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.

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 chi(2) = 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.

Inter general practice variability in use of referral guidelines for colorectal cancer.

OBJECTIVE: The Two-Week Wait (TWW) referral system for suspected colorectal cancers has a low yield. To examine this, we assessed the referral pattern of general practices within four primary care trusts and looked at the variability of yield of colorectal cancer amongst all TWW referrals and assessed the reasons for variability. METHOD: A prospectively collected database of all colorectal cancers was examined for new cases diagnosed in the 12 months from April 1st 2004. Patients were cross-referenced via general practitioner (GP) codes to identify the referral origin. Reasons for the variability in referral patterns from each general practice were assessed in relation to TWW referrals, population demographics and through postal questionnaire of GPs. RESULTS: A total of 175 patients diagnosed with colorectal cancer were referred from 49 general practices. Whilst there was a positive correlation between the number of TWW referrals and colorectal cancer per 1000-practice population (P = 0.001; Spearman correlation coefficient r(s=0.447,) two-tailed), there was a big discrepancy between referrals and cancer diagnosed in many general practices. Twenty-six general practices (53%) had no colorectal cancer diagnosed via the TWW route and these practices had significantly lower utilization of the TWW referral pathway. In the postal survey, 22% of GPs were unaware of TWW clinics or colorectal cancer referral guidelines and only 8% of GPs knew the number of referral criteria. CONCLUSION: This study demonstrates wide variability within primary care, in the appropriate use of colorectal cancer referral guidelines. General practices should be targeted for education.

Should we pursue patients who fail to attend colorectal clinics? A 9-year study.

INTRODUCTION: No uniform protocol exists on how to deal with patients who fail to attend colorectal clinics. Our aim was to identify whether the tendency to 'failure to attend' (FTA) in the colorectal clinic was associated with FTA in other clinics and also whether FTA patients have serious pathology. PATIENTS AND METHODS: This was a retrospective study of a prospectively recorded list of FTA patients, in colorectal urgent or two-week wait clinics from 1996-2004. RESULTS: A total of 151 patients, who failed to attend their first appointment, were included in the study. Of these, 61 (40.4%) were colorectal referrals, 76 (50.3%) were general surgical referrals, and for 14 (9.3%) case notes were not available. There were 59 FTA episodes in 61 colorectal patients associated with 59 FTA episodes in other clinics (Pearson correlation: r = 0.411; P = 0.01, two-tailed, SPSS v.12). Of 58 colorectal outcomes, five (8.6%) colorectal cancers (CRC) were diagnosed, 23 (39.6%) were persistent non-attendees, 16 (27.5%) had benign colorectal pathology, two (3.4%) benign non-colorectal outcomes and 12 (20.6%) normal outcomes. CONCLUSIONS: Tendency to FTA is habitual. Care needs to be exercised in the management of FTAs to avoid delayed presentation of colorectal cancer.

Low anastomotic leak rate after colorectal surgery: a single-centre study.

OBJECTIVE: Anastomotic leak after colorectal surgery is a serious event associated with significant morbidity and mortality. There is little consensus regarding 'acceptable' rates of leakage, however. This study describes the experience of anastomotic leakage after both elective and emergency colorectal surgery in a district general hospital. METHOD: A prospectively collected database of all patients with a diagnosis of colorectal cancer in a single hospital formed the basis of the study. Leak was defined as breakdown of the anastomosis contributing to death or requiring reoperation or reintervention. RESULTS: A total of 949 patients underwent surgery with an anastomosis between 1996 and 2004, including 331 patients treated with anterior resection. Anastomotic leaks requiring reoperation occurred in eight patients (0.8%). Thirty-day and in-hospital mortality was 4%. CONCLUSION: A very low rate of anastomotic leakage after colorectal surgery is possible in a district general hospital setting. Given the impact of anastomotic leakage on function, tumour recurrence and long-term survival, it should be considered as a marker of surgical quality when evaluating surgical performance.

Cause and place of death in patients dying with colorectal cancer.

OBJECTIVE: Few studies on colorectal cancer look at the one-third of patients for whom treatment fails and who need a management strategy for death. This paper has examined the mode and place of death in patients with colorectal cancer. METHOD: This study was a review of 209 deaths, analysed between January 2001 and September 2004 by retrospective review of a prospectively collected database. RESULTS: A total of 118 patients (group 1) had undergone resection of their primary colorectal cancer, 20 (group 2) had had a defunctioning stoma or bypass surgery and the remaining 71 patients (group 3) had either had no surgery, an open and close laparotomy or had a colonic stent. One hundred and fifty-six (75%) patients died of colorectal cancer with the remainder dying of other causes. The number of admissions to hospital and the number of days spent in hospital from diagnosis to death were greatest in group 1. Overall, only 34 patients (22%) dying from colorectal cancer died at home. Forty (26%) died in hospital and 70 (45%) died in a palliative care unit. CONCLUSIONS: Patients dying from colorectal cancer who undergo surgical resection of their primary tumour spend more time between diagnosis and death in hospital. They are also more likely to die in hospital than patients treated by surgical palliation or nonsurgically. Patients who are treated palliatively from the outset (group 3) are most likely to die at home. If hospital is accepted as an appropriate place for death from colorectal cancer, then greater provision for this should be made.