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Signs Of Rectal Cancer

Although most cases of rectal bleeding are due to local conditions, this symptom is a major sign of colorectal cancer. Little research exists on whether to refer a patient with rectal bleeding for further evaluation.[1-3] We therefore studied the diagnostic value of rectal bleeding in relation to a subsequent diagnosis of colorectal cancer.

Subjects, methods, and results

In Belgium, a network of sentinel practices, coveting 1% of the population, registers epidemiological data.[4] The methods used to estimate the denominator (in patient years) have been published.[4]

We analysed data on all patients with colorectal cancer diagnosed in 1993-4 to evaluate sensitivity (retrospective study). We chose rectal bleeding as the reason for visiting a general practitioner before colorectal cancer was diagnosed as the main outcome measure.

To obtain a positive predictive value (prospective part of study), we included all patients presenting with rectal bleeding in 1993-4. Our reference standard was colorectal cancer diagnosed during a clinical follow up of 18-90 months. Investigations, such as endoscopy, were not systematically performed. To obtain the number of all new cases of cancer, we sent recall letters to the practices every six months and at the end of the follow up period.

Patients were recorded as having rectal bleeding if they mentioned to their doctor of any blood of rectal origin on stool, underwear, or toilet paper, irrespective of the duration. Colorectal cancer was defined as any histologically confirmed malignancy of the colorectum.

Associated signs and symptoms that were recorded were fatigue, weight loss, pain, or cramps mentioned to the doctor and a palpable rectal tumour. Ethical approval for our study was obtained from the local ethics committee.

We calculated sensitivity and positive prospective values from the retrospective and prospective data, and we estimated negative predictive values and specificity on the basis of both results. We estimated the effect of the variables of age, sex, and additional signs or symptoms by comparing the sensitivity, specificity, and predictive values in patients with and without each variable.

We recorded 83 890 patient years. Overall, 106 patients had colorectal cancer (table), and of these 31 had visited their doctor with rectal bleeding in the weeks preceding the diagnosis. Sensitivity was 29.2% (95% confidence interval 20.8% to 38.8%). We found no relation between sensitivity and age.

Positive predictive values of rectal bleeding for diagnosis of colorectal cancer, stratified for age

                    Rectal bleeding

                             With           Positive
                          colorectal    predictive value
Age group           All     cancer          (95% CI)

[is greater than     51        3        5.8 (1.2 to 16.2)
  or equal to] 80
70-79                66       14       21.2 (12.0 to 33.0)
60-69                71                11.2 (5.0 to 21.0)
50-59                57        1        1.7 (0 to 9.4)
<50                 141        1        0.7 (0 to 4.9)
Total               386       27          7 (4.6 to 10.0)

Of 386 patients with rectal bleeding, 27 had colorectal cancer, giving a positive predictive value of 7.0% (4.6% to 10.0%). The positive predictive value strongly increased with age (table). Positive predictive values in patients with additional other symptoms were: 0% (0% to 10.2%) for pain, 5.4% (2.0% to 11.4%) for spasms, 7.1% (8.3% to 15.8%) for fatigue, 16.0% (4.5% to 36.1%) for weight loss, and 31.5% (12.5% to 56.5%) for palpable tumour.

The negative predictive value and specificity were 99.9% and 99.5% respectively. The likelihood ratio was 68.3 (49.9 to 93.4) for presence of rectal bleeding and 0.7 (0.6 to 0,8) for its absence.

Comment

Although most cases of rectal bleeding are due to self limiting diseases, the probability of colorectal cancer increases greatly both in people older than fit3 years and in association with fatigue, weight loss, or a palpable tumour, indicating the need for a more thorough investigation in such instances. People, particularly those older than 60 years, should be better informed and encouraged to seek medical advice if rectal bleeding occurs. However, a negative likelihood ratio of 0.71 indicates that absence of rectal bleeding is not predictive for the absence of cancer.

A follow up period of 18-30 months is acceptable because colorectal malignancy is not self limiting and would progress to overt disease within this period. The completeness of our data is supported by the similarity of our data on incidence (63/100 000 patient years) with that of the Limburg Cancer Registry (men 63/100 000, women 47/100 000).[5]

We thank Professor Jan Vandenbroucke, department of clinical epidemiology, University of Leiden (Netherlands) for his remarks on the epidemiological analysis of the data.

Contributors: FB and VVC designed the study. VVC is the coordinator of the network and was responsible for data collection. HW performed the initial analyses and was responsible for the first draft of the report. FB supervised the analyses; he will act as guarantor for the paper. All authors discussed the results and approved the final report.

Funding: The Belgian sentinel practices network is funded by the Flemish and French community government.

Competing interests: None declared.

[1] Fijten GH. Rectal bleeding, a danger signal? [dissertation]. University of Limburg, Netherlands, 1993.

[2] Goulston KJ, Cook I, Dent OF. How important is rectal bleeding in the diagnosis of bowel cancer and polyps? Lancet 1986;ii:261-5.

[3] Mant A, Bokey EL, Chapuis PH, Killingback M, Hughes W, Korrey SG, et al. Rectal bleeding. Do other symptoms aid in diaganosis? Dis Col Rect 1989;32:191-6.

[4] Lobet MP, Stroobant A, Mertens R, van Casteren V, Walckiers D, Masuy-Stroobant G, et al. Tool for validation of the network of sentinel general practitioners in the Belgian health care system, Int J Epidemiol 1987;16:612-8.

[5] Buntinx F, Cloes E, Dhollander D, Lousbergh D, Op de Beeck L, Rummens JL et al. Incidence of cancer in the Belgian province of Limburg in 1996-1998. Hasselt LIKAS: Limburg Cancer Registry, 2000.

(Accepted 12 May 2000)

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Members of the network of sentinel practices appear on the BMJ's website

Department of General Practice, Catholic University of Leuven, 3000 Leuven, Belgium

Hans Wauters general practitioner

Frank Buntinx professor

Department of Epidemiology, Scientific Institute of Public Health, B 1050, Brussels

Viviane Van Casteren epidemiologist

Correspondence to: F Buntinx frank.buntinx@ med.kuleuven.ac.be

BMJ 2000;321:998-9

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