Reducing Delays in Diagnosing Colorectal Cancer

Analysis of The Doctors Company's claims experience reveals that suits alleging delayed diagnosis of cancer continue to proliferate. Among the most common are suits involving colorectal cancer.

Colorectal Cancer

Colorectal cancer is common. One in every 20 American men and women will develop this disease. The following are primary reasons for delayed diagnosis of colorectal cancer.

• Presentations are usually nonspecific. Typical signs and symptoms include: ¹, ⁵

  Rectum and Rectosigmoid
  Melena	85%
  Constipation	46%
  Tenesmus	30%
  Diarrhea	30%
  Abdominal pain	26%
  Left Colon
  Abdominal pain	72%
  Melena	53%
  Constipation	42%
  Nausea	25%
  Vomiting	23%
  Right Colon
  Abdominal pain	74%
  Weakness	29%
  Melena	27%
  Nausea	24%
  Abdominal mass	23%

  Colorectal cancer is not necessarily the most likely diagnosis for any of these symptoms, yet the possibility must be considered each time a patient is evaluated for one or more of them.

• Rectal bleeding is often not adequately evaluated. Because studies show that as much as 50 percent of otherwise healthy adults experience the passage of blood per rectum, there is a tendency on the part of both patients and doctors to minimize its significance. This can be a serious mistake. Hemorrhoids, even when known to be present, cannot be assumed to be the source of GI blood loss unless the bleeding is actually seen during anoscopy. Even then, barium enema is still advisable.

This message was dramatically underscored by a study that retrospectively evaluated 100 consecutive cases of colorectal cancer.² The median delay from the onset of symptoms to diagnosis was 9.7 months. However, 30 of these cases were characterized by "severe delay" (median of 18.1 months, of which 14.7 months was attributable to physician delay and only 3.4 months to patient delay).

• Inadequate evaluation of iron deficiency is common. A diagnosis of iron deficiency is never complete by itself. The reason for the iron deficit must be specifically defined. In one case, a 28-year-old woman with menometrorrhagia was started on iron therapy for iron deficiency anemia. One of the attending physicians actually did a stool Hemoccult test that was positive. Unfortunately, no further study was done until an advanced carcinoma of the colon was found.

The lesson is not that every woman with menometrorrhagia requires a barium enema. Rather, every patient with iron deficiency requires screening for fecal blood loss and rigorous evaluation if any is found.

Inadequate evaluations are also frequently performed on patients with positive Hemoccults who:

• Use aspirin.
• Drink significant quantities of alcohol.
• Are known to have diverticulitis, hiatus hernia, gastritis, or ulcer disease.
• Require anticoagulants.

In each of these settings, there is a tendency to feel that gastrointestinal blood loss is explained. It cannot be emphasized too strongly, however, that each episode of bleeding requires complete evaluation. The ease of iron replacement should not obscure the need to identify the cause of the problem.

• The incentive for filing a lawsuit is high when a diagnosis of colorectal cancer is delayed. Early therapy for this disease is associated with an extremely high cure rate (more than 90 percent for Duke's A lesions); advanced disease is rarely cured. Thus, the patient injury is real, and the delay may literally be fatal.

Routine Colorectal Screenings

Because symptoms often occur only relatively late in the natural history of the disease, physicians should carefully consider screening patients they see regularly.

The American Cancer Society (ACS) recommends yearly cancer-related checkups for people 40 and older. Beginning at age 50, ACS recommends the following colorectal testing schedule for both men and women:

• Yearly fecal occult blood test plus flexible sigmoidoscopy and digital rectal examination every 5 years, or
• Colonoscopy and digital rectal examination every 10 years, or
• Double-contrast barium enema and digital rectal examination every 5 to 10 years.^*

With more than 100,000 new cases yearly, it is essential for physicians to be familiar with the specific risk factors for colorectal cancer. Patients with any of the following risk factors should begin colorectal cancer screening earlier and/or undergo screening more often:

• Age greater than 40 (risk doubles every decade).
• Ulcerative colitis (overall increased risk of colon cancer by five- to elevenfold).
• Granulomatous colitis.
• Adenomas (associated with increased risk of cancer developing either within the polyp itself or elsewhere in the colon).
• Prior history of colon cancer (threefold increase in new colon tumors compared with unaffected population).
• Familial syndromes:
• Familial polyposis.
• Cancer families.
• Ordinary positive family history.

• Other factors, including:
• History of female genital cancer.
• History of breast cancer.
• History of radiation therapy for cervical cancer.

With the widespread availability of barium enemas and colonoscopy, the diagnosis of colorectal cancer can usually be made easily. Unfortunately, the diagnosis can also be easily ignored until very late in the natural history of the disease.

CEA Unsuitable for Screening

Specifically note that the carcinoembryonic antigen (CEA) is not sufficiently sensitive to be used as a screening test for colorectal cancer.⁴ In one study of 2,372 adults, 73 had an elevated CEA and 9 of those had an underlying cancer.⁵ By contrast, 25 patients in this group had cancer with a normal CEA. Thus, 88 percent of the CEA elevations were in patients without cancer. Expressed differently, there were 64 false positives for each new case of cancer detected by CEA testing.

Summary of Recommendations

• The American Cancer Society recommends routine screening for colorectal cancer for all adults, beginning at age 50. In addition, high-risk populations should be defined.
• The symptoms of colorectal cancer are protean; even the most common complaints can be associated with a potentially fatal lesion.
• Causes of rectal bleeding must be specifically identified in every patient.
• Iron deficiency anemias require evaluating and identifying the cause of the iron deficit.

*The digital rectal examination should be done at the same time as sigmoidoscopy, colonoscopy, or double-contrast barium enema. The American Cancer Society, Cancer Facts and Figures, July 1998, Atlanta, Ga.