequency of bowel movements (OR: 2.5), CRC diagnosed in a first-degree relative over the age of 50 years (OR: 2.6), male gender (OR: 2.2) and mono-symptomatic fresh rectal blood (OR: 1.7).

CONCLUSION

No self-reported symptoms presented by outpatients without CRC risk factors can be used accurately to identify patients with CRC with certainty. For clinical purposes self-reported symptoms seems thus not to be a useful accurate tool to distinguish between symptomatic outpatients with and without CRC.

Rectal bleeding and previous anticoagulant treatment in patients with colorectal cancer do not predict outcome

BACKGROUND

The aim of this study was to determine whether the outcome of patients with colorectal cancer who presented with bleeding and a history of anticoagulant treatment was different from those who did not have bleeding or previous anticoagulant treatment.

METHODS

This was a single institution, retrospective study of patients with colorectal cancer with and without a history of rectal bleeding and treatment with anticoagulants, assessed for age, gender, tumor site, stage, recurrence rate, and survival.

RESULTS

A total of 621 consecutive patients (309 men) with a mean age of 70 years (range, 36-94 years) diagnosed with colorectal cancer between 1998 and 2004 were studied. Of these, 149 patients (24%) were referred for symptoms of rectal bleeding and 161 patients (26%) had been previously treated with anticoagulants. A total of 592 patients (95%) underwent curative or palliative surgery; endoscopic polypectomy was performed in 3 cases only and in 26 patients (4%) surgery was not performed due to advanced disease or critical illness. Patients with bleeding and a history of anticoagulant treatment presented commonly with stage I cancer. In addition, tumor stage III was less common in patients with previous anticoagulant treatment irrespective of presenting signs. Disease-free and overall survival rates were similar in all groups, irrespective of bleeding at presentation or anticoagulant treatment.

CONCLUSIONS

Rectal bleeding and anticoagulant treatment do not affect the outcome of newly diagnosed patients with colorectal cancer.

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

OBJECTIVE

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

DESIGN

Cohort study.

SETTING

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

MAIN OUTCOME MEASURE

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

RESULTS

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

CONCLUSION

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

Rectal and postmenopausal bleeding: consultation and referral of patients with and without severe mental health problems

BACKGROUND

People with severe mental health problems receive less effective care for some physical conditions. There is concern that this could apply to rectal bleeding or postmenopausal bleeding. Published estimates of consultation rates and outcomes for these symptoms vary widely.

AIM

To estimate rates of first-ever consultation for rectal bleeding and postmenopausal bleeding in general practice, together with subsequent referrals and outcomes. To identify inequalities for patients with severe mental health problems.

DESIGN OF STUDY

Cohort study.

SETTING

Primary care.

METHOD

Patients with first-ever consultations for rectal or postmenopausal bleeding were identified among more than 3 million patients from 328 practices contributing routine data to the QRESEARCH database. Their records were followed for 2 years.

RESULTS

There were 30 175 first consultations for rectal bleeding (2.6 per thousand patients per year at age 25-29 years, rising to 4.8 over age 85 years) and 10 142 for postmenopausal bleeding (highest at 7.4 per thousand per year aged 55-59 years). Overall, 2.2% of those with rectal bleeding and 1.7% of those with postmenopausal bleeding went on to have a relevant cancer diagnosis within 2 years. Cancer risk was strongly related to age, and was higher for males with rectal bleeding than females with rectal bleeding. Recorded referrals were at similar rates among patients with and without severe mental health problems.

CONCLUSION

The rate of first consultations for rectal bleeding or postmenopausal bleeding is relatively low. Less than 2.5% overall have a relevant cancer diagnosis within 2 years. There is no evidence of inequality in referral for patients with severe mental health problems.

Colonoscopic evaluation of hematochezia in low and average risk patients for colorectal cancer: A prospective study

AIM: To relate the endoscopic findings in patients with hematochezia with regard to age in “low and average risk” for colorectal cancer (CRC) and to localize significant lesions in order to identify patients who need sigmoidoscopy or total colonoscopy.

METHODS: This prospective study was performed in an open access GI endoscopy unit. Out of 4322 consecutive patients undergoing colonoscopy, 918 reported hematochezia. The final study group comprized 180 patients aged below 45 and 237 over 45. Main exclusion criteria were a 1^st-degree family history of colorectal carcinoma, patients reporting blood mixed with stools and/or progressive colonic symptoms, or patients who had undergone colon surgery for neoplastic lesions.

RESULTS: Total colonoscopy could be performed in 96% of patients. Abnormal findings were observed in 34.3% of the younger and in 65.7% of the older ones. Findings were the presence of polyps in the distal colon (n = 2) and IBD in the proximal colon (n = 29) in the group of the younger patients, and polyps (n = 15), IBD (n = 13), and carcinoma (n = 6, 4 of the lesions were located proximal to the splenic flexure) in the elderly. Our findings suggest that the diagnostic potential of total colonoscopy in patients younger than 45 referring scant hematochezia, is not mandatory. By exploring only the distal tract of the colon we have misdiagnosed two cases of IBD located in the ascending colon. In this group of patients additional risk factors must be identified before performing a total colonoscopy. Regarding the patients older than 45 yr, the exploration of the distal colon would have led to our overlooking a carcinoma, two neoplastic polyps and one IBD located in the proximal colon.

CONCLUSION: Young patients with scant hematochezia but without risk factors for neoplasia do not need a total colonoscopy, whereas is mandatory performing a total colonoscopy in older patients even in the presence of anal pathology.

Predicting colorectal cancer risk in patients with rectal bleeding

BACKGROUND

Rectal bleeding is an important symptom of colorectal cancer but has low predictive value in primary care.

AIM

To determine which characteristics of rectal bleeding, along with other factors, are predictive of colorectal cancer.

DESIGN OF STUDY

Observation study of patients with rectal bleeding referred to an open-access diagnostic clinic.

SETTING

Primary care, southern England.

METHOD

Symptom data were collected, using a self-completed questionnaire. Logistic regression techniques were used to determine predictors of colorectal cancer.

RESULTS

There were 604 patients in the study and 22 (3.6%, 95% confidence interval [CI] = 2.0% to 5.2%) were diagnosed with colorectal cancer. Significant predictors of colorectal cancer were found to be age (<50 years: odds ratio [OR] = 1; 50-69 years: OR = 5.1, 95% CI = 1.4 to 18.6; > or = 70 years: OR = 8.2, 95% CI = 2.1 to 31.8) and blood mixed with the stool (Likelihood ratio [LR] 1.5; adjusted OR = 3.8; 95% CI = 1.4 to 10.5). Presence of haemorrhoids associated with bright red bleeding not mixed with stool reduced the likelihood of cancer (OR = 0.4, 95% CI = 0.1 to 1.2) but did not eliminate it--a cancer was present in 2% of patients with these symptoms.

CONCLUSION

Patient-reported type of rectal bleeding as an isolated symptom has insufficient diagnostic value to be useful in general practice. By studying referred patients, we may even have overestimated its value. At best, it could be useful as a component of a composite symptom score to guide referral decisions.

Risk in primary care of colorectal cancer from new onset rectal bleeding: 10 year prospective study

OBJECTIVE

To measure the risk of colorectal cancer and adenoma with new onset rectal bleeding reported to primary care.

DESIGN

Cohort study.

SETTING

A rural general practice in the United Kingdom.

PARTICIPANTS

Patients aged 45 or more with new onset rectal bleeding, irrespective of other symptoms.

MAIN OUTCOME MEASURES

Percentage of participants in whom colorectal cancer or colonic adenoma was identified after investigation of the bowel.

RESULTS

During a 10 year period, 265 patients reported new rectal bleeding. Of these, 15 (5.7%, 95% confidence interval 3.2% to 9.2%) had colorectal cancer, and 13 (4.9%, 2.6% to 8.4%) had colonic adenoma. Only two of the patients with cancer had had diarrhoea.

CONCLUSIONS

One in 10 patients aged 45 or more with new onset rectal bleeding had colonic neoplasia, so investigation of the bowel should be offered to all such patients, whether or not they have other symptoms.

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

The aim was to use data routinely collected in general practice to assess the absolute risk of colorectal cancer in patients newly presenting to their general practitioner (GP) with relevant symptoms. Three cohorts were identified from patients attending a sample of UK general practices. Patients with new symptoms of rectal bleeding, changes in bowel habit or anaemia were identified, and their incident rate for colorectal cancer and the positive predictive value (PPV) of each symptom in the following 12 months were calculated by age and gender. The total population over the age of 40 years was 2.8 million, and 9143 incident cases of colorectal cancer were identified. A total of 67,164 patients (28% men) were identified with anaemia, 27,524 (40% men) with changes in bowel habit and 44,741 (48% men) with rectal bleeding. For each cohort, the absolute risk rose with increasing age, and men were twice as likely to develop colorectal cancer. The PPV for developing colorectal cancer in the subsequent 12 months in those aged 60-69 years with anaemia was 3.02% for men, 1.38% for women; with changes in bowel habit 6.89% for men, 2.42% for women; and with rectal bleeding was 5.99% for men, 3.50% for women. A combination of any two signs and symptoms doubled the risk of an underlying cancer. In UK general practice, men are less likely to present with symptoms and signs of colorectal cancer compared with women, but after investigation are much more likely to have a colorectal cancer diagnosed. This should be taken into account in guidelines for referral.

Factors identifying higher risk rectal bleeding in general practice

BACKGROUND

Rectal bleeding is a common symptom. The ability to distinguish those patients having serious underlying pathology from those with self-limiting conditions is a continuing dilemma in general practice.

AIM

To determine the factors affecting the predictive and diagnostic value of rectal bleeding for bowel cancer in primary care.

DESIGN OF STUDY

One-year prospective observational study.

SETTING

Three large general practices.

METHOD

Three hundred and nineteen consecutive patients over the age of 34 years consulting their GPs with rectal bleeding were included in the study. Investigation was by flexible sigmoidoscopy or a questionnaire and review of all patients took place after 18 months. The main outcome measures were consultation rates; the prevalence of cancer, colitis and significant polyps in patients presenting with rectal bleeding; its diagnostic value when occurring with or without a change in bowel habit, perianal symptoms and abdominal pain.

RESULTS

The consultation rate for rectal bleeding in patients over the age of 34 years was 15 per 1000 per year; 3.4% had colorectal cancer. The prevalence of cancer increased to 9.2% when the rectal bleeding was associated with a change in bowel habit, and to 11.1% when it was without perianal symptoms. Thirty-six per cent of cancer patients had a palpable rectal mass.

CONCLUSION

Over 96% of the patients who present to their GPs with rectal bleeding do not have cancer. Greater awareness of the diagnostic value of the different symptom combinations of rectal bleeding could help GPs adopt different management strategies for patients at higher and very low risk of cancer.

Clinical features of colorectal cancer before diagnosis: a population-based case-control study

Most colorectal cancers are diagnosed after the onset of symptoms. However, the risk of colorectal cancer posed by particular symptoms is largely unknown, especially in unselected populations like primary care. This was a population-based case–control study in all 21 general practices in Exeter, Devon, UK, aiming to identify and quantify the prediagnostic features of colorectal cancer. In total, 349 patients with colorectal cancer, aged 40 years or more, and 1744 controls, matched by age, sex and general practice, were studied. The full medical record for 2 years before diagnosis was coded using the International Classification of Primary Care-2. We calculated odds ratios for variables independently associated with cancer, using multivariable conditional logistic regressions, and then calculated the positive predictive values of these variables, both individually and in combination. In total, 10 features were associated with colorectal cancer before diagnosis. The positive predictive values (95% confidence interval) of these were rectal bleeding 2.4% (1.9, 3.2); weight loss 1.2% (0.91, 1.6); abdominal pain 1.1% (0.86, 1.3); diarrhoea 0.94% (0.73, 1.1); constipation 0.42% (0.34, 0.52); abnormal rectal examination 4.0% (2.4, 7.4); abdominal tenderness 1.1% (0.77, 1.5); haemoglobin <10.0 g dl⁻¹ 2.3% (1.6, 3.1); positive faecal occult bloods 7.1% (5.1, 10); blood glucose>10 mmol l⁻¹ 0.78% (0.51, 1.1): all P<0.001. Earlier diagnosis of colorectal cancer may be possible using the predictive values for single or multiple symptoms, physical signs or test results.

Frequent DNA hypomethylation of human juxtacentromeric BAGE loci in cancer

The BAGE (B melanoma antigens) sequence family contains 15 nearly identical sequences that are in the juxtacentromeric regions of chromosomes 9, 13, 18, and 21. BAGE loci are expressed in male germ tissue and in a high percentage of cancers and cancer cell lines. We analyzed the DNA methylation state of the sequences in or near the promoters of the BAGE loci by a quantitative bisulfite and PCR-based assay (multiplex COBRA) using MboI and HphI in 18 somatic tissue samples, 4 testis and 4 sperm samples, and 48 tumors and tumor cell lines. In 94% of the control somatic tissue samples, DNA was highly methylated in the analyzed regions. In contrast, 98% of tumor DNA samples displayed hypomethylation. Also, DNA from testes and sperm was hypomethylated in at least one of the BAGE loci. BAGE transcripts were observed in only 47% of the analyzed tumor samples. Consequently, we propose BAGE hypomethylation as a new, highly informative epigenetic biomarker for the diagnosis of cancer, whose hypomethylation in cancer may be causally related to that of juxtacentromeric satellite DNA.

Abdominal complaints in general practice

OBJECTIVE

The study evaluates the prevalence and diagnoses of abdominal complaints in general practice, and compares characteristics and symptoms of patients with functional gastrointestinal disorders (FGIDs) and organic diseases.

DESIGN

A cross-sectional study.

SETTING

Nine centres with 26 participating general practitioners (GPs) in Norway.

SUBJECTS

3097 out of 3369 consecutive adult patients answered a questionnaire regarding abdominal complaints IN the last 3 months. Those who consulted for the complaints were eligible for this study.

MAIN OUTCOME MEASURES

The GPs' diagnoses and patients' characteristics were reported in questionnaires.

RESULTS

460 out of 1499 patients with abdominal complaints consulted for these complaints; 392 were included in this study. The GPs diagnosed an FGID in 167 (42.6%) patients, organic disease in 145 (37.0%), and made no diagnosis in 80 (20.4%). Stress-related symptoms were a statistically significant predictor of a FGID (OR 1.95) and weight loss predicted in addition organic disease (OR 2.7) in 128 patients with a verified diagnosis.

CONCLUSION

Abdominal complaints are a common problem in general practice. The distinction between FGID, which accounted for half of the diagnoses, and organic disease was difficult. The only significant predictor for FGID was stress-related symptoms.

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.

The two week referral for colorectal cancer: a retrospective analysis

OBJECTIVE

The two-week referral (TWR) system was introduced in July 2000 to address the delays in referral, diagnosis and treatment of colorectal cancer (CRC) and lessen the associated psychological morbidity of prolonged waiting. General practitioners complete a proforma outlining 'high-risk' criteria for CRC to ensure an urgent referral within 14 days. The aim of the study was to analyse the TWR process and the proforma criteria.

PATIENTS AND METHODS

One hundred and forty-nine two-week referral proforma were retrospectively reviewed between January and August 2001. The waiting times and proforma data, together with investigations performed and diagnoses made were gathered for 144 patients. Three did not attend clinic and two sets of notes were missing.

RESULTS

Ninety-six percent of patients (n = 144) were two week compliant and 14 CRC (10%) were diagnosed. The most common referral symptom was a recent change in bowel habit (36.6%) but specificity for all criteria was low. The highest diagnostic yield was a palpable abdominal or rectal mass where 16.7% had CRC and iron deficiency anaemia had high sensitivity (90%) for surgical pathology. Per rectum examination and haemoglobin analysis by general practitioners was infrequently performed.

DISCUSSION

Our study has shown that CRC is difficult to diagnose by history and examination alone with a 10% detection rate. CRC incidence in TWR may be improved by primary care through routine rectal examinations, increased detection of iron deficiency anaemia and public education to reduce presentation via other referral routes. Further studies are needed to address these issues.

The diagnostic value of macroscopic haematuria for the diagnosis of urological cancer in general practice

BACKGROUND

The diagnostic value and the impact of some signs and symptoms in most diseases in primary care have only been studied incompletely.

AIM

To assess the diagnostic value of macroscopic haematuria for the idagnosis of urological cancer (bladder, kidney) in a general practice setting, as well the influence of age, sex, and some additional signs and symptoms.

DESIGN OF STUDY

Diagnostic study.

SETTING

The study was performed in a sentinel station network of general practices in Belgium, covering almost 1% of the population.

SUBJECTS

All patients attending their general practitioner and complaining of haematuria during 1993 and 1994 were included for the prospective part of the study. Every patient diagnosed with a urological cancer in this period was registered for the retrospective part.

METHOD

Mean outcome measures of sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratio were used to assess diagnostic value.

RESULTS

Within the registration year 1993-1994, patient-doctor encounters, related to 83,890 patient-years, were registered. The positive predictive value (PPV) for urological cancer was 10.3% (95% CI = 7.6% to 13.7%). Sensitivity was 59.5% (95% CI = 50.4% to 60.1%). The PPV of patients aged over 60 years was 22.1% (95% CI = 15.8% to 30.1%) for men and 8.3% (95% CI = 3.4% to 17.9%) for women. In the age group 40 to 59 years, the PPV was 3.6% (95% CI = 0.6% to 13.4%) for men and 6.4% (95% CI = 1.7% to 18.6%) for women. In the prospective part of the study, no urological cancer was found in the age group under 40 years.

CONCLUSION

Men older than 60 years of age with macroscopic haematuria have a high positive predictive value for urological cancer. In these patients, a thorough investigation is indicated. In patients over 40 years of age of either sex, referral or watchful waiting can be justified.