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We performed a cohort study of patients with primary colorectal cancer in whom all their prediagnostic symptoms and investigation results were known.
Survival data for 3—8 years after diagnosis were taken from the cancer registry. Six features were studied: Two of these were significantly associated with different staging and mortality.
Rectal bleeding as an initial symptom was associated with less advanced staging odds ratio from one Duke's stage to the next 0. Mild anaemia, with a haemoglobin of When corrected for emergency admission, sex, and the site of the tumour, the HR for mild anaemia was 1.
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No relationship was found between the duration of symptoms and staging or mortality. Earlier diagnosis can arise from screening or improved recognition of symptomatic cancers.
In the UK, approximately three-quarters of colorectal cancers present initially to their general practitioner GP with non-emergency symptoms, such as rectal bleeding, abdominal pain, or change in bowel habit Barrett et al, Even after the proposed introduction of screening in the UK init is likely that the majority of patients will still present with symptoms Hamilton et al, NICE, The assumption behind these clinics is that cancers have a symptomatic phase of sufficient duration to offer the possibility of earlier diagnosis, leading to mortality benefits.
This assumption can be explored by examination of the relationships between mortality or staging and the duration of symptoms. Several such studies have been reported. There is a clear relationship between the staging of the cancer and mortality Mulcahy and O'Donoghue, ; Roncoroni et al, ; Ponz de Leon et al, ; Gonzalez-Hermoso et al, ; Olsson et al, Conversely, most studies have shown no relationship between the duration of symptoms and staging or mortality Stubbs and Long, ; Barillari et al, ; Kyle et al, ; Mulcahy and O'Donoghue, ; Majumdar et al, ; Roncoroni et al, ; Kiran and Glass, ; Gonzalez-Hermoso et al, ; Olsson et al, ; Bharucha et al, ; Khattak et al, ; Rupassara et al, Some have reported an inverse relationship, with a shorter duration of symptoms being associated with both worse staging and worse prognosis Mulcahy and O'Donoghue, ; Olsson et al, ; Rupassara et al, Once emergency admissions, which generally have a shorter duration of symptoms, are corrected for, this inverse relationship disappears Mulcahy and O'Donoghue, ; Olsson et al, ; Rupassara et al, Only two previous studies have examined the relationship between the first symptom of the cancer and mortality Gonzalez-Hermoso et al, ; Korsgaard et al, However, all these previous studies have either dated the onset of symptoms from the dates given in the doctor's referral letter, or by interviewing patients after the diagnosis had been made.
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These methods are prone to inaccuracy, with some patients able only to specify the calendar year that their symptoms began, and others giving illogical dates of onset, such as dates after their diagnosis had been made Olsson et al, Furthermore, only two studies were community based, including all cases from a specific area Olsson et al, ; Korsgaard et al, The remainder were hospital-based, raising the possibility that cases referred to that hospital were not typical of the whole colorectal cancer population.
We sought to address these methodological issues by an analysis of a cohort of patients with colorectal cancers occurring in a 5-year period from Exeter, Devon, UK Hamilton et al, In this cohort, all symptoms recorded in primary care before diagnosis were collected and coded systematically.
This methodology eliminates concerns about the accuracy of patient recall, although it does not address symptoms experienced but not reported to primary care.
In that study, all primary colorectal cancer cases in patients aged 40 years or more from Exeter Primary Care Trust PCTdiagnosed between andwere identified from the local cancer registry. This list was augmented by computer searches at all 21 general practices in the PCT, identifying a further three cases.
Twelve of the total cases could not be studied as they had either died five or left Exeter sevenand their primary care records were unobtainable. Emergency presentations were defined as those requiring surgical admission for suspected bowel obstruction or perforation, and who had their cancer diagnosed during the admission, almost always at laparotomy.
The entire primary care record for the 2 years preceding diagnosis for all subjects was coded using the International Classification of Primary Care-2, WONCA, although for this paper only data from the year before diagnosis were used. The second year before diagnosis was omitted because the rate of reporting of the various clinical features was similar in both cases and controls for that year, so reporting of features in that year by cases would probably be unrelated to their future cancer Hamilton et al, Survival data were obtained from the cancer registry, up to the 8 Decemberso were available for between 3 and 8 years.
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