The use of symptoms to predict colorectal cancer site. Can we reduce the pressure on our endoscopy services?

Kent, Alexandra; Woolf, David; McCue, J. L.; Greenfield, S.

doi:10.1111/j.1463-1318.2009.01770.x

Cited by 21 publications

(23 citation statements)

References 11 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…A prospective cohort study by Thompson et 31 The findings of this study also supported the tailoring of initial investigations. In patients with CRC, distal lesions were associated with a CIBH and rectal bleeding.…”

Section: Tailoring Initial Investigations For Suspected Colorectal Casupporting

confidence: 78%

“…28 It has been suggested that there is scope within the NHS to reduce the diagnostic burden for patients and endoscopy services by implementing clinical protocols which incorporate the selective use of FS, in place of WCI, for the initial investigation of patients with symptoms suggestive of distal CRC. [29][30][31][32][33] For WCI to be avoided in favour of FS, diagnostic protocols using FS for first-line investigation must be able to demonstrate INTRODUCTION NIHR Journals Library www.journalslibrary.nihr.ac.uk favourable risk-benefit profiles, in which the benefits of this less invasive procedure are balanced against the risk of a missed diagnosis of proximal cancer. [34][35][36] The use of such protocols is likely to be most relevant in clinical practice for which the clinical index of suspicion for proximal colon cancer is low, for example when patient and symptom profiles favour a diagnosis of distal CRC.…”

Section: Computerised Tomography Colonographymentioning

confidence: 99%

“…16,31,33,52 Another symptom associated with a proximal colon cancer diagnosis is unexplained weight loss. 53 Weight loss, similar to IDA and abdominal mass, could be symptomatic of more advanced disease 16 and might be related to the observation by some that proximal disease is often diagnosed at a more advanced stage.…”

Section: Symptoms Suggestive Of Distal Colorectal Cancermentioning

confidence: 99%

“…In patients with CRC, distal lesions were associated with a CIBH and rectal bleeding. No patients with rectal bleeding alone had a proximal cancer 31 and proximal disease was associated with anaemia (defined by low Hb level). A total of 88 (70%) out of 126 CRCs (the subset diagnosed in the outpatient setting) diagnosed in this cohort were in the distal colorectum.…”

Section: Tailoring Initial Investigations For Suspected Colorectal Camentioning

confidence: 99%

“…The initial diagnostic tool used to investigate the majority of patients with CRC diagnoses was colonoscopy; only 11% of patients were initially investigated by FS, compared with 50% initially investigated by colonoscopy. 31 In a response to this study, other authors carried out an audit of 835 colonoscopies performed at their London hospital. 30 In this audit, there were 177 CRC diagnoses between January 2008 and December 2009, and 45 (25%) of these were proximal colon cancers.…”

Section: Tailoring Initial Investigations For Suspected Colorectal Camentioning

confidence: 99%

See 4 more Smart Citations

Is whole-colon investigation by colonoscopy, computerised tomography colonography or barium enema necessary for all patients with colorectal cancer symptoms, and for which patients would flexible sigmoidoscopy suffice? A retrospective cohort study

Atkin

Wooldrage

Shah

et al. 2017

Health Technol Assess

View full text Add to dashboard Cite

BackgroundFor patients referred to hospital with suspected colorectal cancer (CRC), it is current standard clinical practice to conduct an examination of the whole colon and rectum. However, studies have shown that an examination of the distal colorectum using flexible sigmoidoscopy (FS) can be a safe and clinically effective investigation for some patients. These findings require validation in a multicentre study.ObjectivesTo investigate the links between patient symptoms at presentation and CRC risk by subsite, and to provide evidence of whether or not FS is an effective alternative to whole-colon investigation (WCI) in patients whose symptoms do not suggest proximal or obstructive disease.DesignA multicentre retrospective study using data collected prospectively from two randomised controlled trials. Additional data were collected from trial diagnostic procedure reports and hospital records. CRC diagnoses within 3 years of referral were sourced from hospital records and national cancer registries via the Health and Social Care Information Centre.SettingParticipants were recruited to the two randomised controlled trials from 21 NHS hospitals in England between 2004 and 2007.ParticipantsMen and women aged ≥ 55 years referred to secondary care for the investigation of symptoms suggestive of CRC.Main outcome measureDiagnostic yield of CRC at distal (to the splenic flexure) and proximal subsites by symptoms/clinical signs at presentation.ResultsThe data set for analysis comprised 7380 patients, of whom 59% were women (median age 69 years, interquartile range 62–76 years). Change in bowel habit (CIBH) was the most frequently presenting symptom (73%), followed by rectal bleeding (38%) and abdominal pain (29%); 26% of patients had anaemia. CRC was diagnosed in 551 patients (7.5%): 424 (77%) patients with distal CRC, 122 (22%) patients with cancer proximal to the descending colon and five patients with both proximal and distal CRC. Proximal cancer was diagnosed in 96 out of 2021 (4.8%) patients with anaemia and/or an abdominal mass. The yield of proximal cancer in patients without anaemia or an abdominal mass who presented with rectal bleeding with or without a CIBH or with a CIBH to looser and/or more frequent stools as a single symptom was low (0.5%). These low-risk groups for proximal cancer accounted for 41% (3032/7380) of the cohort; only three proximal cancers were diagnosed in 814 low-risk patients examined by FS (diagnostic yield 0.4%).LimitationsA limitation to this study is that changes to practice since the trial ended, such as new referral guidelines and improvements in endoscopy quality, potentially weaken the generalisability of our findings.ConclusionsSymptom profiles can be used to determine whether or not WCI is necessary. Most proximal cancers were diagnosed in patients who presented with anaemia and/or an abdominal mass. In patients without anaemia or an abdominal mass, proximal cancer diagnoses were rare in those with rectal bleeding with or without a CIBH or with a CIBH to looser and/or more frequent stools as a single symptom. FS alone should be a safe and clinically effective investigation in these patients. A cost-effectiveness analysis of symptom-based tailoring of diagnostic investigations for CRC is recommended.Trial registrationCurrent Controlled Trials ISRCTN95152621.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 21, No. 66. See the NIHR Journals Library website for further project information.

show abstract

Section: Tailoring Initial Investigations For Suspected Colorectal Casupporting

confidence: 78%