Colorectal cancer and rectal bleeding in primary care: Rectal bleeding needs attention in primary care

Abstract Background In an abdominal symptom study in primary care in six European countries, 511 cases of cancer were recorded prospectively among 61,802 patients 16 years and older in Norway, Denmark, Sweden, Netherlands, Belgium and Scotland. Colorectal cancer is one of the main types of cancer associated with abdominal symptoms; hence, an in-depth subgroup analysis of the 94 colorectal cancers was carried out in order to study variation in symptom presentation among cancers in different anatomical locations. Method Initial data capture was by completion of standardised forms containing closed questions about symptoms recorded during the consultation. Follow-up data were provided by the GP after diagnosis, based on medical record data made after the consultation. GPs also provided free text comments about the diagnostic procedure for individual patients. Fisher’s exact test was used to analyse differences between groups. Results Almost all symptoms recorded could indicate colorectal cancer. ‘Rectal bleeding’ had a specificity of 99.4% and a PPV of 4.0%. Faecal occult blood in stool (FOBT) or anaemia may indicate gastrointestinal bleeding: when these symptoms and signs were combined, sensitivity reached 57.5%, with 69.2% for cancer in the distal colon. For proximal colon cancers, none of 18 patients had ‘Rectal bleeding’ at the initial consultation, but three of the 18 did so at a later consultation. ‘Abdominal pain, lower part’, ‘Constipation’ and ‘Distended abdomen, bloating’ were less specific and also less sensitive than ‘Rectal bleeding’, and with PPV between 0.7% and 1.9%. Conclusions Apart from rectal bleeding, single symptoms did not reach the PPV 3% NICE threshold. However, supplementary information such as a positive FOBT or persistent symptoms may revise the PPV upwards. If a colorectal cancer is suspected by the GP despite few symptoms, the total clinical picture may still reach the NICE PPV threshold of 3% and justify a specific referral.

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EP.TU.333FIT stratification in the COVID era - Is it safe for rectal bleeding?

British Journal of Surgery ◽

10.1093/bjs/znab311.043 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Jaspreet Seehra ◽

James Bailey ◽

Caroline Chapman ◽

Joanne Morling ◽

David Humes ◽

...

Keyword(s):

Colorectal Cancer ◽

Primary Care ◽

Rectal Bleeding ◽

Digital Rectal Examination ◽

Final Analysis ◽

Bowel Habit ◽

Hospital System ◽

Testing Protocol ◽

Low Threshold ◽

Electronic Hospital

Abstract Aims Faecal Immunochemical Tests (FIT) are increasingly used for stratification of colorectal cancer risk in symptomatic patients. FIT is not currently recommended for use in patients with rectal bleeding, but recent studies have reported its safe use. We report our experiences of FIT in patients presenting with rectal bleeding during the COVID-19 pandemic. Methods Patients referred to NUH NHS Trust with rectal bleeding from 15/04/20-15/08/20 were invited to complete a postal-based FIT (OC-Sensor). Demographics, symptoms, investigations and results were recorded. Outcomes were retrospectively reviewed using an electronic hospital system. Result 344 patients were invited to participate, with 301 (87.5%) returning FITs in accordance with testing protocol. 36 patients declined to be seen, 4 were considered not fit for investigation, and 4 had incomplete records. 257 patients were included in the final analysis with 10 CRC detected (3.9%). Rectal bleeding (257, 100%) was the most common presenting symptom followed by change in bowel habit (133, 51.8%). 10 CRC were diagnosed (3.9%). 2 CRC were detected with FIT <4 µg Hb / g faeces (2/137, 1.5%) and 8 were detected >100 µg Hb / g faeces (8/45, 17.8%). FIT result was significantly associated with CRC diagnosis (p < 0.0001). 4 with CRC had anaemia (4/53, 7.5%), 1 had thrombocytosis (1/12, 8.3%). Conclusions FIT missed 20% of CRC in this patient group with the application of a very low threshold (<4 µg Hb / g faeces). Both cancers missed by FIT were detectable on digital rectal examination, emphasising the importance of this examination in primary care.

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Risk in primary care of colorectal cancer from new onset rectal bleeding: 10 year prospective study

BMJ ◽

10.1136/bmj.38846.684850.2f ◽

2006 ◽

Vol 333 (7558) ◽

pp. 69-70 ◽

Cited By ~ 23

Author(s):

Jennifer du Toit ◽

William Hamilton ◽

Kevin Barraclough

Keyword(s):

Colorectal Cancer ◽

Primary Care ◽

Prospective Study ◽

Rectal Bleeding ◽

New Onset

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Qualitative faecal immunochemical tests (FITs) for diagnosing colorectal cancer in patients with histories of rectal bleeding in primary care: a cohort study

International Journal of Colorectal Disease ◽

10.1007/s00384-020-03672-1 ◽

2020 ◽

Vol 35 (11) ◽

pp. 2035-2040

Author(s):

Cecilia Högberg ◽

Ulf Gunnarsson ◽

Olof Cronberg ◽

Hans Thulesius ◽

Mikael Lilja ◽

...

Keyword(s):

Colorectal Cancer ◽

Primary Care ◽

Rectal Bleeding ◽

Predictive Value ◽

Primary Care Physicians ◽

Occult Blood ◽

Health Records ◽

Alarm Symptom ◽

History Of ◽

Patient’S History

Abstract Background Rectal bleeding is considered an alarm symptom for colorectal cancer (CRC) but it is common and mostly caused by benign conditions. Qualitative faecal immunochemical tests (FITs) for occult blood have been used as diagnostic aids for many years in Sweden when CRC is suspected. The study aimed to evaluate the usefulness of FITs requested by primary care physicians for patients with and without histories of rectal bleeding, in the diagnosis of CRC. Methods Results of all FITs requested in primary care for symptomatic patients in the Örebro region during 2015 were retrieved. Data on each patient’s history of rectal bleeding was gathered from electronic health records. Patients diagnosed with CRC within 2 years were identified from the Swedish Cancer Register. The analysis focused on three-sample FITs, the customary FIT in Sweden. Results A total of 4232 patients provided three-sample FITs. Information about the presence/absence of rectal bleeding was available for 2027 patients, of which 59 were diagnosed with CRC. For 606 patients with the presence of rectal bleeding, the FIT showed sensitivity 96.2%, specificity 60.2%, positive predictive value 9.8% (95% CI 6.1–13.4) and negative predictive value 99.7% (95% CI 99.2–100) for CRC. For 1421 patients without rectal bleeding, the corresponding figures were 100%, 73.6%, 8.3% (95% CI 5.6–10.9) and 100% (95% CI 99.6–100). Conclusion The diagnostic performance of a qualitative three-sample FIT provided by symptomatic patients in primary care was similar for those with and without a history of rectal bleeding. FITs seem useful for prioritising patients also with rectal bleeding for further investigation.

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Colorectal cancer and rectal bleeding in primary care: Urban or rural myth?

BMJ ◽

10.1136/bmj.333.7560.201-c ◽

2006 ◽

Vol 333 (7560) ◽

pp. 201.4-202 ◽

Cited By ~ 1

Author(s):

Sanjay Purkayastha ◽

Ara Darzi

Keyword(s):

Colorectal Cancer ◽

Primary Care ◽

Rectal Bleeding

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Assessing the clinical utility of genetic risk scores for targeted cancer screening

Journal of Translational Medicine ◽

10.1186/s12967-020-02699-w ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Carly A. Conran ◽

Zhuqing Shi ◽

William Kyle Resurreccion ◽

Rong Na ◽

Brian T. Helfand ◽

...

Keyword(s):

Colorectal Cancer ◽

Primary Care ◽

High Risk ◽

Risk Score ◽

Genetic Risk ◽

Clinical Utility ◽

Low Risk ◽

Risk Scores ◽

Average Risk ◽

Genetic Risk Scores

Abstract Background Genome-wide association studies have identified thousands of disease-associated single nucleotide polymorphisms (SNPs). A subset of these SNPs may be additively combined to generate genetic risk scores (GRSs) that confer risk for a specific disease. Although the clinical validity of GRSs to predict risk of specific diseases has been well established, there is still a great need to determine their clinical utility by applying GRSs in primary care for cancer risk assessment and targeted intervention. Methods This clinical study involved 281 primary care patients without a personal history of breast, prostate or colorectal cancer who were 40–70 years old. DNA was obtained from a pre-existing biobank at NorthShore University HealthSystem. GRSs for colorectal cancer and breast or prostate cancer were calculated and shared with participants through their primary care provider. Additional data was gathered using questionnaires as well as electronic medical record information. A t-test or Chi-square test was applied for comparison of demographic and key clinical variables among different groups. Results The median age of the 281 participants was 58 years and the majority were female (66.6%). One hundred one (36.9%) participants received 2 low risk scores, 99 (35.2%) received 1 low risk and 1 average risk score, 37 (13.2%) received 1 low risk and 1 high risk score, 23 (8.2%) received 2 average risk scores, 21 (7.5%) received 1 average risk and 1 high risk score, and no one received 2 high risk scores. Before receiving GRSs, younger patients and women reported significantly more worry about risk of developing cancer. After receiving GRSs, those who received at least one high GRS reported significantly more worry about developing cancer. There were no significant differences found between gender, age, or GRS with regards to participants’ reported optimism about their future health neither before nor after receiving GRS results. Conclusions Genetic risk scores that quantify an individual’s risk of developing breast, prostate and colorectal cancers as compared with a race-defined population average risk have potential clinical utility as a tool for risk stratification and to guide cancer screening in a primary care setting.

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