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Delay in diagnosis of colorectal cancer in elderly patients.

Introduction

Colorectal cancer is one of the most common malignant tumours in western countries. It is the second leading cause of cancer death in the United States [1]. In Britain, colorectal cancer causes 20000 deaths annually [2]. In Finland, colorectal cancer was in fifth place in men and in third place in women among all cancers in the 1980s [3]. The number of colorectal cancers will increase in the future. It is predicted that in Finland the number of new colorectal cancers will almost double by the first decade after 2000 [3].

Cancer of the colon and rectum is especially a disease of older people, as incidence doubles with every decade of age over 40 years [2]. Necropsy studies show that the prevalence of colorectal cancer in asymptomatic patients is 1.6% in 50-60 year olds and 3% in those over 75 [4]. An improvement has been found in the 5-year relative survival rates in all age groups for both colonic and rectal cancers [5].

Delay in the diagnosis of colorectal cancer is still a problem although improvement has been taking place during recent decades. A reduction in the delay before treatment has been reported from 7 months in 1950 to 2 months in 1970 [6]. The time from the first symptom to the first medical consultation has been reported to be 113.4 days (16.2 weeks) for rectal cancer and 88.9 days (12.7 weeks) for colonic cancer [7]. The time from first examination to treatment was 154.0 days (22.0 weeks) for rectal cancer and 135.1 days (19.3 weeks) for colonic cancer [7]. The delay may be a particular problem for those patients in whom emergency surgery becomes necessary (obstruction or perforation). Emergency surgery is associated with higher hospital fatality than elective surgery. Early diagnosis may place more patients in the elective group. As a whole, the present delay in diagnosing colorectal cancer is a considerable one and needs attention.

This retrospective study was planned to find out how the diagnosis and related factors differ in elderly patients compared with younger ones.

Patients

The medical histories of 178 consecutive colorectal cancer patients were examined retrospectively from hospital records. The patients were admitted to and treated in Turku University Hospital and Turku City Hospital during the years 1989 and 1990. The group consisted of 79 men and 99 women. The average age at the time of diagnosis was 71.0 (SD [+ or -] 12.6, range 27-97) years in the whole group, 69.1 (SD [+ or -] 12.3, range 32-97) years in men and 72.6 (SD [+ or -] 12.7, range 27-93) years in women.

Methods

The patients' medical histories were studied by the same physician (M.K.) and the information collected in a planned form. The main symptom at the time of diagnosis was recorded (blood in stools, diarrhoea, constipation, obstruction, stomach pain, loss of weight, general weakness, other symptom). The time between onset of symptoms and the first medical consultation, and the time between the first medical consultation and diagnosis were recorded. The haemoglobin value was obtained from all records. Rectal examination was recorded as follows: (1) normal, (2) palpable tumour, and (3) information lacking. Special interest was focused on the methods of diagnosis (barium enema, rectoscopy, sigmoidoscopy, colonoscopy, operation, autopsy) and also on the possibility that some diagnostic method missed a tumour. These variables were compared between three age groups (under 65 years old, 65-80 years old and over 80 years old) and between sexes.

The differences between means were compared by Student's t test. The Mann-Whitney U test was used for data with nonparametric distribution. Comparisons between groups were made using Pearson's [[chi].sup.2] test.

Results

The main symptom: Seven different main symptoms were identified in this group of colorectal cancer patients. Table I shows the main symptoms which did not differ between the three age groups.

[TABULAR DATA OMITTED]

The time from the first symptom to the first medical consultation: This could be identified in 101 patients and was 82.8 days in the whole group, 77.8 days in men and 86.6 days in women. Table II shows the mean time in three age groups in men and women; men under 65 years old and women over 80 years had a longer interval between first symptom and first medical examination than the other groups.

Table II. Time from the first symptom to the first medical consultation in three age groups in men and women
                       Days
Age group
(years)       Mean          [+ or -] SD     n
Men
<65           112.7(a)       95.0           18
65-80          38.1(b)       54.7           16
>80            78.8          62.6            9
All            77.8          81.2           43
Women
<65            77.9          94.5           11
65-80          75.2          53.9           28
>80           108.3         114.0           19
All            86.6          85.3           58
(a) p = 0.0081 as compared with men aged 65 80 years.
(b) p = 0.034 as compared with women aged 65-80
years.


The time from the first medical consultation to diagnosis: It was possible to find this for 129 patients. The mean time was 44.7 days in the whole group, 58.0 days in men and 35.1 days in women. Table III shows the mean time in three age groups in men and women. In women, the oldest age group (over 80 years) had a longer interval between first medical examination and diagnosis than the other two groups although statistical significance was not reached.

Table III. Time from the first medical consultation to the diagnosis in three age groups in men and women
                        Days
Age group
(years)       Mean     [+ or -] SD     n

Men
<65           32.3      54.6           15
65-80         76.6     184.5           25
>80           52.4      73.9           14
All           58.0     133.8           54

Women
<65           19.9      13.5           16
65-80         16.9      13.1           32
>80           65.6     149.5           27
All           35.1      92.2           75


Haemoglobin: The haemoglobin value was found in 164 patients' records. The mean value was 111.1 g/l in the whole group, 116.6 g/l in men and 106.9 g/l in women. In Table IV the haemoglobin value is shown in three age groups for men and women. In the oldest age group (over 80 years), haemoglobin is lower in both men and women than in the other two age groups. The percentage of anaemic patients (in men, haemoglobin under 122 g/l and, in women, under 113 g/l) was as follows: under 65 years old 40%, 65-80 years old 46% and over 80 years old 65% (p = 0.032).

Table IV. The value of haemoglobin in three age groups in men and women
               Haemoglobin (g/l)
Age group
(years)        Mean          SD      n
Men
<65           117.4         33.0     22
65-80         119.6         23.8     32
>80           110.1         22.0     18
All           116.6         26.5     72
Women
<65           120.9         26.1     16
65-80         109.6         23.5     45
>80            95.8(ab)     28.7     31
All           106.9         27.1     92
(a) p = 0.025 compared with women aged 65-80 years.
(b) p = 0.0054 compared with women aged under 65
years.


Rectal examination: Information on rectal examination was found in 75 patients' hospital records, which is only 42.1% of all the patients. It was missing in 46% (29) of patients under 65 years, in 56% (45) of patients between 65 and 80 years and in 72% of patients over 80 years (p = 0.029). Altogether 18 rectal cancers were found by rectal examination. Because this group of 75 examined patients had 30 rectal cancers, 60% of all rectal cancers were found by digital rectal examination. In 13 of 18 rectal cancers so detected the main symptom was blood in stool.

Diagnostic methods: Double-contrast barium enema was the most commonly used diagnostic method, and 79 cancers were so found. The second most important method was rectoscopy which detected 36 carcinomas. With sigmoidoscopy, diagnosis was made in 17 patients and, with colonoscopy, in only four patients. Both double-contrast enema and recto-sigmoidoscopy were needed in 18 patients to make the diagnosis. In 19 patients, operation was needed to find the cancer and in four patients the cancer was found at autopsy. Occult blood tests were used with only 15.2% (27/178) of patients before diagnosis was made. A guaiac test was used with 33% (9/27) and an immunological occult blood test with 67% (18/27) of patients.

Missed diagnosis: The diagnosis of colorectal cancer was missed in 20 patients at the first examination. The diagnostic method responsible for this was double-contrast barium enema in all cases. The time between first and second examination ranged from 3 weeks up to 128 weeks. The cancer was missed at the first examination most often in the sigmoid area in nine patients (45%), in the caecum in six patients (30%), in the ascending colon in three patients (15%) and in the rectum in two patients (19%). No differences between the three age groups could be found in risk of missing a cancer at the first examination. The final diagnosis on re-examining the patients was made by double-contrast enema in 12 patients, by sigmoidoscopy in four patients and by other methods in two patients.

Discussion

The time from first symptom to first medical consultation in this study was a little shorter than in a previous report [7]. Times were longer than the rest in men under 65 years (112.7 days) and women over 80 years (108.3 days). One may speculate that men in the young age group are ignorant of the possible significance of their symptoms and so delay before contacting a physician. Women over 80 years often live alone. Depression is common in this group of elderly persons and may cause passiveness and lack of interest in health and this prevents their seeking examination.

In this study the time from first medical consultation to diagnosis was shorter, 58.0 days for men and 35.1 days for women, than in an earlier report [7]. When this time was compared in three age groups, women aged over 80 years had the longest waiting time before diagnosis was made. The delay may affect the outcome if more emergency operations are needed since emergency surgery has higher hospital fatality than elective surgery. This observation leads to interesting questions: are elderly women considered too old for clinical investigations or are their symptoms neglected by physicians?

Loss of blood was found to be the most common presenting feature of this group of colorectal cancer patients. It appeared either as blood in stools or as general weakness because of anaemia. Anaemia is an important finding in colorectal cancer because tumours usually bleed. The percentage of anaemic patients was high in those over 80 years and especially so in women. The long waiting times before first medical examination and before diagnosis may explain this. Also iron balance may easily be disturbed in elderly patients.

Rectal examination can be regarded as the most important simple clinical method when examining patients with anaemia, abdominal symptoms or blood in stools. It is therefore surprising that information about rectal examination was lacking in over half of all patients and in two-thirds of patients over 80 years. Since 6000 of rectal cancers were digitally palpable, it is clearly important to do a careful digital examination of the rectum when examining patients with abdominal symptoms.

In the present study, the most common diagnostic method at first examination was double-contrast barium enema. Almost all tumours on the right side of the colon (87.5%) were found by this method because colonoscopy was performed in four cases only. This shows that colonoscopy is not yet a routine procedure in Finland. Of all endoscopies, rectoscopy was most used and 61% of all the rectal cancers were diagnosed by it. When the diagnostic methods were compared in three age groups no differences could be found. Occult blood tests were seldom used which suggests that they were not considered very reliable in investigating symptomatic patients.

One of the most important findings in this study was that the diagnosis of colorectal cancer was missed at first examination in 20 patients, in 11% of the whole group. Double-contrast barium enema was responsible for this failure. It has been reported that the sigmoid area and right colon are the most difficult to examine with it [9-12], as was found also in this study. Colonoscopy is thought to be the best diagnostic tool in finding colorectal tumours [13, 14]. No reports could be found in which colonoscopy is regarded as too difficult and risky for very old people. In the light of this study, colonoscopy can be recommended as the primary investigation method when colorectal cancer is suspected.

Because it has been found that the 5-year relative survival rate has improved even in the old age group [5], early and accurate diagnosis is needed among elderly patients. This could be achieved by directing the examinations, preferably colonoscopy, especially towards those patients who are anaemic or have rectal bleeding. In elderly patients with sideropenic anaemia, re-examination of the colon should be performed early if the first examination is negative.

References

[1.] Bedine MS. Colorectal carcinoma: causes, diagnosis, and prevention. Compr Ther 1990; 16(1):14-18.

[2.] Cancer Research Campaign. Facts on cancer. Mortality in the U.K. London: Cancer Research Campaign, 1988.

[3.] Cancer in Finland in 1954-2008: incidence, mortality and prevalence by region. Helsinki: Finnish Foundation for Cancer Research, 1989.

[4.] Delendi M, Gardison D, Ribol E, Sasco AJ. Latent colorectal cancer found at necropsy. Lancet 1989;ii:1331-2.

[5.] Enblad P, Adami H-O, Bergstrom R, Glimelius B, Krusemo U, Pahlman L. Improved survival of patients with cancers of the colon and rectum. J Natl Cancer Inst 1988;80:586-91.

[6.] Welch JP, Donaldsson GA. Recent experience in the management of cancer of the colon and rectum. Am J Surg 1974;127:258-66.

[7.] Holliday HW, Hardcastle JD. Delay in diagnosis and treatment of symptomatic colorectal cancer. Lancet 1979;ii:309-11.

[8.] Durdy P, Weston PMT, Williams NS. Colonoscopy or barium enema as initial investigation of colonic disease. Lancet 1987;ii:549-51.

[9.] Hardcastle JD, Farrands PA, Ballfour TW, Chamberlain J, Amar SS, Sheldon MG. Controlled trial of faecal occult blood testing in the detection of colorectal cancer. Lancet 1983;ii: 1-4.

[10.] Kewenter J, Jensen J, Boijsen M, Lycke G, Tylen U. Perception errors with double contrast enema after a positive guaiac test. Gastrointest Radiol 1987;12:79-82.

[11.] Fork FT. Radiographic findings in overlooked colon carcinomas. Acta Radiol 1988;12:79 82.

[12.] Williams CB, Macrae FA, Bartram CJ. A prospective study of diagnostic methods in adenoma follow-up. Endoscopy 1982;14:74-8.

[13.] Jensen J, Kewenter J, Haglind E, Lycke G, Svensson C, Ahren C. Diagnostic accuracy of double contrast enema and rectosigmoidoscopy in connection with faecal occult blood testing of rectosigmoid neoplasms. Br J Surg 1986; 73:961-4.

[14.] Thoeni RF, Petras A. Double contrast barium enema examination in the detection of polypoid lesions in the caecum and ascending colon. Radiology 1982;144:257-60.

Authors' address

Department of Geriatrics, University of Turku,

Turku, Finland

Address correspondence to: Dr M. Kemppainen, Department of Geriatrics, Turku City Hospital, Kunnallissairaalantie 20, SF-20700 Turku, Finland.

Received in revised form 28 October 1992
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Author:Kemppainen, M.; Raiha, I.; Rajala, T.; Sourander, L.
Publication:Age and Ageing
Date:Jul 1, 1993
Words:2556
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