Factors associated time to diagnosis and stage at diagnosis of colorectal cancer: a prospective cohort study

Abstract

Objective To identify symptom and patient factors influencing time to colorectal cancer (CRC) diagnosis. Design Prospective cohort study, recruiting participants upon referral for suspicion of CRC in two English regions. Data on symptoms and healthcare presentation were collected using a patient questionnaire; primary care and hospital records were examined for diagnostic routes, intervals and clinical outcomes. Descriptive and regression analyses examined associations between symptoms and patient factors with: Total Diagnostic Interval (TDI), Patient Interval (PI), Health System Interval (HSI), stage. Results 2,677 patients responded; after exclusions, 2,507 remained. 6.1% were diagnosed with CRC (56% late stage), 2.0% with other cancers, 91.9% with other conditions. Only half the cohort had a solitary first symptom (1332, 53.1%); synchronous first symptoms were common. In this referred population rectal bleeding was the only initial symptom more frequent among cancer than non-cancer cases (34.2% vs 23.9%, p=0.004). There was no evidence of differences in TDI, PI or HSI for those with cancer versus non-cancer diagnoses (median TDI CRC 124 vs non-cancer 138 days, p=0.142). First symptoms associated with shorter TDIs were rectal bleeding (HR=1.79, 95%CI 1.62-1.98, p<0.001), change in bowel habit (HR=1.55, 95%CI 1.42-1.69, p<0.001), ‘feeling different’ (HR=1.21, 95%CI 1.08-1.35, p=0.001) and fatigue/tiredness (HR=1.14, 95%CI 1.02-1.27, p=0.021). Anxiety, depression and gastro-intestinal comorbidities were associated with longer HSIs. Conclusion Rectal bleeding is the strongest symptom predictor of CRC but is the first symptom in only a third of symptomatic patients. Healthcare professionals should be vigilant to CRC symptoms in patients with mental health or gastro-intestinal comorbidities.