©2013 Esteva et al; licensee BioMed Central Ltd.
Factors related with symptom duration until diagnosis and treatment of symptomatic colorectal cancer
1Unit of Research, Majorca Department of Primary Health Care, Balearic Institute of Health, Reina Esclaramunda 9, 07003, Palma de Mallorca, Spain
2Department of Public Health, Balearic Department of Health, Majorca Cancer Registry, C/ Jesus n 33, 07001, Palma de Mallorca, Spain
3Clinical Epidemiology and Biostatistics Unit, A Coruña University, Complexo Hospitalario Universitario A Coruña, Xubias de Arriba, 84, Hotel de los pacientes 7ª planta, 15006, A Coruña, Spain
4Serreria II Primary Care Centre, Valencia Institute of Health, C/ Pedro de Valencia 28, 46022, Valencia, Spain
5Health Consorcium of Barcelona, Parc Sanitari Pere Virgili - Edifici Mestral, Esteve Terrades, 30, 08023, Barcelona, Spain
6Canal Imperial Primary Care Centre, Paseo Colon 4, 50006, Zaragoza, Spain
7Can Misses Primary Care Centre, Primary Health Care Eivissa Department, Avinguda de la Pau s/n, 07800, Eivissa, Spain
8Nazareth Primary Care Centre, Parque Nazareth 16, 46024, Valencia, Spain
9Department of Gastroenterology, University Clinic Hospital of Valencia, Avenida Blasco Ibañez 17, 46010, Valencia, Spain
10Evaluation and Clinical Epidemiology Department, Hospital del Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain
11Lluis Saye Primary Care Centre, C/ Torres i Amat 8, 08001, Barcelona, Spain
12Pirinees High Resolution Hospital, Calzada de Rapit s/n, 22700, Jaca, Spain
13Department of Anatomical Pathology, A Coruña University, Complexo Hospitalario Universitario A Coruña, Xubias de Arriba, 84, Hotel de los pacientes 7ª planta, 15006, A Coruña, Spain
14Department of Anatomical Pathology, Hospital Universitario Son Espases, Carretera Valldemosa, Palma, Spain
15Department of Oncology, Hospital Universitario Son Espases, Carretera Valldemosa, Palma, Spain
16Primary Care Research Unit, Arrabal Health Centre, Gracia Gazulla, 50015, Zaragoza, Spain
Received April 28, 2012; Accepted February 18, 2013.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0
), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
A total of 950 incident colorectal cancer patients were recruited. For the present study, 155 asymptomatic patients were excluded; 94 (9.9%) screen detected and 61 (6.4%) incidental findings. Finally, 795 symptomatic cases were included; 481 (60.5%) were colon cases and 314 (39.5%) rectum. Hospital record information was available for all patients and primary care records for 780 patients (98.1%). In 66 (8.3%) patients the interview was not completed. The interview was completed during inpatient stay in 310 patients (44.7%), prior to surgery in 48 (6.9%), during outpatients visits in 267 (38.5%) and 69 (9.9%) at home.
Various time intervals are shown in Table . The median SDI and STI for CRC were 128 and 155 days respectively. Three months following symptom onset, four in ten patients are diagnosed and nearly three treated. No statistically significant differences were observed in SDI between colon and rectum, 125 (59–258) vs. 121 (53–256) respectively (p=0.51), or in STI 150 (80–280.5) vs. 153 (79–283), (p=0.08). Most of the treatment interval stemmed from health services time interval to diagnosis and less from the patient or interval from diagnosis to treatment.
Distribution of delay intervals (in days)
Women present higher diagnostic time intervals than men. No significant differences in symptom duration intervals were found for age, level of education, social class or marital status. Finally, those patients with family history of cancer had longer diagnosis and treatment time intervals (Table ).
Concerning initial symptoms (Table ), the presence of abdominal pain, vomiting and intestinal obstruction are associated with shorter time between symptom onset and diagnosis or treatment. There were no differences between SDI and STI with regard to other symptoms or the number of symptoms at presentation. Moreover, we observed a clear gradient in the duration of SDI depending on perceived symptom severity with shorter SDI and STI for those perceived as very serious. Therefore, the duration of intervals is related to patient attitude toward the symptom, that is, the interval duration diminishes when patients disclose the symptom to those close to them; when they do not wait for symptom clear up, or when they visit emergency services (either primary care or hospital). We found an association between trust in the GP and time to diagnosis or treatment.
Relationship with presenting symptom, help-seeking behaviour and trust in their GP
With regard to GP performance (Table ), some non-indicated investigations, such as abdominal transit and gastroscopy were prescribed very rarely: in only 6 and 16 patients, respectively. GPs requested 109 colonoscopies, 4 rectoscopies and 3 rectosigmoidoscopies. When general practitioners ask for diagnostic tests of blood, iron, or blood in the stools, the time to diagnosis or treatment increases. No relationship has been detected between these time intervals and lack of abdominal or rectal examination and other image investigations. Shorter SDI and SDT were observed when the general practitioner referral to hospital was urgent or when the GP mentioned suspected diagnosis in the referral. Greater duration to diagnosis was observed in those with an increasing number of visits to the GP for symptoms related to CRC and shorter duration for those frequently attended by their family or nursing practitioner in the previous year.
Relationship of GP performance with delay
Regarding secondary care of CRC cases (Table ), we observed that the first contact is made mainly through the Emergency or Gastroenterology services. Sixty-three per cent of patients were referred by their GP and a quarter contacted hospitals by themselves. Shorter intervals are observed when the patient contacts the emergency service on his or her own initiative. Additionally, patients with abdominal or rectal examination, blood test, XT or CT, are diagnosed or treated earlier; in contrast with patients with MRI.
Performance of hospital doctors and relationship with delay
This study has been financed with grants from the Ministry of Health, Carlos III Institute; PI:052273, PI050787,PI050700, PI052692, PI052141. It also received the support of the Health Promotion and Preventive Activities-Primary Health Care Network, sustained by the Ministry of Health ISCIII-RETCI G03/170 and RD06/0018. The authors would like to thank surgeons, gastroenterologists and general practitioners for their participation in contact with patients, especially to Dr. Julio Lago.
*Collaborators DECCIRE GROUP
Baleares: Magdalena Esteva, María Ramos, Alfonso Leiva, Amador Ruiz, Maria Martín-Rabadán, María Teresa Novella, Elena Cabeza, Joana Ripoll, Hermini Manzano, Isabel Amengual, Aina Forteza, Maria Company, Maria de Lluch Bennassar, Joan Llobera.
Aragón: Maria Antónia Sánchez, Rosa Magallón, Barbara Olivan, Carmen Yus, Sergio Lafita.
Catalunya: Monserrat Casamitjana, Josep Mª Segura, Francesc Macià, Angels Hospital
Galicia: Salvador Pita, Sonia Pertega, Arturo Louro, Joaquín Serrano, Francisco Arnal, Paloma González-Santamaria.
Valencia: Luis González-Lujan, Ana Costa-Alcaraz, Alejandro Espí, Marta M Bosca, Nelly Balza, Rosa A Villagrasa, Juan F Vázquez y Alba González-Timoneda.