Timely Diagnosis of Colorectal Cancer

125 Pages·2018·1.658 MB·English

by  Louise Olsson (eds.)

Louise Olsson
Editor
Timely Diagnosis
of Colorectal Cancer
123
Timely Diagnosis of Colorectal Cancer
Louise Olsson
Editor
Timely Diagnosis of
Colorectal Cancer
Editor
Louise Olsson
Karolinska Institutet
Stockholm
Sweden
ISBN 978-3-319-65285-6 ISBN 978-3-319-65286-3 (eBook)
https://doi.org/10.1007/978-3-319-65286-3
Library of Congress Control Number: 2017956940
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Preface
An overwhelming majority of colorectal cancer patients worldwide are diagnosed
via the clinical route. Screening programmes are not implemented in all countries,
compliance rates are far from complete, and the screening test itself is likely not to
be fully sensitive. The aim of this book is therefore to target the searchlight, not on
screening but on the important and difficult task of diagnosing colorectal cancer in
symptomatic patients.
The design of the diagnostic process, or simply ordinary clinical work to diag-
nose disease, naturally involves those who are finally found to harbour a cancer. But
it also involves a large number of patients who seek an explanation of their symp-
toms, potentially associated with bowel cancer. The challenge, in spite of all the
alternative benign explanations, is to establish the diagnosis of colorectal cancer in
a timely manner.
In our era of abundant information, and some disinformation, on the Internet, the
acceptance of all but a very prompt investigation of symptoms possibly associated
with serious diseases like cancer is decreasing. The claims from patients to rule out
colorectal cancer very early on will probably get more pronounced. In addition,
many countries face ageing populations, with an increasing risk of both gastrointes-
tinal symptoms and colorectal cancer.
This book will be of interest to all professionals who struggle with these issues.
Whether you are a qualified clinician, perhaps with a special interest in colorectal
cancer, or a dedicated clinical researcher, the chapters will provide you with knowl-
edge and inspiration at a cutting-edge level. Together they evoke some optimism for
the way forward.
Non-invasive tests for an optimal selection of patients and further adequate
examinations of the large bowel are crucial to sustain the increasing demands. You
will find a hopeful chapter on the merits of faecal immunochemical tests, and a bal-
anced discussion on computed tomographic colonography and colonoscopy. A new
idea worth further exploration is the ability to make better use of already collected
haemoglobin values by using computerized algorithms for trend analyses. The low
predictive value of bowel symptoms is highlighted separately and, on the other
hand, there is a valuable account of standardized colorectal cancer pathways based
on the referral of alarm symptoms. You will also find two very thought-provoking
chapters on a poor general awareness of colorectal cancer and on the psychological
implications of diagnostic delay.
v
vi Preface
Let’s hope the book will bring about many further optimizing ideas on how to
proceed in the future. After all, a timely diagnosis is associated not only with a swift
procedure, but also with a high clinical quality in the management of patients.
Welcome to some rewarding hours of reading, and to share my appreciation of the
authors. I also wish to express my gratitude to Evgenia Koutsouki at Springer for
her professional support. Thank you all!
Stockholm, Sweden Louise Olsson
Contents
1 Awareness of Colorectal Cancer: Recognition of Symptoms
and Risk Factors by Socio-demographic Characteristics . . . . . . . . . . . . 1
Maja Niksic and Lindsay J.L. Forbes
2 Bowel Symptoms in Relation to Colorectal Cancer . . . . . . . . . . . . . . . . 21
Barbara-Ann Adelstein, Petra Macaskill, Peter H. Katelaris,
and Les Irwig
3 Faecal Immunochemical Tests (FIT) for Haemoglobin for Timely
Assessment of Patients with Symptoms of Colorectal Disease . . . . . . . 39
Robert J.C. Steele and Callum G. Fraser
4 Enhancing Earlier Diagnosis of Colorectal Cancer by Algorithmic
Analysis of Trends in Complete Blood Counts . . . . . . . . . . . . . . . . . . . 67
Varda Shalev, Inbal Goldshtein, Gideon Koren, Pinchas Akiva,
and Ran Goshen
5 Investigating Symptoms Suggestive of Colorectal Cancer:
Computed Tomographic Colonography or Colonoscopy? . . . . . . . . . . 77
A.A. Plumb and S. Halligan
6 Standardised Investigation and Referral of Alarm Symptoms
for Colorectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Jane Young and Michael Solomon
7 The Psychological Implications of Diagnostic Delay
in Colorectal Cancer Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Anne Miles
vii
Awareness of Colorectal Cancer: 1
Recognition of Symptoms and Risk
Factors by Socio-demographic
Characteristics
Maja Niksic and Lindsay J.L. Forbes
Key Points

• Only about 10% of participants, in a large survey of the English population, were
aware that colorectal cancer is the third most common type of cancer in men and
women.
• Almost half of participants could not recall any symptom (46%) or any risk fac-
tor (44%) for colorectal cancer.
• Awareness about cancer symptoms and risk factors varied greatly between dif-
ferent demographic groups, but the lowest awareness overall was observed
among the most socio-economically deprived people.
• Over a third of participants (38%) reported that they would delay help-seeking
for more than 2 weeks for “unexplained weight loss”, but only 5% reported this
for “unexplained bleeding”.
• The results suggest an urgent need to improve public awareness of colorectal
cancer symptoms symptoms and encourage early presentation.
1.1 Introduction
Colorectal cancer is the third most common malignant tumour diagnosed in males
and the second in females, with over 1.3 million new cases and 694,000 deaths esti-
mated to have occurred worldwide in 2012 [1]. In England it is the third most com-
mon type of cancer in both men and women [2]. In comparison with similar
high-income countries such as Australia, Canada, Denmark, Norway, and Sweden,
M. Niksic (*)
Cancer Survival Group, Department of Non-Communicable Disease Epidemiology,
London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
e-mail: [email protected]
L.J.L. Forbes
Centre for Health Services Studies, University of Kent, Canterbury CT2 7NZ, UK
© Springer International Publishing AG 2018 1
L. Olsson (ed.), Timely Diagnosis of Colorectal Cancer,
https://doi.org/10.1007/978-3-319-65286-3_1
2 M. Niksic and L.J.L. Forbes
England has the lowest survival from colorectal cancer [3, 4]. Possible reasons for
this finding include lack of awareness of cancer symptoms and late diagnosis [5–7].
A recent study reported that higher cancer symptom awareness is associated with
better cancer survival, highlighting the need for effective early presentation cam-
paigns [8].
Many people are not aware of early symptoms of colorectal cancer. Yardley et al.
[9] reported that 69% of the general population in the UK was not able to identify a
single symptom of colorectal cancer. Among patients attending a colorectal clinic in
England, only 37% of patients could name a bowel cancer symptom [10]. This sug-
gests that awareness of colorectal cancer symptoms was low, even among people who
experienced some of the symptoms. Based on a national survey of 1520 people, Power
et al. [11] concluded that people in England have relatively poor recognition of early
symptoms of colorectal cancer, particularly when open-ended (unprompted recall)
questions were used. Average recall was less than one symptom per person. “Change
in bowel habit” was mentioned by only 23% of participants, “blood in stools” by 15%,
less than 10% of participants mentioned any other symptom, and 25% stated they did
not know any symptom of colorectal cancer. Although recognition of symptoms was
better if prompted with a list of symptoms rather than with an open-ended question,
men, younger participants, and the most socio-economically disadvantaged groups
were least likely to recognise early cancer symptoms. More than 76% of participants
recognised that a change in bowel habit, bleeding from the back passage, blood in
stools and pain in abdomen could be symptoms of colorectal cancer.
Women and the socio-economically disadvantaged people had the lowest knowl-
edge of risk factors for colorectal cancer [11]. For example, only 9% of people
recalled that being overweight was a risk factor, and 37% recognised this factor
from the list; 19% of people recalled that drinking alcohol was a risk factor, and
46% recognised it from the list; while older age was recalled by only 3% of people,
45% recognised this factor from the list. Similar results were reported in another
study, where recall and recognition of colorectal cancer symptoms and risk factors
was even lower [12]. One of the limitations of previous studies is that they have
included few people from the oldest, youngest and most socio-economically disad-
vantaged groups, and the analyses were often not adjusted for potential confounding
factors.
A systematic review concluded that poor recognition of symptoms of colorectal
cancer and their seriousness increased delay in seeking medical help [13]. The
researchers found no association between delay in help-seeking and patients’ age,
gender and socioeconomic position. In contrast, Robb et al. [14] found that people
with lower socio-economic position (SEP) reported that they would take longer
before seeking help for early symptoms of colorectal cancer and other common
cancers than those with higher SEP. It seems that delay in help-seeking is more
likely in patients diagnosed with colorectal cancer, than, for example, breast or
bladder cancer [15]. However, not all symptoms appear to be linked with delay.
Unexplained bleeding, especially rectal bleeding was linked with delay in help-
seeking [15, 16], while change in bowel habit was reported to be a risk factor for
delay in some studies [15, 17] but not in others [16, 18]. It is not clear which risk
1 Awareness of Colorectal Cancer: Recognition of Symptoms and Risk Factors 3
factors are associated with delay in help-seeking, and how long it takes to visit a GP
after noticing some of the most common symptoms of colorectal cancer.
To address these issues, we aimed to assess public awareness of symptoms of
colorectal cancer, anticipated time to help-seeking in relation to these symptoms,
knowledge about the most common types of cancer and risk factors for diagnosis of
colorectal cancer in the English population, and whether these vary by socio-
demographic factors.
1.2 Materials and Methods
We collated a uniquely large data set (n = 47,270), which allowed us to examine
recall and recognition of cancer symptoms, risk factors and anticipated time to help-
seeking with high statistical power, even after controlling for potential confounding
factors. The data set included 18 cross-sectional surveys carried out across England
during 2009/2011, which used the Cancer Research UK Cancer Awareness Measure
(CAM) [19]. This is the first validated measure of public cancer awareness. The
response rate was 51%. A more detailed description of the surveys and data collec-
tion procedure can be found elsewhere [20].
To explore whether participants are aware of the most common cancers in men
and women, we asked the following questions: “What do you think is the most/
second most/third most common cancer in women?”, and “What do you think is the
most/second most/third common cancer in men?”. Awareness of cancer symptoms
was measured with two types of questions, unprompted (open) and prompted (inter-
viewer reads the list of possible answers). The unprompted question about cancer
symptom was: “There are many warning signs and symptoms of cancer. Please
name as many as you can think of”. Cancer symptom awareness was also measured
using the prompted question: “The following may or may not be warning signs of
cancer. We are interested in your opinion. Do you think X is a warning sign for can-
cer?” (Yes/No/Don’t know). For the purpose of this analysis we used four symp-
toms, which were associated with colorectal cancer: “unexplained pain”,
“unexplained bleeding”, “persistent change in bowel or bladder habits”, and
“unexplained weight loss”. As this was a generic measure of public cancer aware-
ness, the four symptoms used in this study were not exclusively linked to colorectal
cancer. We do not know if participants had in mind specific type of pain (e.g. in one
area of their body) or generic pain, or whether the bleeding they considered was
occult or rectal. However, it is still relevant to know whether people have general
awareness about these symptoms, which might be early symptoms of colorectal
cancer.
To explore when a participant would seek help for one of these four symptom
that they thought could be suggestive of cancer, we asked: “If you had a symptom
(X) that you thought might be a sign of cancer how soon would you contact your
doctor to make an appointment to discuss it?” We defined prompt presentation as
“two weeks or less” and delay as “more than two weeks”, as in previous studies
[7, 14, 15].