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

OBJECTIVE: To identify the clinical features of colorectal cancer presenting as a surgical emergency. DESIGN: Population-based case-control study. SETTING: All general practices in Exeter Primary Care Trust, Devon, UK. Participants. 349 patients with colorectal cancer, 62 of these having an emergency presentation. Five randomly selected controls matched by age, sex and general practice for each case. DATA: The entire primary care record, from 24 months to 30 days before diagnosis, was coded using the International Classification of Primary Care-2. MAIN OUTCOME MEASURES: Symptom reporting by patients with emergency presentation of colorectal cancer compared with matched controls and non-emergency presentations. RESULTS: Eight features of colorectal cancer were associated with the 62 emergency presentations of colorectal cancer. 39 (63%) of patients had reported at least one symptom to their doctors a minimum of 30 days before the diagnosis. In multivariable analysis, three features remained independently associated with cancer: abdominal pain, odds ratio 6.2 (95% CI 2.8-14), P<0.001; loss of weight 3.4 (1.3-8.5), P=0.01; and diarrhoea 3.4 (1.2-5.7), P=0.02. When emergency presentations were compared with elective cases, abdominal pain was more common [interaction odds ratio 2.3 (1.6-3.3); P=0.047] and rectal bleeding less common [0.30 (0.08, 1.0); P=0.040]. CONCLUSION: The majority of patients destined to have an emergency presentation of colorectal cancer have reported symptoms of their cancer to their doctor well before the emergency. Some emergency presentations should therefore be preventable.     

Diagnosis of colorectal cancer in primary care: the evidence base for guidelines

BACKGROUND: Colorectal cancer is common, causing approximately 11% of cancer deaths in the UK. However, a GP would only expect to see one new presentation each year. Referral guidelines outlining clinical scenarios of high risk have been published. These aim to help GPs select patients for rapid investigation. OBJECTIVES: The purpose of this study was to review the presenting features of colorectal cancer in primary care, using the basic structure of the UK Referral Guidelines for Suspected Cancer. METHODS: A structured literature review was carried out. RESULTS: Two symptoms have a high predictive value for cancer: rectal bleeding and change in bowel habit towards increased looseness or increased stool frequency. Other symptoms, such as abdominal pain, are so prevalent in the community that they have little predictive value. There is little published evidence on abdominal or rectal masses and iron deficiency anaemia as presenting features for colorectal cancer. However, these are so likely to have an important cause, investigation is mandated. Two areas in the Referral Guidelines are questioned: the need to defer investigation of change in bowel habit towards increased looseness or increased stool frequency for 6 weeks, and the low risk nature of constipation. CONCLUSION: The Referral Guidelines have a reasonable evidence base.     

The clinical assessment of patients with large bowel symptoms by general practitioners

Objective: To describe the nature and extent of the clinical assessment of patients prior to referral for barium enema examinations within a health district in the UK.

Method: By means of a modified barium enema request form, general practitioners' clinical practices prior to making requests for a barium enema examination were examined over the course of one year. Using a request form with a ‘tear-off’ slip, GPs in Hudders-field, UK, were asked to indicate up to two primary reasons for referral, provide some simple demographic details on patients and to indicate what specific clinical activities had been undertaken prior to ordering a barium enema.

Results: Over the course of the one-year study period, 275 modified x-ray request forms were returned. In relation to the 326 primary reasons given for referral these were subdivided into change in bowel habit (101 [42%]), abdominal pain (55 [23%]), frank or occult rectal bleeding (26 [11%]), weight loss (21 [9%]), iron-deficiency anaemia (6 [3%]), and other (117 [49%]). Patients presenting for barium enema examinations were only likely to have had a rectal examination in 72% of situations, an abdominal examination in 89% and a full blood count in 38%. Proctoscopy was very infrequently performed. In relation to the primary reason for referral, 72% had undergone a rectal examination if they had had a change in bowel habit (90% an abdominal examination). If the patients being referred had experienced abdominal pain, 60% of these would have had a rectal examination and 91% an abdominal examination. No significant effect of age on the tendency to perform rectal or abdominal examinations was noted. Any patient presenting for a barium enema was significantly more likely to have had an abdominal than a rectal examination (odds ratio=3.23 [1.99-5.27]).

Conclusions: This study, taken in context, highlights a need to encourage the adoption of a more rational approach to the assessment of patients within primary care settings. Unfortunately the available evidence to assist general practitioners in the diagnosis of colorectal cancer amongst the types of patients they encounter and in the settings where they work remains unsatisfactory.     

Detection of laryngeal cancer--the case for early specialist assessment.

The first 300 patients referred from 11 participating general practices (GPs) to the Hoarse Voice Clinic, Queen Elizabeth Hospital, Birmingham, were studied prospectively to estimate the accuracy of GPs' diagnosis of laryngeal symptoms and to assess whether the provision of a direct referral immediate access service for the assessment of persistent laryngeal symptoms is an effective way of ensuring early referral and detection of laryngeal cancer. The GPs' assessment of laryngeal symptoms was inaccurate. Diagnosis after the initial clinic visit was accurate, predicting all histological cases of cancer. Laryngoscopy was possible in all patients at the first clinic visit. Disease requiring admission for direct laryngoscopy and biopsy was found in 39 patients (14%). Ten (3.3%) were found to have laryngeal cancer, of which eight were early lesions. When seen in the clinic 102 (34%) had normal voices and larynxes. A hoarse voice is a symptom requiring specialist assessment. By using the flexible fibreoptic nasendoscope all patients larynxes can be seen in clinic, an accurate diagnosis quickly made and the appropriate management instigated. It is feasible to offer this service without appointments to patients with persistent hoarseness.     

Compliance with professional guidelines with reference to familial cancer services

Objective: Professional guidelines define the risk categorisation of patients for a genetic predisposition to cancer based on family history. These guidelines inform the appropriate referral of patients to specialist familial cancer services. Our study aimed to determine the quality of referral letters from general practitioners and specialists to genetic services for breast, ovarian and colorectal cancers, and their compliance with relevant professional guidelines. Methods: A retrospective review of the referral letters and patient files of 241 consecutive patients referred between June and October 2008. Results: Sufficient information to make a risk assessment was provided in 71% of referrals. Of these, 89% were compliant with guidelines. Genetic counsellors collected further information on 167 of the 241 referred patients and of these 83% were appropriate for referral according to guidelines. Conclusions and implications: Overall, referrals to familial cancer genetic services complied with professional referral guidelines. The majority of referrals were high quality, and with additional information, most patients were shown to be appropriate for review in a familial cancer clinic. Despite this, a better understanding of the reasons for non compliant referrals, and appropriate targeted education and resources is recommended to improve referral quality and compliance.     

General practitioner referral of patients with lower gastrointestinal symptoms.

Of 500 consecutive patients with symptoms of colorectal disease referred to a specialist hospital for outpatient assessment, 305 were studied. There was a low incidence of examination by the general practitioner; less than half the patients had a rectal examination and 31% had no examination at all. In cases where GPs made a diagnosis, this was correct in half, which both demonstrates the potential for dangerous misdiagnosis and confirms the fact that many anorectal conditions can be identified by the history alone. It is suggested that direct-access clinics in a colorectal unit would minimize delay in accurate diagnosis. The resource implications for such a system would be limited in terms of special investigations and additional clinic facilities.     

Less haste more speed: factors that prolong the interval from presentation to diagnosis in some cancers

BACKGROUND: In the UK, the GP is the gatekeeper to specialist services in addition to many other roles. Recently, the GP is also expected to select cases that warrant 'urgent' as opposed to 'routine' specialist investigation. Failure to refer on the appropriate timetable may have implications for timely diagnosis. OBJECTIVE: Our aim was to explore the circumstances in which the diagnosis of cancer is delayed with reference to the primary care records and by a structured investigation of clinical records in one practice. METHODS: The study was set in an urban group practice serving a mixed population of deprived and affluent communities. List size was 10 440 patients, with five whole time equivalent partners and three practice nurses. The appointment system was fully computerized and there were no personal lists. Records for all cases with specified common cancers diagnosed since 1990 and still registered in the practice were reviewed. The interval from presentation to referral, referral to diagnosis and presentation to diagnosis was compared for a series of factors including 'urgent' referral. The clinical team currently working in the practice conducted a structured review of the case records for the most delayed cases. RESULTS: Fifty-four cases were listed in the practice. A series of factors were identified as having a bearing on delayed diagnosis, including a reticence on the part of patients to seek to expedite specialist appointments, failures of communication, and patients presenting multiple problems in short general practice consultations. The action plan agreed by the clinical team includes improving the quality of communication with secondary care, follow-up of patients who have been referred for radiological or ultrasound investigation and reviewing patients who fail to attend specialist clinics. CONCLUSIONS: The data imply that delays sometimes result from avoidable errors before and after referral and especially by the patient entering secondary care on the wrong pathway. Improving the patients' experience in health care requires the provider to take a global view of the service. Primary care is not merely a filter but influences and is influenced by policies in other parts of the health care system.     

Waiting times for treatment of rectal cancer in North West England

An interim goal of the NHS National Cancer Plan is that, by 2005, patients with cancer should be treated within one month of diagnosis and within two months from urgent general practitioner referral. Preoperative radiotherapy for rectal cancer reduces the risk of local recurrence and may translate into improved patient survival. We conducted a prospective audit of existing waiting times for preoperative radiotherapy experienced by 65 patients with rectal cancer referred to the Christie Cancer Centre, Manchester, UK, between May and November 2002. The median time between referral from the surgeon to the start of radiotherapy was 40 days (range 11-85). Only 4 patients (6%) received radiotherapy within 28 days of referral by the surgeon. 62 patients (95%) underwent surgery within 14 days of completing radiotherapy. Delays in the provision of preoperative radiotherapy were primarily due to shortages of radiography staff and equipment. Lack of such infrastructure will prove a major stumbling block to achieving the targets of the NHS Cancer Plan.     

Diagnosis of lung cancer in primary care: a structured review

BACKGROUND: Lung cancer has the highest cancer incidence and mortality in the UK. Despite this, an individual GP encounters only one new presentation approximately every 8 months, so gains relatively little experience of its diagnosis. This is partly addressed by referral guidelines which aim to help GPs in selection of patients for chest X-ray or referral for specialist investigation. OBJECTIVE: The purpose of this study was to review the primary care presenting features of lung cancer, in the light of the UK Referral Guidelines for Suspected Cancer. METHODS: A structured literature review was carried out. RESULTS: Little research has been undertaken in primary care, and the predictive values for most symptoms are unknown. Approximate likelihood ratios could be calculated for six symptoms or signs: haemoptysis 13; fatigue 5.7; cough 5.3; finger clubbing 3.9; weight loss 2.9; and dyspnoea 1.5-5.7, but none of these figures derived from single primary care studies. Three recommendations for urgent investigation of possible lung cancer in the UK Referral Guidelines are questioned: for unexplained dyspnoea, hoarseness or cervical lymphadenopathy. For all these presentations, other serious diagnoses are more likely. CONCLUSION: The UK Guidelines for referral of suspected lung cancer have a weak evidence base.     

The contribution of bone densitometry to the diagnosis and treatment of osteoporosis

Objective: It has recently been proposed that a specialist osteoporosis service, including bone densitometry, should be made available to those most at risk in the UK population. The aim of this study was to evaluate such a service, and in particular the role of bone densitometry, in terms of its effect on the diagnosis of osteoporosis and clinical management of the disease.Methods: A retrospective data abstraction study was performed to investigate the diagnosis and management of patients referred to the Metabolic Clinic, City Hospital Nottingham, with a potential diagnosis of osteoporosis. Hospital records were available for 117 patients, aged between 45 and 59, who had attended the Clinic in a given time period and undergone bone mineral density measurement.Results: Forty-eight patients (41.0%) had osteoporosis of the lumbar spine. The final diagnosis of osteoporosis after attending the clinic was different from that on referral in a substantial proportion (62.6%) of cases. Only 48.9% of patients with spinal osteoporosis were identified by their referring doctor. The percentage of patients receiving treatment for osteoporosis increased from 34.2% to 72.6% after attending the clinic.Conclusions: Measurement of bone mineral density identifies cases of osteoporosis who would not otherwise be detected and as a consequence contributes to the proportion of patients receiving treatment after referral. The osteoporosis service provided by the Metabolic Clinic including measurement of bone mineral density was thus found to have a considerable impact on the diagnosis and treatment of patients with osteoporosis.     

Facilities for investigating occupational asthma in UK non-specialist respiratory departments

BACKGROUND: The facilities which should be available to physicians offering specialist occupational asthma services have recently been agreed upon by a UK panel of experts. AIMS: This study aimed to investigate whether these facilities are available in UK non-specialist secondary care respiratory departments and to document tertiary care referral patterns. METHODS: A random sample of 100 UK respiratory units was selected, and the lead consultant invited to participate. Face-to-face interviews were conducted to document information on departmental facilities available for investigating cases of occupational asthma and utilization of tertiary referral centres. RESULTS: In total, 66% of consultants interviewed had seen a case of occupational asthma in the previous month, and 76% reported having ever referred a patient with suspected occupational asthma to a specialist centre for further investigation (referral distance range 1-111 miles). All the departments were able to perform the investigations previously deemed an absolute necessity in all patients. The availability of in-house facilities that were deemed as must be available varied between 3-100%. CONCLUSIONS: The results of this study demonstrate that while the majority of basic facilities are widely available, many respiratory departments do not have direct access to investigations routinely required to investigate occupational asthma. Access to specialist occupational respiratory centres varies within the UK, and in some parts of the country involves long travelling distances for patients.     

Is travel-time to a specialist centre a risk factor for non-referral,non-attendance and loss to follow-up among patients with hepatitis C (HCV) infection?

Little is known about why many people diagnosed with hepatitis C virus (HCV) infection fail to reach and stay within specialist care services. We used a Geographic Information System and logit regression to investigate whether travel-time to a specialist centre was associated with an increased likelihood of non-referral, non-attendance and loss to follow-up among persons diagnosed with HCV between 1991 and 2003 in Tayside, Scotland (UK). Information was available on referral to, and utilisation of, the single HCV specialist centre in Tayside between 1991 and 2006. Longer travel-time to a specialist centre was associated with an increased likelihood of non-referral to a specialist centre following diagnosis (Odds Ratio: 1.25, 95% Confidence Interval: 1.09, 1.44). Patients living further from an HCV specialist centre were less likely to be referred to it for treatment that could cure their HCV infection. Neither a history of intravenous drug use (IDU), nor area deprivation predicted non-referral. Subsequent to referral, travel-time to a specialist centre was not associated with either non-attendance (0.83 (0.56, 1.21)) or loss to follow-up (0.98 (0.78, 1.22)), although a history of IDU was a strong predictor of both non-attendance and loss to follow-up. Non-attendance was less likely among older patients, while loss to follow-up was more common among those living in deprived areas. Once referred, patients appear able to cope with stress and financial cost of long and frequent journeys to hospital. However, as rates of referral improve from more geographically remote areas, long travel-times to an HCV specialist centre may become an important factor determining future utilisation.     

The 2-week rule for patients with suspected breast cancer: what can be learnt by analysing policy documents?

The '2-week rule', introduced in the UK during 1999, represents a significant organisational change for referral of patients with suspected breast cancer. From an analysis of policy documents, a mixture of influences and agendas from different interest groups are apparent in the current working of the policy. These include political/modernisation agendas with a variety of aims including: reducing variation in care, efficient administration, reassuring patients, improving public confidence, earlier referral and lowering the threshold for referral to improve mortality figures. Specialist agendas, exemplified by the guidelines for referral under the policy but apparent in preceding specialist literature, represent an attempt to modify the working of the policy to ensure that high proportions of those women referred have breast cancer. The agendas of these interest groups are in conflict and have implications for the future development of this particular policy. Similar considerations are likely to apply more widely to other controversial health policy developments. It may be of value to identify the agendas of the groups responsible for the introduction of such policies, as well as the agendas of groups with influence on how the policy is actually implemented, and assess the areas of conflict.     

The role of the nurse endoscopist

Colorectal nurse specialist roles have developed since the publication of the Calman-Hine report, with most of the post-holders dealing specifically with patients with a diagnosis of colorectal cancer. While posts vary, many of these nurses also perform endoscopy as part of their role.     

Referral pattern of patients received at the national referral hospital: challenges in low income countries

OBJECTIVE: To examine the medical referral pattern of patients received at the Muhimbili National Hospital (MNH) in order to inform the process of strengthening the referral system. METHODS: The study design was a prospective study conducted at MNH during a 10-week study period from January to March 2004. The study sample consisted of patients referred to MNH. RESULTS: Of the 11,412 patients seen, 72.5% were self-referrals. More than 70% of the patients seen required admission, though not necessarily at tertiary level. Only 0.8% came from outside the Dar es Salaam region. More than 70% of the patients seen required admission. Surgical services were required by 66.8% of patients, with obstetric conditions being most prominent (24.6% of all patients). For those who were formally referred from other health services, lack of expertise and equipment were the most common reasons given for referral (96.3%). CONCLUSION: Efforts to improve referral systems in low-income countries require that the primary and secondary level hospitals services be strengthened and increased so as to limit inappropriate use of national referral hospitals.     

In the absence of evidence, who chooses? A qualitative study of patients' needs after treatment for colorectal cancer

OBJECTIVES: To identify the range of patient pathways following surgery for colorectal cancer and explore patients' needs and preferences for follow-up. METHODS: A survey of hospitals within the UK Colorectal Cancer Services Collaborative and qualitative thematic analysis of 39 in-depth narrative interviews with colorectal cancer patients. Participants volunteered or were contacted through hospital consultants, support groups and general practitioners (GPs). Most of the interviews were collected in respondents' homes, throughout the UK. RESULTS: Thirty-five (70%) hospitals supplied details of their follow-up regime. There was a wide variation: only three hospitals specifically stated that patients were given a choice about the type of follow-up. The patients' interviews highlighted their need for a responsive GP and realistic information about recovery, resources and diet. Choice is particularly important because patients differ in their views of the benefits of hospital follow-up. CONCLUSIONS: The absence of evidence about what constitutes ideal clinical follow-up for colorectal cancer is reflected in current hospital practice. In such circumstances, the preferences of individual patients are particularly important. Not all patients want repeated specialist investigations but those without stomas, and therefore no access to a stoma nurse, need another source of advice about recovery and long-term practical help. Follow-up care organised by GPs may be acceptable to many patients. We suggest a list of topics for GPs to discuss with their patients about follow-up. The needs described by patients are not extensive and could often be met by existing resources.     

Paediatric referrals in rural Tanzania: the Kilombero District Study - a case series

BACKGROUND: Referral is a critical part of appropriate primary care and of the Integrated Management of Childhood Illness (IMCI) strategy. We set out to study referrals from the aspect both of primary level facilities and the referral hospital in Kilombero District, southern Tanzania. Through record review and a separate prospective study we estimate referral rates, report on delays in reaching referral care and summarise the appropriateness of pediatric referral cases in terms of admission to the pediatric ward at a district hospital METHODS: A sample of patient records from primary level government health facilities throughout 1993 were summarised by age, diagnosis, whether a new case or a reattendance, and whether or not they were referred. From August 1994 to July 1995, mothers or carers of all sick children less than five years old attending the Maternal and Child Health (MCH) clinic or outpatient department (OPD) of SFDDH were interviewed using a standard questionnaire recording age, sex, diagnosis, place of residence, whether the child was admitted to the paediatric ward, and whether the child was referred. RESULTS: From record review, only 0.6% of children from primary level government facilities were referred to a higher level of care. At the referral hospital, 7.8 cases per thousand under five catchment population had been referred annually. The hospital MCH clinic and OPD were generally used by children who lived nearby: 91% (n = 7,166) of sick children and 75% (n = 607) of admissions came from within 10 km. Of 235 referred children, the majority (62%) had come from dispensaries. Almost half of the referrals (48%) took 2 or more days to arrive at the hospital. Severe malaria and anaemia were the leading diagnoses in referred children, together accounting for a total of 70% of all the referrals. Most referred children (167/235, 71%) were admitted to the hospital paediatric ward. CONCLUSIONS: The high admission rate among referrals suggests that the decision to refer is generally appropriate, but the low referral rate suggests that too few children are referred. Our findings suggest that the IMCI strategy may need to be adapted in sparsely-populated areas with limited transport, so that more children may be managed at peripheral level and fewer children need referral.     

Are Grampian general practitioners good gatekeepers for access to emergency general surgical care?

BACKGROUND: Direct admission from primary care is the predominant emergency general surgical referral route in north-east Scotland. Recent primary and secondary care reconfiguration has increased resources necessary to support the current system, therefore alternative models are proposed. We seek to analyse frequency and accuracy of provisional diagnosis by general practitioners within our current admission system. METHOD: Presence of referral letter, provisional diagnosis, discharge diagnosis and management were prospectively recorded for all emergency general surgical admissions to Aberdeen Royal Infirmary over three weeks. RESULTS: One hundred and sixty three primary care admissions: 69.3% from patient's own practice and 30.7% from the out-of-hours service. Of these patients 98.1% came with a referral letter, 86.1% including a provisional diagnosis, which was correct in 43.6% of cases. Fourteen patients (8.6%) were transferred to another ward for treatment. DISCUSSION: General practitioners provide written provisional diagnoses with most referrals, accurate in almost half of cases, with only a minority of patients requiring transfer for management of presenting problems. This is despite limited investigations, clinical isolation, restricted facilities for examination and limited time for assessment. We believe Grampian general practitioners are good gatekeepers to emergency general surgical care and support the current direct admission pathway.     

大肠癌153例临床、肠镜及病理分析

目的探讨153例大肠癌的临床、肠镜及病理特点。方法回顾性总结我院2003年~2006年153例大肠癌患者,按年龄段分≤39岁组、40~59岁组及≥60岁组,分析其临床、肠镜及病理特点。结果153例大肠癌病例中40~59岁组人数最多,为67例,占43.79%。临床表现主要以便血为主,其次为腹痛、大便异常;≥60岁组以便血就诊的占75.00%,≤39岁组以腹痛就诊的占70.00%,说明临床症状具不典型性。大肠癌好发部位以直肠、左半结肠为主,各占44.44%及32.03%。病理结果分析,各组以高-中分化腺癌为主;≤39岁组低分化腺癌、印戒细胞癌及黏液细胞癌共占30.00%(9/30),明显高于≥60岁组和40~59岁组。结论大肠癌好发于中老年人,但青年人亦不容忽视,癌肿恶性程度高者占较高比例;大肠癌早期临床症状不典型,易误诊。在无症状老年人中开展筛检普查,对可疑病人进行肠镜检查,可大大提高大肠癌的早期诊断,改善大肠癌患者的预后。大肠癌好发于直肠,故部分病例可通过肛诊提供早期诊断依据。     

Treating patients with colorectal cancer in rural and urban areas: a qualitative study of the patients' perspective

OBJECTIVES: The aim of the present study was to explore the perspectives of patients receiving treatment for colorectal cancer and compare priorities and attitudes in rural and urban areas. METHOD: A qualitative study was carried out involving four focus groups in the Aberdeen and Northern Centre for Haematology, Oncology and Radiotherapy. The sample comprised 22 patients at various stages of treatment for colorectal cancer and 10 of their relatives from different locations of Northeast Scotland and Shetland. The main themes generated by participants were identified, and similarities and differences between urban and rural patients were noted within these themes. RESULTS: Components of care that were important to rural and urban patients were speed of referral to specialists for treatment and issues of communication including test results and delivery of bad news. Tensions were perceived at the interface of primary and secondary care and these were blamed for delays in referral and communication breakdowns. For some, the referral process comprised a series of barriers to be overcome, and there were additional hurdles for remote patients referred initially to local (non-specialist) hospitals. Rural patients appeared to be less demanding than their urban counterparts when evaluating their care, and this was extended to the acceptance of some clear transport problems. CONCLUSIONS: For patients, the most important components of cancer care were similar, whether rural or urban residents. The main differences for rural patients were lower expectations of care and more hurdles before reaching specialist care. These differences might explain the trend to more advanced disease at diagnosis in rural patients if they lead to significant delays. GPs have major influences on this and all the patients' priorities.