Opportunities for reducing emergency diagnoses of colon cancer in women and men: A data-linkage study on pre-diagnostic symptomatic presentations and benign diagnoses

Abstract

Objectives To identify opportunities for reducing emergency colon cancer diagnoses, we evaluated symptoms and benign diagnoses recorded before emergency presentations (EP). Methods Cohort of 5,745 colon cancers diagnosed in England 2005–2010, with individually linked cancer registry and primary care data for the 5‐year pre‐diagnostic period. Results Colon cancer was diagnosed following EP in 34% of women and 30% of men. Among emergency presenters, 20% of women and 15% of men ( p = 0.002) had alarm symptoms (anaemia/rectal bleeding/change in bowel habit) 2–12 months pre‐diagnosis. Women with abdominal symptoms (change in bowel habit/constipation/diarrhoea) received a benign diagnosis (irritable bowel syndrome (IBS)/diverticular disease) more frequently than men in the year before EP: 12% vs. 6% among women and men ( p = 0.002). EP was more likely in women (OR = 1.20; 95% CI 1.1–1.4), independently of socio‐demographic factors and symptoms. Benign diagnoses in the pre‐diagnostic year (OR = 2.01; 95% CI 1.2–3.3) and anaemia 2–5 years pre‐diagnosis (OR = 1.91; 95% CI 1.2–3.0) increased the risk of EP in women but not men. The risk was particularly high for women aged 40–59 with a recent benign diagnosis vs. none (OR = 4.41; 95% CI 1.3–14.9). Conclusions Women have an increased risk of EP, in part due to less specific symptoms and their more frequent attribution to benign diagnoses. For women aged 40–59 years with new‐onset IBS/diverticular disease innovative diagnostic strategies are needed, which might include use of quantitative faecal haemoglobin testing (FIT) or other colorectal cancer investigations. One‐fifth of women had alarm symptoms before EP, offering opportunities for earlier diagnosis.

Does changing healthcare use signal opportunities for earlier detection of cancer? A review of studies using information from electronic patient records

“…Six studies examined variation by tumour characteristics. As indicated by changes in primary care consultation rates in two studies, reported diagnostic windows were generally longer for proximal colon compared to distal colon or rectal cancer [17] , [33] . Increases in prescription rates for any newly-prescribed drug occurred earlier for proximal colon compared to distal colon or rectal cancer, [33] whereas increases in haemorrhoid prescription rates were earlier for rectal compared to colon cancers [10] .…”

“…763 studies were initially identified, of which 28 were included in the final review ( Fig. 2 ) [10] , [11] , [12] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] , [36] , [37] , [38] , [39] . All but four of the selected studies were carried out in Denmark or the UK, while the four remaining studies were set in Germany, Sweden, Australia, and the Netherlands.…”

“…The longest reported diagnostic windows (for all patients or at least a subgroup of patients) were four years (43–48 months) pre-diagnosis for all brain tumours combined [30] , three years for multiple myeloma [12] , and two years for colorectal cancer [10] , [17] , [18] , [27] , and benign brain tumours [24] , [37] . Diagnostic windows of between six to 12 months were reported for lung cancer [22] , [25] , [35] , sarcoma [16] , [31] , bladder and kidney cancers combined [15] , childhood/ adolescent lymphoma and leukaemia [31] , [37] , malignant brain cancer [11] , liver [34] , and gall bladder/ biliary tract cancer [34] .…”

Influence of doctor-patient conversations on behaviours of patients presenting to primary care with new or persistent symptoms: a video observation study

“…Approximately a third of colorectal and lung cancer diagnoses in the USA have missed diagnostic opportunities despite ‘red flag’ symptoms (eg, rectal bleeding) 5 6. In England, one in five patients with colorectal cancer diagnosed after an emergency presentation had typical ‘alarm’ symptoms in the year leading up to their diagnosis, and 16%–22% had three or more consultations in primary care with relevant symptoms, suggesting potential opportunities for earlier diagnosis 7 8. This points to the importance of understanding what happens within the consultation to prevent patient harm resulting from missed or delayed diagnosis 9…”

When cancer is diagnosed as an emergency

“…In this issue of the journal, Renzi, Lyratzopoulos, Hamilton, and Rachet () examined emergency diagnosis of colon cancer in women and men. Women were at increased risk, due, it seemed, to less specific symptomology or more frequent attribution to a benign diagnosis.…”