Original Study
Colorectal Cancer Initial Diagnosis: Screening Colonoscopy, Diagnostic Colonoscopy, or Emergent Surgery, and Tumor Stage and Size at Initial Presentation

https://doi.org/10.1016/j.clcc.2015.07.004Get rights and content

Abstract

Introduction/Background

Rates of colorectal cancer screening are improving but remain suboptimal. Limited information is available regarding how patients are diagnosed with colorectal cancer (for example, asymptomatic screened patients or diagnostic workup because of the presence of symptoms). The purpose of this investigation was to determine how patients were diagnosed with colorectal cancer (screening colonoscopy, diagnostic colonoscopy, or emergent surgery) and tumor stage and size at diagnosis.

Patients and Methods

Adults evaluated between 2011 and 2014 with a diagnosis of colorectal cancer were identified. Clinical notes, endoscopy reports, surgical reports, radiology reports, and pathology reports were reviewed. Sex, race, ethnicity, age at the time of initial diagnosis, method of diagnosis, presenting symptom(s), and primary tumor size and stage at diagnosis were recorded. Colorectal cancer screening history was also recorded.

Results

The study population was 54% male (265 of 492) with a mean age of 58.9 years (range, 25-93 years). Initial tissue diagnosis was established at the time of screening colonoscopy in 10.7%, diagnostic colonoscopy in 79.2%, and during emergent surgery in 7.1%. Cancers diagnosed at the time of screening colonoscopy were more likely to be stage 1 than cancers diagnosed at the time of diagnostic colonoscopy or emergent surgery (38.5%, 7.2%, and 0%, respectively). Median tumor size was 3.0 cm for the screening colonoscopy group, 4.6 cm for the diagnostic colonoscopy group, and 5.0 cm for the emergent surgery group. At least 31% of patients diagnosed at the time of screening colonoscopy, 19% of patients diagnosed at the time of diagnostic colonoscopy, and 26% of patients diagnosed at the time of emergent surgery had never undergone a screening colonoscopy.

Conclusion

Nearly 90% of colorectal cancer patients were diagnosed after development of symptoms and had more advanced disease than asymptomatic screening patients. Colorectal cancer outcomes will be improved by improving rates of colorectal cancer screening.

Introduction

Colorectal cancer is the third most common type of cancer and cause of cancer-related death in the United States.1 An estimated 136,830 individuals were newly diagnosed with colorectal cancer and 50,319 people died as a result of the disease in the United States in 2014.1 Colorectal cancer screening reduces mortality by identifying cancers at an earlier and more treatable stage and by identifying and removing precancerous adenomatous polyps.2, 3, 4, 5, 6, 7, 8 However, only approximately 34% to 59% of Americans for whom screening is recommended undergo recommended colorectal cancer screening.9, 10, 11 The United States Preventive Services Task Force currently recommends screening for colorectal cancer using colonoscopy, sigmoidoscopy, or fecal occult blood testing beginning at age 50 years and continuing until age 75 years.12

Approximately 15% of colorectal cancers present as a surgical emergency in the United States.13 To our knowledge, no studies have reported on what percentage of colorectal malignancies is diagnosed at the time of screening versus diagnostic colonoscopy. Accurately extracting such information from claims databases is challenging.14, 15, 16 For example, a colonoscopy that begins as a screening colonoscopy in an asymptomatic individual is typically coded as a diagnostic colonoscopy if a biopsy is performed or a polyp removed.16

The purpose of this investigation was to determine through detailed chart review how patients who presented to our institution between 2011 and 2014 were diagnosed with colorectal cancer (screening colonoscopy, diagnostic colonoscopy, or emergent surgery) and tumor stage and size at the time of diagnosis.

Section snippets

Patients and Methods

Institutional review board approval was obtained, and a waiver of informed consent was granted for this Health Insurance Portability and Accountability Act-compliant study.

The (X [institution name blinded during the review process]) electronic data warehouse was searched for patient encounters in which the Current Procedural Terminology codes for new patient visit (99201, 99202, 99203, 99204, 99205) and the International Classification of Diseases, 9th edition codes for colorectal cancer

Results

A data warehouse search yielded 527 patients. Based on chart review, 35 individuals (6.6%) were coded incorrectly because they did not have a diagnosis of colorectal cancer, and these individuals were excluded from the analysis. The remaining 492 individuals were our study population.

Discussion

Interestingly, only 10.7% of colorectal cancers in our series were diagnosed at the time of screening colonoscopy. For individuals 50 to 75 years of age, 14% of cancers were diagnosed at the time of screening colonoscopy. Most individuals treated for colorectal cancer at our institution sought medical attention on the basis of a symptom. At least 31% of patients diagnosed with cancer at the time of screening colonoscopy, 19% of patients diagnosed with cancer at the time of diagnostic

Conclusion

Nearly 90% of colorectal cancer patients were diagnosed after development of symptoms and had more advanced disease than asymptomatic patients whose cancers were detected with screening. Colorectal cancer outcomes will be improved by improving rates of colorectal cancer screening.

Disclosure

The authors have stated that they have no conflicts of interest.

References (23)

  • J.V. Selby et al.

    A case-control study of screening sigmoidoscopy and mortality from colorectal cancer

    N Engl J Med

    (1992)
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