Accurate diagnostic activity in general practice before colorectal cancer (CRC) diagnosis is crucial for an early detection of CRC. This study aimed to investigate the rates of daytime consultations, hemoglobin (Hb) measurements and medicine prescriptions for hemorrhoids in general practice in the year preceding CRC diagnosis. Using Danish registries, we conducted a population-based matched cohort study including CRC patients aged 40-80 years (n 5 19,209) and matched references (n 5 192,090). We calculated odds ratios (ORs) using a conditional logistical regression model and incidence rate ratios (IRRs) using a negative binomial regression model. The CRC patients had significantly more consultations from 9 months before diagnosis and significantly increased rates of Hb measurements from up to 17 months before diagnosis compared with references. Furthermore, up to 18 months before diagnosis, CRC patients had significantly higher rates of prescriptions for hemorrhoids; and 2 months before diagnosis, the IRR was 12.24 (95% confidence interval (CI): 10.29-14.55) for men. The positive predictive value (PPV) of CRC for having a first-time prescription for hemorrhoids was highest among men aged 70-80 years [PPV 5 3.2% (95% CI: 2.8-3.7)]. High prescription rates were predominantly seen among rectal cancer patients, whereas colon cancer patients had higher rates of consultations and Hb measurements. This study revealed a significant increase in healthcare seeking and diagnostic activity in general practice in the year prior to CRC diagnosis, which indicates the presence of a "diagnostic time window" and a potential for earlier diagnosis of CRC based on clinical signs and symptoms.

BackgroundKnowledge is sparse on the prevalence of suspicion of cancer and other serious diseases in general practice. Likewise, little is known about the possible implications of this suspicion on future healthcare use and diagnoses.

BackgroundAbdominal symptoms are diagnostically challenging to general practitioners (GPs): although common, they may indicate cancer. In a prospective cohort of patients, we examined abdominal symptom frequency, initial diagnostic suspicion, and actions of GPs in response to abdominal symptoms.MethodsOver a 10-day period, 493 GPs in Norway, Denmark, Sweden, Belgium, the Netherlands, and Scotland, recorded consecutive consultations: sex, date of birth and any specified abdominal symptoms. For patients with abdominal symptoms, additional data on non-specific symptoms, GPs’ diagnostic suspicion, and features of the consultation were noted. Data on all cancer diagnoses among all included patients were requested from the GPs eight months later.FindingsConsultations with 61802 patients were recorded. Abdominal symptoms were recorded in 6264 (10.1%) patients. A subsequent malignancy was reported in 511 patients (0.8%): 441 (86.3%) had a new cancer, 70 (13.7%) a recurrent cancer. Abdominal symptoms were noted in 129 (25.2%) of cancer patients (P < 0.001), rising to 34.5% for the 89 patients with cancer located in the abdominal region. PPV for any cancer given any abdominal symptom was 2.1%.In symptomatic patients diagnosed with cancer, GPs noted a suspicion of cancer for 85 (65.9%) versus 1895 (30.9%) when there was no subsequent cancer (P < 0.001). No suspicion was noted in 32 (24.8%) cancer patients. The GP’s intuitive cancer suspicion was independently associated with a subsequent new cancer diagnosis (OR 2.11, 95% CI 1.15–3.89).Laboratory tests were ordered for 45.4% of symptomatic patients, imaging for 10.4%, referral or hospitalization for 20.0%: all were more frequent in subsequent cancer patients (P < 0.001).InterpretationAbdominal symptoms pointed to abdominal cancers rather than to other cancers. However, the finding of abdominal symptoms in only one third of patients with an abdominal cancer, and the lack of cancer suspicion in a quarter of symptomatic cancer patients, provide challenges for GPs’ diagnostic thinking and referral practices.

Knowledge is sparse about the consequences of variation in prostate-specific antigen (PSA) testing rates in general practice. This study investigated associations between PSA testing and prostate cancer-related outcomes in Danish general practice, where screening for prostate cancer is not recommended. National registers were used to divide general practices into four groups based on their adjusted PSA test rate [2004][2005][2006][2007][2008][2009]. We analysed associations between PSA test rate and prostate cancer-related outcomes using Poisson regression adjusted for potential confounders. We included 368 general practices, 303,098 men and 4,199 incident prostate cancers. Men in the highest testing quartile of practices compared to men in the lowest quartile had increased risk of trans-rectal ultrasound (incidence rate ratio (IRR): 1.20, 95% CI, 0.95-1.51), biopsy (IRR: 1.76, 95% CI, 1.54-2.02), and getting a prostate cancer diagnosis (IRR: 1.37, 95% CI, 1.23-1.52). More were diagnosed with local stage disease (IRR: 1.61, 95% CI, 1.37-1.89) with no differences regarding regional or distant stage. The IRR for prostatectomy was 2.25 (95% CI, 1.72-2.94) and 1.28 (95% CI, 1.02-1.62) for radiotherapy. No differences in prostate cancer or overall mortality were found between the groups. These results show that the highest PSA testing general practices may not reduce prostate cancer mortality but increase the downstream use of diagnostic and surgical procedures with potentially harmful side effects.

BackgroundDifferent abdominal symptoms may signal cancer, but their role is unclear.AimTo examine associations between abdominal symptoms and subsequent cancer diagnosed in the abdominal region.Design and settingProspective cohort study comprising 493 GPs from surgeries in Norway, Denmark, Sweden, Scotland, Belgium, and the Netherlands.MethodOver a 10-day period, the GPs recorded consecutive consultations and noted: patients who presented with abdominal symptoms pre-specified on the registration form; additional data on non-specific symptoms; and features of the consultation. Eight months later, data on all cancer diagnoses among all study patients in the participating general practices were requested from the GPs.ResultsConsultations with 61 802 patients were recorded and abdominal symptoms were documented in 6264 (10.1%) patients. Malignancy, both abdominal and non-abdominal, was subsequently diagnosed in 511 patients (0.8%). Among patients with a new cancer in the abdomen (n = 251), 175 (69.7%) were diagnosed within 180 days after consultation. In a multivariate model, the highest sex- and age-adjusted hazard ratio (HR) was for the single symptom of rectal bleeding (HR 19.1, 95% confidence interval = 8.7 to 41.7). Positive predictive values of >3% were found for macroscopic haematuria, rectal bleeding, and involuntary weight loss, with variations according to age and sex. The three symptoms relating to irregular bleeding had particularly high specificity in terms of colorectal, uterine, and bladder cancer.ConclusionsA patient with undiagnosed cancer may present with symptoms or no symptoms. Irregular bleeding must always be explained. Abdominal pain occurs with all types of abdominal cancer and several symptoms may signal colorectal cancer. The findings are important as they influence how GPs think and act, and how they can contribute to an earlier diagnosis of cancer.