Delay of treatment is associated with advanced stage of rectal cancer but not of colon cancer

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Abstract

Background: Dukes’ stage is the most important predictor of prognosis of colorectal cancer, but the association between delay of treatment (DT) and Dukes’ stage is still controversial. Methods: From 1 January 2001 to 31 July 2002, we conducted a population-based prospective observational study based on 733 Danish colorectal cancer patients. DT was determined through questionnaire-interviews, and Dukes’ stage was obtained from medical records and pathological forms. DT was classified into three groups: short (0–60 days), intermediate (61–150 days) and long (>150 days) DT. Dukes’ stage was classified into two groups: non-advanced (Dukes’ stage A or B) and advanced (Dukes’ stage C or D) cancer. Using relative risk (RR) the association between DT and stage was estimated, with short delay as the reference group. Results: The RR of advanced cancer was 1.0 (95% confidence intervals (CI): 0.8–1.3) for colon cancer patients with an intermediate DT, and 1.1 (95% CI: 0.9–1.4) for patients with a long DT. For rectal cancer patients the RR of advanced cancer was 1.9 (95% CI: 1.1–3.1) for patients with an intermediate DT and 2.1 (95% CI: 1.3–3.4) for patients with a long DT. Conclusion: DT was strongly associated with advanced stage of rectal cancer, but not of colon cancer.

Introduction

Colorectal cancer is one of the most common cancers in western countries. Although the incidence and mortality are decreasing in many countries [1], [2], [3], colorectal cancer is a serious disease, and on average only 50% are alive 5 years after diagnosis [1], [2], [3]. It is estimated that worldwide there are about 400,000 deaths from colorectal cancer annually [1], [2], [3].

Dukes’ stage is one of the most important predictors of long-term outcome. In Denmark the expected 5-year survival for Dukes’ stage A is about 95%, for Dukes’ stage B is 50%, for Dukes’ stage C is 25%, and for Dukes’ stage D is 0%. At the time of diagnosis, 15% of all colorectal cancer patients are at Dukes’ stage A, 30% are at Dukes’ stage B, 35% are at Dukes’ stage C, and 20% are at Dukes’ stage D [4].

There is increasing evidence that screening for colorectal cancer can result in longer survival due to early detection at a non-advanced Dukes’ stage [5]. Thus, it is likely that we could improve prognosis and increase survival if more patients were to be diagnosed in Dukes’ stage A or B. However, for symptomatic patients, many aspects of the association between delay of treatment (interval between onset of symptoms and surgery or other treatment) and stage are poorly understood.

It has been suggested that delay of treatment may be a predictor of the stage of colorectal cancer; this idea, however, is controversial [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24]. Several studies have indicated no association between diagnostic delay or delay of treatment and stage of colorectal cancer at the time of diagnosis [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [23]. However, five studies found delay of treatment associated with the stage of cancer for rectal cancer [18], [19], [20], [21], [22], and three of them found delay of treatment associated with stage for colon cancer, as well [20], [21], [22].

Relatively few patients were included in the existing prospectively obtained studies (between 100 and 554 colorectal cancer patients). Most studies were based on delay data obtained solely from medical records [8], [12], [13], [14], [15], [16], [20], [25]. In some studies, rectal cancer and colon cancer were combined in the analysis [6], [8], [9], [10], [11], [14], [15], [17], [23], [24]. Other studies included either rectal cancer patients [12], [19] or colon cancer patients [13], [16], but not both.

The aim of this study was to examine the association between delay of treatment and stage of cancer at time of operation for colorectal cancer, based on prospectively recorded data in a population-based setting.

Section snippets

Study population and period

From 1 January 2001 to 30 June 2002, we conducted this prospective observational study in all the13 hospitals treating colorectal cancer, located in three counties in Denmark: Aarhus County (6 hospitals and about 630,000 inhabitants), and Ringkoebing and Ribe counties (7 hospitals and 475,000 inhabitants). Denmark has a tax-supported public health system for free hospital care in which private hospitals treat very few patients. More than 95% of Danes are registered with their own general

Descriptive data

Table 1 shows descriptive data of the 456 included colon cancer patients and the 277 included rectal cancer patients. The distribution of main variables was equal between all patients and included patients (data not shown).

Delay

The median delay for colon cancer patients was a little shorter than for rectal cancer patients (116 days versus 134 days). Table 2 shows data of delay of treatment. More colon cancer patients than rectal cancer patients had a short delay (27% versus 18%). Among colon cancer

Discussion

In this large population-based study, we found delay of treatment strongly associated with the risk of having an advanced cancer at time of operation for rectal cancer, but not for colon cancer.

To the best of our knowledge, this study has the largest number of prospective, registered colorectal cancer patients concerning delay in a population-based setting. The main strengths of our study are its large size, the uniformly organized free and tax-supported health care system with primary

Acknowledgements

Contributors include: Aarhus University Hospital—Consultants: Søren Laurberg, Marianne Korsgaard MD, Professor Henrik Toft Sørensen, Chief Biostatistician Lars Pedersen, Department of Clinical Epidemiology, Esbjerg Hospital—Consultants: Karl Erik Juul Jensen, Peiman Poornoroozy, Vagn Juhl Jensen, Grenå Hospital—Consultant: Jan Lindholt, Grindsted Hospital—Consultants: Anders Larsen, Vagn Berg, Herning Hospital—Consultants: Mogens Rørbæk, Holstebro Hospital—Consultants: Mads Mark, Erik Skoubo

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