Colorectal cancer: Incidence, delay in diagnosis and stage of disease

doi:10.1016/0277-5379(86)90025-8

European Journal of Cancer and Clinical Oncology

Volume 22, Issue 2, February 1986, Pages 157-161

European Journal of ...

https://doi.org/10.1016/0277-5379(86)90025-8 Get rights and content

Abstract

In a study of 445 patients with colorectal cancer referred to our center during a 3-yr period, we investigated the following parameters and their interrelationships: sex, marital status, ethnic origin, place of residence, stage of disease, delay in diagnosis and factors responsible for delay. Localized disease was found in 52% of the patients, regional disease in 29% and metastatic disease in 19%. The incidence of colorectal cancer was significantly higher in Jews of European (occidental) descent than in Jews of Asian or North African (oriental) descent or in Arabs. The median and mean ages were significantly higher in the occidental than in the oriental Jewish group and significantly lower in the Arabs than in the oriental Jews. Diagnosis was delayed for more than 6 weeks in 52% of the patients. Responsibility for the delay could be attributed to the patient in 54% of these cases and to the physician in 47%. Administrative factors were responsible for the delay in 26% (In 27% of the above delayers there was more than one agent responsible for the delay.) On average, patients in whom diagnosis was delayed had more advanced disease than those without delay. Also, patients with advanced disease had a longer delay on average than those with localized disease. The stage of disease at diagnosis was more advanced in the oriental than in the occidental Jews. No correlations were found between delay in diagnosis and either age or sex. There were more widowers with delay (21%) than with no delay (16%). In patients living outside Haifa delay was more prolonged than in those residing in the city. Educational programs aimed at the population at risk of developing neoplasm and especially at those likely to undergo delay in diagnosis are recommended. Postgraduate courses should be designed to instruct physicians on how to minimize delay in diagnosis.

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Cited by (54)

A systematic review of methodological considerations in time to diagnosis and treatment in colorectal cancer research
2023, Cancer Epidemiology
Research focusing on timely diagnosis and treatment of colorectal cancer is necessary to improve outcomes for people with cancer. Previous attempts to consolidate research on time to diagnosis and treatment have noted varied methodological approaches and quality, limiting the comparability of findings. This systematic review was conducted to comprehensively assess the scope of methodological issues in this field and provide recommendations for future research. Eligible articles had to assess the role of any interval up to treatment, on any outcome in colorectal cancer, in English, with no limits on publication time. Four databases were searched (Ovid Medline, EMBASE, EMCARE and PsycInfo). Papers were screened by two independent reviewers using a two-stage process of title and abstract followed by full text review. In total, 130 papers were included and had data extracted on specific methodological and statistical features. Several methodological problems were identified across the evidence base. Common issues included arbitrary categorisation of intervals (n = 107, 83%), no adjustment for potential confounders (n = 65, 50%), and lack of justification for included covariates where there was adjustment (n = 40 of 65 papers that performed an adjusted analysis, 62%). Many articles introduced epidemiological biases such as immortal time bias (n = 37 of 80 papers that used survival as an outcome, 46%) and confounding by indication (n = 73, 56%), as well as other biases arising from inclusion of factors outside of their temporal sequence. However, determination of the full extent of these problems was hampered by insufficient reporting. Recommendations include avoiding artificial categorisation of intervals, ensuring bias has not been introduced due to out-of-sequence use of key events and increased use of theoretical frameworks to detect and reduce bias. The development of reporting guidelines and domain-specific risk of bias tools may aid in ensuring future research can reliably contribute to recommendations regarding optimal timing and strengthen the evidence base.
Lack of association between diagnostic and therapeutic delay and stage of colorectal cancer
2008, European Journal of Cancer
Citation Excerpt :
In another six studies, multivariate analysis was performed to study the influence of delay on survival, with disease stage being one of the variables included. In 26 of the 37 studies, no statistically significant association was noted between delay and disease stages;15–18,20,21,23,27,30,32,34,36–39,44,45,47,49,50,52,54,57,59,61,64 in 4, a longer delay was associated with less advanced disease19,25,29,35,51 (in one case in the colon only51), and in 7, a shorter delay was associated with less advanced disease24,26,28,51,53,55,63 (in one case in the rectum only51). Independently of statistical significance, in 5 studies a greater delay was associated with disease at an earlier stage;19,25,29,30,35 in 12, a shorter delay was associated with disease at an earlier stage,17,20,24,26,28,32,36,38,44,45,53,63 and no association was noted in the remaining studies.
A recent review suggests that there is no association between diagnostic and therapeutic delays and survival in colorectal cancer patients. However, the effect of tumour stage on the relationship between delay and survival in CRC should be clarified. We review here the evidence on the relationship between diagnostic and therapeutic delays and stage in colorectal cancer.
We conducted a systematic review of Medline, Embase, Cancerlit and the Cochrane Database of Systematic Reviews to identify publications published between 1965 and 2006 dealing with delay, stage and colorectal cancer. A meta-analysis was performed based on the estimation of the odds ratios (OR) and on a random effects model.
We identified 50 studies, representing 18,649 patients. Thirty studies were excluded due to excessively restricted samples (e.g. exclusion of patients with intestinal obstruction or who died 1–3 months after surgery) or because they studied only a portion of the delay. Of the 37 remaining studies, great variability was noted in connection with the type of classification used for disease stage and the type of measurement used for the delay. Meta-analysis was performed based on 17 studies that included 5209 patients. The combined OR was 0.98 (95% confidence interval (CI): 0.76–1.25), suggesting a lack of association between delay and disease stage. In four studies, cancers of the colon and rectum were dealt with separately, and a meta-analysis was performed using the data for colon cancer (1001 patients) and for rectal cancer (799 patients). In both cases, the combined ORs overlapped 1.0, and showed opposite associations when studied separately: 0.86 (95% CI: 0.63–1.19) for the colon (i.e. more delay is associated with the earlier stage at diagnosis) and 1.93 (95% CI: 0.89-4.219) for the rectum (i.e. less delay is associated with the earlier stage).
When colorectal cancers are taken as a whole, there appears to be no association between diagnostic delay and disease stage when diagnosis is made. However, when cancers of the colon and the rectum are studied separately, there may be an opposite association. More studies about this issue are needed with larger and unrestricted samples.
Delay of diagnosis and treatment of colorectal cancer-A population-based Danish Study
2008, Cancer Detection and Prevention
Citation Excerpt :
It is reasonable to expect that treatment delay will be associated with the stage of colorectal cancer (CRC) at the time of treatment. Treatment delays should be reduced, as CRC stage is an important indicator of survival, although the association between treatment delay and stage of the cancer has been controversial [1–19]. In our prospective population-based cohort of 733 colorectal cancer patients, we have recently shown a doubled relative risk of having an advanced rectal cancer (Dukes’ stage C or D) at the time of treatment, if the treatment delay was more than 60 days (reference-group <60 days).
Background: Recently, the authors have shown a doubled risk of having an advanced rectal cancer (RC) (Dukes’ stage C or D) at the time of treatment, if the interval between onset of symptoms and start of treatment (treatment delay) was >60 days [Korsgaard M, Pedersen L, Sorensen HT, Laurberg S. Treatment delay is associated with advanced stage of rectal cancer but not of colon cancer. Cancer Detect Prev 2006;30(4):341–6]. The authors examined the treatment delay for colorectal cancer (CRC), as influenced by the patients, the general practitioners (G.P.), and the hospitals. Method: Population-based prospective observational study based on 743 Danish CRC-patients. Treatment delay was determined through questionnaire interviews. We examined the patient delay, the G.P. delay, and the hospital delay, and thereby the frequency of patients for whom the Danish fast-track recommendations of a maximum of 14 days to diagnose CRC, and 14 days from the diagnosis to start the of treatment, were met. Colon cancer (CC) and RC-patients were analyzed separately. Results: Patient delay, in particular, was long, and longest for RC-patients (median 44 days vs.18 days). Median G.P. delay was short, but 25% of the CC-patients had a G.P. delay of 59 days or more, and 25% of the RC-patients had a G.P. delay of 53 days or more. The fast-track recommendations were poorly met; 53% of the CC-patients and 39% of the RC-patients waited >14 days after referral for the diagnosis. 29% of the CC-patients, and 53% of the RC-patients waited >14 days before the start of treatment. Conclusion: The total delay was too long, and can be shortened by optimizing all delay intervals.
Relationship of diagnostic and therapeutic delay with survival in colorectal cancer: A review
2007, European Journal of Cancer
Background. Early diagnosis of colorectal cancer before the onset of symptoms improves survival. Once symptoms have occurred, however, the effect of delay on survival is unclear. We review here evidence on the relationship of diagnostic and therapeutic delay with survival in colorectal cancer.
Methods. We conducted a systematic of Medline, Embase, Cancerlit and the Cochrane Database of Systematic Reviews to identify publications published between 1962 and 2006 dealing with delay, survival and colon cancer. A meta-analysis was performed based on the calculation of the relative risk (RR) and on a model of random effects.
Results. We identified 40 studies, representing 20,440 patients. Fourteen studies were excluded due to excessively restricted samples (e.g. exclusion of patients with intestinal obstruction, with tumours at stage C or D at the time of diagnosis, or who died 1–3 months after surgery); or because they studied only a portion of the delay. Of the 26 remaining studies, 20 showed no association between delay and survival. In contrast, four studies showed that delay was a factor contributing to better prognosis, and two showed that it contributed to poorer prognosis. There was no association between delay and survival when the colon and rectum were considered separately, when a multivariate analysis was performed, and when the effects of tumour stage and degree of differentiation were taken into account. To perform a meta-analysis, 18 additional studies were excluded, since the published articles did not specify the absolute numbers. In the remaining eight studies, the combined relative risk (RR) of delay was 0.92 (confidence interval (CI) 95%: 0.87–0.97).
Conclusions. The results of the review suggest that there is no association between diagnostic and therapeutic delay and survival in colorectal cancer patients. Colon and rectum should be assessed separately, and it is necessary to adjust for other relevant variables such as tumour stage.
Delay of treatment is associated with advanced stage of rectal cancer but not of colon cancer
2006, Cancer Detection and Prevention
Background: Dukes’ stage is the most important predictor of prognosis of colorectal cancer, but the association between delay of treatment (DT) and Dukes’ stage is still controversial. Methods: From 1 January 2001 to 31 July 2002, we conducted a population-based prospective observational study based on 733 Danish colorectal cancer patients. DT was determined through questionnaire-interviews, and Dukes’ stage was obtained from medical records and pathological forms. DT was classified into three groups: short (0–60 days), intermediate (61–150 days) and long (>150 days) DT. Dukes’ stage was classified into two groups: non-advanced (Dukes’ stage A or B) and advanced (Dukes’ stage C or D) cancer. Using relative risk (RR) the association between DT and stage was estimated, with short delay as the reference group. Results: The RR of advanced cancer was 1.0 (95% confidence intervals (CI): 0.8–1.3) for colon cancer patients with an intermediate DT, and 1.1 (95% CI: 0.9–1.4) for patients with a long DT. For rectal cancer patients the RR of advanced cancer was 1.9 (95% CI: 1.1–3.1) for patients with an intermediate DT and 2.1 (95% CI: 1.3–3.4) for patients with a long DT. Conclusion: DT was strongly associated with advanced stage of rectal cancer, but not of colon cancer.
The effect of time before diagnosis and treatment on colorectal cancer outcomes: systematic review and dose–response meta-analysis
2023, British Journal of Cancer

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View full text

Colorectal cancer: Incidence, delay in diagnosis and stage of disease

Abstract

Lancet

Colorectal cancer staging as a prognostic feature

Cancer

Cancer of the colon and rectum: general aspects, diagnosis, treatment and prognosis

Results of treatment of carcinoma of the colon and rectum

Carcinoma of the colon and rectum

N Engl J Med

Risk factors from geographic epidemiology for gastrointestinal cancer

Cancer

The distribution of cancer within the large bowel

Int J Cancer

Geographic pattern of large bowel cancer in the USA

JNCI

Carcinoma of the colon and rectum

Acta Chir Scand