1. Flexible Sigmoidoscopy And Whole Colon Imaging In The Diagnosis Of Cancer In Patients With Colorectal Symptoms Peter O’Leary Journal Club 13/10/08

2. Aims Identify patients with colorectal symptoms most likely to benefit from Whole Colon Imaging (WCI) to diagnose colorectal cancer Identify patients with colorectal symptoms most likely to benefit from Whole Colon Imaging (WCI) to diagnose colorectal cancer Identify patients for whom flexible sigmoidoscopy may be sufficient initially Identify patients for whom flexible sigmoidoscopy may be sufficient initially

3. Methods Prospective observational study Prospective observational study 3 Hospitals 3 Hospitals 17,271 new referrals 17,271 new referrals Between 1986 and 2001 Between 1986 and 2001 Most patients examined with flexible sigmoidoscopy alone or followed by barium enema, colonoscopy or CT colongraphy Most patients examined with flexible sigmoidoscopy alone or followed by barium enema, colonoscopy or CT colongraphy

4. Methods A cancer was defined as missed if A cancer was defined as missed if –Not detected at initial examination in the colorectal outpatient clinic or after referral for WCI, but was diagnosed within 3 years Cancers diagnosed using flexible sigmoidoscopy were defined as distal Cancers diagnosed using flexible sigmoidoscopy were defined as distal Cancers not diagnosed with fs but diagnosed with WCI were defined as proximal Cancers not diagnosed with fs but diagnosed with WCI were defined as proximal

5. Methods Outcome variable was detection of proximal or distal cancer Outcome variable was detection of proximal or distal cancer Other variables collected Other variables collected –Sex, age group (under/over 60 years of age) –Presence/absence of suspicious bowel symptoms Rectal bleeding Rectal bleeding Change in bowel habit Change in bowel habit Abdominal pain Abdominal pain Weight loss Weight loss Fe deficiency anaemia Fe deficiency anaemia Abdominal mass Abdominal mass

6. Results 17,271 new referrals 17,271 new referrals 838 referrals were excluded 838 referrals were excluded –100 diagnosed at another clinic –738 had DRE and no further investigation Remaining 16,433 referrals Remaining 16,433 referrals –969 patients had multiple referrals 881 had 2 referrals 881 had 2 referrals 76 had 3 referrals 76 had 3 referrals 11 had 4 referrals 11 had 4 referrals 1 had 5 referrals 1 had 5 referrals Median age of referrals was 61 Median age of referrals was 61 56% of referrals were female 56% of referrals were female 94.1% of referrals presented with one or more suspicious bowel symptoms outlined 94.1% of referrals presented with one or more suspicious bowel symptoms outlined The remaining referrals were for a variety of reasons including positive family history, anal symptoms and incontinence The remaining referrals were for a variety of reasons including positive family history, anal symptoms and incontinence

7. Results

8. Results

9. Discussion Patients with Fe deficiency anaemia together with an abdominal mass, have a high (15.6%) chance of having a proximal colonic cancer Patients with Fe deficiency anaemia together with an abdominal mass, have a high (15.6%) chance of having a proximal colonic cancer –This group constituted only 3.7% of all patients in this study By contrast, 96.3% of all patients referred with rectal bleeding, altered bowel habit or abdominal pain without Fe def anaemia or abdominal mass had a 0.2% chance of having a proximal colonic cancer By contrast, 96.3% of all patients referred with rectal bleeding, altered bowel habit or abdominal pain without Fe def anaemia or abdominal mass had a 0.2% chance of having a proximal colonic cancer 24 colorectal cancers were missed from a total of 946 cancers diagnosed 24 colorectal cancers were missed from a total of 946 cancers diagnosed –1.3% miss rate for flexi sigmoidoscopy –14% miss rate for double contrast barium enema –0.6% miss rate for colonoscopy In conclusion, a patient who presents without fe def anaemia, abdominal mass or severe symptoms and has had a normal flexible sigmoidoscopy - ‘treat, wait and watch’ approach is appropriate In conclusion, a patient who presents without fe def anaemia, abdominal mass or severe symptoms and has had a normal flexible sigmoidoscopy - ‘treat, wait and watch’ approach is appropriate