Dame Deborah James, the ‘Bowelbabe’ and host of the You, Me and the Big C BBC podcast has had a huge impact in breaking down stigma and raising awareness as well as millions of pounds for bowel cancer. A blog that she wrote about her diagnosis is very moving, but makes uncomfortable reading for us in primary care. She tells a GP three times over a period of six months of her concern that she has bowel cancer, but is reassured each time that must have IBS, haemorrhoids or at worst inflammatory bowel disease since her bloods and stool test have come back as normal. She admits to having health anxiety, and it is possible that this contributed to a cognitive bias in the clinician’s mind that she was a ‘worrier’. Eventually she was diagnosed with Stage 4 cancer. We will all have had similar tragic cases in our practices. In my practice, we have had a recent case of a younger patient who had normal blood and FIT test 18 months ago, was reassured but then a year later had an emergency presentation with advanced Stage 4 colorectal cancer. How can we stop this happening?
recent editorial in the Lancet March 2022 discusses early onset colorectal cancer. The epidemiology of the disease has changed in recent decades. Previously thought of as a disease of older people, the incidence in older adults has shown signs of stabilisation or decline but new cases in adults under 50 have been rising worldwide. The reasons for this are not clear. Changing trends in diet and lifestyle are likely to play a part, but it has also been suggested that the greater use of antibiotics in early life and in the food chain may play a role. Colorectal cancers in younger people are diagnosed at a later stage and have a worse prognosis. The reasons for this are easier to understand. Both patients and clinicians are more likely to dismiss gastrointestinal symptoms leading to a longer lag time between onset of symptoms and diagnosis. Had Deborah James been aged over 55, it is very likely that she would have had an urgent referral at first presentation. The Lancet paper cites lack of awareness of hereditary cancer syndromes, such as Lynch syndrome, as another contributing factor. Perhaps now we should also factor in the potential impact of remote consulting.
The incidence of bowel cancer in young adults is rising, but of course it is still rare given how incredibly common gastrointestinal symptoms are. So, how do we balance not missing bowel cancer in younger adults with avoiding over investigation and referral? We should do more than just ticking red flag boxes. We need to: listen carefully to explore concerns, to check family history not just of bowel cancer but of cancer generally in the family (Lynch again), be aware of the ‘amber flag’ of symptom change and to lower threshold for face-to-face examination (including rectal exam), simple bloods and FIT testing in symptomatic patients. This includes people with IBS and anxiety, who after all are just as likely to get bowel cancer as anyone else so if their symptoms have changed they warrant re-investigation. If these tests are negative, we can reassure but we need to make sure that the safety netting is robust so that the patient has a clear time frame in which they should re-present if symptoms persist.
The problem of course is that to do all of this effectively what we really need is urgent primary care investment to provide more time, space and capacity, all of which are in short supply at present. In the meantime, we should be aware of this line from the Lancet editorial: ‘Existing assumptions that colorectal cancer is a disease that only affects older individuals must be dispelled’.