Colorectal cancer diagnosis: Pitfalls and opportunities

Abstract

Colorectal cancer (CRC) is a major health problem in the Western world. The diagnostic process is a challenge in all health systems for many reasons: There are often no specific symptoms; lower abdominal symptoms are very common and mostly related to non-neoplastic diseases, not CRC; diagnosis of CRC is mainly based on colonoscopy, an invasive procedure; and the resource for diagnosis is usually scarce. Furthermore, the available predictive models for CRC are based on the evaluation of symptoms, and their diagnostic accuracy is limited. Moreover, diagnosis is a complex process involving a sequence of events related to the patient, the initial consulting physician and the health system. Understanding this process is the first step in identifying avoidable factors and reducing the effects of diagnostic delay on the prognosis of CRC. In this article, we describe the predictive value of symptoms for CRC detection. We summarize the available evidence concerning the diagnostic process, as well as the factors implicated in its delay and the methods proposed to reduce it. We describe the different prioritization criteria and predictive models for CRC detection, specifically addressing the two-week wait referral guideline from the National Institute of Clinical Excellence in terms of efficacy, efficiency and diagnostic accuracy. Finally, we collected information on the usefulness of biomarkers, specifically the faecal immunochemical test, as non-invasive diagnostic tests for CRC detection in symptomatic patients.

Keywords: Colonoscopy; Colorectal cancer; Diagnostic accuracy; Diagnostic yield; Faecal immunochemical test; Health plan implementation; Open endoscopy unit; Practice guidelines; Primary health care; Risk stratification.

Figure 1

Diagnostic accuracy of symptoms for colorectal cancer detection. Adapted from Ford et al[22].The results are expressed as the median (%) and 95%CI.

Figure 2

Distribution of delay intervals in colorectal cancer diagnosis (in days). Adapted from Esteva et al[25]. CRC: Colorectal cancer.