The role of primary care

doi:10.1136/bmj.321.7268.1068

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F D Richard Hobbs

Every general practitioner in the United Kingdom will on average see one new case of colorectal cancer each year. For most primary care doctors the most important contributions they make to the care of patients with colorectal cancer relate to early diagnosis of the condition (including the point of referral) and to palliation of symptoms in those with established disease. Further roles in the future primary care service are screening for colorectal cancer (possibly using faecal occult blood testing) and a greater involvement in monitoring patients after curative procedures.

Guidelines for urgent referral of patients with suspected colorectal cancer based on symptoms presented*

These combinations of symptoms and signs, when occurring for the first time, should be used to identify patients for urgent referral (that is, within two weeks). Patients need not have all symptoms

All ages

Definite, palpable, right sided, abdominal mass
Definite, palpable, rectal (not pelvic) mass
Rectal bleeding with change in bowel habit to more frequent defecation or looser stools (or both) persistent over six weeks
Iron deficiency anaemia (haemoglobin concentration <110 g/l in men or <100 g/l in postmenopausal women) without obvious cause

Age over 60 years (maximum age threshold could be 55 or 50)

Rectal bleeding persistently without anal symptoms (soreness, discomfort, itching, lumps, prolapse, pain)
Change of bowel habit to more frequent defecation or looser stools (or both), without rectal bleeding, and persistent for six weeks

* Adapted from the NHS Executive's Referral Guidelines for Suspected Cancer (London: Department of Health, 2000)

As colorectal cancer is the sixth most common cause of mortality in the United Kingdom, a general practitioner will on average care for a patient dying from colorectal cancer every 18 months

Early diagnosis and referral guidelines

Early diagnosis of colorectal cancer is essential in view of the stage related prognosis. Three potential levels of delay occur in the diagnosis of the disease: delay by the patient in presenting to the general practitioner; delay in referral by the general practitioner to a specialist; and …