Practice Easily Missed?

Colorectal cancer

BMJ 2013; 346 doi: (Published 21 May 2013) Cite this as: BMJ 2013;346:f3172
  1. William Hamilton, professor of primary care diagnostics 1,
  2. Mark G Coleman, director and consultant surgeon2,
  3. Greg Rubin, professor of general practice and primary care3
  1. 1University of Exeter, Veysey Building, Exeter EX2 4SG, UK
  2. 2Lapco National Training Programme in Laparoscopic Colorectal Surgery, Derriford Hospital, Plymouth, UK
  3. 3Durham University, Wolfson Research Institute, Stockton on Tees, UK
  1. Correspondence to: W Hamilton w.hamilton{at}

A 72 year old recently widowed man presents to his general practitioner with vague symptoms, including fatigue. Nothing is found on examination, but his haemoglobin concentration is 114 g/L (range 140-180 g/L) with a hypochromic, normocytic picture and serum ferritin 75 ng/mL (30-336 ng/mL). As his diet has been poor since his wife died, he was treated with ferrous sulphate, which was associated with a small improvement in his fatigue and haemoglobin level. Six months later he presented with intestinal obstruction, which was subsequently found to be due to a carcinoma of the colon.

Surgically, the colon and rectum are distinct, but for the purposes of this diagnostic article, they have been merged.

Search strategy

WH and colleagues recently performed a systematic review of primary care symptoms of colorectal cancer.1 This was supplemented by specific searches on missed or delayed diagnoses, plus searches on young people, irritable bowel syndrome, and inflammatory bowel disease. No randomised controlled trials have been reported on the selection of patients for investigation, so most of the quoted studies are large cohort studies, often using national primary care databases. Cited studies can be assumed to be of this nature unless specifically stated otherwise.

How common is colorectal cancer?

  • Colorectal cancer is the third most prevalent cancer in the United Kingdom, the incidence increasing with age, and it is slightly more common in men

  • More than 41 000 new cases of colorectal cancer are diagnosed annually in the United Kingdom, with the median age at diagnosis 72 years, although 6% occur below the age of 402

  • Screening identifies a few patients with cancers; the remainder present with symptoms, with around a quarter presenting as an emergency3

  • A full time general practitioner will have around one patient with a new diagnosis of colorectal cancer each year

Why is colorectal cancer missed?

Many colorectal cancers are diagnosed easily and …

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