Flexible sigmoidoscopy ‘appropriate’ triage for bowel cancer symptom investigations
MedWire News: Flexible sigmoidoscopy (FS) is an adequate investigation for patients presenting to their primary care practitioner with a change in bowel habit or rectal bleeding, UK researchers believe.
Following the introduction of a 2-week wait rule for investigation of bowel cancer symptoms in the UK, colorectal cancer referrals have increased significantly and physicians must choose between whole bowel screening (WBS), which is expensive and requires bowel preparation, or FS with the possibility of missing a proximal tumor.
Noting that change in bowel habit and rectal bleeding are not symptomatic of right-sided colon cancer, and that left colon screening is adequate, Sarit Badiani (Good Hope Hospital, Sutton Coldfield, Birmingham) and co-workers investigated symptom patterns in patients with right-sided colorectal cancer.
The team examined medical records for 206 patients who underwent right-sided hemicolectomy for colorectal cancer between January 2004 and January 2008. The patients were aged a median of 74 years.
Overall, 90% of patients presented to their primary care practitioner with iron deficiency anemia (IDA, defined as a hemoglobin level <13.0 g/dL for men and <12.0 g/dL in women), and/or a palpable abdominal mass, with or without rectal bleeding, a change in bowel habit or both.
Specifically, 78.5% of patients presented with symptoms of IDA, 9.1% presented with a palpable abdominal mass, and 12.4% of patients presented with both IDA and an abdominal mass.
Just 9.7% of patients reported rectal bleeding and/or a change in bowel habit without experiencing IDA or abdominal mass. Of these 20 individuals, endoscopy revealed left-sided pathology in 12, including 10 cases of adenoma, one villous rectal tumor, and one patient with evidence of an adenomatous polyp who died before investigation was complete. One further patient had a strong family history of bowel cancer.
The researchers say that, following current guidelines, these 13 patients would have been referred for WBS. Thus, proximal cancer would have gone undetected in seven (3.4%) of the patients if sigmoid endoscopy had been the only investigation performed.
"Whether a 'miss rate' of 3% is acceptable is a matter for discussion between the clinician, patient and the provider of healthcare resources," Badiani et al comment.
"However, with regard to the UK fast track referral system when patients present with symptoms of a change in bowel habit and/or rectal bleeding, we feel it would be appropriate to triage this group to FS and not WCI."
Recommending that patients with a normal FS be followed-up by watchful waiting, they conclude: "If this policy was accepted there would be considerable savings to the [National Health Service] and patient morbidity associated with WCI."
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By Lynda Williams