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Low cancer suspicion may mean longer wait for referral
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Colorectal cancer patients who initially presented to primary care with no alarming symptoms had to wait longer for a referral to a specialist, according to recent study findings.
Charles Helsper, MD, MSc, PhD, of the Julius Centre for Health Sciences and Primary Care in the Netherlands, and colleagues noted that most patients with colorectal cancer symptoms will present to a general practitioner first, making them essential to reducing the time to diagnosis.
The researchers retrospectively reviewed the records of 309 patients with a confirmed colorectal cancer diagnosis who had presented in primary care with symptoms.
In a univariable analysis, they found that several groups of patients had to wait the longest — 59 days or longer — to be referred to a specialist. These included women, patients who did not have “alarm symptoms” (eg, anemia, a palpable tumor, rectal blood loss or unintended weight loss), did not have a family medical history on file, had previously had malignancies or had hemorrhoids. In a multivariable analysis, only presentation without alarm symptoms remained associated with a longer referral period (RR = 1.7; 95% CI, 1.1-2.6).
“The delicate balance between not wanting to miss cancer and preventing unnecessary referrals and the corresponding burden for patients and health care systems is subject to preference and may differ between patients, cultures and time periods,” the researchers wrote. “Improving identification and referral of [colorectal cancer] patients for those initially presenting with low risk but not no risk symptoms requires innovations in the [general practitioner’s] diagnostic toolbox.” – by Janel Miller
Disclosures: The researchers report no relevant financial disclosures.
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Durado Brooks, MD, MPH
It is hard to say if van Erp and colleagues’ results would have been replicated had the study been conducted in the United States. That’s because 1) the Netherlands has an organized, government-run health care system that is strikingly different from most systems in the U.S., and 2) while patient and provider awareness of colorectal cancer symptoms and screening in the U.S. is high, whether or not such characteristics hold true in the Netherlands is not clear.
Most of the delays that the researchers described in this study were brief. While it is possible that some of the 10% of patients that researchers identified as having long delays in their diagnosis had negative outcomes, a number of studies have shown that a delay of a few weeks, or even a couple of months, does not often lead to a significant, dramatic change in colorectal cancer outcomes in most patients.
Perhaps the biggest takeaway from this study for primary care physicians and others in the medical community is that van Erp and colleagues observed that there is a growing trend in patients younger than 50 years of age being diagnosed with colorectal cancer in the Netherlands. This trend has also been observed in a variety of other countries, including the U.S.
This has not always been the case. It was just last year that the American Cancer Society responded to this trend and changed its recommendations to start colorectal cancer screening at 45 years of age. Patients with first-degree relatives who have been previously diagnosed with the disease should be screened even younger.
Evidence shows that many patients will push back on the idea of undergoing a colonoscopy. These reasons will range from patients not seeing the need for it, lack of insurance (or their insurance won’t cover it), or they may live in area where a doctor or facility that provides colonoscopies is too far away to travel to. But patients often won’t tell their clinician that they aren’t willing or able to have a colonoscopy. For that reason, clinicians should inform all patients that there are other tests, including stool tests, that are highly effective screening options, and help patients choose the test that they are likely to complete. And in some instances, these alternate tests are more affordable than colonoscopy and can be done on samples collected at home and sent through the mail.
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