Delays in primary care are associated with a late stage and worse prognosis for colorectal cancer patients: A population based study


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Chanpreet Arhi1,Elaine Burns1,Alex Bottle1,George Bouras1,Paul Aylin1,Paul Ziprin1,Ara Darzi1
1Imperial College London

Abstract

Background

Delays in referral for colorectal cancer patients may occur if the presenting symptom is falsely attributed to a benign condition. We hypothesis primary care delays are associated with a later stage at diagnosis and worse prognosis.

Method

Patients with a non-emergency colon or rectal cancer in the cancer registry with linkage to the Clinical Practice Research Datalink were included. All had a colorectal associated symptom defined as ‘red flag’ (rectal bleeding, abdominal mass, change in bowel habit, diarrhoea, anaemia) or ‘non-specific’ (abdominal pain, weight loss, constipation, other bowel function) and a relevant referral recorded in the year leading up to diagnosis. The primary care interval (presentation to referral), hospital interval (referral to diagnosis) and stage was compared for each symptom individually and after grouping as above. Cox modelling determined the hazard ratios(HR) of death for each symptom compared with rectal bleeding, and whether delays in referral were associated with a worse prognosis.

Results

4527(63.5%) colon and 2603 (36.5%) rectal cancer patients were included. 16.9% and 13.5% presenting with red-flag symptoms respectively experienced a delay of over three months before referral, compared with 35.7% and 42.9% of those with non-specific symptoms. Delays in primary care did not increase the hospital interval.   Each symptom was associated with reduced survival compared with rectal bleeding for both cancers. Patients referred after three months who had presented with red-flag symptoms(Colon: HR 1.53 (1.29–1.81) Rectal: HR 1.30 (1.06 – 1.60)), demonstrated a significantly worse prognosis compared with referrals within two weeks with similar symptoms. This was not seen for patients with non-specific symptoms. Delays in referral significantly increased the proportion of late stage cancers.

Conclusion

The first presentation to the GP provides a referral opportunity to identify the underlying cancer, which if missed for patients presenting with red-flag symptoms, is associated with a later stage in diagnosis and worse survival.