View Article PDF

We read with interest the commentary from Bagshaw and Cox regarding the adequacy, or lack thereof, of publicly funded colonoscopy services in New Zealand.1 Their article summarises concerns about provision of colonoscopy, underscoring again what was first noted in The New Zealand Medical Journal in 2007 regarding the already significant gap between colonoscopy demand and provision.2 They highlight in particular the pressing concern that introduction of screening will have on symptomatic patients, currently the main avenue of colorectal cancer (CRC) diagnosis, let alone other important gastrointestinal conditions.

The challenge of diagnosis of these numerous symptomatic patients is that they may present with a heterogenous and diverse spectrum of symptoms, often mimicking more benign gastrointestinal pathology. There have been attempts to encapsulate these difficulties within grading criteria, with prioritisation of risk factors, symptoms and signs based on the UK National Institute of Clinical Excellence (NICE) Guidelines for Suspected Colorectal Cancer.3 However, a local retrospective review of these criteria demonstrated that they may miss a quarter of the patients with CRC in the referral population.4

To review and understand the presenting features of patients in our locality and ascertain the suitability of our diagnostic pathways, we completed a prospective, case-controlled study comparing risk factors, symptoms and signs of all CRC diagnosed at Middlemore Hospital, Auckland, in 2018, recorded from referrals and patient consultation documents. Conditional logistic regression analysis was performed on patients diagnosed with CRC, stratified 1:2 matched by age, gender and ethnicity to compare to patients referred and accepted for diagnostic colonoscopy who were not diagnosed with CRC. In this year, 177 symptomatic patients were diagnosed with CRC and 354 matched controls were recruited: 54% were male; 57% New Zealand European, 15% Asian, 11% Polynesian and 7% Māori. The mean age was 68. Other than excess alcohol intake (4% vs 1% OR 4.17, 95% CI [1.04,17.16], p=0.04), no traditional risk factors were predictive of CRC. This included analysis of obesity status, smoking,5 family history of CRC and personal history of inflammatory bowel disease. The only significant discriminatory symptom for CRC patients was haematochezia (40% vs 26%, OR 1.84, 95% CI [1.28,2.89], p=0.007). Independent predictors for CRC included a palpable mass (OR=6.71, 95% CI [2.31,19.54], p<0.001) and iron deficiency anaemia (OR=1.94, 95% CI [1.22,3.08], p=0.005). Twenty-seven percent of CRCs were already metastatic at presentation. Thirty percent of those diagnosed were less than 60 years old, our current age of screening commencement. Of these patients, 22% were of Pasifika ethnicity, compared with 6.5% of Pasifika patients who were diagnosed over 60 (p=0.02). Of the controls, 155 patients had normal findings (43.7%) and 172 (48.6%) were diagnosed with diverticulosis and/or haemorrhoids.

These results, coupled with the current limitations in resources for our symptomatic patients, suggest that alternative methods should be considered as an adjunct to clinical assessment and acumen to improve objective determination of risk of CRC. Biomarkers used in screening programmes, such as faecal occult blood testing (FOB), have emerged as an option for prioritising symptomatic patients internationally. A primary care case-control study in the UK noted that a positive FOB was nearly three times higher (PPV 7.1%) than their most predictive symptom of rectal bleeding (PPV 2.4%).6 Faecal immunochemical tests (FITs) have also been established to be cost effective for evaluation of lower abdominal symptoms to determine need for colonoscopy and rule out CRC.7–10 It has been suggested that this approach may reduce the burden of outpatient colonoscopic evaluation by as much as 80%.11

In 2015, the National Institute for Health and Care Excellence (NICE) guidelines included a recommendation for testing of FOB in patients without rectal bleeding who are:

  • aged 50 years and over and have unexplained abdominal pain or weight loss
  • under 60 years of age and have changes in their bowel habit or iron deficiency anaemia
  • aged 60 years and over and have anaemia in the absence of iron deficiency.12

These guidelines have been proven to be effective in a single-centre UK study in primary care.13

As a profession, we have an obligation to advocate for the appropriate levels and access to colonoscopy. This investigation is a basic and vital tool for diagnosis, treatment and surveillance of patients with a number of serious colorectal diseases. While many of these may be FIT negative and still require colonoscopy to diagnose (ie, microscopic colitis), improved risk stratification may assist with prioritisation and management of waiting times.

In conclusion, these local data are consistent with international literature that shows that prioritisation by clinical features alone is inefficient. There is increasing research on the use of FIT for symptomatic patients. Introduction of this strategy may help to reduce colonoscopy workload.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Cameron KMW Schauer, MBChB, FRACP: Gastroenterology Department, Middlemore Hospital, Counties Manukau District Health Board, Auckland. Uddaka Wijesinghe, MBChB: Gastroenterology Department, Middlemore Hospital, Counties Manukau District Health Board, Auckland. Michael TM Wang, MBChB: Department of Medicine, University of Auckland, Auckland, New Zealand. Sriharan Selvaratnam, MBChB, FRACP: Gastroenterology Department, Middlemore Hospital, Counties Manukau District Health Board, Auckland. Dinesh Lal, MBBS, FRACP: Gastroenterology Department, Middlemore Hospital, Counties Manukau District Health Board, Auckland.

Acknowledgements

Correspondence

Dr Cameron Schauer, C/O North Shore Hospital, 124 Shakespeare Road, Takapuna, Auckland 0620, +64210368637

Correspondence Email

cameron.schauer@gmail.com

Competing Interests

Nil.

1. Adequacy of publicly funded colonoscopy services in New Zealand [Internet]. [cited 2020 Dec 9]. Available from: https://www.nzma.org.nz/journal-articles/adequacy-of-publicly-funded-colonoscopy-services-in-new-zealand

2. Yeoman A, Parry S. A survey of colonoscopy capacity in New Zealand’s public hospitals. N Z Med J [Internet]. 2007 Jul 20 [cited 2020 Feb 29];120(1258):U2632. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17653250

3. Clinical Governance Research and Development Unit (CGRDU), Department of Health Sciences U of L. NATIONAL COLLABORATING CENTRE FOR PRIMARY CARE [Internet]. Referral Guidelines for Suspected Cancer in Adults and Children. 2005 [cited 2020 Mar 5]. 421 p. Available from: http://www.ncbi.nlm.nih.gov/books/NBK45764/

4. Hsiang JC, Bai W, Lal D. Symptom presentations and other characteristics of colorectal cancer patients and the diagnostic performance of the Auckland Regional Grading Criteria for Suspected Colorectal Cancer in the South Auckland population. N Z Med J. 2013;126(1382):95–107.

5. Richardson A, Hayes J, Frampton C, Potter J. Modifiable lifestyle factors that could reduce the incidence of colorectal cancer in New Zealand. N Z Med J. 2016 Oct 16;129(1447):13–20.

6. 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 Aug 22;93(4):399–405.

7. Jellema P, Van Der Windt DAWM, Bruinvels DJ, Mallen CD, Van Weyenberg SJB, Mulder CJ, et al. Value of symptoms and additional diagnostic tests for colorectal cancer in primary care: Systematic review and meta-analysis. Vol. 340, BMJ (Online). BMJ; 2010. p. 795.

8. Adelstein BA, Macaskill P, Chan SF, Katelaris PH, Irwig L. Most bowel cancer symptoms do not indicate colorectal cancer and polyps: A systematic review. BMC Gastroenterol [Internet]. 2011 May 30 [cited 2020 Mar 5];11:65. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21624112

9. D’Souza N, Hicks G, Benton SC, Abulafi M. The diagnostic accuracy of the faecal immunochemical test for colorectal cancer in risk-stratified symptomatic patients. Ann R Coll Surg Engl. 2020;102(3):174–9.

10. Westwood M, Ramos IC, Lang S, Luyendijk M, Zaim R, Stirk L, et al. Faecal immunochemical tests to triage patients with lower abdominal symptoms for suspected colorectal cancer referrals in primary care: A systematic review and cost-effectiveness analysis. Vol. 21, Health Technology Assessment. NIHR Journals Library; 2017.

11. Westwood M, Lang S, Armstrong N, van Turenhout S, Cubiella J, Stirk L, et al. Faecal immunochemical tests (FIT) can help to rule out colorectal cancer in patients presenting in primary care with lower abdominal symptoms: a systematic review conducted to inform new NICE DG30 diagnostic guidance. BMC Med [Internet]. 2017 Dec 24 [cited 2020 May 23];15(1):189. Available from: http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0944-z

12. Suspected cancer: recognition and referral NICE guideline Your responsibility Your responsibility [Internet]. 2015 [cited 2020 May 23]. Available from: www.nice.org.uk/guidance/ng12

13. Mowat C, Digby J, Strachan JA, McCann R, Hall C, Heather D, et al. Impact of introducing a faecal immunochemical test (FIT) for haemoglobin into primary care on the outcome of patients with new bowel symptoms: A prospective cohort study. BMJ Open Gastroenterol. 2019 May 1;6(1).

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

We read with interest the commentary from Bagshaw and Cox regarding the adequacy, or lack thereof, of publicly funded colonoscopy services in New Zealand.1 Their article summarises concerns about provision of colonoscopy, underscoring again what was first noted in The New Zealand Medical Journal in 2007 regarding the already significant gap between colonoscopy demand and provision.2 They highlight in particular the pressing concern that introduction of screening will have on symptomatic patients, currently the main avenue of colorectal cancer (CRC) diagnosis, let alone other important gastrointestinal conditions.

The challenge of diagnosis of these numerous symptomatic patients is that they may present with a heterogenous and diverse spectrum of symptoms, often mimicking more benign gastrointestinal pathology. There have been attempts to encapsulate these difficulties within grading criteria, with prioritisation of risk factors, symptoms and signs based on the UK National Institute of Clinical Excellence (NICE) Guidelines for Suspected Colorectal Cancer.3 However, a local retrospective review of these criteria demonstrated that they may miss a quarter of the patients with CRC in the referral population.4

To review and understand the presenting features of patients in our locality and ascertain the suitability of our diagnostic pathways, we completed a prospective, case-controlled study comparing risk factors, symptoms and signs of all CRC diagnosed at Middlemore Hospital, Auckland, in 2018, recorded from referrals and patient consultation documents. Conditional logistic regression analysis was performed on patients diagnosed with CRC, stratified 1:2 matched by age, gender and ethnicity to compare to patients referred and accepted for diagnostic colonoscopy who were not diagnosed with CRC. In this year, 177 symptomatic patients were diagnosed with CRC and 354 matched controls were recruited: 54% were male; 57% New Zealand European, 15% Asian, 11% Polynesian and 7% Māori. The mean age was 68. Other than excess alcohol intake (4% vs 1% OR 4.17, 95% CI [1.04,17.16], p=0.04), no traditional risk factors were predictive of CRC. This included analysis of obesity status, smoking,5 family history of CRC and personal history of inflammatory bowel disease. The only significant discriminatory symptom for CRC patients was haematochezia (40% vs 26%, OR 1.84, 95% CI [1.28,2.89], p=0.007). Independent predictors for CRC included a palpable mass (OR=6.71, 95% CI [2.31,19.54], p<0.001) and iron deficiency anaemia (OR=1.94, 95% CI [1.22,3.08], p=0.005). Twenty-seven percent of CRCs were already metastatic at presentation. Thirty percent of those diagnosed were less than 60 years old, our current age of screening commencement. Of these patients, 22% were of Pasifika ethnicity, compared with 6.5% of Pasifika patients who were diagnosed over 60 (p=0.02). Of the controls, 155 patients had normal findings (43.7%) and 172 (48.6%) were diagnosed with diverticulosis and/or haemorrhoids.

These results, coupled with the current limitations in resources for our symptomatic patients, suggest that alternative methods should be considered as an adjunct to clinical assessment and acumen to improve objective determination of risk of CRC. Biomarkers used in screening programmes, such as faecal occult blood testing (FOB), have emerged as an option for prioritising symptomatic patients internationally. A primary care case-control study in the UK noted that a positive FOB was nearly three times higher (PPV 7.1%) than their most predictive symptom of rectal bleeding (PPV 2.4%).6 Faecal immunochemical tests (FITs) have also been established to be cost effective for evaluation of lower abdominal symptoms to determine need for colonoscopy and rule out CRC.7–10 It has been suggested that this approach may reduce the burden of outpatient colonoscopic evaluation by as much as 80%.11

In 2015, the National Institute for Health and Care Excellence (NICE) guidelines included a recommendation for testing of FOB in patients without rectal bleeding who are:

  • aged 50 years and over and have unexplained abdominal pain or weight loss
  • under 60 years of age and have changes in their bowel habit or iron deficiency anaemia
  • aged 60 years and over and have anaemia in the absence of iron deficiency.12

These guidelines have been proven to be effective in a single-centre UK study in primary care.13

As a profession, we have an obligation to advocate for the appropriate levels and access to colonoscopy. This investigation is a basic and vital tool for diagnosis, treatment and surveillance of patients with a number of serious colorectal diseases. While many of these may be FIT negative and still require colonoscopy to diagnose (ie, microscopic colitis), improved risk stratification may assist with prioritisation and management of waiting times.

In conclusion, these local data are consistent with international literature that shows that prioritisation by clinical features alone is inefficient. There is increasing research on the use of FIT for symptomatic patients. Introduction of this strategy may help to reduce colonoscopy workload.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Cameron KMW Schauer, MBChB, FRACP: Gastroenterology Department, Middlemore Hospital, Counties Manukau District Health Board, Auckland. Uddaka Wijesinghe, MBChB: Gastroenterology Department, Middlemore Hospital, Counties Manukau District Health Board, Auckland. Michael TM Wang, MBChB: Department of Medicine, University of Auckland, Auckland, New Zealand. Sriharan Selvaratnam, MBChB, FRACP: Gastroenterology Department, Middlemore Hospital, Counties Manukau District Health Board, Auckland. Dinesh Lal, MBBS, FRACP: Gastroenterology Department, Middlemore Hospital, Counties Manukau District Health Board, Auckland.

Acknowledgements

Correspondence

Dr Cameron Schauer, C/O North Shore Hospital, 124 Shakespeare Road, Takapuna, Auckland 0620, +64210368637

Correspondence Email

cameron.schauer@gmail.com

Competing Interests

Nil.

1. Adequacy of publicly funded colonoscopy services in New Zealand [Internet]. [cited 2020 Dec 9]. Available from: https://www.nzma.org.nz/journal-articles/adequacy-of-publicly-funded-colonoscopy-services-in-new-zealand

2. Yeoman A, Parry S. A survey of colonoscopy capacity in New Zealand’s public hospitals. N Z Med J [Internet]. 2007 Jul 20 [cited 2020 Feb 29];120(1258):U2632. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17653250

3. Clinical Governance Research and Development Unit (CGRDU), Department of Health Sciences U of L. NATIONAL COLLABORATING CENTRE FOR PRIMARY CARE [Internet]. Referral Guidelines for Suspected Cancer in Adults and Children. 2005 [cited 2020 Mar 5]. 421 p. Available from: http://www.ncbi.nlm.nih.gov/books/NBK45764/

4. Hsiang JC, Bai W, Lal D. Symptom presentations and other characteristics of colorectal cancer patients and the diagnostic performance of the Auckland Regional Grading Criteria for Suspected Colorectal Cancer in the South Auckland population. N Z Med J. 2013;126(1382):95–107.

5. Richardson A, Hayes J, Frampton C, Potter J. Modifiable lifestyle factors that could reduce the incidence of colorectal cancer in New Zealand. N Z Med J. 2016 Oct 16;129(1447):13–20.

6. 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 Aug 22;93(4):399–405.

7. Jellema P, Van Der Windt DAWM, Bruinvels DJ, Mallen CD, Van Weyenberg SJB, Mulder CJ, et al. Value of symptoms and additional diagnostic tests for colorectal cancer in primary care: Systematic review and meta-analysis. Vol. 340, BMJ (Online). BMJ; 2010. p. 795.

8. Adelstein BA, Macaskill P, Chan SF, Katelaris PH, Irwig L. Most bowel cancer symptoms do not indicate colorectal cancer and polyps: A systematic review. BMC Gastroenterol [Internet]. 2011 May 30 [cited 2020 Mar 5];11:65. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21624112

9. D’Souza N, Hicks G, Benton SC, Abulafi M. The diagnostic accuracy of the faecal immunochemical test for colorectal cancer in risk-stratified symptomatic patients. Ann R Coll Surg Engl. 2020;102(3):174–9.

10. Westwood M, Ramos IC, Lang S, Luyendijk M, Zaim R, Stirk L, et al. Faecal immunochemical tests to triage patients with lower abdominal symptoms for suspected colorectal cancer referrals in primary care: A systematic review and cost-effectiveness analysis. Vol. 21, Health Technology Assessment. NIHR Journals Library; 2017.

11. Westwood M, Lang S, Armstrong N, van Turenhout S, Cubiella J, Stirk L, et al. Faecal immunochemical tests (FIT) can help to rule out colorectal cancer in patients presenting in primary care with lower abdominal symptoms: a systematic review conducted to inform new NICE DG30 diagnostic guidance. BMC Med [Internet]. 2017 Dec 24 [cited 2020 May 23];15(1):189. Available from: http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0944-z

12. Suspected cancer: recognition and referral NICE guideline Your responsibility Your responsibility [Internet]. 2015 [cited 2020 May 23]. Available from: www.nice.org.uk/guidance/ng12

13. Mowat C, Digby J, Strachan JA, McCann R, Hall C, Heather D, et al. Impact of introducing a faecal immunochemical test (FIT) for haemoglobin into primary care on the outcome of patients with new bowel symptoms: A prospective cohort study. BMJ Open Gastroenterol. 2019 May 1;6(1).

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

We read with interest the commentary from Bagshaw and Cox regarding the adequacy, or lack thereof, of publicly funded colonoscopy services in New Zealand.1 Their article summarises concerns about provision of colonoscopy, underscoring again what was first noted in The New Zealand Medical Journal in 2007 regarding the already significant gap between colonoscopy demand and provision.2 They highlight in particular the pressing concern that introduction of screening will have on symptomatic patients, currently the main avenue of colorectal cancer (CRC) diagnosis, let alone other important gastrointestinal conditions.

The challenge of diagnosis of these numerous symptomatic patients is that they may present with a heterogenous and diverse spectrum of symptoms, often mimicking more benign gastrointestinal pathology. There have been attempts to encapsulate these difficulties within grading criteria, with prioritisation of risk factors, symptoms and signs based on the UK National Institute of Clinical Excellence (NICE) Guidelines for Suspected Colorectal Cancer.3 However, a local retrospective review of these criteria demonstrated that they may miss a quarter of the patients with CRC in the referral population.4

To review and understand the presenting features of patients in our locality and ascertain the suitability of our diagnostic pathways, we completed a prospective, case-controlled study comparing risk factors, symptoms and signs of all CRC diagnosed at Middlemore Hospital, Auckland, in 2018, recorded from referrals and patient consultation documents. Conditional logistic regression analysis was performed on patients diagnosed with CRC, stratified 1:2 matched by age, gender and ethnicity to compare to patients referred and accepted for diagnostic colonoscopy who were not diagnosed with CRC. In this year, 177 symptomatic patients were diagnosed with CRC and 354 matched controls were recruited: 54% were male; 57% New Zealand European, 15% Asian, 11% Polynesian and 7% Māori. The mean age was 68. Other than excess alcohol intake (4% vs 1% OR 4.17, 95% CI [1.04,17.16], p=0.04), no traditional risk factors were predictive of CRC. This included analysis of obesity status, smoking,5 family history of CRC and personal history of inflammatory bowel disease. The only significant discriminatory symptom for CRC patients was haematochezia (40% vs 26%, OR 1.84, 95% CI [1.28,2.89], p=0.007). Independent predictors for CRC included a palpable mass (OR=6.71, 95% CI [2.31,19.54], p<0.001) and iron deficiency anaemia (OR=1.94, 95% CI [1.22,3.08], p=0.005). Twenty-seven percent of CRCs were already metastatic at presentation. Thirty percent of those diagnosed were less than 60 years old, our current age of screening commencement. Of these patients, 22% were of Pasifika ethnicity, compared with 6.5% of Pasifika patients who were diagnosed over 60 (p=0.02). Of the controls, 155 patients had normal findings (43.7%) and 172 (48.6%) were diagnosed with diverticulosis and/or haemorrhoids.

These results, coupled with the current limitations in resources for our symptomatic patients, suggest that alternative methods should be considered as an adjunct to clinical assessment and acumen to improve objective determination of risk of CRC. Biomarkers used in screening programmes, such as faecal occult blood testing (FOB), have emerged as an option for prioritising symptomatic patients internationally. A primary care case-control study in the UK noted that a positive FOB was nearly three times higher (PPV 7.1%) than their most predictive symptom of rectal bleeding (PPV 2.4%).6 Faecal immunochemical tests (FITs) have also been established to be cost effective for evaluation of lower abdominal symptoms to determine need for colonoscopy and rule out CRC.7–10 It has been suggested that this approach may reduce the burden of outpatient colonoscopic evaluation by as much as 80%.11

In 2015, the National Institute for Health and Care Excellence (NICE) guidelines included a recommendation for testing of FOB in patients without rectal bleeding who are:

  • aged 50 years and over and have unexplained abdominal pain or weight loss
  • under 60 years of age and have changes in their bowel habit or iron deficiency anaemia
  • aged 60 years and over and have anaemia in the absence of iron deficiency.12

These guidelines have been proven to be effective in a single-centre UK study in primary care.13

As a profession, we have an obligation to advocate for the appropriate levels and access to colonoscopy. This investigation is a basic and vital tool for diagnosis, treatment and surveillance of patients with a number of serious colorectal diseases. While many of these may be FIT negative and still require colonoscopy to diagnose (ie, microscopic colitis), improved risk stratification may assist with prioritisation and management of waiting times.

In conclusion, these local data are consistent with international literature that shows that prioritisation by clinical features alone is inefficient. There is increasing research on the use of FIT for symptomatic patients. Introduction of this strategy may help to reduce colonoscopy workload.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Cameron KMW Schauer, MBChB, FRACP: Gastroenterology Department, Middlemore Hospital, Counties Manukau District Health Board, Auckland. Uddaka Wijesinghe, MBChB: Gastroenterology Department, Middlemore Hospital, Counties Manukau District Health Board, Auckland. Michael TM Wang, MBChB: Department of Medicine, University of Auckland, Auckland, New Zealand. Sriharan Selvaratnam, MBChB, FRACP: Gastroenterology Department, Middlemore Hospital, Counties Manukau District Health Board, Auckland. Dinesh Lal, MBBS, FRACP: Gastroenterology Department, Middlemore Hospital, Counties Manukau District Health Board, Auckland.

Acknowledgements

Correspondence

Dr Cameron Schauer, C/O North Shore Hospital, 124 Shakespeare Road, Takapuna, Auckland 0620, +64210368637

Correspondence Email

cameron.schauer@gmail.com

Competing Interests

Nil.

1. Adequacy of publicly funded colonoscopy services in New Zealand [Internet]. [cited 2020 Dec 9]. Available from: https://www.nzma.org.nz/journal-articles/adequacy-of-publicly-funded-colonoscopy-services-in-new-zealand

2. Yeoman A, Parry S. A survey of colonoscopy capacity in New Zealand’s public hospitals. N Z Med J [Internet]. 2007 Jul 20 [cited 2020 Feb 29];120(1258):U2632. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17653250

3. Clinical Governance Research and Development Unit (CGRDU), Department of Health Sciences U of L. NATIONAL COLLABORATING CENTRE FOR PRIMARY CARE [Internet]. Referral Guidelines for Suspected Cancer in Adults and Children. 2005 [cited 2020 Mar 5]. 421 p. Available from: http://www.ncbi.nlm.nih.gov/books/NBK45764/

4. Hsiang JC, Bai W, Lal D. Symptom presentations and other characteristics of colorectal cancer patients and the diagnostic performance of the Auckland Regional Grading Criteria for Suspected Colorectal Cancer in the South Auckland population. N Z Med J. 2013;126(1382):95–107.

5. Richardson A, Hayes J, Frampton C, Potter J. Modifiable lifestyle factors that could reduce the incidence of colorectal cancer in New Zealand. N Z Med J. 2016 Oct 16;129(1447):13–20.

6. 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 Aug 22;93(4):399–405.

7. Jellema P, Van Der Windt DAWM, Bruinvels DJ, Mallen CD, Van Weyenberg SJB, Mulder CJ, et al. Value of symptoms and additional diagnostic tests for colorectal cancer in primary care: Systematic review and meta-analysis. Vol. 340, BMJ (Online). BMJ; 2010. p. 795.

8. Adelstein BA, Macaskill P, Chan SF, Katelaris PH, Irwig L. Most bowel cancer symptoms do not indicate colorectal cancer and polyps: A systematic review. BMC Gastroenterol [Internet]. 2011 May 30 [cited 2020 Mar 5];11:65. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21624112

9. D’Souza N, Hicks G, Benton SC, Abulafi M. The diagnostic accuracy of the faecal immunochemical test for colorectal cancer in risk-stratified symptomatic patients. Ann R Coll Surg Engl. 2020;102(3):174–9.

10. Westwood M, Ramos IC, Lang S, Luyendijk M, Zaim R, Stirk L, et al. Faecal immunochemical tests to triage patients with lower abdominal symptoms for suspected colorectal cancer referrals in primary care: A systematic review and cost-effectiveness analysis. Vol. 21, Health Technology Assessment. NIHR Journals Library; 2017.

11. Westwood M, Lang S, Armstrong N, van Turenhout S, Cubiella J, Stirk L, et al. Faecal immunochemical tests (FIT) can help to rule out colorectal cancer in patients presenting in primary care with lower abdominal symptoms: a systematic review conducted to inform new NICE DG30 diagnostic guidance. BMC Med [Internet]. 2017 Dec 24 [cited 2020 May 23];15(1):189. Available from: http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0944-z

12. Suspected cancer: recognition and referral NICE guideline Your responsibility Your responsibility [Internet]. 2015 [cited 2020 May 23]. Available from: www.nice.org.uk/guidance/ng12

13. Mowat C, Digby J, Strachan JA, McCann R, Hall C, Heather D, et al. Impact of introducing a faecal immunochemical test (FIT) for haemoglobin into primary care on the outcome of patients with new bowel symptoms: A prospective cohort study. BMJ Open Gastroenterol. 2019 May 1;6(1).

Contact diana@nzma.org.nz
for the PDF of this article

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