title: Patient- and system-related barriers for the earlier diagnosis of colorectal cancer.
abstract: BACKGROUND
  A cohort of colorectal cancer (CRC) patients represents an opportunity to study missed opportunities for earlier diagnosis.
  
  
  OBJECTIVE
  To study the epidemiology of diagnostic delays and failures to offer/complete CRC screening.
  
  
  OBJECTIVE
  To identify system- and patient-related factors that may contribute to diagnostic delays or failures to offer/complete CRC screening.
  
  
  METHODS
  
  
  
  METHODS
  Rural Veterans Administration (VA) Healthcare system.
  
  
  METHODS
  CRC cases diagnosed within the VA between 1/1/2000 and 3/1/2007.
  
  
  METHODS
  progress notes, orders, and pathology, laboratory, and imaging results obtained between 1/1/1995 and 12/31/2007. Completed CRC screening was defined as a fecal occult blood test or flexible sigmoidoscopy (both within five years), or colonoscopy (within 10 years); delayed diagnosis was defined as a gap of more than six months between an abnormal test result and evidence of clinician response. A summary abstract of the antecedent clinical care for each patient was created by a certified gastroenterologist (GI), who jointly reviewed and coded the abstracts with a general internist (TW).
  
  
  RESULTS
  The study population consisted of 150 CRC cases that met the inclusion criteria. The mean age was 69.04 (range 35-91); 99 (66%) were diagnosed due to symptoms; 61 cases (46%) had delays associated with system factors; of them, 57 (38% of the total) had delayed responses to abnormal findings. Fifteen of the cases (10%) had prompt symptom evaluations but received no CRC screening; no patient factors were identified as potentially contributing to the failure to screen/offer to screen. In total, 97 (65%) of the cases had missed opportunities for early diagnosis and 57 (38%) had patient factors that likely contributed to the diagnostic delay or apparent failure to screen/offer to screen.
  
  
  CONCLUSIONS
  Missed opportunities for earlier CRC diagnosis were frequent. Additional studies of clinical data management, focusing on following up abnormal findings, and offering/completing CRC screening, are needed.
authors.affiliation: VA Iowa City Health Care System, Iowa City, Iowa, USA. Terry.Wahls@va.gov
authors.forename: Terry L
authors.initials: TL
authors.lastname: Wahls
authors.forename: Ika
authors.initials: I
authors.lastname: Peleg
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D015179:Colorectal Neoplasms / Q000175:diagnosis* / Q000453:epidemiology / Q000517:prevention & control; D057210:Delayed Diagnosis / Q000706:statistics & numerical data; D003951:Diagnostic Errors; D055088:Early Detection of Cancer / Q000379:methods* / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods; D008499:Medical Records / Q000706:statistics & numerical data; D008875:Middle Aged; D009780:Occult Blood; D010342:Patient Acceptance of Health Care; D010817:Physician-Patient Relations; D012812:Sigmoidoscopy; D014481:United States / Q000453:epidemiology; D014493:United States Department of Veterans Affairs; D014728:Veterans / Q000706:statistics & numerical data