Is whole-colon investigation by colonoscopy, computerised tomography colonography or barium enema necessary for all patients with colorectal cancer symptoms, and for which patients would flexible sigmoidoscopy suffice? A retrospective cohort study
Background: For patients referred to hospital with suspected colorectal cancer (CRC), it is current standard clinical practice to conduct an examination of the whole colon and rectum. However, studies have shown that an examination of the distal colorectum using flexible sigmoidoscopy (FS) can be a...
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NIHR Journals Library
2017-11-01
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| Series: | Health Technology Assessment |
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| Online Access: | https://doi.org/10.3310/hta21660 |
| _version_ | 1818522390859087872 |
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| author | Wendy Atkin Kate Wooldrage Urvi Shah Kate Skinner Jeremy P Brown Willie Hamilton Ines Kralj-Hans Michael R Thompson Karen G Flashman Steve Halligan Siwan Thomas-Gibson Margaret Vance Amanda J Cross |
| author_facet | Wendy Atkin Kate Wooldrage Urvi Shah Kate Skinner Jeremy P Brown Willie Hamilton Ines Kralj-Hans Michael R Thompson Karen G Flashman Steve Halligan Siwan Thomas-Gibson Margaret Vance Amanda J Cross |
| author_sort | Wendy Atkin |
| collection | DOAJ |
| description | Background: For patients referred to hospital with suspected colorectal cancer (CRC), it is current standard clinical practice to conduct an examination of the whole colon and rectum. However, studies have shown that an examination of the distal colorectum using flexible sigmoidoscopy (FS) can be a safe and clinically effective investigation for some patients. These findings require validation in a multicentre study. Objectives: To investigate the links between patient symptoms at presentation and CRC risk by subsite, and to provide evidence of whether or not FS is an effective alternative to whole-colon investigation (WCI) in patients whose symptoms do not suggest proximal or obstructive disease. Design: A multicentre retrospective study using data collected prospectively from two randomised controlled trials. Additional data were collected from trial diagnostic procedure reports and hospital records. CRC diagnoses within 3 years of referral were sourced from hospital records and national cancer registries via the Health and Social Care Information Centre. Setting: Participants were recruited to the two randomised controlled trials from 21 NHS hospitals in England between 2004 and 2007. Participants: Men and women aged ≥ 55 years referred to secondary care for the investigation of symptoms suggestive of CRC. Main outcome measure: Diagnostic yield of CRC at distal (to the splenic flexure) and proximal subsites by symptoms/clinical signs at presentation. Results: The data set for analysis comprised 7380 patients, of whom 59% were women (median age 69 years, interquartile range 62–76 years). Change in bowel habit (CIBH) was the most frequently presenting symptom (73%), followed by rectal bleeding (38%) and abdominal pain (29%); 26% of patients had anaemia. CRC was diagnosed in 551 patients (7.5%): 424 (77%) patients with distal CRC, 122 (22%) patients with cancer proximal to the descending colon and five patients with both proximal and distal CRC. Proximal cancer was diagnosed in 96 out of 2021 (4.8%) patients with anaemia and/or an abdominal mass. The yield of proximal cancer in patients without anaemia or an abdominal mass who presented with rectal bleeding with or without a CIBH or with a CIBH to looser and/or more frequent stools as a single symptom was low (0.5%). These low-risk groups for proximal cancer accounted for 41% (3032/7380) of the cohort; only three proximal cancers were diagnosed in 814 low-risk patients examined by FS (diagnostic yield 0.4%). Limitations: A limitation to this study is that changes to practice since the trial ended, such as new referral guidelines and improvements in endoscopy quality, potentially weaken the generalisability of our findings. Conclusions: Symptom profiles can be used to determine whether or not WCI is necessary. Most proximal cancers were diagnosed in patients who presented with anaemia and/or an abdominal mass. In patients without anaemia or an abdominal mass, proximal cancer diagnoses were rare in those with rectal bleeding with or without a CIBH or with a CIBH to looser and/or more frequent stools as a single symptom. FS alone should be a safe and clinically effective investigation in these patients. A cost-effectiveness analysis of symptom-based tailoring of diagnostic investigations for CRC is recommended. Trial registration: Current Controlled Trials ISRCTN95152621. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 66. See the NIHR Journals Library website for further project information. |
| first_indexed | 2024-12-11T05:32:38Z |
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| institution | Directory Open Access Journal |
| issn | 1366-5278 2046-4924 |
| language | English |
| last_indexed | 2024-12-11T05:32:38Z |
| publishDate | 2017-11-01 |
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| series | Health Technology Assessment |
| spelling | doaj.art-864dc21102224db7906650aea0ac88062022-12-22T01:19:23ZengNIHR Journals LibraryHealth Technology Assessment1366-52782046-49242017-11-01216610.3310/hta2166011/136/120Is whole-colon investigation by colonoscopy, computerised tomography colonography or barium enema necessary for all patients with colorectal cancer symptoms, and for which patients would flexible sigmoidoscopy suffice? A retrospective cohort studyWendy Atkin0Kate Wooldrage1Urvi Shah2Kate Skinner3Jeremy P Brown4Willie Hamilton5Ines Kralj-Hans6Michael R Thompson7Karen G Flashman8Steve Halligan9Siwan Thomas-Gibson10Margaret Vance11Amanda J Cross12Department of Surgery and Cancer, Imperial College London, London, UKDepartment of Surgery and Cancer, Imperial College London, London, UKDepartment of Surgery and Cancer, Imperial College London, London, UKDepartment of Surgery and Cancer, Imperial College London, London, UKDepartment of Surgery and Cancer, Imperial College London, London, UKInstitute of Health Research, University of Exeter Medical School, Exeter, UKDepartment of Surgery and Cancer, Imperial College London, London, UKDepartment of Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UKDepartment of Colorectal Surgery, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UKUniversity College London Centre for Medical Imaging, University College London, London, UKDepartment of Surgery and Cancer, Imperial College London, London, UKWolfson Unit for Endoscopy, St Mark’s Hospital, London, UKDepartment of Surgery and Cancer, Imperial College London, London, UKBackground: For patients referred to hospital with suspected colorectal cancer (CRC), it is current standard clinical practice to conduct an examination of the whole colon and rectum. However, studies have shown that an examination of the distal colorectum using flexible sigmoidoscopy (FS) can be a safe and clinically effective investigation for some patients. These findings require validation in a multicentre study. Objectives: To investigate the links between patient symptoms at presentation and CRC risk by subsite, and to provide evidence of whether or not FS is an effective alternative to whole-colon investigation (WCI) in patients whose symptoms do not suggest proximal or obstructive disease. Design: A multicentre retrospective study using data collected prospectively from two randomised controlled trials. Additional data were collected from trial diagnostic procedure reports and hospital records. CRC diagnoses within 3 years of referral were sourced from hospital records and national cancer registries via the Health and Social Care Information Centre. Setting: Participants were recruited to the two randomised controlled trials from 21 NHS hospitals in England between 2004 and 2007. Participants: Men and women aged ≥ 55 years referred to secondary care for the investigation of symptoms suggestive of CRC. Main outcome measure: Diagnostic yield of CRC at distal (to the splenic flexure) and proximal subsites by symptoms/clinical signs at presentation. Results: The data set for analysis comprised 7380 patients, of whom 59% were women (median age 69 years, interquartile range 62–76 years). Change in bowel habit (CIBH) was the most frequently presenting symptom (73%), followed by rectal bleeding (38%) and abdominal pain (29%); 26% of patients had anaemia. CRC was diagnosed in 551 patients (7.5%): 424 (77%) patients with distal CRC, 122 (22%) patients with cancer proximal to the descending colon and five patients with both proximal and distal CRC. Proximal cancer was diagnosed in 96 out of 2021 (4.8%) patients with anaemia and/or an abdominal mass. The yield of proximal cancer in patients without anaemia or an abdominal mass who presented with rectal bleeding with or without a CIBH or with a CIBH to looser and/or more frequent stools as a single symptom was low (0.5%). These low-risk groups for proximal cancer accounted for 41% (3032/7380) of the cohort; only three proximal cancers were diagnosed in 814 low-risk patients examined by FS (diagnostic yield 0.4%). Limitations: A limitation to this study is that changes to practice since the trial ended, such as new referral guidelines and improvements in endoscopy quality, potentially weaken the generalisability of our findings. Conclusions: Symptom profiles can be used to determine whether or not WCI is necessary. Most proximal cancers were diagnosed in patients who presented with anaemia and/or an abdominal mass. In patients without anaemia or an abdominal mass, proximal cancer diagnoses were rare in those with rectal bleeding with or without a CIBH or with a CIBH to looser and/or more frequent stools as a single symptom. FS alone should be a safe and clinically effective investigation in these patients. A cost-effectiveness analysis of symptom-based tailoring of diagnostic investigations for CRC is recommended. Trial registration: Current Controlled Trials ISRCTN95152621. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 66. See the NIHR Journals Library website for further project information.https://doi.org/10.3310/hta21660anaemiaclinical studycolorectal cancerdiagnosissigmoidoscopysigns and symptoms |
| spellingShingle | Wendy Atkin Kate Wooldrage Urvi Shah Kate Skinner Jeremy P Brown Willie Hamilton Ines Kralj-Hans Michael R Thompson Karen G Flashman Steve Halligan Siwan Thomas-Gibson Margaret Vance Amanda J Cross Is whole-colon investigation by colonoscopy, computerised tomography colonography or barium enema necessary for all patients with colorectal cancer symptoms, and for which patients would flexible sigmoidoscopy suffice? A retrospective cohort study Health Technology Assessment anaemia clinical study colorectal cancer diagnosis sigmoidoscopy signs and symptoms |
| title | Is whole-colon investigation by colonoscopy, computerised tomography colonography or barium enema necessary for all patients with colorectal cancer symptoms, and for which patients would flexible sigmoidoscopy suffice? A retrospective cohort study |
| title_full | Is whole-colon investigation by colonoscopy, computerised tomography colonography or barium enema necessary for all patients with colorectal cancer symptoms, and for which patients would flexible sigmoidoscopy suffice? A retrospective cohort study |
| title_fullStr | Is whole-colon investigation by colonoscopy, computerised tomography colonography or barium enema necessary for all patients with colorectal cancer symptoms, and for which patients would flexible sigmoidoscopy suffice? A retrospective cohort study |
| title_full_unstemmed | Is whole-colon investigation by colonoscopy, computerised tomography colonography or barium enema necessary for all patients with colorectal cancer symptoms, and for which patients would flexible sigmoidoscopy suffice? A retrospective cohort study |
| title_short | Is whole-colon investigation by colonoscopy, computerised tomography colonography or barium enema necessary for all patients with colorectal cancer symptoms, and for which patients would flexible sigmoidoscopy suffice? A retrospective cohort study |
| title_sort | is whole colon investigation by colonoscopy computerised tomography colonography or barium enema necessary for all patients with colorectal cancer symptoms and for which patients would flexible sigmoidoscopy suffice a retrospective cohort study |
| topic | anaemia clinical study colorectal cancer diagnosis sigmoidoscopy signs and symptoms |
| url | https://doi.org/10.3310/hta21660 |
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