Spiral.imperial.ac.uk



Colorectal cancer patients under the age of 50 experience delays in primary care leading to emergency diagnoses: a population based study Authors: Chanpreet S Arhi clinical research fellow1, Paul Ziprin consultant surgeon1, Alex Bottle reader in medical statisitcs2, Elaine M Burns clinical lecturer1, Paul Aylin2 professor in epidemiology and public health2, Ara Darzi professor of surgery1Addresses: 1. Imperial College London, Department of Surgery and Cancer, St Mary’s Hospital Campus, Praed Street, W2 1NY 2. Imperial College London, School of Public Health, 3 Dorset Rise, EC4Y 8ENCorresponding author: Chanpreet Arhi, c.arhi@Running title: Delays for young colorectal cancer patientsAbstractBackground: The incidence of colorectal cancer the under 50s is increasing. In this national population based study, we hypothesise that missed opportunities for diagnosis in primary care are leading to referral delays and emergency diagnoses in young patients. Method: We compared the interval before diagnosis, presenting symptom and the odds ratio(OR) of an emergency diagnosis for those under the age of 50 with older patients, sourced from the cancer registry with linkage to a national database of primary care records. Results: The study included 7315 patients, of whom 508 (7.7%) were aged under 50 years, 1168 (16.0%) were aged 50–59, 2294 (31.4%) were aged 60–69 and 3345 (45.7%) were aged 70–79 years. Young patients were more likely to present with abdominal pain and via an emergency, with the lowest percentage of early stage cancer. They experienced a longer interval between referral to diagnosis (12.5 days) compared with those aged 60–69, reflecting the higher proportion of referrals via the non-urgent pathway (33.3%). The OR of an emergency diagnosis did not differ with age if a red-flag symptom was noted at presentation, but increased significantly for young patients if the symptom was non-specific. Conclusion: Young patients present to primary care with symptoms outside the national referral guidelines, increasing the likelihood of an emergency diagnosis.Keywords: Delayed referral, primary care, young patients, colorectal cancer, emergency diagnosis, NICE guidelinesThe authors have no conflict of interests to declareWhat does this paper add to the literature?The incidence of colorectal cancer in young patients continues to rise. This study demonstrates that young patients not only present with symptoms which fall outside the national referral criteria, they are also more likely to experience a missed opportunity for a non-emergency diagnosis even if they present with the same symptoms as older patients.IntroductionThe incidence of colorectal cancer (CRC) in young patients is increasingADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.mayocp.2013.09.006","ISSN":"0025-6196","author":[{"dropping-particle":"","family":"Ahnen","given":"Dennis J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wade","given":"Sally W","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jones","given":"Whitney F","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sifri","given":"Randa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Silveiras","given":"Jose Mendoza","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Greenamyer","given":"Jasmine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Guiffre","given":"Stephanie","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Axilbund","given":"Jennifer","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Spiegel","given":"Andrew","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"You","given":"Y Nancy","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Mayo Clinic Proceedings","id":"ITEM-1","issue":"2","issued":{"date-parts":[["2014"]]},"page":"216-224","publisher":"Elsevier Inc","title":"The Increasing Incidence of Young-Onset Colorectal Cancer: A Call to Action","type":"article-journal","volume":"89"},"uris":[""]}],"mendeley":{"formattedCitation":"¹","plainTextFormattedCitation":"1","previouslyFormattedCitation":"¹"},"properties":{"noteIndex":0},"schema":""}1. In 2013 6% of colorectal cancer cases were diagnosed in those under 50 in EnglandADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Office for National Statistics..","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Cancer Registration Statistics","id":"ITEM-1","issued":{"date-parts":[["0"]]},"page":"","title":"Cancer Registration Statistics","type":"webpage"},"uris":[""]}],"mendeley":{"formattedCitation":"²","plainTextFormattedCitation":"2","previouslyFormattedCitation":"²"},"properties":{"noteIndex":0},"schema":""}2. By 2030 it is estimated over 1 in 10 colon and over 1 in 4 rectal cancers will be diagnosed in this age groupADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.mayocp.2013.09.006","ISSN":"0025-6196","author":[{"dropping-particle":"","family":"Ahnen","given":"Dennis J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wade","given":"Sally W","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jones","given":"Whitney F","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sifri","given":"Randa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Silveiras","given":"Jose Mendoza","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Greenamyer","given":"Jasmine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Guiffre","given":"Stephanie","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Axilbund","given":"Jennifer","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Spiegel","given":"Andrew","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"You","given":"Y Nancy","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Mayo Clinic Proceedings","id":"ITEM-1","issue":"2","issued":{"date-parts":[["2014"]]},"page":"216-224","publisher":"Elsevier Inc","title":"The Increasing Incidence of Young-Onset Colorectal Cancer: A Call to Action","type":"article-journal","volume":"89"},"uris":[""]}],"mendeley":{"formattedCitation":"¹","plainTextFormattedCitation":"1","previouslyFormattedCitation":"¹"},"properties":{"noteIndex":0},"schema":""}1. In contrast the incidence in those aged over 55 is decreasingADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1093/jnci/djw322","ISSN":"0027-8874","PMID":"28376186","abstract":"Background: Colorectal cancer (CRC) incidence in the United States is declining rapidly overall but, curiously, is increasing among young adults. Age-specific and birth cohort patterns can provide etiologic clues, but have not been recently examined. Methods: CRC incidence trends in Surveillance, Epidemiology, and End Results areas from 1974 to 2013 (n = 490 305) were analyzed by five-year age group and birth cohort using incidence rate ratios (IRRs) and age-period-cohort modeling. Results: After decreasing in the previous decade, colon cancer incidence rates increased by 1.0% to 2.4% annually since the mid-1980s in adults age 20 to 39 years and by 0.5% to 1.3% since the mid-1990s in adults age 40 to 54 years; rectal cancer incidence rates have been increasing longer and faster (eg, 3.2% annually from 1974–2013 in adults age 20–29 years). In adults age 55 years and older, incidence rates generally declined since the mid-1980s for colon cancer and since 1974 for rectal cancer. From 1989–1990 to 2012–2013, rectal cancer incidence rates in adults age 50 to 54 years went from half those in adults age 55 to 59 to equivalent (24.7 vs 24.5 per 100 000 persons: IRR = 1.01, 95% confidence interval [CI] = 0.92 to 1.10), and the proportion of rectal cancer diagnosed in adults younger than age 55 years doubled from 14.6% (95% CI = 14.0% to 15.2%) to 29.2% (95% CI = 28.5% to 29.9%). Age-specific relative risk by birth cohort declined from circa 1890 until 1950, but continuously increased through 1990. Consequently, compared with adults born circa 1950, those born circa 1990 have double the risk of colon cancer (IRR = 2.40, 95% CI = 1.11 to 5.19) and quadruple the risk of rectal cancer (IRR = 4.32, 95% CI = 2.19 to 8.51). Conclusions: Age-specific CRC risk has escalated back to the level of those born circa 1890 for contemporary birth cohorts, underscoring the need for increased awareness among clinicians and the general public, as well as etiologic research to elucidate causes for the trend. Further, as nearly one-third of rectal cancer patients are younger than age 55 years, screening initiation before age 50 years should be considered.","author":[{"dropping-particle":"","family":"Siegel","given":"Rebecca L.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fedewa","given":"Stacey A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Anderson","given":"William F.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Miller","given":"Kimberly D.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ma","given":"Jiemin","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rosenberg","given":"Philip S.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jemal","given":"Ahmedin","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"JNCI: Journal of the National Cancer Institute","id":"ITEM-1","issue":"8","issued":{"date-parts":[["2017"]]},"page":"27-32","title":"Colorectal Cancer Incidence Patterns in the United States, 1974–2013","type":"article-journal","volume":"109"},"uris":[""]}],"mendeley":{"formattedCitation":"³","plainTextFormattedCitation":"3","previouslyFormattedCitation":"³"},"properties":{"noteIndex":0},"schema":""}3. Decreasing physical activity and worsening levels of obesity, together with the introduction of screening for older patients, are thought to be contributory factors for these trendsADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.mayocp.2013.09.006","ISSN":"0025-6196","author":[{"dropping-particle":"","family":"Ahnen","given":"Dennis J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wade","given":"Sally W","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jones","given":"Whitney F","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sifri","given":"Randa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Silveiras","given":"Jose Mendoza","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Greenamyer","given":"Jasmine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Guiffre","given":"Stephanie","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Axilbund","given":"Jennifer","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Spiegel","given":"Andrew","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"You","given":"Y Nancy","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Mayo Clinic Proceedings","id":"ITEM-1","issue":"2","issued":{"date-parts":[["2014"]]},"page":"216-224","publisher":"Elsevier Inc","title":"The Increasing Incidence of Young-Onset Colorectal Cancer: A Call to Action","type":"article-journal","volume":"89"},"uris":[""]}],"mendeley":{"formattedCitation":"¹","plainTextFormattedCitation":"1","previouslyFormattedCitation":"¹"},"properties":{"noteIndex":0},"schema":""}1. Only ‘high-risk’ young patients, defined as those with underlying inflammatory bowel disease, significant family history or a genetic predisposition, are offered regular surveillance in the UK. As these factors represent about 20% of all new CRC diagnosis in young patients, most patients of this age group will present with de novo symptoms.Identifying the young patient with CRC from the majority with an underlying benign condition is a difficult task for the primary care physician. The current UK referral guidelines predominately concentrate on patients aged over 50, as the positive predictive value of associated symptoms increases with ageADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"ISBN":"1846290538","author":[{"dropping-particle":"","family":"NICE","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2005"]]},"title":"Referral guidelines for suspected cancer","type":"book"},"uris":[""]}],"mendeley":{"formattedCitation":"⁴","plainTextFormattedCitation":"4","previouslyFormattedCitation":"⁴"},"properties":{"noteIndex":0},"schema":""}4. In this national population-based study we hypothesise that differences in presenting symptoms make delays in referral and emergency diagnoses more common in young patients (defined as those under the age of 50) than in older ones. An improved understanding of differences between age groups may reduce the rate of emergency diagnoses, with a subsequent improvement in stage and survivalADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1136/bmjopen-2014-006965","ISSN":"2044-6055 (Electronic)","PMID":"25838506","abstract":"OBJECTIVE: To identify patient and practitioner factors that influence cancer diagnosis via emergency presentation (EP). DESIGN: Systematic review. DATA SOURCES: MEDLINE, EMBASE, CINAHL, EBM Reviews, Science and Social Sciences Citation Indexes, Conference Proceedings Citation Index-Science and Conference Proceedings Citation Index-Social Science and Humanities. Searches were undertaken from 1996 to 2014. No language restrictions were applied. STUDY SELECTION: Studies of any design assessing factors associated with diagnosis of colorectal or lung cancer via EP, or describing an intervention to impact on EP, were included. Studies involving previously diagnosed cancer patients, assessing only referral pathway effectiveness, outcomes related to diagnosis or post-EP management were excluded. The population was individual or groups of adult patients or primary care practitioners. Two authors independently screened studies for inclusion. RESULTS: 22 studies with over 200,000 EPs were included, most providing strong evidence. Five were graded 'insufficient', primarily due to missing information rather than methodological weakness. Older patient age was associated with EP for lung and colorectal cancers (OR 1.11-11.03 and 1.19-5.85, respectively). Women were more at risk of EP for lung but not colorectal cancer. Higher deprivation increased the likelihood of lung cancer EP, but evidence for colorectal was less conclusive. Being unmarried (or divorced/widowed) increased the likelihood of EP for colorectal cancer, which was also associated with pain, obstruction and weight loss. Lack of a regular source of primary care, and lower primary care use were positively associated with EP. Only three studies considered practitioner factors, two involving diagnostic tests. No conclusive evidence was found. CONCLUSIONS: Patient-related factors, such as age, gender and deprivation, increase the likelihood of cancer being diagnosed as the result of an EP, while cancer symptoms and patterns of healthcare utilisation are also relevant. Further work is needed to understand the context in which risk factors for EP exist and influence help-seeking.","author":[{"dropping-particle":"","family":"Mitchell","given":"Elizabeth D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pickwell-Smith","given":"Benjamin","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Macleod","given":"Una","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"BMJ open","id":"ITEM-1","issue":"4","issued":{"date-parts":[["2015"]]},"language":"eng","page":"e006965","publisher-place":"England","title":"Risk factors for emergency presentation with lung and colorectal cancers: a systematic review.","type":"article-journal","volume":"5"},"uris":[""]}],"mendeley":{"formattedCitation":"⁵","plainTextFormattedCitation":"5","previouslyFormattedCitation":"⁵"},"properties":{"noteIndex":0},"schema":""}5. MethodData sourceAnonymised patient data was provided by the Clinical Practice Research Datalink (CPRD) (protocol 15_247), a primary care based dataset covering approximately 8 – 10% of the population in England. Symptoms, diagnoses and investigations are recorded by the general practitioner (GP - primary care physician in the UK) into an electronic database based on Read codes. These codes are translated into numerical ‘medcodes’ which are provided to researchers. As in this study, the linked Hospital Episodes Statistics (HES) and cancer registry data was available from practices that had provided consentADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1177/2042098611435911","ISSN":"2042-0986","PMID":"25083228","abstract":"Since its inception in the mid-1980s, the General Practice Research Database (GPRD) has undergone many changes but remains the largest validated and most utilised primary care database in the UK. Its use in pharmacoepidemiology stretches back many years with now over 800 original research papers. Administered by the Medicines and Healthcare products Regulatory Agency since 2001, the last 5 years have seen a rebuild of the database processing system enhancing access to the data, and a concomitant push towards broadening the applications of the database. New methodologies including real-world harm-benefit assessment, pharmacogenetic studies and pragmatic randomised controlled trials within the database are being implemented. A substantive and unique linkage program (using a trusted third party) has enabled access to secondary care data and disease-specific registry data as well as socio-economic data and death registration data. The utility of anonymised free text accessed in a safe and appropriate manner is being explored using simple and more complex techniques such as natural language processing.","author":[{"dropping-particle":"","family":"Williams","given":"Tim","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Staa","given":"Tjeerd","non-dropping-particle":"van","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Puri","given":"Shivani","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Eaton","given":"Susan","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Therapeutic advances in drug safety","id":"ITEM-1","issue":"2","issued":{"date-parts":[["2012","4","1"]]},"note":"No real description of publications from linked datasets\n\nNo specific validation work has been conducted on this method (to check for quality) as much of it is based on logical inconsistency of the registration data. \n\nVision GP system provides GPRD data\n\nGPRD can be used to produce a study with direct patient contact\n\nEach parameter generated an earliest date at which it is accepta- ble, and the UTS date was set to the earliest date at which nine of these were acceptable, with the exception of the mortality parameter which was mandatory\n\nIn its current form the UTS date is based on two central concepts: assurance of con- tinuity in data recording, and mortality rate com- pared with an expected range.\n\nA collaboration involving GPRD has recently been undertaken to develop such data quality parameters, initial pilot phase results exploring baseline parameters across the data [Tate et al. 2011].\n\nGPRD has a long history of validation studies which has been recently reviewed [Herret et al. 2010]. This study reviewed 212 publications involving 357 validations classifying them as either internal (manual/algorithmic review of database records or sensitivity analysis) or exter- nal (questionnaires or patient record requests to GPs and comparison with external data sources). Generally a high proportion of cases were con- firmed but for the majority of studies only positive predictive values (PPVs) are obtainable.\n\nThe importance of code selection is an area explored by a GPRD stroke study which stresses the need for trans- parency and an understanding of the context of code selection [Gulliford et al. 2009]. \n\nA smaller review of GPRD validation studies [Khan et al. 2010] came to similar conclusions reporting high PPVs, citing the Morbidity Statistics from General Practice 1991–1992 (MSGP4) as a frequent external comparator, and also noting the use of both Read codes and OXMIS codes (Oxford Medical Information System codes: an early clinical dictionary used by VM system) as a complication of coding.\n\nAll previous monthly databases are retained and at any one time six previous monthly versions are available for access on the online system.","page":"89-99","title":"Recent advances in the utility and use of the General Practice Research Database as an example of a UK Primary Care Data resource.","type":"article-journal","volume":"3"},"uris":[""]}],"mendeley":{"formattedCitation":"⁶","plainTextFormattedCitation":"6","previouslyFormattedCitation":"⁶"},"properties":{"noteIndex":0},"schema":""}6. Patient selectionCPRD provided linked data for patients with a colorectal cancer diagnosis (ICD C18 – 20) in the cancer registry from 2006 to 2013. Patients with any cancer noted in CPRD, HES or the cancer registry preceding the CRC diagnosis date, or a previous history of IBD, were excluded as regular surveillance is available for these high risk groups. Study variablesDiagnostic routeThe route of diagnosis was provided with the cancer registry, as defined by Elliss-Brookes et al.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1038/bjc.2012.408","ISBN":"0007-0920","ISSN":"1532-1827","PMID":"22996611","abstract":"Cancer survival in England is lower than the European average, which has been at least partly attributed to later stage at diagnosis in English patients. There are substantial regional and demographic variations in cancer survival across England. The majority of patients are diagnosed following symptomatic or incidental presentation. This study defines a methodology by which the route the patient follows to the point of diagnosis can be categorised to examine demographic, organisational, service and personal reasons for delayed diagnosis.","author":[{"dropping-particle":"","family":"Elliss-Brookes","given":"L","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"McPhail","given":"S","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ives","given":"A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Greenslade","given":"M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shelton","given":"J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hiom","given":"S","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Richards","given":"M","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British journal of cancer","id":"ITEM-1","issue":"8","issued":{"date-parts":[["2012"]]},"page":"1220-6","publisher":"Nature Publishing Group","title":"Routes to diagnosis for cancer - determining the patient journey using multiple routine data sets.","type":"article-journal","volume":"107"},"uris":[""]}],"mendeley":{"formattedCitation":"⁷","plainTextFormattedCitation":"7","previouslyFormattedCitation":"⁷"},"properties":{"noteIndex":0},"schema":""}7 ‘Two-week wait’, ‘urgent’, ‘in-patient elective’ and ‘other outpatient’ cases were considered non-emergency, while ‘death certificate only’ (DCO), ‘screening’ and ‘unknown’ were excluded as primary care involvement is unclear. Emergency diagnoses included direct emergency referrals by GPs. Presenting symptomThe initial presentation to the GP due to CRC was defined as the first consultation with a relevant symptom in the year leading up to the cancer registry diagnosis date. As in previous epidemiological studies, consultations during a pre-determined time leading up to the diagnosis date were not interrogated for the first consultationADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1038/bjc.2016.250","ISBN":"0007-0920","ISSN":"0007-0920","PMID":"27537389","abstract":"BACKGROUND: More than 20% of colorectal cancers are diagnosed following an emergency presentation. We aimed to examine pre-diagnostic primary-care consultations and related symptoms comparing patients diagnosed as emergencies with those diagnosed through non-emergency routes. METHODS: Cohort study of colorectal cancers diagnosed in England 2005 and 2006 using cancer registration data individually linked to primary-care data (CPRD/GPRD), allowing a detailed analysis of clinical information referring to the 5-year pre-diagnostic period. RESULTS: Emergency diagnosis occurred in 35% and 15% of the 1029 colon and 577 rectal cancers. 'Background' primary-care consultations (2-5 years before diagnosis) were similar for either group. In the year before diagnosis, >95% of emergency and non-emergency presenters had consulted their doctor, but emergency presenters had less frequently relevant symptoms (colon cancer: 48% vs 71% (P<0.001); rectal cancer: 49% vs 61% (P=0.043)). 'Alarm' symptoms were recorded less frequently in emergency presenters (e.g., rectal bleeding: 9 vs 24% (P=0.002)). However, about 1/5 of emergency presenters (18 and 23% for colon and rectal cancers) had 'alarm' symptoms the year before diagnosis. CONCLUSIONS: Emergency presenters have similar 'background' consultation history as non-emergency presenters. Their tumours seem associated with less typical symptoms, however opportunities for earlier diagnosis might be present in a fifth of them.","author":[{"dropping-particle":"","family":"Renzi","given":"C","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lyratzopoulos","given":"G","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Card","given":"T","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chu","given":"T P C","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Macleod","given":"U","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rachet","given":"B","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British Journal of Cancer","id":"ITEM-1","issue":"August","issued":{"date-parts":[["2016"]]},"note":"examine patterns of presentation in primary care with symptoms/signs potentially related to colon and rectal cancer during the years and months before the cancer diagnosis.\n\nPAtients sourced from NCIN\nEmergency determined by NCIN routes fo diagnosis\n2005-2006\n25 years and older\nNo previous diagnosis of cancer\n\n58359 incident colon and rectal cancer patients in NCIN, 1922 (3.3%) linked to CPRD. \n\nLoss of 121 patients as no RTD - not as much as I would have thought - same as our data from 2006 onwards\n1606 patients in the study sample\n\nDiagnosis either emergency or non-emergency\nAnalysis of Gp consultation 5 years up to NCIN cancer diagnosis date\n\nSocio-economic\nNumber of consutlations\ntype of symptom\ntiming before diagnosis\n\n30 days befoe diagnosis excluded\n\nThe Wilcoxon rank-sum test was used for comparing median number of visits. Test for trend was calculated for categorical variable of GP visits.\n\nPoisson regression used to determine whether consultation rates with relveant symptoms signifiacntly varied by emergency status\nModels included age, sex and IMD\n\nMutivariable logistic regression analysis for risk of emergency diagnosis based on a priori factors\n\nInteractions examined but excluded due to sparse data\n\nThey have included actiual counts for totals only, \n\n","page":"1-10","publisher":"Nature Publishing Group","title":"Do colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms? A longitudinal data-linkage study in England","type":"article-journal","volume":"115"},"uris":[""]}],"mendeley":{"formattedCitation":"⁸","plainTextFormattedCitation":"8","previouslyFormattedCitation":"⁸"},"properties":{"noteIndex":0},"schema":""}8. During this period the consultation may have directly led to an emergency referral, and so do not represent missed opportunities in primary care to identify the underlying cancer. In our study this period was defined as 28 days. The relevant symptoms were agreed upon by the authors of this study, were based on the 2005 NICE referral criteria, and have been used in previous publicationsADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1038/bjc.2013.791","ISBN":"1532-1827 (Electronic)\\r0007-0920 (Linking)","ISSN":"0007-0920","PMID":"24366304","abstract":"Background:The primary aim was to use routine data to compare cancer diagnostic intervals before and after implementation of the 2005 NICE Referral Guidelines for Suspected Cancer. The secondary aim was to compare change in diagnostic intervals across different categories of presenting symptoms.Methods:Using data from the General Practice Research Database, we analysed patients with one of 15 cancers diagnosed in either 2001-2002 or 2007-2008. Putative symptom lists for each cancer were classified into whether or not they qualified for urgent referral under NICE guidelines. Diagnostic interval (duration from first presented symptom to date of diagnosis in primary care records) was compared between the two cohorts.Results:In total, 37 588 patients had a new diagnosis of cancer and of these 20 535 (54.6%) had a recorded symptom in the year prior to diagnosis and were included in the analysis. The overall mean diagnostic interval fell by 5.4 days (95% CI: 2.4-8.5; P<0.001) between 2001-2002 and 2007-2008. There was evidence of significant reductions for the following cancers: (mean, 95% confidence interval) kidney (20.4 days, -0.5 to 41.5; P=0.05), head and neck (21.2 days, 0.2-41.6; P=0.04), bladder (16.4 days, 6.6-26.5; P0.001), colorectal (9.0 days, 3.2-14.8; P=0.002), oesophageal (13.1 days, 3.0-24.1; P=0.006) and pancreatic (12.6 days, 0.2-24.6; P=0.04). Patients who presented with NICE-qualifying symptoms had shorter diagnostic intervals than those who did not (all cancers in both cohorts). For the 2007-2008 cohort, the cancers with the shortest median diagnostic intervals were breast (26 days) and testicular (44 days); the highest were myeloma (156 days) and lung (112 days). The values for the 90th centiles of the distributions remain very high for some cancers. Tests of interaction provided little evidence of differences in change in mean diagnostic intervals between those who did and did not present with symptoms specifically cited in the NICE Guideline as requiring urgent referral.Conclusion:We suggest that the implementation of the 2005 NICE Guidelines may have contributed to this reduction in diagnostic intervals between 2001-2002 and 2007-2008. There remains considerable scope to achieve more timely cancer diagnosis, with the ultimate aim of improving cancer outcomes.British Journal of Cancer advance online publication, 24 December 2013; doi:10.1038/bjc.2013.791 .","author":[{"dropping-particle":"","family":"Neal","given":"R D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Din","given":"N U","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hamilton","given":"W","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ukoumunne","given":"O C","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Carter","given":"B","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Stapley","given":"S","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rubin","given":"G","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British Journal of Cancer","id":"ITEM-1","issue":"3","issued":{"date-parts":[["2014","2","4"]]},"language":"eng","page":"584-592","publisher":"Nature Publishing Group","publisher-place":"England","title":"Comparison of cancer diagnostic intervals before and after implementation of NICE guidelines: analysis of data from the UK General Practice Research Database","type":"article-journal","volume":"110"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1038/bjc.2016.250","ISBN":"0007-0920","ISSN":"0007-0920","PMID":"27537389","abstract":"BACKGROUND: More than 20% of colorectal cancers are diagnosed following an emergency presentation. We aimed to examine pre-diagnostic primary-care consultations and related symptoms comparing patients diagnosed as emergencies with those diagnosed through non-emergency routes. METHODS: Cohort study of colorectal cancers diagnosed in England 2005 and 2006 using cancer registration data individually linked to primary-care data (CPRD/GPRD), allowing a detailed analysis of clinical information referring to the 5-year pre-diagnostic period. RESULTS: Emergency diagnosis occurred in 35% and 15% of the 1029 colon and 577 rectal cancers. 'Background' primary-care consultations (2-5 years before diagnosis) were similar for either group. In the year before diagnosis, >95% of emergency and non-emergency presenters had consulted their doctor, but emergency presenters had less frequently relevant symptoms (colon cancer: 48% vs 71% (P<0.001); rectal cancer: 49% vs 61% (P=0.043)). 'Alarm' symptoms were recorded less frequently in emergency presenters (e.g., rectal bleeding: 9 vs 24% (P=0.002)). However, about 1/5 of emergency presenters (18 and 23% for colon and rectal cancers) had 'alarm' symptoms the year before diagnosis. CONCLUSIONS: Emergency presenters have similar 'background' consultation history as non-emergency presenters. Their tumours seem associated with less typical symptoms, however opportunities for earlier diagnosis might be present in a fifth of them.","author":[{"dropping-particle":"","family":"Renzi","given":"C","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lyratzopoulos","given":"G","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Card","given":"T","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chu","given":"T P C","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Macleod","given":"U","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rachet","given":"B","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British Journal of Cancer","id":"ITEM-2","issue":"August","issued":{"date-parts":[["2016"]]},"note":"examine patterns of presentation in primary care with symptoms/signs potentially related to colon and rectal cancer during the years and months before the cancer diagnosis.\n\nPAtients sourced from NCIN\nEmergency determined by NCIN routes fo diagnosis\n2005-2006\n25 years and older\nNo previous diagnosis of cancer\n\n58359 incident colon and rectal cancer patients in NCIN, 1922 (3.3%) linked to CPRD. \n\nLoss of 121 patients as no RTD - not as much as I would have thought - same as our data from 2006 onwards\n1606 patients in the study sample\n\nDiagnosis either emergency or non-emergency\nAnalysis of Gp consultation 5 years up to NCIN cancer diagnosis date\n\nSocio-economic\nNumber of consutlations\ntype of symptom\ntiming before diagnosis\n\n30 days befoe diagnosis excluded\n\nThe Wilcoxon rank-sum test was used for comparing median number of visits. Test for trend was calculated for categorical variable of GP visits.\n\nPoisson regression used to determine whether consultation rates with relveant symptoms signifiacntly varied by emergency status\nModels included age, sex and IMD\n\nMutivariable logistic regression analysis for risk of emergency diagnosis based on a priori factors\n\nInteractions examined but excluded due to sparse data\n\nThey have included actiual counts for totals only, \n\n","page":"1-10","publisher":"Nature Publishing Group","title":"Do colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms? A longitudinal data-linkage study in England","type":"article-journal","volume":"115"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.1371/journal.pone.0126608","ISSN":"1932-6203","PMID":"25933397","abstract":"Rapid diagnostic pathways for cancer have been implemented, but evidence whether shorter diagnostic intervals (time from primary care presentation to diagnosis) improves survival is lacking. Using the Clinical Practice Research Datalink, we identified patients diagnosed with female breast (8,639), colorectal (5,912), lung (5,737) and prostate (1,763) cancers between 1998 and 2009, and aged >15 years. Presenting symptoms were classified as alert or non-alert, according to National Institute for Health and Care Excellence guidance. We used relative survival and excess risk modeling to determine associations between diagnostic intervals and five-year survival. The survival of patients with colorectal, lung and prostate cancer was greater in those with alert, compared with non-alert, symptoms, but findings were opposite for breast cancer. Longer diagnostic intervals were associated with lower mortality for colorectal and lung cancer patients with non-alert symptoms, (colorectal cancer: Excess Hazards Ratio, EHR >6 months vs <1 month: 0.85; 95% CI: 0.72-1.00; Lung cancer: EHR 3-6 months vs <1 month: 0.87; 95% CI: 0.80-0.95; EHR >6 months vs <1 month: 0.81; 95% CI: 0.74-0.89). Prostate cancer mortality was lower in patients with longer diagnostic intervals, regardless of type of presenting symptom. The association between diagnostic intervals and cancer survival is complex, and should take into account cancer site, tumour biology and clinical practice. Nevertheless, unnecessary delay causes patient anxiety and general practitioners should continue to refer patients with alert symptoms via the cancer pathways, and actively follow-up patients with non-alert symptoms in the community.","author":[{"dropping-particle":"","family":"Redaniel","given":"Maria Theresa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Martin","given":"Richard M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ridd","given":"Matthew J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wade","given":"Julia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jeffreys","given":"Mona","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"PloS one","id":"ITEM-3","issue":"5","issued":{"date-parts":[["2015","1","1"]]},"language":"eng","page":"e0126608","publisher-place":"United States","title":"Diagnostic intervals and its association with breast, prostate, lung and colorectal cancer survival in England: historical cohort study using the clinical practice research datalink.","type":"article-journal","volume":"10"},"uris":[""]}],"mendeley":{"formattedCitation":"^8–10","plainTextFormattedCitation":"8–10","previouslyFormattedCitation":"^8–10"},"properties":{"noteIndex":0},"schema":""}8–10 (see Appendix A): red-flag - bleeding, anaemia, change in bowel habit, diarrhoea, abdominal mass or non-specific - constipation, abdominal pain, weight loss, fatigue. At any consultation more than one symptom may have been recorded. Patient and tumour variablesYoung patients were defined as those aged under 50 at diagnosis as this age group falls outside most of the 2005 NICE referral criteria and allows comparisons with other studies. Patients over the age of 80 years were excluded as they are more likely to be diagnosed as an emergencyADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1038/bjc.2016.250","ISBN":"0007-0920","ISSN":"0007-0920","PMID":"27537389","abstract":"BACKGROUND: More than 20% of colorectal cancers are diagnosed following an emergency presentation. We aimed to examine pre-diagnostic primary-care consultations and related symptoms comparing patients diagnosed as emergencies with those diagnosed through non-emergency routes. METHODS: Cohort study of colorectal cancers diagnosed in England 2005 and 2006 using cancer registration data individually linked to primary-care data (CPRD/GPRD), allowing a detailed analysis of clinical information referring to the 5-year pre-diagnostic period. RESULTS: Emergency diagnosis occurred in 35% and 15% of the 1029 colon and 577 rectal cancers. 'Background' primary-care consultations (2-5 years before diagnosis) were similar for either group. In the year before diagnosis, >95% of emergency and non-emergency presenters had consulted their doctor, but emergency presenters had less frequently relevant symptoms (colon cancer: 48% vs 71% (P<0.001); rectal cancer: 49% vs 61% (P=0.043)). 'Alarm' symptoms were recorded less frequently in emergency presenters (e.g., rectal bleeding: 9 vs 24% (P=0.002)). However, about 1/5 of emergency presenters (18 and 23% for colon and rectal cancers) had 'alarm' symptoms the year before diagnosis. CONCLUSIONS: Emergency presenters have similar 'background' consultation history as non-emergency presenters. Their tumours seem associated with less typical symptoms, however opportunities for earlier diagnosis might be present in a fifth of them.","author":[{"dropping-particle":"","family":"Renzi","given":"C","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lyratzopoulos","given":"G","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Card","given":"T","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chu","given":"T P C","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Macleod","given":"U","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rachet","given":"B","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British Journal of Cancer","id":"ITEM-1","issue":"August","issued":{"date-parts":[["2016"]]},"note":"examine patterns of presentation in primary care with symptoms/signs potentially related to colon and rectal cancer during the years and months before the cancer diagnosis.\n\nPAtients sourced from NCIN\nEmergency determined by NCIN routes fo diagnosis\n2005-2006\n25 years and older\nNo previous diagnosis of cancer\n\n58359 incident colon and rectal cancer patients in NCIN, 1922 (3.3%) linked to CPRD. \n\nLoss of 121 patients as no RTD - not as much as I would have thought - same as our data from 2006 onwards\n1606 patients in the study sample\n\nDiagnosis either emergency or non-emergency\nAnalysis of Gp consultation 5 years up to NCIN cancer diagnosis date\n\nSocio-economic\nNumber of consutlations\ntype of symptom\ntiming before diagnosis\n\n30 days befoe diagnosis excluded\n\nThe Wilcoxon rank-sum test was used for comparing median number of visits. Test for trend was calculated for categorical variable of GP visits.\n\nPoisson regression used to determine whether consultation rates with relveant symptoms signifiacntly varied by emergency status\nModels included age, sex and IMD\n\nMutivariable logistic regression analysis for risk of emergency diagnosis based on a priori factors\n\nInteractions examined but excluded due to sparse data\n\nThey have included actiual counts for totals only, \n\n","page":"1-10","publisher":"Nature Publishing Group","title":"Do colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms? A longitudinal data-linkage study in England","type":"article-journal","volume":"115"},"uris":[""]}],"mendeley":{"formattedCitation":"⁸","plainTextFormattedCitation":"8","previouslyFormattedCitation":"⁸"},"properties":{"noteIndex":0},"schema":""}8 and so do not provide a suitable standard for comparison. The remaining patients were split into decades.Socioeconomic status was based on the Index of Multiple Deprivation (IMD) categorised from 1 (least deprived) to 5 (most deprived). Charlson score was calculated from a combination of HES and CPRD data in the three years leading up to the CRC diagnosis date. Site and stage were provided by the cancer registry. The former was defined as colon (C18-C19) and rectal (C20), the latter as I, II, III, IV and missing.Referral, hospital and diagnostic intervalA subgroup of patients had both a relevant symptom and referral for suspected cancer recorded in the year leading up to the CRC diagnosis date. This allowed calculation of the referral interval (presentation to referral), hospital interval (from referral to diagnosis) and diagnostic interval (from presentation to diagnosis). Statistical analysisGender, Charlson score, IMD, stage, diagnostic route and the presence of a symptom were expressed in percentages for each age group. Stage was considered as early (I & II), late (III, IV) and missing. Primary care usage in the year leading up to the CRC diagnosis was compared between age groups by the number of consultations with a relevant symptom recorded, stratified according to red-flag or non-specific symptom. A consultation may be represented twice as a patient may be concerned by both red-flag and non-specific symptoms. The odds ratio for presenting with a particular symptom for an age group compared with the youngest patients was determined using logistic regression modelling, adjusted a priori for patient demographics, site of tumour and emergency diagnosis. By considering only cases with the same symptom recorded at the first consultation, logistic regression modelling was used to determine the risk of a young patient being diagnosed as an emergency despite presenting with the same symptom as older patients. This was carried out for each symptom individually and again after grouping into red-flag or non-specific. Categorical data was compared using the χ2 test, with the Mantel-Haenszel test of trend used for the number of consultations before diagnosis, IMD and Charlson score. The intervals were expressed as medians and interquartile ranges, with each age group compared with the youngest age group using the Mann-Whitney U test. Generalised Estimating Equation modelling was used for regression analysis to account for clustering within practices. All analysis was carried out using SPSS (IBM, v24), significance taken at p < 0.05.ResultsPatient selectionOf the 13911 patients with a CRC diagnosis between 2006 and 2013, 3448 patients were excluded due to screening, DCO, unknown diagnostic route and a previous diagnosis of cancer or underlying IBD (figure 1). Of the remaining 10463 patients, 508 (5.0%) were under the age of 50, 1168 (11.5%) between 50 and 59, 2294 (21.9%) between 60 and 69, 3345 (31.5%) between 70 and 79 and 3148 (30.9%) 80 years and over. After excluding the oldest group, 7315 patients formed the study population. Gender, IMD and Charlson score A significantly higher proportion of patients under the age of 50 were female (51.4%) compared with all other age groups (table 1). The Charlson score increased with age, with 23.5% of 70-79 year-old scored ≥2 compared with 1.6% of those under the age of 50 (p < 0.01). There was no significant difference in IMD (p = 0.55). Diagnostic route and site and stage of tumour Colon cancer was most common site for patients aged 70 – 79 (72.2%), while 67.5% of young patients had colon cancer. The youngest age group were more commonly diagnosed as an emergency (29.1%), and less commonly diagnosed through a two week wait referral (22.6%) (p < 0.01). The most common route for this group was the non-urgent ‘GP referral’ (33.3%). Patients aged 60 – 69 had the highest proportion of two week wait referrals (38.5%). Early stage cancer was significantly less common in patients under the age of 50, compared with all other age groups, while missing stage was highest in this group. Late stage was highest in the 50 - 59 year group (50.0%), and the lowest in those aged 70 – 79 (41.6%). Number of consultations before diagnosis There was no significant difference in the number of consultations with associated symptoms between age groups (p=0.71) (table 2). 3.3% of young patients were seen by their GP five or more times before diagnosis, which was higher than all other groups. The youngest age group demonstrated the highest proportion of patients seen at least once with a non-specific symptom (37.4% vs 27.4%, 27.4%, 28.2% respectively, p = 0.03), while this group had the lowest proportion of patients seen at least once with a red-flag symptom (p<0.01). Symptom at presentationYoung patients were more likely to present with bleeding (14.0%) than all other age groups except the 50 – 59 year olds in unadjusted analysis. Abdominal pain (21.1%) and ‘other bowel function’ (3.9%) were most common in the youngest age group, while change in bowel habit, anaemia and weight loss increased with age (supplementary data table A). The under 50 group had the lowest percentage of red-flag (28.5%) and the highest percentage of consultations with non-specific symptoms (32.1%), although only the latter reached significance (p < 0.01). Young patients were more likely to present to their GP in the year leading up to diagnosis (excluding the final 28 days) than all other age groups (table 3) in regression analysis. Young patients were also more likely to present with abdominal pain and ‘other bowel function’. Those aged between 70 and 79 were the only group less likely than young patients to present with rectal bleeding (OR 0.66 95% CI 0.50 – 0.87, p < 0.005) but were more likely to present with anaemia (OR 1.83, 95% CI 1.17 -2.88, p < 0.05). There was no difference if the symptoms were grouped into ‘red-flag’ but all age groups were significantly less likely to present with a non-specific symptom compared with the under 50 age group. Symptoms associated with an emergency diagnosisAll age groups were less likely to be diagnosed as an emergency compared with the under 50-year-old patients (table 4). Worse deprivation, higher Charlson score and colon cancer were associated with an emergency diagnosis (data in supplementary table C). Patients who presented with non-specific symptoms were more likely to be diagnosed as an emergency if they were young compared with all other age groups (50 – 59: OR 0.62, 95% CI 0.47 – 0.82; 60 – 69: OR 0.62, 95% CI 0.49 – 0.80; 70 – 79: OR 0.63, 95% CI 0.50 – 0.81 respectively) (table 4). A similar finding was noted for patients presenting with abdominal pain, although no difference was seen if patients presented with rectal bleeding. Compared with young patients, the 60 – 69 year olds was the only group less likely to be diagnosed as an emergency if the ‘red-flag’ symptoms were considered together. ‘Other bowel function’ as a presenting symptom was also less likely to lead to an emergency diagnosis (OR 0.10 95% CI 0.01 – 0.84) only for the 50 – 59 age group. There were no associations between the other symptoms and an emergency diagnosis according to age. Referral intervalFrom the initial cohort, 2928 (37.8%) patients were identified with a recording of a relevant symptoms and a referral for cancer, of which 216 (7.4%) were under 50 (table 5). There was no significant difference in the referral interval between all ages and the youngest age group. The interval from referral to diagnosis was significantly longer in the youngest age group (median 59 days, IQR 35 – 105), compared with all age groups. Only the 60-69 group demonstrated a significantly shorter interval from presentation to diagnosis compared with those under 50. DiscussionThe aim of our study was to determine whether young patients experience potentially missed opportunities to identify an underlying CRC in primary care and the symptoms most likely to lead to an emergency diagnosis. We found that young patients were most likely to be diagnosed as an emergency. Although the percentage of patients with at least one CRC associated presentation did not differ with age, young patients were most likely to present with a non-specific symptom. Compared with older patients also presenting with non-specific symptoms, younger patients were more likely to be diagnosed as an emergency. However, there was no difference in the risk of an emergency presentation if the presenting consultation included a red-flag. For patients diagnosed as a non-emergency, there was no significant delay in referral between the age groups. However, young patients experienced a significantly longer interval from referral to diagnosis compared with all other age, reflecting the higher proportion of non-urgent referrals. Our study suggests young patients are experiencing missed opportunities for a non-emergency diagnosis.Relevance to clinical practiceOur findings demonstrated the decision regarding the time to refer did not differ with age. However, a relatively high proportion of young patients were non-urgent referrals, whereas those between 60 and 69 years were most commonly referred by the two-week wait route. This reflects the suspicion of cancer and the current referral guidelines, leading to a median difference of up to 12.5 days for the interval from referral to diagnosis. In both the UK and Denmark, primary care physicians play a similar gatekeeper role for access to investigations and secondary careADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1038/sj.bjc.6605383","ISSN":"1532-1827","PMID":"19956163","abstract":"BACKGROUND: Denmark has poorer 5-year survival rates than many other Western European countries, and cancer patients tend to have more advanced stages at diagnosis than those in other Scandinavian countries. Part of this may be due to delay in diagnosis. The aim of this paper is to give an overview of the initiatives currently underway to reduce delays. METHODS: Description of Danish actions to reduce delay. RESULTS: Results of surveys of patient-, doctor- and system-related delays are presented and so are the political initiatives to ensure that cancer is seen as an acute disease. CONCLUSION: In future, fast-track diagnosis and treatment will be provided for suspected cancers and access to general diagnostic investigations will be improved. A large national experiment with cancer seen as an acute disease is currently being implemented, and as yet the results are unknown.","author":[{"dropping-particle":"","family":"Olesen","given":"F","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hansen","given":"R P","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Vedsted","given":"P","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British journal of cancer","id":"ITEM-1","issue":"S2","issued":{"date-parts":[["2009"]]},"page":"S5-S8","publisher":"Nature Publishing Group","title":"Delay in diagnosis: the experience in Denmark.","type":"article-journal","volume":"101 Suppl"},"uris":[""]}],"mendeley":{"formattedCitation":"¹¹","plainTextFormattedCitation":"11","previouslyFormattedCitation":"¹¹"},"properties":{"noteIndex":0},"schema":""}11. Therefore it has been suggested delayed diagnosis in primary care may partly explain the worse survival in these countries compared with their northern and western European neighbours, especially as the majority of patients diagnosed as an emergency have previously presented to their GPADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.3399/bjgp17X690869","ISSN":"0960-1643","author":[{"dropping-particle":"","family":"Abel","given":"Gary A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mendonca","given":"Silvia C","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"McPhail","given":"Sean","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Zhou","given":"Yin","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Elliss-Brookes","given":"Lucy","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lyratzopoulos","given":"Georgios","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British Journal of General Practice","id":"ITEM-1","issued":{"date-parts":[["2017"]]},"page":"1-11","title":"Emergency diagnosis of cancer and previous general practice consultations: insights from linked patient survey data","type":"article-journal"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1093/fampra/cml059","ISSN":"02632136","PMID":"17142248","abstract":"OBJECTIVE: To identify the clinical features of colorectal cancer presenting as a surgical emergency. DESIGN: Population-based case-control study. SETTING: All general practices in Exeter Primary Care Trust, Devon, UK. Participants. 349 patients with colorectal cancer, 62 of these having an emergency presentation. Five randomly selected controls matched by age, sex and general practice for each case. DATA: The entire primary care record, from 24 months to 30 days before diagnosis, was coded using the International Classification of Primary Care-2. MAIN OUTCOME MEASURES: Symptom reporting by patients with emergency presentation of colorectal cancer compared with matched controls and non-emergency presentations. RESULTS: Eight features of colorectal cancer were associated with the 62 emergency presentations of colorectal cancer. 39 (63%) of patients had reported at least one symptom to their doctors a minimum of 30 days before the diagnosis. In multivariable analysis, three features remained independently associated with cancer: abdominal pain, odds ratio 6.2 (95% CI 2.8-14), P<0.001; loss of weight 3.4 (1.3-8.5), P=0.01; and diarrhoea 3.4 (1.2-5.7), P=0.02. When emergency presentations were compared with elective cases, abdominal pain was more common [interaction odds ratio 2.3 (1.6-3.3); P=0.047] and rectal bleeding less common [0.30 (0.08, 1.0); P=0.040]. CONCLUSION: The majority of patients destined to have an emergency presentation of colorectal cancer have reported symptoms of their cancer to their doctor well before the emergency. Some emergency presentations should therefore be preventable.","author":[{"dropping-particle":"","family":"Cleary","given":"Jonathan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Peters","given":"Tim J.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sharp","given":"Deborah","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hamilton","given":"William","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Family Practice","id":"ITEM-2","issued":{"date-parts":[["2007"]]},"page":"3-6","title":"Clinical features of colorectal cancer before emergency presentation: A population-based case - Control study","type":"article-journal","volume":"24"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.1038/bjc.2012.423","ISSN":"0007-0920","PMID":"23047590","author":[{"dropping-particle":"","family":"Hamilton","given":"W","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British Journal of Cancer","id":"ITEM-3","issue":"8","issued":{"date-parts":[["2012","10","9"]]},"language":"eng","page":"1205-1206","publisher-place":"England","title":"Emergency admissions of cancer as a marker of diagnostic delay","type":"article-journal","volume":"107"},"uris":[""]}],"mendeley":{"formattedCitation":"^12–14","plainTextFormattedCitation":"12–14","previouslyFormattedCitation":"^12–14"},"properties":{"noteIndex":0},"schema":""}12–14. As young patients were more likely to report a non-specific symptom at first presentation, many patients within this age group are at risk of missed diagnoses unless there is a better understanding of how young CRC patients present. This study adds to this growing area of research.Whether in practice an emergency diagnosis can be prevented in a significant proportion of young patients remains debatable, considering a primary care physician in the UK may only see up to two patients per year with one of the four most common cancersADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.3399/bjgp09X420860","ISBN":"10.3399/bjgp09X420860","ISSN":"09601643","PMID":"19520027","abstract":"Much investment has been put into facilities for early cancer diagnosis. It is difficult to know how successful this investment has been. New facilities for rapid investigation in the UK have not reduced mortality, and may cause delays in diagnosis of patients with low-risk, or atypical, symptoms. In part, the failure of new facilities to translate into mortality benefits can be explained by five misconceptions. These are described, along with suggested research and organisational remedies. The first misconception is that cancer is diagnosed in hospitals. Consequently, secondary care data have been used to drive primary care decisions. Second, GPs are thought to be poor at cancer diagnosis, yet the type of education on offer to improve this may not be what is needed. Third, symptomatic cancer diagnosis has been downgraded in importance with the introduction of screening, yet screening identifies only a small minority of cancers. Fourth, pressure is put on GPs to make referrals for those with an individual high risk of cancer - disenfranchising those with 'low-risk but not no-risk' symptoms. Finally, considerable nihilism exists about the value of early diagnosis, despite considerable observational evidence that earlier diagnosis of symptomatic cancer is beneficial.","author":[{"dropping-particle":"","family":"Hamilton","given":"William","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British Journal of General Practice","id":"ITEM-1","issue":"563","issued":{"date-parts":[["2009"]]},"page":"441-447","title":"Five misconceptions in cancer diagnosis","type":"article-journal","volume":"59"},"uris":[""]}],"mendeley":{"formattedCitation":"¹⁵","plainTextFormattedCitation":"15","previouslyFormattedCitation":"¹⁵"},"properties":{"noteIndex":0},"schema":""}15. Also, the reasons why patients are diagnosed as an emergency is complex, with missed opportunities in primary care not the only issueADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"ISSN":"1759-4782","abstract":"Many patients with cancer are diagnosed through an emergency presentation, which is associated with inferior clinical and patient-reported outcomes compared with those of patients who are diagnosed electively or through screening. Reducing the proportion of patients with cancer who are diagnosed as emergencies is, therefore, desirable; however, the optimal means of achieving this aim are uncertain owing to the involvement of different tumour, patient and health-care factors, often in combination. Most relevant evidence relates to patients with colorectal or lung cancer in a few economically developed countries, and defines emergency presentations contextually (that is, whether patients presented to emergency health-care services and/or received emergency treatment shortly before their diagnosis) as opposed to clinically (whether patients presented with life-threatening manifestations of their cancer). Consistent inequalities in the risk of emergency presentations by patient characteristics and cancer type have been described, but limited evidence is available on whether, and how, such presentations can be prevented. Evidence on patients' symptoms and health-care use before presentation as an emergency is sparse. In this Review, we describe the extent, causes and implications of a diagnosis of cancer following an emergency presentation, and provide recommendations for public health and health-care interventions, and research efforts aimed at addressing this under-researched aspect of cancer diagnosis.","author":[{"dropping-particle":"","family":"Zhou","given":"Yin","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Abel","given":"Gary A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hamilton","given":"Willie","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pritchard-Jones","given":"Kathy","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gross","given":"Cary P","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Walter","given":"Fiona M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Renzi","given":"Cristina","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Johnson","given":"Sam","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"McPhail","given":"Sean","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Elliss-Brookes","given":"Lucy","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lyratzopoulos","given":"Georgios","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Nat Rev Clin Oncol","id":"ITEM-1","issued":{"date-parts":[["2016","10","11"]]},"publisher":"Nature Publishing Group, a division of Macmillan Publishers Limited. All Rights Reserved.","title":"Diagnosis of cancer as an emergency: a critical review of current evidence","type":"article-journal","volume":"advance on"},"uris":[""]}],"mendeley":{"formattedCitation":"¹⁶","plainTextFormattedCitation":"16","previouslyFormattedCitation":"¹⁶"},"properties":{"noteIndex":0},"schema":""}16. The most recent referral guidelines have now included abdominal pain, with the threshold of 40 years of age and weight loss, or 50 years of age with rectal bleedingADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"National Initiative for Health and Care Excellence","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issue":"June","issued":{"date-parts":[["2015"]]},"title":"NICE guidlelines for suspected cancer","type":"article-journal"},"uris":[""]}],"mendeley":{"formattedCitation":"¹⁷","plainTextFormattedCitation":"17","previouslyFormattedCitation":"¹⁷"},"properties":{"noteIndex":0},"schema":""}17. This may make the GP more aware of the association of this symptom and cancer, even in younger patients. By simply removing the age criterion a reduction in emergency diagnoses may be expected. However, this will significantly reduce the sensitivity of the referral guidelines, thereby overwhelming secondary care with patients with an underlying benign condition. Alternative methods of detection in primary care need to be considered than simply relying on the type of symptom, especially as the symptom profile in young patients will change as rectal tumours become more commonADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1001/jamasurg.2014.1756","ISSN":"2168-6254","abstract":"<h3>Importance</h3><p>The overall incidence of colorectal cancer (CRC) has been decreasing since 1998 but there has been an apparent increase in the incidence of CRC in young adults.</p><h3>Objective</h3><p>To evaluate age-related disparities in secular trends in CRC incidence in the United States.</p><h3>Design, Setting, and Patients</h3><p>A retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER) CRC registry. Age at diagnosis was analyzed in 15-year intervals starting at the age of 20 years. SEER*Stat was used to obtain the annual cancer incidence rates, annual percentage change, and corresponding<i>P</i>values for the secular trends. Data were obtained from the National Cancer Institute’s SEER registry for all patients diagnosed as having colon or rectal cancer from January 1, 1975, through December 31, 2010 (N?=?393?241).</p><h3>Main Outcome and Measure</h3><p>Difference in CRC incidence by age.</p><h3>Results</h3><p>The overall age-adjusted CRC incidence rate decreased by 0.92% (95% CI, ?1.14 to ?0.70) between 1975 and 2010. There has been a steady decline in the incidence of CRC in patients age 50 years or older, but the opposite trend has been observed for young adults. For patients 20 to 34 years, the incidence rates of localized, regional, and distant colon and rectal cancers have increased. An increasing incidence rate was also observed for patients with rectal cancer aged 35 to 49 years. Based on current trends, in 2030, the incidence rates for colon and rectal cancers will increase by 90.0% and 124.2%, respectively, for patients 20 to 34 years and by 27.7% and 46.0%, respectively, for patients 35 to 49 years.</p><h3>Conclusions and Relevance</h3><p>There has been a significant increase in the incidence of CRC diagnosed in young adults, with a decline in older patients. Further studies are needed to determine the cause for these trends and identify potential preventive and early detection strategies.</p>","author":[{"dropping-particle":"","family":"Bailey","given":"Christina E.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hu","given":"Chung-Yuan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"You","given":"Y. Nancy","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bednarski","given":"Brian K.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rodriguez-Bigas","given":"Miguel A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Skibber","given":"John M.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cantor","given":"Scott B.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chang","given":"George J.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"JAMA Surgery","id":"ITEM-1","issue":"1","issued":{"date-parts":[["2015","1","1"]]},"page":"17","publisher":"American Medical Association","title":"Increasing Disparities in the Age-Related Incidences of Colon and Rectal Cancers in the United States, 1975-2010","type":"article-journal","volume":"150"},"uris":[""]}],"mendeley":{"formattedCitation":"¹⁸","plainTextFormattedCitation":"18","previouslyFormattedCitation":"¹⁸"},"properties":{"noteIndex":0},"schema":""}18. Comparison with previous studies This is the first study to describe the most common symptoms in young patients, and the symptoms most likely to lead to an emergency diagnosis in this group. Data of patients experiences of primary care in England has shown young patients with colon or rectal cancer are more likely than those aged 65 – 74 to see their GP three or more times before referral. Although the referral interval was longer for the youngest age group, this did not reach statistical significance ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/S1470-2045(12)70041-4","ISBN":"1470-2045","ISSN":"14702045","PMID":"22365494","abstract":"Background: Information from patient surveys can help to identify patient groups and cancers with the greatest potential for improvement in the experience and timeliness of cancer diagnosis. We aimed to examine variation in the number of pre-referral consultations with a general practitioner between patients with different cancers and sociodemographic characteristics. Methods: We analysed data from 41 299 patients with 24 different cancers who took part in the 2010 National Cancer Patient Experience Survey in England. We examined variation in the number of general practitioner consultations with cancer symptoms before hospital referral to diagnose cancer. Logistic regression was used to identify independent predictors of three or more pre-referral consultations, adjusting for cancer type, age, sex, deprivation quintile, and ethnic group. Findings: We identified wide variation between cancer types in the proportion of patients who had visited their general practitioner three or more times before hospital referral (7??4% [625 of 8408] for breast cancer and 10??1% [113 of 1124] for melanoma; 41??3% [193 of 467] for pancreatic cancer and 50??6% [939 of 1854] for multiple myeloma). In multivariable analysis, with patients with rectal cancer as the reference group, those with subsequent diagnosis of multiple myeloma (odds ratio [OR] 3??42, 95% CI 3??01-3??90), pancreatic cancer (2??35, 1??91-2??88), stomach cancer (1??96, 1??65-2??34), and lung cancer (1??68, 1??48-1??90) were more likely to have had three or more pre-referral consultations; conversely patients with subsequent diagnosis of breast cancer (0??19; 0??17-0??22), melanoma (0??34, 0??27-0??43), testicular cancer (0??47, 0??33-0??67), and endometrial cancer (0??59, 0??49-0??71) were more likely to have been referred to hospital after only one or two consultations. The probability of three or more pre-referral consultations was greater in young patients (OR for patients aged 16-24 years . vs 65-74 years 2??12, 95% CI 1??63-2??75; p<0??0001), those from ethnic minorities (OR for Asian . vs white 1??73, 1??45-2??08; p<0??0001; OR for black . vs white 1??83, 1??51-2??23; p<0??0001), and women (OR for women . vs men 1??28, 1??21-1??36; p<0??0001). We identified strong evidence of interactions between cancer type and age group and sex (p<0??0001 for both), and between age and ethnicity (p=0??0013). The model including these interactions showed a particularly strong sex effect for bladder cancer (OR for wo…","author":[{"dropping-particle":"","family":"Lyratzopoulos","given":"Georgios","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Neal","given":"Richard D.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Barbiere","given":"Josephine M.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rubin","given":"Gregory P.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Abel","given":"Gary A.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The Lancet Oncology","id":"ITEM-1","issue":"4","issued":{"date-parts":[["2012"]]},"page":"353-365","publisher":"Elsevier Ltd","title":"Variation in number of general practitioner consultations before hospital referral for cancer: Findings from the 2010 National Cancer Patient Experience Survey in England","type":"article-journal","volume":"13"},"uris":[""]}],"mendeley":{"formattedCitation":"¹⁹","plainTextFormattedCitation":"19","previouslyFormattedCitation":"¹⁹"},"properties":{"noteIndex":0},"schema":""}19.The overall referral interval in our study was longer than that noted by Lyratzopolous et al.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1038/bjc.2015.40","ISSN":"1532-1827","PMID":"25734380","abstract":"BACKGROUND: Appreciating variation in the length of pre- or post-presentation diagnostic intervals can help prioritise early diagnosis interventions with either a community or a primary care focus.\\n\\nMETHODS: We analysed data from the first English National Audit of Cancer Diagnosis in Primary Care on 10?953 patients with any of 28 cancers. We calculated summary statistics for the length of the patient and the primary care interval and their ratio, by cancer site.\\n\\nRESULTS: Interval lengths varied greatly by cancer. Laryngeal and oropharyngeal cancers had the longest median patient intervals, whereas renal and bladder cancer had the shortest (34.5 and 30 compared with 3 and 2 days, respectively). Multiple myeloma and gallbladder cancer had the longest median primary care intervals, and melanoma and breast cancer had the shortest (20.5 and 20 compared with 0 and 0 days, respectively). Mean patient intervals were longer than primary care intervals for most (18 of 28) cancers, and notably so (two- to five-fold greater) for 10 cancers (breast, melanoma, testicular, vulval, cervical, endometrial, oropharyngeal, laryngeal, ovarian and thyroid).\\n\\nCONCLUSIONS: The findings support the continuing development and evaluation of public health interventions aimed at shortening patient intervals, particularly for cancers with long patient interval and/or high patient interval over primary care interval ratio.","author":[{"dropping-particle":"","family":"Lyratzopoulos","given":"G","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Saunders","given":"C L","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Abel","given":"G A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"McPhail","given":"S","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Neal","given":"R D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wardle","given":"J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rubin","given":"G P","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British journal of cancer","id":"ITEM-1","issue":"s1","issued":{"date-parts":[["2015"]]},"page":"S35-40","publisher":"Nature Publishing Group","title":"The relative length of the patient and the primary care interval in patients with 28 common and rarer cancers.","type":"article-journal","volume":"112 Suppl "},"uris":[""]}],"mendeley":{"formattedCitation":"²⁰","plainTextFormattedCitation":"20","previouslyFormattedCitation":"²⁰"},"properties":{"noteIndex":0},"schema":""}20 (median 6 days IQR 0 – 29) in their study using the English National Audit of Cancer Diagnosis in Primary Care. Whereas we have calculated the interval from non-specific symptoms in the year before diagnosis, a GP may have not considered this a relevant symptom before submitting the audit data. In addition, the latter is susceptible to selection bias if the GP felt a delay in primary care may have led to a worse outcome for their patient. There is inconsistency in published studies as to whether a change in bowel habit, diarrhoea or weight loss are associated with an emergency diagnosis, perhaps due to variation in the definition of these symptoms, while per rectal bleeding and anaemia seem to be protectiveADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1136/bmjopen-2014-006965","ISSN":"2044-6055 (Electronic)","PMID":"25838506","abstract":"OBJECTIVE: To identify patient and practitioner factors that influence cancer diagnosis via emergency presentation (EP). DESIGN: Systematic review. DATA SOURCES: MEDLINE, EMBASE, CINAHL, EBM Reviews, Science and Social Sciences Citation Indexes, Conference Proceedings Citation Index-Science and Conference Proceedings Citation Index-Social Science and Humanities. Searches were undertaken from 1996 to 2014. No language restrictions were applied. STUDY SELECTION: Studies of any design assessing factors associated with diagnosis of colorectal or lung cancer via EP, or describing an intervention to impact on EP, were included. Studies involving previously diagnosed cancer patients, assessing only referral pathway effectiveness, outcomes related to diagnosis or post-EP management were excluded. The population was individual or groups of adult patients or primary care practitioners. Two authors independently screened studies for inclusion. RESULTS: 22 studies with over 200,000 EPs were included, most providing strong evidence. Five were graded 'insufficient', primarily due to missing information rather than methodological weakness. Older patient age was associated with EP for lung and colorectal cancers (OR 1.11-11.03 and 1.19-5.85, respectively). Women were more at risk of EP for lung but not colorectal cancer. Higher deprivation increased the likelihood of lung cancer EP, but evidence for colorectal was less conclusive. Being unmarried (or divorced/widowed) increased the likelihood of EP for colorectal cancer, which was also associated with pain, obstruction and weight loss. Lack of a regular source of primary care, and lower primary care use were positively associated with EP. Only three studies considered practitioner factors, two involving diagnostic tests. No conclusive evidence was found. CONCLUSIONS: Patient-related factors, such as age, gender and deprivation, increase the likelihood of cancer being diagnosed as the result of an EP, while cancer symptoms and patterns of healthcare utilisation are also relevant. Further work is needed to understand the context in which risk factors for EP exist and influence help-seeking.","author":[{"dropping-particle":"","family":"Mitchell","given":"Elizabeth D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pickwell-Smith","given":"Benjamin","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Macleod","given":"Una","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"BMJ open","id":"ITEM-1","issue":"4","issued":{"date-parts":[["2015"]]},"language":"eng","page":"e006965","publisher-place":"England","title":"Risk factors for emergency presentation with lung and colorectal cancers: a systematic review.","type":"article-journal","volume":"5"},"uris":[""]}],"mendeley":{"formattedCitation":"⁵","plainTextFormattedCitation":"5","previouslyFormattedCitation":"⁵"},"properties":{"noteIndex":0},"schema":""}5. The symptoms deemed relevant in our study were agreed by the authors and have previously been used in other studies to determine intervals from presentation to diagnosisADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1038/bjc.2016.250","ISBN":"0007-0920","ISSN":"0007-0920","PMID":"27537389","abstract":"BACKGROUND: More than 20% of colorectal cancers are diagnosed following an emergency presentation. We aimed to examine pre-diagnostic primary-care consultations and related symptoms comparing patients diagnosed as emergencies with those diagnosed through non-emergency routes. METHODS: Cohort study of colorectal cancers diagnosed in England 2005 and 2006 using cancer registration data individually linked to primary-care data (CPRD/GPRD), allowing a detailed analysis of clinical information referring to the 5-year pre-diagnostic period. RESULTS: Emergency diagnosis occurred in 35% and 15% of the 1029 colon and 577 rectal cancers. 'Background' primary-care consultations (2-5 years before diagnosis) were similar for either group. In the year before diagnosis, >95% of emergency and non-emergency presenters had consulted their doctor, but emergency presenters had less frequently relevant symptoms (colon cancer: 48% vs 71% (P<0.001); rectal cancer: 49% vs 61% (P=0.043)). 'Alarm' symptoms were recorded less frequently in emergency presenters (e.g., rectal bleeding: 9 vs 24% (P=0.002)). However, about 1/5 of emergency presenters (18 and 23% for colon and rectal cancers) had 'alarm' symptoms the year before diagnosis. CONCLUSIONS: Emergency presenters have similar 'background' consultation history as non-emergency presenters. Their tumours seem associated with less typical symptoms, however opportunities for earlier diagnosis might be present in a fifth of them.","author":[{"dropping-particle":"","family":"Renzi","given":"C","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lyratzopoulos","given":"G","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Card","given":"T","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chu","given":"T P C","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Macleod","given":"U","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rachet","given":"B","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British Journal of Cancer","id":"ITEM-1","issue":"August","issued":{"date-parts":[["2016"]]},"note":"examine patterns of presentation in primary care with symptoms/signs potentially related to colon and rectal cancer during the years and months before the cancer diagnosis.\n\nPAtients sourced from NCIN\nEmergency determined by NCIN routes fo diagnosis\n2005-2006\n25 years and older\nNo previous diagnosis of cancer\n\n58359 incident colon and rectal cancer patients in NCIN, 1922 (3.3%) linked to CPRD. \n\nLoss of 121 patients as no RTD - not as much as I would have thought - same as our data from 2006 onwards\n1606 patients in the study sample\n\nDiagnosis either emergency or non-emergency\nAnalysis of Gp consultation 5 years up to NCIN cancer diagnosis date\n\nSocio-economic\nNumber of consutlations\ntype of symptom\ntiming before diagnosis\n\n30 days befoe diagnosis excluded\n\nThe Wilcoxon rank-sum test was used for comparing median number of visits. Test for trend was calculated for categorical variable of GP visits.\n\nPoisson regression used to determine whether consultation rates with relveant symptoms signifiacntly varied by emergency status\nModels included age, sex and IMD\n\nMutivariable logistic regression analysis for risk of emergency diagnosis based on a priori factors\n\nInteractions examined but excluded due to sparse data\n\nThey have included actiual counts for totals only, \n\n","page":"1-10","publisher":"Nature Publishing Group","title":"Do colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms? A longitudinal data-linkage study in England","type":"article-journal","volume":"115"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1038/bjc.2013.791","ISBN":"1532-1827 (Electronic)\\r0007-0920 (Linking)","ISSN":"0007-0920","PMID":"24366304","abstract":"Background:The primary aim was to use routine data to compare cancer diagnostic intervals before and after implementation of the 2005 NICE Referral Guidelines for Suspected Cancer. The secondary aim was to compare change in diagnostic intervals across different categories of presenting symptoms.Methods:Using data from the General Practice Research Database, we analysed patients with one of 15 cancers diagnosed in either 2001-2002 or 2007-2008. Putative symptom lists for each cancer were classified into whether or not they qualified for urgent referral under NICE guidelines. Diagnostic interval (duration from first presented symptom to date of diagnosis in primary care records) was compared between the two cohorts.Results:In total, 37 588 patients had a new diagnosis of cancer and of these 20 535 (54.6%) had a recorded symptom in the year prior to diagnosis and were included in the analysis. The overall mean diagnostic interval fell by 5.4 days (95% CI: 2.4-8.5; P<0.001) between 2001-2002 and 2007-2008. There was evidence of significant reductions for the following cancers: (mean, 95% confidence interval) kidney (20.4 days, -0.5 to 41.5; P=0.05), head and neck (21.2 days, 0.2-41.6; P=0.04), bladder (16.4 days, 6.6-26.5; P0.001), colorectal (9.0 days, 3.2-14.8; P=0.002), oesophageal (13.1 days, 3.0-24.1; P=0.006) and pancreatic (12.6 days, 0.2-24.6; P=0.04). Patients who presented with NICE-qualifying symptoms had shorter diagnostic intervals than those who did not (all cancers in both cohorts). For the 2007-2008 cohort, the cancers with the shortest median diagnostic intervals were breast (26 days) and testicular (44 days); the highest were myeloma (156 days) and lung (112 days). The values for the 90th centiles of the distributions remain very high for some cancers. Tests of interaction provided little evidence of differences in change in mean diagnostic intervals between those who did and did not present with symptoms specifically cited in the NICE Guideline as requiring urgent referral.Conclusion:We suggest that the implementation of the 2005 NICE Guidelines may have contributed to this reduction in diagnostic intervals between 2001-2002 and 2007-2008. There remains considerable scope to achieve more timely cancer diagnosis, with the ultimate aim of improving cancer outcomes.British Journal of Cancer advance online publication, 24 December 2013; doi:10.1038/bjc.2013.791 .","author":[{"dropping-particle":"","family":"Neal","given":"R D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Din","given":"N U","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hamilton","given":"W","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ukoumunne","given":"O C","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Carter","given":"B","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Stapley","given":"S","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rubin","given":"G","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British Journal of Cancer","id":"ITEM-2","issue":"3","issued":{"date-parts":[["2014","2","4"]]},"language":"eng","page":"584-592","publisher":"Nature Publishing Group","publisher-place":"England","title":"Comparison of cancer diagnostic intervals before and after implementation of NICE guidelines: analysis of data from the UK General Practice Research Database","type":"article-journal","volume":"110"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.1038/sj.bjc.6603439","ISSN":"0007-0920","PMID":"17060933","abstract":"The association between the staging of colorectal cancer and mortality is well known. Much less researched is the relationship between the duration of symptoms and outcome, and whether particular initial symptoms carry a different prognosis. We performed a cohort study of 349 patients with primary colorectal cancer in whom all their prediagnostic symptoms and investigation results were known. Survival data for 3-8 years after diagnosis were taken from the cancer registry. Six features were studied: rectal bleeding, abdominal pain, diarrhoea, constipation, weight loss, and anaemia. Two of these were significantly associated with different staging and mortality. Rectal bleeding as an initial symptom was associated with less advanced staging (odds ratio from one Duke's stage to the next 0.50, 95% confidence interval 0.31, 0.79; P=0.003) and with reduced mortality (Cox's proportional hazard ratio (HR) 0.56 (0.41, 0.79); P=0.001. Mild anaemia, with a haemoglobin of 10.0-12.9 g dl(-1), was associated with more advanced staging (odds ratio 2.2 (1.2, 4.3); P=0.021) and worse mortality (HR 1.5 (0.98, 2.3): P=0.064). When corrected for emergency admission, sex, and the site of the tumour, the HR for mild anaemia was 1.7 (1.1, 2.6); P=0.015. No relationship was found between the duration of symptoms and staging or mortality.","author":[{"dropping-particle":"","family":"Stapley","given":"S","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Peters","given":"T J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sharp","given":"D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hamilton","given":"W","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British journal of cancer","id":"ITEM-3","issue":"10","issued":{"date-parts":[["2006","11","20"]]},"page":"1321-5","title":"The mortality of colorectal cancer in relation to the initial symptom at presentation to primary care and to the duration of symptoms: a cohort study using medical records.","type":"article-journal","volume":"95"},"uris":[""]},{"id":"ITEM-4","itemData":{"DOI":"10.1038/bjc.2014.424","ISSN":"1532-1827","PMID":"25072256","abstract":"BACKGROUND Survival in cancer patients diagnosed following emergency presentations is poorer than those diagnosed through other routes. To identify points for intervention to improve survival, a better understanding of patients' primary and secondary health-care use before diagnosis is needed. Our aim was to compare colorectal cancer patients' health-care use by diagnostic route. METHODS Cohort study of colorectal cancers using linked primary and secondary care and cancer registry data (2009-2011) from four London boroughs. The prevalence of all and relevant GP consultations and rates of primary and secondary care use up to 21 months before diagnosis were compared across diagnostic routes (emergency, GP-referred and consultant/other). RESULTS The data set comprised 943 colorectal cancers with 24% diagnosed through emergency routes. Most (84%) emergency patients saw their GP 6 months before diagnosis but their symptom profile was distinct; fewer had symptoms meeting urgent referral criteria than GP-referred patients. Compared with GP-referred, emergency patients used primary care less (IRR: 0.85 (95% CI 0.78-0.93)) and urgent care more frequently (IRR: 1.56 (95% CI 1.12; 2.17)). CONCLUSIONS Distinct patterns of health-care use in patients diagnosed through emergency routes were identified in this cohort. Such analyses using linked data can inform strategies for improving early diagnosis of colorectal cancer.","author":[{"dropping-particle":"","family":"Sheringham","given":"J R","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Georghiou","given":"T","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chitnis","given":"X a","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bardsley","given":"M","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British journal of cancer","id":"ITEM-4","issue":"8","issued":{"date-parts":[["2014","10","14"]]},"note":"I think I can do this with Upper gI cancer patients\n\nLooking at just symptoms\n\nComparing benign and cancer patients \n\nInclude cancer patients\n\nVariables on graph - first presenting symptom - i.e NICE vs non NiCe\n\nStage - 1&amp;2 vs 3 &amp; 4\n\ny - axis - as they have done or I prefer my method of mean presentations per month","page":"1490-9","publisher":"Nature Publishing Group","title":"Comparing primary and secondary health-care use between diagnostic routes before a colorectal cancer diagnosis: cohort study using linked data.","type":"article-journal","volume":"111"},"uris":[""]}],"mendeley":{"formattedCitation":"^8,9,21,22","plainTextFormattedCitation":"8,9,21,22","previouslyFormattedCitation":"^8,9,21,22"},"properties":{"noteIndex":0},"schema":""}8,9,21,22. Although anaemia may not be a presenting complaint for most patients, it nevertheless should prompt a referral from primary care without the need for an associated symptom. Strengths and limitationsBy using a large national dataset this study describes in detail the difference in presenting symptoms and how young patients are managed in primary care despite presenting with similar symptoms. CPRD is not liable to recall or selection bias as the consultation is recorded at the time of presentation, without the confirmation of the underlying diagnosis. We were also able to determine the difference in the route of referral for non-emergency patients as this information was provided by NCIN using the protocol described by Elliss-Brookes et al.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1038/bjc.2012.408","ISBN":"0007-0920","ISSN":"1532-1827","PMID":"22996611","abstract":"Cancer survival in England is lower than the European average, which has been at least partly attributed to later stage at diagnosis in English patients. There are substantial regional and demographic variations in cancer survival across England. The majority of patients are diagnosed following symptomatic or incidental presentation. This study defines a methodology by which the route the patient follows to the point of diagnosis can be categorised to examine demographic, organisational, service and personal reasons for delayed diagnosis.","author":[{"dropping-particle":"","family":"Elliss-Brookes","given":"L","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"McPhail","given":"S","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ives","given":"A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Greenslade","given":"M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shelton","given":"J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hiom","given":"S","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Richards","given":"M","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British journal of cancer","id":"ITEM-1","issue":"8","issued":{"date-parts":[["2012"]]},"page":"1220-6","publisher":"Nature Publishing Group","title":"Routes to diagnosis for cancer - determining the patient journey using multiple routine data sets.","type":"article-journal","volume":"107"},"uris":[""]}],"mendeley":{"formattedCitation":"⁷","plainTextFormattedCitation":"7","previouslyFormattedCitation":"⁷"},"properties":{"noteIndex":0},"schema":""}7 By accounting for the socioeconomic deprivation level and Charlson co-morbidity score, and by excluding patients over the age of 79, potential confounders to emergency diagnosis were removed, as noted in previous studiesADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1038/bjc.2012.320","ISBN":"1532-1827","ISSN":"1532-1827","PMID":"22828606","abstract":"BACKGROUND: To identify patient and general practice (GP) characteristics associated with emergency (unplanned) first admissions for cancer in secondary care. METHODS: Patients who had a first-time admission with a primary diagnosis of cancer during 2007/08 to 2009/10 were identified from administrative hospital data. We modelled the associations between the odds of these admissions being unplanned and various patient and GP practice characteristics using national data sets, including the Quality and Outcomes Framework (QOF). RESULTS: There were 639,064 patients with a first-time admission for cancer, with 139,351 unplanned, from 7957 GP practices. The unplanned proportion ranged from 13.9% (patients aged 15-44 years) to 44.9% (patients aged 85 years and older, P<0.0001), with large variation by ethnicity (highest in Asians), deprivation, rurality and cancer type. In unadjusted analyses, all included patient and practice-level variables were statistically significant predictors of the admissions being unplanned. After adjustment, patient area-level deprivation was a key factor (most deprived compared with least deprived quintile OR 1.36, 95% CI 1.32-1.40). Higher total QOF performance protected against unplanned admission (OR 0.94 per 100 points; 95% CI 0.91-0.97); having no GPs with a UK primary medical qualification (OR 1.08, 95% CI 1.04-1.11) and being less able to offer appointments within 48 h were associated with higher odds. CONCLUSION: We have identified some patient and practice characteristics associated with a first-time admission for cancer being unplanned. The former could be used to help identify patients at high risk, while the latter raise questions about the role of practice organisation and staff training.","author":[{"dropping-particle":"","family":"Bottle","given":"a","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tsang","given":"C","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Parsons","given":"C","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Majeed","given":"a","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Soljak","given":"M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Aylin","given":"P","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British journal of cancer","id":"ITEM-1","issue":"8","issued":{"date-parts":[["2012"]]},"page":"1213-9","publisher":"Nature Publishing Group","title":"Association between patient and general practice characteristics and unplanned first-time admissions for cancer: observational study.","type":"article-journal","volume":"107"},"uris":[""]}],"mendeley":{"formattedCitation":"²³","plainTextFormattedCitation":"23","previouslyFormattedCitation":"²³"},"properties":{"noteIndex":0},"schema":""}23. By using Generalised Estimating Equation modelling, clustering within practices was taken into consideration. Without the availability of the free text from the patients’ electronic medical record, CPRD is liable to missing data, especially for non-specific symtpomsADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1136/bmjopen-2016-011664","ISBN":"2044-6055 (Electronic)\\r2044-6055 (Linking)","ISSN":"2044-6055","PMID":"27178981","abstract":"OBJECTIVES: To estimate data loss and bias in studies of Clinical Practice Research Datalink (CPRD) data that restrict analyses to Read codes, omitting anything recorded as text. DESIGN: Matched case-control study. SETTING: Patients contributing data to the CPRD. PARTICIPANTS: 4915 bladder and 3635 pancreatic, cancer cases diagnosed between 1 January 2000 and 31 December 2009, matched on age, sex and general practitioner practice to up to 5 controls (bladder: n=21 718; pancreas: n=16 459). The analysis period was the year before cancer diagnosis. PRIMARY AND SECONDARY OUTCOME MEASURES: Frequency of haematuria, jaundice and abdominal pain, grouped by recording style: Read code or text-only (ie, hidden text). The association between recording style and case-control status (chi(2) test). For each feature, the odds ratio (OR; conditional logistic regression) and positive predictive value (PPV; Bayes' theorem) for cancer, before and after addition of hidden text records. RESULTS: Of the 20 958 total records of the features, 7951 (38%) were recorded in hidden text. Hidden text recording was more strongly associated with controls than with cases for haematuria (140/336=42% vs 556/3147=18%) in bladder cancer (chi(2) test, p<0.001), and for jaundice (21/31=67% vs 463/1565=30%, p<0.0001) and abdominal pain (323/1126=29% vs 397/1789=22%, p<0.001) in pancreatic cancer. Adding hidden text records corrected PPVs of haematuria for bladder cancer from 4.0% (95% CI 3.5% to 4.6%) to 2.9% (2.6% to 3.2%), and of jaundice for pancreatic cancer from 12.8% (7.3% to 21.6%) to 6.3% (4.5% to 8.7%). Adding hidden text records did not alter the PPV of abdominal pain for bladder (codes: 0.14%, 0.13% to 0.16% vs codes plus hidden text: 0.14%, 0.13% to 0.15%) or pancreatic (0.23%, 0.21% to 0.25% vs 0.21%, 0.20% to 0.22%) cancer. CONCLUSIONS: Omission of text records from CPRD studies introduces bias that inflates outcome measures for recognised alarm symptoms. This potentially reinforces clinicians' views of the known importance of these symptoms, marginalising the significance of 'low-risk but not no-risk' symptoms.","author":[{"dropping-particle":"","family":"Price","given":"Sarah J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Stapley","given":"Sal A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Shephard","given":"Elizabeth","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Barraclough","given":"Kevin","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hamilton","given":"William T","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"BMJ Open","id":"ITEM-1","issue":"5","issued":{"date-parts":[["2016"]]},"page":"e011664","title":"Is omission of free text records a possible source of data loss and bias in Clinical Practice Research Datalink studies? A case–control study","type":"article-journal","volume":"6"},"uris":[""]}],"mendeley":{"formattedCitation":"²⁴","plainTextFormattedCitation":"24","previouslyFormattedCitation":"²⁴"},"properties":{"noteIndex":0},"schema":""}24. If, by definition, all patients diagnosed through the non-emergency pathway would have seen their GP at least once, then we found no significant difference between the age groups in the proportion of patients with at least one consultation recorded in CPRD (Under 50: 65.0% (n = 234); 50 – 59: 58.2% (n = 545), 60 – 69: 59.7% (n = 1084); 70 – 79: 60.0% (n = 1553)). This indicates missing data does not influence a particular age group. We were unable to ascertain with certainty whether the symptoms recorded were due to the cancer, although this is an issue with any observational study investigating delays. We only used one year of data preceding the cancer diagnosis to search for associated symptoms because previous studies have shown medical seeking behaviour changes in this period relative to those with an underlying benign conditionADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1038/sj.bjc.6602714","ISBN":"0007-0920 (Print) 0007-0920 (Linking)","ISSN":"0007-0920","PMID":"16106247","abstract":"Most colorectal cancers are diagnosed after the onset of symptoms. However, the risk of colorectal cancer posed by particular symptoms is largely unknown, especially in unselected populations like primary care. This was a population-based case-control study in all 21 general practices in Exeter, Devon, UK, aiming to identify and quantify the prediagnostic features of colorectal cancer. In total, 349 patients with colorectal cancer, aged 40 years or more, and 1744 controls, matched by age, sex and general practice, were studied. The full medical record for 2 years before diagnosis was coded using the International Classification of Primary Care-2. We calculated odds ratios for variables independently associated with cancer, using multivariable conditional logistic regressions, and then calculated the positive predictive values of these variables, both individually and in combination. In total, 10 features were associated with colorectal cancer before diagnosis. The positive predictive values (95% confidence interval) of these were rectal bleeding 2.4% (1.9, 3.2); weight loss 1.2% (0.91, 1.6); abdominal pain 1.1% (0.86, 1.3); diarrhoea 0.94% (0.73, 1.1); constipation 0.42% (0.34, 0.52); abnormal rectal examination 4.0% (2.4, 7.4); abdominal tenderness 1.1% (0.77, 1.5); haemoglobin <10.0 g dl(-1) 2.3% (1.6, 3.1); positive faecal occult bloods 7.1% (5.1, 10); blood glucose >10 mmol l(-1) 0.78% (0.51, 1.1): all P < 0.001. Earlier diagnosis of colorectal cancer may be possible using the predictive values for single or multiple symptoms, physical signs or test results.","author":[{"dropping-particle":"","family":"Hamilton","given":"W","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Round","given":"A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sharp","given":"D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Peters","given":"T J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"British journal of cancer","id":"ITEM-1","issue":"4","issued":{"date-parts":[["2005","8"]]},"language":"eng","page":"399-405","publisher-place":"England","title":"Clinical features of colorectal cancer before diagnosis: a population-based case-control study.","type":"article-journal","volume":"93"},"uris":[""]}],"mendeley":{"formattedCitation":"²⁵","plainTextFormattedCitation":"25","previouslyFormattedCitation":"²⁵"},"properties":{"noteIndex":0},"schema":""}25. The decision to refer by the GP would also be influenced by the duration of symptoms before presentation, which was beyond the scope of this study. ConclusionOur study demonstrates that young patients are more likely to present with non-specific symptoms that fall outside the national referral criteria, such as abdominal pain, compared with older patients. Primary care physicians should be made aware of these differences if there is to be a reduction in missed opportunities to prevent emergency diagnoses. Table SEQ Table \* ARABIC 1 - Patients demographics, stage and site of colorectal cancer. X2 test for trend used for Charlson score and IMD. IMD – Index of multilevel deprivation, TWW – Two week wait, GP – General PractitionerUnder 5050 - 5960 - 6970 - 79Allp valuen%n%n%n%n%GenderMale24748.666657.0140161.1191857.3423257.9< 0.01Female26151.450243.089338.9142742.7308342.1Charlson045589.693279.8156668.3179053.5474364.8< 0.011458.916614.244919.677023.0143019.52+81.6706.027912.278523.5114215.6IMD111622.828224.150021.877823.3167622.90.41212825.228524.456524.686725.3182524.939218.124220.748321.167320.1149020.449618.919416.642218.462618.7133818.357615.016514.132414.142112.698613.5PresentationTWW11522.643527.288338.5123036.8266336.3< 0.01GP referral16933.333128.360826.589526.8200327.4Other outpatient387.51038.81797.82908.76108.3Inpatient elective387.5675.71466.41725.14235.8Emergency14829.123219.947820.875822.7161622.1< 0.01Non-emergency36070.993680.1181679.2258777.3569977.9StageEarly16031.543237.081735.6132339.6273237.3< 0.01Late24448.058450.0111148.4139341.6333245.6Missing10420.515213.036616.062918.8125117.1SiteColon34367.573963.3160169.8241672.2509969.7< 0.01Rectum16532.542936.769330.292927.8221630.3Table SEQ Table \* ARABIC 2 - Number of patients with 0, 1-2, 3- 4 and 5+ consultations in the year leading up to the cancer diagnosis for each age group stratified according to whether the symptom recorded at the time of consultation was red-flag or non-specific. X2 for test of trend was used for analysis. FrequencyUnder 5050 - 5960 - 6970 - 79Alln%n%n%n%n%pRelevant consultations020340.053045.4102244.6144843.3320343.80.711 – 224347.852144.6105045.8151345.2332745.53 – 4458.9998.51807.83009.06248.55+173.3181.5421.8842.51612.2Consultations with red-flag symptoms033365.675464.6146463.8205161.3492862.9< 0.011 – 215630.738332.876633.4115733.7246233.73 – 4173.3262.2612.71193.02233.05+20.450.430.1180.4280.4Consultations with non-specific symptoms031862.684872.6166672.6240371.8523571.60.031 - 216031.526222.452022.778823.6173023.73 - 4224.3494.2853.71173.52733.75+81.690.8231.0371.1771.1Table SEQ Table \* ARABIC 3 – Odds ratio (OR) for presentation of a symptoms, after accounting for site, socioeconomic deprivation, Charlson score, gender and emergency presentation. Number and percentage of patients presenting with each symptom is also included. There was no difference noted with change in bowel habit, weight loss and diarrhoea. These data are found in supplementary data table BPresenting symptomn (%)OR95% CIp valueAny symptomUnder 50305 (60.0)ref50 - 59638 (54.6)0.720.59 - 0.89< 0.0160 - 691272 (55.4)0.730.60 - 0.88< 0.0170 - 791897 (56.7)0.730.61 - 0.89< 0.01Red- flagUnder 50145 (28.5)ref50 - 59353 (30.2)0.930.75 - 1.170.5560 - 69723 (31.5)1.000.81 - 1.230.9970 - 791085 (32.4)1.020.83 - 1.250.89Non-specificUnder 50163 (32.1)ref50 - 59294 (25.2)0.730.59 – 0.92< 0.0160 - 69564 (24.6)0.680.55 – 0.84< 0.0170 - 79833 (24.9)0.680.55 – 0.83< 0.01BleedingUnder 5071 (14.0)ref50 - 59186 (15.9)1.070.80 – 1.430.6660 - 69287 (12.5)0.870.65 – 1.140.3170 - 79329 (9.8)0.660.50 - 0.87< 0.01AnaemiaUnder 5020 (3.9)ref50 - 5952 (4.5)1.010.61 - 1.690.9760 - 69161 (7.0)1.380.87 - 2.200.1770 - 79341 (10.2)1.831.17 - 2.88< 0.05Abdominal painUnder 50107 (21.1)ref50 - 59188 (16.1)0.760.59 - 0.990.0460 - 69375 (16.1)0.740.58 - 0.940.0170 - 79424 (12.7)0.550.43 - 0.70< 0.01Other bowel functionUnder 5020 (3.9)ref50 - 5929 (2.5)0.570.32 - 0.990.0560 - 6941 (0.8)0.460.27 - 0.77< 0.0170 - 7938 (1.1)0.330.20 - 0.57< 0.01Table SEQ Table \* ARABIC 4 - Odds ratio (OR) for emergency presentation dependent on the presenting symptom.Adjusted for Charlson score, socioeconomic level, gender, site of cancer. The number of patients per age group diagnosed as an emergency are included stratified according to presenting symptom. No differences were seen with anaemia, change in bowel habit, Diarrhoea and Weight loss.n (%) patientsEmergency diagnosisNon-emergencyEmergencyOR95% CIp valueAll patients Under 50360 (70.9)148 (29.1)ref50 - 59936 (80.1)232 (19.9)0.610.48 – 0.77< 0.0160 - 691816 (79.2)478 (20.8)0.620.50 – 0.77< 0.0170 - 792587 (77.3)758 (22.7)0.660.53 – 0.82< 0.01Red- flagUnder 50127 (35.3)18 (12.2)50 - 59327 (34.9)26 (11.2)0.540.28 – 1.030.0660 - 69663 (36.5)60 (12.6)0.520.30 – 0.930.0370 - 79959 (37.1)126 (16.6)0.680.39 – 1.180.17Non-specificUnder 50110 (30.6)53 (25.8)50 - 59226 (24.1)68 (29.3)0.620.47 – 0.82< 0.0160 - 69434 (23.9)130 (27.2)0.620.49 – 0.80< 0.0170 - 79612 (23.7)221 (29.2)0.630.50 – 0.81< 0.01BleedingUnder 5067 (18.6)4 (2.7)50 - 59176 (18.8)10 (4.3)0.880.26 – 3.000.8460 - 69277 (15.3)10 (2.1)0.380.11 – 1.310.1270 - 79307 (11.9)22 (2.9)0.680.21 – 2.190.52Abdominal painUnder 5068 (18.9)39 (26.4)50 - 59136 (14.5)52 (22.4)0.610.36 – 0.79< 0.0160 - 69285 (15.7)90 (18.8)0.490.31 – 0.78< 0.0170 - 79299 (11.6)125 (16.5)0.620.39 – 0.88< 0.01Other bowel functionUnder 5014 (3.9)6 (4.1)50 - 5928 (3.0)1 (0.4)0.100.01 – 0.840.0460 - 6934 (1.9)7 (1.5)0.380.10 – 1.480.1670 - 7929 (1.1)9 (1.2)0.770.20 – 3.000.70Table SEQ Table \* ARABIC 5 –The median and interquartile referral, hospital and diagnostic interval in days according to age. *indicates significantly different compared with under 50 group.Under 5050 - 5960 - 6970 - 79Alln (%)216 (7.4)467 (15.9)912 (31.1)1333 (45.5)2928 (100)Presentation to referral27 (1 – 101)21.5 (1 – 104)21 (1 – 91.5)28 (3 – 117.25)25 (2 – 105)Referral to diagnosis59 (35 – 105)46.5 (28 – 85.25)*49 (29 – 83)*47 (28 – 87.25)*49 (28 – 86.75)Presentation to diagnosis108 (60 – 225)91.5 (54 – 198)92 (54 – 189)*100 (55 – 216.25)97 (55 – 206)Figure 1 - Patient selection for study . CRC - Colorectal cancer, DCO - Death Certificate Only, IBD - Inflammatory Bowel Disease5508411997713911 patients with CRC between 2006 - 201369 (0.5%) DCO901 (6.5%) Screening741 (5.3%) Unknown12200 patients1543 (12.6%) previous cancer10657 patients10463 patients3148 (30.1%) ≥ 80 years old7315 patients13911 patients with CRC between 2006 - 201369 (0.5%) DCO901 (6.5%) Screening741 (5.3%) Unknown12200 patients1543 (12.6%) previous cancer10657 patients10463 patients3148 (30.1%) ≥ 80 years old7315 patients17614909525194 (1.8%) previous IBD0194 (1.8%) previous IBDADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY 1. Ahnen DJ, Wade SW, Jones WF, et al. The Increasing Incidence of Young-Onset Colorectal Cancer: A Call to Action. Mayo Clin Proc. 2014;89(2):216-224. doi:10.1016/j.mayocp.2013.09.006.2. Office for National Statistics.. Cancer Registration Statistics. Cancer Registration Statistics.3. Siegel RL, Fedewa SA, Anderson WF, et al. 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Bailey CE, Hu C-Y, You YN, et al. Increasing Disparities in the Age-Related Incidences of Colon and Rectal Cancers in the United States, 1975-2010. JAMA Surg. 2015;150(1):17. doi:10.1001/jamasurg.2014.1756.19. Lyratzopoulos G, Neal RD, Barbiere JM, Rubin GP, Abel GA. Variation in number of general practitioner consultations before hospital referral for cancer: Findings from the 2010 National Cancer Patient Experience Survey in England. Lancet Oncol. 2012;13(4):353-365. doi:10.1016/S1470-2045(12)70041-4.20. Lyratzopoulos G, Saunders CL, Abel GA, et al. The relative length of the patient and the primary care interval in patients with 28 common and rarer cancers. Br J Cancer. 2015;112 Suppl(s1):S35-40. doi:10.1038/bjc.2015.40.21. Stapley S, Peters TJ, Sharp D, Hamilton W. The mortality of colorectal cancer in relation to the initial symptom at presentation to primary care and to the duration of symptoms: a cohort study using medical records. Br J Cancer. 2006;95(10):1321-1325. doi:10.1038/sj.bjc.6603439.22. Sheringham JR, Georghiou T, Chitnis X a, Bardsley M. Comparing primary and secondary health-care use between diagnostic routes before a colorectal cancer diagnosis: cohort study using linked data. Br J Cancer. 2014;111(8):1490-1499. doi:10.1038/bjc.2014.424.23. Bottle a, Tsang C, Parsons C, Majeed a, Soljak M, Aylin P. Association between patient and general practice characteristics and unplanned first-time admissions for cancer: observational study. Br J Cancer. 2012;107(8):1213-1219. doi:10.1038/bjc.2012.320.24. Price SJ, Stapley SA, Shephard E, Barraclough K, Hamilton WT. Is omission of free text records a possible source of data loss and bias in Clinical Practice Research Datalink studies? A case–control study. BMJ Open. 2016;6(5):e011664. doi:10.1136/bmjopen-2016-011664.25. Hamilton W, Round A, Sharp D, Peters TJ. Clinical features of colorectal cancer before diagnosis: a population-based case-control study. Br J Cancer. 2005;93(4):399-405. doi:10.1038/sj.bjc.6602714.Appendix A – Read codes for symptomsRead codeRead termAbdominal pain1962colicky abdominal pain1963Non-colicky abdominal pain1964Shoulder pain from abdomen1967type of git pain1968abdominal discomfort1969abdominal pain1971central abdominal pain1972Epigastric pain1977right iliac fossa pain1978left iliac fossa pain1979suprapubic pain1969000Abdominal wall pain196..00Type of GIT pain196..11abdominal pain type196..12Type of GIT pain - symptom196Z.00Type of GIT pain NOS197..00Site of GIT pain197..12iliac fossa pain197..13site of abdominal pain197A.00generalised abdominal pain197A.11General abdominal pain-symptom197B.00upper abdominal pain197C.00lower abdominal pain197D.00Right upper quadrant pain197Z.00site of git pain25C..00O/E - abdo. pain on palpation25C..11O/E - epigastric pain on palp.25C..14O/E – umbilical pain on palpation25C..15o/e - abdomen tender25C2.00O/E - abd.pain-R.hypochondrium25C3.00O/E - abd. pain - epigastrium25C4.00O/E - abd.pain-L.hypochondrium25C5.00O/E - abd. pain - R.lumbar25C6.00O/E - abd. pain - umbilical25C7.00O/E - abd. pain - L.lumbar25C8.00O/E – abd. Pain - R iliac25C9.00O/e – abd. Pain – hypogastrium25CA.00O/E – abd. Pain – L.iliac25CZ.00O/E -abd.pain on palpation NOS25D2.00O/E - guarding-R.hypochondrium25D4.00O/E - guarding-L.hypochondrium25E2.00O/E - rebound-R.hypochondrium25E4.00O/E - rebound-L.hypochondrium7NB2X00[SO]HypochondriumJ574700anal painJ574800rectal painJ574F00Anorectal painK58y000Other pelvic pain - femaleR073.00[d]flatulence, eructation and gas painR073200gas pain (abdominal)R073z00[D]Flatulence, eructation andR079.00[D] Defaecation painfulR090.00[d]abdominal painR090000[d]abdominal tendernessR090100[d]abdominal colicR090200[d]colic nosR090400[d]abdominal crampsR090500[D]Epigastric painR090600[D]Umbilical painR090700[D] Hypochondrial painR090800[d]suprapubic painR090900[d]pain in right iliac fossaR090A00pain in left iliac fossaR090E00[d]recurrent acute abdominal pR090G00[d]pelvic and perineal painR090G12[d] perineal painR090H00[d]upper abdominal painR090J00[d]right upper quadrant painR090K00[D]Left upper quadrant painR090L00[D]Left lower quadrant painR090M00[D]Right lower quadrant painR090N00nonspecific abdominal painR090y00[D]Other specified abdominal pR090z00[d]abdominal pain nosRyu1100[X]Other and unspecified abdomAnaemia1451H/O: anaemia - iron deficient1454H/O: anaemia NOS4235Haemoglobin low6884Anaemia screen145..11h/o: anaemia2C2..00o/e - anaemia2C2..11o/e - anaemic2C22.00O/E - equivocally anaemic2C23.00O/E - clinically anaemic2C24.00O/E - profoundly anaemic2C2Z.00O/E - anaemia NOS688..00Anaemia/blood screening688..11Anaemia screen688Z.00Anaemia/blood screen NOSB937X00refractory anaemia, unspecifiedC294300Iron deficiencyD0...00deficiency anaemiasD00..00iron deficiency anaemiasD00..11hypochromic - microcytic anaemiaD00..12Microcytic - hypochromic anaemiaD000.00Iron deficiency anaemia due to chronic blood lossD000.11Normocytic anaemia due to chronic blood lossD000.12Iron deficiency anaemia due to blood lossD001.00Iron deficiency anaemia due to dietary causesD00y.00Other specified iron deficiency anaemiaD00y100microcytic hypochromic anaemiaD00yz00other specified iron deficiency anaemia nosD00z.00unspecified iron deficiency anaemiaD00z200idiopathic hypochromic anaemiaD00zz00iron deficiency anaemia nosD01..00Other deficiency anaemiasD01z.00Other deficiency anaemias NOSD0y..00Other specified deficiency anaemiasD0z..00deficiency anaemias nosD21..00other and unspecified anaemiasD211.00Acute posthaemorrhagic anaemiaD211.11Normocytic anaemia following acute bleedD212.00Anaemia in neoplastic diseaseD213.00Refractory AnaemiaD214.00Chronic anaemiaD21y.00Other specified anaemiasD21yy00Other specified other anaemiaD21yz00Other specified anaemia NOSD21z.00anaemia unspecifiedD21z.11Secondary anaemia NOSD21z.12normocytic anaemia due to unspecified causeD2y..00Other specified anaemiasD2z..00Other anaemias NOSDyu0.00[X]Nutritional anaemiasDyu0000[x]other iron deficiency anaemiasDyu2200[X]Anaemia in other chronic diseases classified elDyu2400[X]Other specified anaemiasZV78100[V]Screening for other or unspecified deficiency aChange in bowel habit19EA.00change in bowel habit19EA.11altered bowel habitJ52z.11bowel dysfunctionR078.00[d]change in bowel habitX76d7urgent desire for stool19C..00constipation19C..11constipation symptom19C2.00Constipated19CZ.00Constipation NOS19EC.00Painful defaecation2AF2.00O/E - defaec.ref.abn.-constip.E264500Psychogenic constipationJ503100faecal impactionJ50zz12Large bowel obstruction NOSJ520.00constipation - functionalJ520000Acute constipationJ520100chronic constipation with overflowJ520200Chronic constipation without overflowJ520300Drug induced constipationJ520400Chronic constipationJ520y00Other specified constipationJ520z00constipation nosJ52y100Difficulty in ability to defaecateDiarrhoea19EE.00Increased frequency of defaecation19F..00diarrhoea symptoms19F..11diarrhoea19F..12loose stools19F2.00diarrhoea19F3.00Spurious (overflow) diarrhoea19FZ.00Diarrhoea symptom NOS19FZ.11diarrhoea & vomiting, symptom19G..00diarrhoea and vomitingA076.11Viral diarrhoeaA082.00Infectious diarrhoeaA082000Dysenteric diarrhoeaA082z00Infectious diarrhoea NOSA083.00Diarrhoea of presumed infectious originA083.11Diarrhoea & vomiting -? infectAyu0H00[X]Diarrhoea+gastroenteritis of presumed infectiouE264300Psychogenic diarrhoeaE264311Spurious diarrhoeaEu45317[X]Psychogenic diarrhoeaJ4...13Noninfective diarrhoeaJ432.11Allergic diarrhoeaJ433.11Dietetic diarrhoeaJ43z.11chronic diarrhoeaJ4z..11Presumed noninfectious diarrhoeaJ4zz.11Diarrhoea - presumed non-infectiousJ521000Irritable bowel syndrome with diarrhoeaJ525.00Functional diarrhoeaR077100[d] stools looseAbdominal mass2643O/E – central pelvic mass25J..00o/e - abdominal mass palpated25J2.00O/E – abdominal mass < 1 quadrant25J3.00O/E –abd.mass fills 1 quadrant25J4.00O/E – abdominal mass fills half abdomen25J5.00O/E – abdominal mass fills abdomen25J7.00right iliac fossa mass25J8.00O/E –left lower abdominal mass25J9.00Epigastric mass25JZ.00O/E – abdominal mass palpated NOS25K..00O/E –abdominal mass consistency25K1.00O/E – abdominal mass – soft25K2.00O/E – abdominal mass – hard25K3.00O/E – abdominal mass very hard25KZ.00O/E – abdominal mass consistency NOS25L..00O/E – abdominal mass shape25L1.00O/E – abdominal mass – regular shape25L2.00O/E –abd.mass –irregular shape25LZ.00O/E – abdominal mass – shape NOS25M..00O/E – abdominal mass movt.with resp.25M1.00O/E – abdominal mass moves with resp25M2.00O/E – abd.mass still with resp25MZ.00O/E – abdominal mass+ respn. NOS25N..00O/E – abdominal mass – border defined25N1.00O/E –abd.mass-upper border def25N2.00O/E –abd.mass –lower border def25NZ.00O/E – abd.mass –border def. NOS25Q3.00o/e - pr - rectal mass25R3.00O/e – dullness over abd. Mass264..00o/e - pelvic mass palpated2I11.00O/E - a lumpR093.00[d]swelling, mass or lump within abdomen or pelvisR093000[d]abdominal swellingR093100[d]abdominal massR093111[D]Lump stomachR093200[d]abdominal lumpR093400[d]pelvic massR093700[d]umbilical massR093800[D]Umbilical lumpR093z00[D] Swelling, mass or lump within abdomen or pelvis NOSOther bowel function14C4.00h/o: colitis19A..00Abdominal distension symptom19B2.00excessive flatulenceA081000colitis - presumed infectiousJ4...11colitis - noninfectiveJ41..11mucous colitis and/or proctitiJ52..00functional gastrointestinal tract disorders necJ521.00irritable colon - irritable bowel syndromeJ521.11irritable bowel syndromeR073000[d]flatulenceR073300[d]abdominal distension, gaseousR073z11[d]windPer rectal bleeding4762.11Blood in faeces14CA.11H/O: GI Bleed196B.00painful rectal bleeding196C.00painless rectal bleeding19E6.00Blood in faeces19E6.11Blood in faeces symptom19ED.00blood on toilet paper19EG.00Blood on pants25T0.00Bleeding stomaG842000Internal bleeding haemorrhoidsG845000External bleeding haemorrhoidsG848000Bleeding haemorrhoids NOSJ573.00haemorrhage of rectum and anusJ573.11bleeding prJ573000rectal haemorrhageJ573011rectal bleedingJ573012prb - rectal bleedingJ573z00haemorrhage of rectum and anus nosJ681.11blood in stoolJ681.12Altered blood in stoolsJ681.13Blood in stools alteredJ68z.11GIB - Gastrointestinal bleedingJ68z100Intestinal haemorrhage NOSFatigue or weight loss1623Weight decreasing1625abnormal weight loss1625.11abnormal weight loss - symptom1627Unintentional weight loss162..00Weight symptom162Z.00Weight symptom NOS1D1A.00complaining of weight loss22A6.00O/E - Underweight22A8.00Weight loss from baseline weight22AZ.00O/E - weight NOSR032.00[d]abnormal loss of weightR034100[D]Failure to gain weightR034800[D]Underweight1682fatigue1683Tired all the time1683.11c/o - "tired all the time"168..00tiredness symptom168..11fatigue - symptom168..12lethargy-symptom168Z.00Tiredness symptom NOSE205.12tired all the timeEu46011[X]Fatigue syndromeF286.00Chronic fatigue syndromeF286.11CFS - Chronic fatigue syndromeF286000Mild chronic fatigue syndromeF286100Moderate chronic fatigue syndromeF286200Severe chronic fatigue syndromeR007.00[D]Malaise and fatigueR007100[d]fatigueR007300[d]lethargyR007500[d]tirednessR007z00[D]Malaise and fatigue NOSAppendix B – Referral read codesRead codeRead term8H48.00Gastroenterological referral8H5..11Surgical referral4794Faecal occult blood: positive8H51.00General surgical referral8HS..00Referral for endoscopy1J0..00Suspected malignancyZL5AD00Referral to gastroenterologistZL5G500Referral to general surgeon8HH8.00Referred to cancer primary healthcare multidisciplinary team8HU1.00Referral for colonoscopyZL5GD00Referral to colorectal surgeon8HV0.00Private referral to general surgeon8H5J.00Referral to colorectal surgeon8HVN.00Private referral to gastroenterologistZL54200Referral to medical oncologist8HS..11Referral for gastroscopy8H7o.00Fast track referral8H5Z.00Referral to surgeon NOS8H5..00Referral to surgeon8HU2.00Referral for sigmoidoscopy1J0D.00Suspected upper gastrointestinal cancer1J0E.00Suspected lower gastrointestinal cancerZL5GA11Referral to GI surgeon8HHt.00Fast track cancer referralZL5GE00Referral to hepatobiliary surgeonZL5GA00Referral to gastrointestinal surgeonZL5GC11Referral to upper GI surgeonZL5GC00Referral to upper gastrointestinal surgeonZL5G.00Referral to surgeonZL5GB11Referral to general GI surgeonZL5GB00Referral to general gastrointestinal surgeon8Hk5.00Referred to hepatology serviceZL54.00Referral to oncologist8H5K.00Referral to upper gastrointestinal surgeonZL62F00Referral to oncology nurseZL5GF00Referral to pancreatic surgeon8Hn..00Priority cancer referral8Hn4.00Fast track referral for suspected colorectal cancer8Hn9.00Fast track referral for suspected upper GI cancer8HVc.00Private referral to colorectal surgeon8HkM.00Referral to hepatobiliary and pancreatic surgery service8Hm1.00Referral to gastroenterology clinical assessment service8H5P.00Referral to gastrointestinal surgeon8Hkn.00Referral to community gastroenterology service8HTE000Referral to rectal bleeding clinic8H5V.00Referral to pancreatic surgeon8HS0000Referral to community sigmoidoscopy service8HS0.00Refer for sigmoidoscopy ................
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