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Advanced-stage diagnosis of colorectal cancer (CRC) leads to poor prognosis and reduced survival rates. The current study seeks to explore the reasons for diagnostic delays in a sample of Australian men with CRC. Semi-structured interviews were conducted in a purposive sample of 20 male CRC patients. Data collection ceased when no new data emerged. Interviews were audiotaped, transcribed and thematically analysed using Andersen's Model of Total Patient Delay as the theoretical framework. Most participants (18/20) had experienced lower bowel symptoms prior to diagnosis. Patient-related delays were more common than delays attributable to the health-care system. Data regarding patient delays fit within the first four stages of Andersen's model. The barriers to seeking timely medical advice were mainly attributed to misinterpretation of symptoms, fear of cancer diagnosis, reticence to discuss the symptoms or consulting a general practitioner. Treatment delays were a minor cause for delayed diagnosis. Delay in referral and scheduling for colonoscopy were among the system-delay factors. In many instances, delays resulted from men's failure to attribute their symptoms to cancer and, subsequently, delay in diagnosis.

Early colorectal cancers do have significant symptoms which can easily be captured by a PCQ and objective scoring tool in the secondary care setting. Detection of these cancers has the potential to improve survival.

INTRODUCTION The aim of this study was to develop a system to compare and validate cancer referral guidelines, identifying the pitfalls in their development and provide a mechanism to evaluate their efficacy.PATIENTS AND METHODS 3302 patients referred from primary care with colorectal symptoms over a 3-year period were assessed. All participants had a comprehensive history obtained via a questionnaire that incorporated all colorectal symptoms. The questionnaires were completed prior to assessment at the hospital. All patients were then assessed at the Colorectal One Stop Clinic (CROSC), underwent investigation and diagnosis achieved. All data were entered into a databank. Current prioritisation guidelines and tools that are used to assess colorectal referrals were applied to this colorectal databank to test their efficacy for cancer detection and referral prioritisation. Sensitivity and specificity for cancer detection and referral rates were assessed.RESULTS Cancer was detected in 156 patients (4.7%). All prioritisation models (NHS guidelines, Weighted Numerical Score [WNS], Netherlands, Harvard, Mersey, and Somerset) differentiated cancer from non-cancer patients. The use of a few symptoms as risk predictors (e.g. NHS guidelines) causes a decrease in specificity in contrast to a comprehensive risk tool, for example, the WNS at a score of 50 (NHS 54.1%, WNS 62.9%). This results in a significantly higher referral rate (NHS 47.6%, WNS 39.4%) and identifies fewer cancers (NHS 80.1%, WNS 85.9%). Non-evidence based modifications of the NHS guidelines (Somerset and Mersey) caused a further deterioration in specificity, which was reflected in an increased referral rate. Using the WNS, which is objective and a continuous scale, allows adaptation of the referral threshold, balancing sensitivity and specificity to the resources available within a hospital. For example, the WNS of ≥ 40 has a sensitivity of 96.8% for cancer detection.CONCLUSIONS Accurate prospective data collection into a data bank allows testing of referral guidelines as well as providing an adjunct to guideline construction.

Our data provides indirect evidence to support the concept that a significant proportion of rectal cancers may arise via an alternative pathway to the Vogelstein model. Polyp behaviour along with malignant propensity may actually be site dependent, with rectal polyps harbouring a more aggressive phenotype.