Review
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Oncol. Dec 15, 2015; 7(12): 422-433
Published online Dec 15, 2015. doi: 10.4251/wjgo.v7.i12.422
Colorectal cancer diagnosis: Pitfalls and opportunities
Pablo Vega, Fátima Valentín, Joaquín Cubiella
Pablo Vega, Fátima Valentín, Joaquín Cubiella, Department of Gastroenterology, Complexo Hospitalario Universitario de Ourense, 32003 Ourense, Spain
Author contributions: All authors contributed equally to this work.
Supported by A grant from Instituto de Salud Carlos III (PI11/00094).
Conflict-of-interest statement: None.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Dr. Joaquín Cubiella, Department of Gastroenterology, Complexo Hospitalario Universitario de Ourense, Rua Ramón Puga 52-54, 32003 Ourense, Spain. joaquin.cubiella.fernandez@sergas.es
Telephone: +34-98-8385399 Fax: +34-98-8385399
Received: April 15, 2015
Peer-review started: April 17, 2015
First decision: July 1, 2015
Revised: August 26, 2015
Accepted: September 25, 2015
Article in press: September 28, 2015
Published online: December 15, 2015
Abstract

Colorectal cancer (CRC) is a major health problem in the Western world. The diagnostic process is a challenge in all health systems for many reasons: There are often no specific symptoms; lower abdominal symptoms are very common and mostly related to non-neoplastic diseases, not CRC; diagnosis of CRC is mainly based on colonoscopy, an invasive procedure; and the resource for diagnosis is usually scarce. Furthermore, the available predictive models for CRC are based on the evaluation of symptoms, and their diagnostic accuracy is limited. Moreover, diagnosis is a complex process involving a sequence of events related to the patient, the initial consulting physician and the health system. Understanding this process is the first step in identifying avoidable factors and reducing the effects of diagnostic delay on the prognosis of CRC. In this article, we describe the predictive value of symptoms for CRC detection. We summarize the available evidence concerning the diagnostic process, as well as the factors implicated in its delay and the methods proposed to reduce it. We describe the different prioritization criteria and predictive models for CRC detection, specifically addressing the two-week wait referral guideline from the National Institute of Clinical Excellence in terms of efficacy, efficiency and diagnostic accuracy. Finally, we collected information on the usefulness of biomarkers, specifically the faecal immunochemical test, as non-invasive diagnostic tests for CRC detection in symptomatic patients.

Keywords: Colorectal cancer, Colonoscopy, Primary health care, Faecal immunochemical test, Diagnostic yield, Diagnostic accuracy, Risk stratification, Open endoscopy unit, Practice guidelines, Health plan implementation

Core tip: In this review, we summarize the pitfalls in the diagnostic procedure for colorectal cancer (CRC) in symptomatic patients. We collected the available information concerning the value of symptoms as predictors of CRC and the factors involved in the delay of CRC diagnosis, including those related to the patient, to the physicians and to hospital delay. In this way, we review the currently available sets of appropriateness criteria for colonoscopy in symptomatic patients, the prioritization criteria and predictive models for CRC detection and, finally, the role of available biomarkers in the evaluation of symptomatic patients.