Comparison of gastrointestinal symptoms in colorectal carcinoma patients and community controls with respect to age

Trends in colorectal cancer screening compliance and incidence among 60- to 74-year-olds in China

BACKGROUND

Compliance with colonoscopy among elderly individuals participating in colorectal cancer (CRC) screening programs is unsatisfactory, despite a high detection rate of bowel-related diseases. In this study, our aim was to analyze the impact of risk factors on the trends of compliance and detection rates in colonoscopy among high-risk individuals aged 60-74.

METHODS

A retrospective study was conducted on the high-risk individuals aged 60-74 participating in the 2021 CRC screening program in Tianjin, China. Logistic regression analyses, including both univariate and multivariate analyses, were performed to explore the impact of different risk factors on colonoscopy compliance among the high-risk individuals. Besides, the study investigated the influence of various risk factors on the detection rates of bowel-related diseases among the high-risk individuals who underwent colonoscopy.

RESULTS

A total of 24,064 high-risk individuals were included, and 5478 individuals received a free colonoscopy, with an overall compliance of 22.76%. Among them, the adenoma detection rate was 55.46%. Males and individuals with a positive FIT had high compliance and detection rates for CRC, advanced adenomas (AA), advanced colorectal neoplasia (ACN), and colorectal neoplasm (CN). Individuals aged 70-74 were associated with low compliance but high CRC, ACN, and CN detection rates. Individuals who reported a history of chronic constipation, bloody mucous, and CRC in first-degree relative showed high compliance but no significantwere associated with the detection rates of CRC, AA, and CN.

CONCLUSION

This study reported several risk factors associated with the screening behaviors for CRC. Patterns and trends in CRC, AA, ACN, and CN compliance and detection rates correlate with risk factors.

The effect of exercise in patients with colorectal cancer surgery: A systematic review

Background

Current reviews have primarily focused on the effect of exercise on colorectal cancer patient's functional abilities and cardiorespiratory performance. There is a need for more comprehensive studies to determine the effects of exercise on different components. We aimed to investigate recent pre-operative and post-operative exercise interventions conducted in patients undergoing or scheduled for colorectal cancer surgery.

Methods

The PRISMA guidelines were followed. PubMed, Web-of-Science (WoS) and Scopus databases were searched. The Physiotherapy Evidence Database (PEDro) tool provided the methodological quality and risk of bias for the included trials. The review findings are presented using the principles of narrative synthesis. The synthesis process encompasses steps such as "developing a preliminary synthesis, exploring relationships within and between studies, and assessing the robustness of the synthesis."

Results

The combined use of aerobic and resistance exercises reduces hospital stay in the preoperative period, long-term exercise interventions significantly improve functional parameters, and progressive relaxation exercises performed during the preoperative and postoperative periods reduce anxiety.

Conclusions

Long-term and combined (relaxation, aerobic and resistance) rehabilitation in colorectal cancer surgery is essential to improve the physical and psychological parameters of patients. Further studies should focus on more comprehensive, long-term exercise programs and separately investigate the effects of each exercise type.

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.

Weight loss as a predictor of cancer in primary care: a systematic review and meta-analysis

BACKGROUND

Weight loss is a non-specific cancer symptom for which there are no clinical guidelines about investigation in primary care.

AIM

To summarise the available evidence on weight loss as a clinical feature of cancer in patients presenting to primary care.

DESIGN AND SETTING

A diagnostic test accuracy review and meta-analysis.

METHOD

Studies reporting 2 × 2 diagnostic accuracy data for weight loss (index test) in adults presenting to primary care and a subsequent diagnosis of cancer (reference standard) were included. QUADAS-2 was used to assess study quality. Sensitivity, specificity, positive likelihood ratios, and positive predictive values were calculated, and a bivariate meta-analysis performed.

RESULTS

A total of 25 studies were included, with 23 (92%) using primary care records. Of these, 20 (80%) defined weight loss as a physician's coding of the symptom; the remainder collected data directly. One defined unexplained weight loss using objective measurements. Positive associations between weight loss and cancer were found for 10 cancer sites: prostate, colorectal, lung, gastro-oesophageal, pancreatic, non-Hodgkin's lymphoma, ovarian, myeloma, renal tract, and biliary tree. Sensitivity ranged from 2% to 47%, and specificity from 92% to 99%, across cancer sites. The positive predictive value for cancer in male and female patients with weight loss for all age groups ≥60 years exceeded the 3% risk threshold that current UK guidance proposes for further investigation.

CONCLUSION

A primary care clinician's decision to code for weight loss is highly predictive of cancer. For such patients, urgent referral pathways are justified to investigate for cancer across multiple sites.

Factors that influence treatment delay in patients with colorectal cancer

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

Development and validation of a clinical decision-making aid for screening bowel symptoms in community pharmacies

RATIONALE, AIMS AND OBJECTIVES

Bowel symptoms are common, and community pharmacies are an ideal setting for health advice about these symptoms. The aim of this study was to develop and validate a questionnaire for use with adults presenting to community pharmacies with lower bowel symptoms. The purpose of the questionnaire was to stratify people into those requiring medical follow-up for symptoms and those with self-limiting symptoms.

METHOD

A self-administered questionnaire, named the Jodi Lee test (JLT), was developed in three stages - review of the literature, questionnaire design and statistical validation - against a validated screening tool, the patient consultation questionnaire (PCQ), to assess the sensitivity and specificity of JLT. The questionnaire was developed to be simple, easy for all pharmacy staff to use and require no score calculation. Its application was designed to facilitate referral from pharmacy assistants to pharmacists and from pharmacists to medical practitioners.

RESULTS

The questionnaire comprises eight questions. It has a Flesh-Kincaid reading score of 79.5. By considering different score thresholds on the PCQ, a receiver operator characteristic (ROC) curve was calculated to assess the effectiveness of the JLT. From a sample of 118 subjects, the area under the ROC curve was 0.94. At a threshold score of 30 on the PCQ, the sensitivity was 100%. The specificity was 65%.

CONCLUSION

The JLT has high sensitivity for identifying patients with symptoms of serious bowel disease. It is also likely to identify patients who have symptoms of relatively benign disease who would benefit from medical advice.

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.

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.

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.

Evaluation of the Danish national strategy for selective use of colonoscopy in symptomatic outpatients without known risk factors for colorectal cancer

OBJECTIVE

A diagnostic strategy implemented in Denmark in 2002 recommends selective use of colonoscopy in outpatients without known colorectal cancer (CRC) risk factors who are referred with symptoms consistent with possible CRC. Selection of patients for colonoscopy was based on the presenting symptom(s) and findings at the initial examination (flexible sigmoidoscopy/faecal occult blood test). The aim of this study was to evaluate the strategy by assessing the prevalence of patients with diagnosed CRC, the frequency of patients with missed CRC, the adherence to the strategy and the number of examinations performed.

MATERIAL AND METHODS

We prospectively studied patients aged 40 years and older without known risk factors for CRC, referred to two surgical outpatient clinics during a period of 15-16 months. Examinations, findings at the examinations, the final diagnoses and date of discharge were recorded. Missed CRCs were identified by follow-up in hospital discharge registries.

RESULTS

CRC was diagnosed in 126 (5.3%; 95% CI: 4.5-6.3%) of the 2361 patients included during the diagnostic work-up. Two additional cancers identified at follow-up were both missed during colonoscopy (1.5%; 95% CI: 0.2-5.4%). The adherence to the strategy was 75.7%, and 125 of the 126 patients with a CRC were examined in conformity with the recommended strategy. Almost 60% of the patients underwent colonoscopy and almost 50% underwent both flexible sigmoidoscopy and colonoscopy.

CONCLUSIONS

The diagnostic strategy is an acceptable alternative to initial colonoscopy, with a low probability of missing a CRC; however, a considerable proportion of the patients undergo colonoscopy and multiple examinations.

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.

Delay of treatment is associated with advanced stage of rectal cancer but not of colon cancer

BACKGROUND

Dukes' stage is the most important predictor of prognosis of colorectal cancer, but the association between delay of treatment (DT) and Dukes' stage is still controversial.

METHODS

From 1 January 2001 to 31 July 2002, we conducted a population-based prospective observational study based on 733 Danish colorectal cancer patients. DT was determined through questionnaire-interviews, and Dukes' stage was obtained from medical records and pathological forms. DT was classified into three groups: short (0-60 days), intermediate (61-150 days) and long (>150 days) DT. Dukes' stage was classified into two groups: non-advanced (Dukes' stage A or B) and advanced (Dukes' stage C or D) cancer. Using relative risk (RR) the association between DT and stage was estimated, with short delay as the reference group.

RESULTS

The RR of advanced cancer was 1.0 (95% confidence intervals (CI): 0.8-1.3) for colon cancer patients with an intermediate DT, and 1.1 (95% CI: 0.9-1.4) for patients with a long DT. For rectal cancer patients the RR of advanced cancer was 1.9 (95% CI: 1.1-3.1) for patients with an intermediate DT and 2.1 (95% CI: 1.3-3.4) for patients with a long DT.

CONCLUSION

DT was strongly associated with advanced stage of rectal cancer, but not of colon 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.

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.

Colorectal cancer in the south of Israel; comparison of the clinical characteristics and survival between two periods, 1981-2 and 1986-7

BACKGROUND

Colorectal cancer has the highest incidence of all malignant tumours in men and women in Israel. The public was introduced to the concept of screening in the early 1980s, and full programs began in 1983.

OBJECTIVES

The study compares patients with colorectal cancer (CRC) who were diagnosed before screening and five years later, for stage differences and survival.

METHODS

All patients with CRC who were diagnosed from 1981 to 1982 (period I) and 1986-87 (period II) at Soroka Medical Centre and who were residents of the Negev area were eligible for the study. Data were collected retrospectively from the Israel Cancer Registry and patient files and endoscopic, histological and surgical reports from the Departments of Pathology, Gastroenterology, Oncology and Surgery at Soroka Medical Centre.

RESULTS

The study groups included 207 patients with CRC, 85-from period I and 122-from period II. The mean annual incidence of CRC for these 2 periods was 18 and 24.8 cases per 100, 000, respectively, for an increase of 37% (P < 0.001). Five-year-survival in period I was 53.3% and in period II, 39.6% (P = 0.025). Survival did not differ by origin or gender. Dukes' stage, well and moderately differentiated tumours, and left-sided tumours were associated with better prognosis (P = 0.03). Forty-two percent of the cases were less than 64-year-old-at diagnosis, compared with 27% of 2069 Israeli patients in whom CRC was diagnosed in 1991 (P < 0.001).

CONCLUSIONS

Before a nation wide decision is made with regard to public screening for CRC with fecal occult blood tests or sigmoidoscopy, the available data should be thoroughly evaluated, and further in-depth investigations performed to determine trends in diagnosis and prognosis.

The impact of bowel cancer awareness week

OBJECTIVES

To assess knowledge of Bowel Cancer Awareness Week (BCAW) amongst patients attending their general practice surgery and to identify whether BCAW could increase knowledge of colorectal cancer symptoms.

METHOD

Questionnaire study with ethics committee approval. Patients attending non-emergency clinics in a single general practice during the week following BCAW were given a questionnaire. Respondents were asked for knowledge of colorectal cancer symptoms, sources of this information and awareness of BCAW compared to similar knowledge of breast cancer.

RESULTS

Seventy-seven patients responded (96% response rate, median age 42, 40% male). Eighty-five percent could name a breast cancer symptom compared to only 44% who could name a colorectal cancer symptom (McNemar's chi2, P < 0.0001). Respondents identified more sources of information for breast than colorectal cancer. Only 21% had heard of BCAW and none could name any symbol for bowel cancer awareness whereas 69% were aware of Breast Cancer Awareness Month and 28% could name its symbol (McNemar's chi2, P < 0.0001). Multivariate analysis demonstrated that patients who were aware of BCAW were 4.6 times more likely to have knowledge of colorectal cancer symptoms (95% CI 1.25-17.1).

CONCLUSIONS

Despite their similar incidence, knowledge of colorectal cancer is much less than breast cancer. In part this may be due to the greater publicity given to breast cancer. BCAW can increase knowledge of colorectal cancer symptoms but currently, too few people are aware of it.

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

AIM AND METHOD

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

RESULTS

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

CONCLUSION

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

Care of the elderly with gastrointestinal problems in family practice

Gastrointestinal problems in older people cause a great amount of anxiety, morbidity and mortality. In general these diseases present for the first time to family practitioners. The management of gastrointestinal problems is more difficult because in an older age group, functional diseases can present in the same way as organic diseases. In addition, family practitioners see a different kind of patient than speciality physicians and may not have immediate access to diagnostic investigations. In this chapter, the role of the family practitioner in screening for gastrointestinal problems in asymptomatic older people is explored. In addition, how they differentiate between organic and non-organic disease and refer appropriately to secondary care is discussed. The role of family practitioners in the on-going maintenance of gastrointestinal diseases and in the management of Helicobacter pylori in community dwelling older people is also considered.

Prevalence of lower gastrointestinal symptoms and associated consultation behaviour in a British elderly population determined by face-to-face interview

BACKGROUND

The incidence of organic lower gastrointestinal disease increases with age. However, the prevalence of lower gastrointestinal symptoms in a British elderly population is unclear, with previous epidemiological studies focusing on younger populations. Furthermore, there is little information about consultation behaviour associated with lower gastrointestinal symptoms.

AIM

To determine the prevalence of lower gastrointestinal symptoms reported by randomly selected, elderly community subjects.

METHODS

An age- and sex-stratified random sample of patients aged 65 years and over was drawn from a general practice register (n = 842). Those who had not refused to participate in an initial postal survey were invited to participate in a semi-structured physician interview at their own home to assess lower gastrointestinal symptomatology (n = 745). Non-participation bias and service use of all subjects were assessed from practice records.

RESULTS

Five hundred and ninety-six (71%) patients were interviewed. Fifty-seven per cent of all participants had at least one lower gastrointestinal symptom. Individual symptoms and symptom complexes were common, affecting up to 32% of subjects. Only 24% of subjects with lower gastrointestinal symptoms consulted their general practitioner (GP) with such symptoms in the previous year. As few as 31% of subjects with new onset of the significant symptoms of rectal bleeding, abdominal pain, and a change in bowel habit consulted their GP.

CONCLUSION

Lower gastrointestinal symptoms are common in a British elderly population and an important reason for GP consultation.

Demographic factors associated with knowledge of colorectal cancer symptoms in a UK population-based survey

Greater public awareness of colorectal cancer symptoms might result in earlier presentation with improved cure by available treatments, but little is known about the extent of public knowledge of colorectal cancer symptoms. We asked a sample of the general population about knowledge of colorectal cancer symptoms and assessed demographic characteristics associated with differences in knowledge. A population-based telephone enquiry into knowledge of colorectal cancer-associated symptoms was conducted by a commercial telephone market-research company. Persons called were asked if they knew any symptom of colorectal cancer. Those who answered 'yes' were asked to state any symptom. The ability to state a colorectal cancer-associated symptom was correlated with demographic characteristics, and the strength of the relation between stating a colorectal cancer associated and unassociated symptom (discrimination) was also assessed. 1019 persons (respondents) from an age, sex, and social class-balanced general population sample were questioned. 328 (31%) of respondents stated a colorectal cancer-associated symptom. Regression analysis identified older age, female sex and higher social class as being significantly associated with ability to state a colorectal cancer-associated symptom. There was a weak trend (P = 0.054) towards a relationship between ability to state an associated symptom and stating fewer unassociated symptoms. These results reveal a total ignorance of colorectal cancer symptoms in the majority of respondents and suggest a need for improved public education about colorectal cancer. Public education should be directed at population groups with higher risk and the least knowledge of colorectal cancer.

Does isolated rectal bleeding suggest colorectal cancer?

Rectal bleeding is associated with colorectal cancer, but does not occur in all cases and is usually a symptom of minor colorectal disorders. Colorectal cancer presents only Infrequently with rectal bleeding in isolation.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[What should be done in weight loss of unknown origin?]

DIFFERENTIAL DIAGNOSIS

Involuntary weight loss is associated with increased mortality and morbidity. Differential diagnosis includes more than 50 disease entities; therefore the diagnostic strategy is determined by additional symptoms. THE SYNDROME OF "CONSUMPTION", i.e. weight loss as an isolated symptom or together with malaise, may indicate tumors (lung, pancreas, kidney cancer, malignant lymphoma), infections (tuberculosis, HIV), immunologic diseases (lupus erythematosus, vasculitis), hyperthyroidism, extraintestinal Crohn's disease, or psychogenic disease (depression, psychogenic eating disorders).

CONCLUSION

Recognition of the underlying disease is often delayed by a lack of awareness for weight changes, both by physicians and by patients. Nutritional counselling and treatment should be initiated in time.

Causes of late diagnosis in cases of colorectal cancer seen in a district general hospital over a 2-year period

Our aim in this prospective study was to identify those patients who were found to have a colorectal cancer after a delay we considered unacceptable; this was taken as 6 months or more from initial presentation to a physician to diagnosis. It was then possible to determine the presenting complaints (always multiple) and the reasons for delay, in the hope that recommendations could be made regarding appropriate, rapid and thorough investigation of patients suspected of having a colorectal cancer. Of the total of 141 patients with colorectal cancer (108 elective, 33 emergency cases) under the care of one consultant during the period studied, 17 patients (12%) (10 men and 7 women), satisfied the criteria for late diagnosis. The mean age was 72.4 years (range 43-86 years). Five common presenting complaints were identified. They were, symptomatic iron deficiency anaemia, rectal bleeding, change in bowel habit, abdominal pain and weight loss. Incomplete imaging of the colon in patients with sinister presenting symptoms was the most commonly identified factor in delay of diagnosis. Inappropriate iron therapy and false-negative reporting of double contrast barium enema investigations were both seen in a number of cases. Other causes were, inappropriate surgical treatment and both clerical error and delay. The mean time for delay was 17.6 months (median 15 months). Late diagnosed cancers were most commonly found in the caecum and least commonly in the rectum. Colonic tumours of each Dukes' stage were identified, Dukes' B most common and Dukes' A least.

Faecal incontinence in adults. 1: Prevalence and causes

Faecal incontinence is much more common in the general population than is often realized. Recent epidemiological work suggests that over 1% of all adults have some degree of faecal leakage. Although the problem increases with advancing age and disability, there are large numbers of otherwise healthy adults with this distressing symptom. Many, possibly the majority, do not seek professional help. The most common causes include childbirth by vaginal delivery, especially if assisted with forceps, any condition causing frequency or diarrhoea, and a variety of anorectal conditions. A detailed and empathic history taking, physical examination, and use of anorectal investigative techniques where indicated, enables an accurate individual diagnosis in most cases. A subsequent article will explore the treatment and management options once a diagnosis has been reached.

Evaluation of abdominal pain in the elderly

Evaluation of the older patient presents a unique challenge to the emergency physician. The increased age of the population, a high incidence of comorbidity, general poverty of history and clinical signs in acute abdominal conditions, poor reliability of diagnostic procedures, and the variable presentations of diseases with significant morbidity and mortality summarize the problems to be encountered with the complaint of abdominal pain in the elderly. The correct diagnosis is often difficult to establish and coexisting complicating diseases influence the patient's condition and the ED management. The emergency physician must maintain a wide differential and have a low threshold for admission and more extensive evaluation in this patient population.

Anorexia in older persons: epidemiology and optimal treatment

Anorexia and weight loss are common findings in older persons. Over a life-time, normal persons decrease their food intake to counterbalance the decrease in physical activity and resting metabolic rate that occurs with aging. This physiological anorexia of aging increases the propensity to develop pathological anorexia and weight loss when an older person develops either a medical or psychological illness. The physiological anorexia of aging is due to a decreased opioid (dynorphin) feeding drive and an increase in the satiating effect of the gastrointestinal hormone, cholecystokinin. Nitric oxide deficiency may play a role in the early satiation commonly seen in older persons. A variety of social, psychological and medical conditions can lead to pathological anorexia. Depression is the most common cause of weight loss and anorexia in older persons. A number of conditions such as cancer and rheumatoid arthritis produce their anorectic and wasting effects by releasing cytokines. An idiopathic pathological senile anorexia has been characterised which also appears to be a cytokine-dependent syndrome. Early screening for malnutrition is a cornerstone of the management of anorexia; the Mini Nutritional Assessment is a well validated screening tool available for this purpose. Aggressive use of caloric supplements, enteral tube feeding and peripheral parenteral nutrition all have a role in the early management of anorexia. Numerous drugs (growth hormone, megestrol, cyproheptadine, tetrahydrocannabinol, anabolic steroids, prokinetic agents and antidepressants) have been utilised to treat the anorexia of aging with varying success.