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Determinants of Medical System Delay in the Diagnosis of Colorectal Cancer Within the Veteran Affairs Health System

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Abstract

Background and Aims

The goals of this study are to evaluate determinants of the time in the medical system until a colorectal cancer diagnosis and to explore characteristics associated with stage at diagnosis.

Methods

We examined medical records and survey data for 468 patients with colorectal cancer at 15 Veterans Affairs medical centers. Patients were classified as screen-detected, bleeding-detected, or other (resulting from the evaluation of another medical concern). Patients who presented emergently with obstruction or perforation were excluded. We used Cox proportional hazards models to determine predictors of time in the medical system until diagnosis. Logistic regression models were used to determine predictors of stage at diagnosis.

Results

We excluded 21 subjects who presented emergently, leaving 447 subjects; the mean age was 67 years and 98% were male, 66% Caucasian, and 43% stage I or II. Diagnosis was by screening for 39%, bleeding symptoms for 27%, and other for 34%. The median times to diagnosis were 73–91 days and were not significantly different by diagnostic category. In the multivariable model for time to diagnosis, older age, having comorbidities, and Atlantic region were associated with a longer time to diagnosis. In the multivariable model for stage-at-diagnosis, only the diagnostic category was associated with stage; the screen-detected category was associated with decreased risk of late-stage cancer.

Conclusions

Our results point to several factors associated with a longer time from the initial clinical event until diagnosis. This increased time in the health care system did not clearly translate into more advanced disease at diagnosis.

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References

  1. Cancer Statistics. 2008. http://www.cancer.org/downloads/STT/2008CAFFfinalsecured.pdf.

  2. Ramos M, Esteva M, Cabeza E, et al. Lack of association between diagnostic and therapeutic delay and stage of colorectal cancer. Eur J Cancer. 2008;44(4):510–521.

    Article  PubMed  Google Scholar 

  3. Wattacheril J, Kramer JR, Richardson P, et al. Lagtimes in diagnosis and treatment of colorectal cancer: determinants and association with cancer stage and survival. Aliment Pharmacol Ther. 2008;28(9):1166–1174.

    Article  CAS  PubMed  Google Scholar 

  4. Korsgaard M, Pedersen L, Sorensen HT, et al. Reported symptoms, diagnostic delay and stage of colorectal cancer: a population-based study in Denmark. Colorectal Disease. 2006;8(8):688–695.

    Article  CAS  PubMed  Google Scholar 

  5. Ayanian JZ, Chrischilles EA, Fletcher RH, et al. Understanding cancer treatment and outcomes: the Cancer Care Outcomes Research and Surveillance Consortium. [erratum appears in J Clin Oncol. 2004 Dec 15;22(24):5026]. J Clin Oncol. 2004;22(15):2992–2996.

    Google Scholar 

  6. Lasson A, Kilander A, Stotzer PO. Diagnostic yield of colonoscopy based on symptoms. Scand J Gastroenterol. 2008;43(3):356–362.

    Article  PubMed  Google Scholar 

  7. Lieberman DA, de Garmo PL, Fleischer DE, et al. Colonic neoplasia in patients with nonspecific GI symptoms. Gastrointest Endosc. 2000;51(6):647–651.

    Article  CAS  PubMed  Google Scholar 

  8. Pepin C, Ladabaum U. The yield of lower endoscopy in patients with constipation: survey of a university hospital, a public county hospital, and a Veterans Administration medical center. Gastrointest Endosc. 2002;56(3):325–332.

    Article  PubMed  Google Scholar 

  9. Piccirillo JF, Tierney RM, Costas I, et al. Prognostic importance of comorbidity in a hospital-based cancer registry. JAMA. 2004;291(20):2441–2447.

    Article  CAS  PubMed  Google Scholar 

  10. VA Facility Complexity Model. Oncology Program Evaluation, Facilities Survey Report at www.va.gov/cancer/ Report.

  11. He YZA, Harrington DP. Imputation in a multiformat and multiwave survey of cancer care. In: Proceedings in Health Policy Statistics. American Statistical Association; 2007.

  12. Hosmer D, Lemeshow S. Applied Logistic Regression. 2nd ed. New York: Wiley; 2000.

    Google Scholar 

  13. Little R, Rubin DB. Statistical Analysis with Missing Data. New York: Wiley; 1986.

    Google Scholar 

  14. Singh HDK, Petersen LA, Collins C, et al. Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis. Am J Gastroenterol. 2009 online publication.

  15. Wennberg JE, Fisher ES, Skinner JS. “Geography and the debate over Medicare reform.” Health Affairs. 2002; W96–114.

  16. Welch WP, Miller ME, Welch HG, Fisher ES, Wennberg JE. Geographic variation in expenditures for physicians’ services in the United States. N Engl J Med. 1993;328:621–627.

    Article  CAS  PubMed  Google Scholar 

  17. Fisher ES, Wennberg JE, Stukel TA, et al. Associations among hospital capacity, utilization, and mortality of US Medicare beneficiaries, controlling for sociodemographic factors. Health Serv Res. 2000;34:1351–1362.

    CAS  PubMed  Google Scholar 

  18. Gellad ZF, Almirall D, Provenzale D et al. Time from positive screening fecal occult blood test to colonoscopy and risk of neoplasia. Dig Dis Sci. 2009 in press.

  19. Hardcastle JD, Chamberlain JO, Robinson MH, et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet. 1996;348(9040):1472–1477.

    Article  CAS  PubMed  Google Scholar 

  20. Kronborg O, Fenger C, Olsen J, Jorgensen OD, et al. Randomised study of screening for colorectal cancer with faecal-occult-blood test. Lancet. 1996;348(9040):1467–1471.

    Article  CAS  PubMed  Google Scholar 

  21. Mandel JS, Bond JH, Church TR, et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota colon cancer control study. N Engl J Med. 1993;328(19):1365–1371.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgments

The work of the CanCORS consortium was supported by grants from the National Cancer Institute to the Statistical Coordinating Center (U01 CA093344) and the NCI supported Primary Data Collection and Research Centers (Dana-Farber Cancer Institute/Cancer Research Network U01 CA093332, Harvard Medical School/Northern California Cancer Center. U01 CA093324, RAND/UCLA U01 CA093348, University of Alabama at Birmingham. U01 CA093329, University of Iowa U01 CA.01013, University of North Carolina. U01CA 093326) and by a Department of Veteran’s Affairs grant to the Durham VA Medical Center CRS 02-164. Dr. Fisher was supported in part by a VA Health Services Research and Development Career Development Transition Award (RCD 03-174). Dr. Provenzale was supported in part by an NIH K24 grant 5 K24 DK002926.

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Correspondence to Deborah A. Fisher.

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Fisher, D.A., Zullig, L.L., Grambow, S.C. et al. Determinants of Medical System Delay in the Diagnosis of Colorectal Cancer Within the Veteran Affairs Health System. Dig Dis Sci 55, 1434–1441 (2010). https://doi.org/10.1007/s10620-010-1174-9

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  • DOI: https://doi.org/10.1007/s10620-010-1174-9

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