title: Screening or Symptoms? How Do We Detect Colorectal Cancer in an Equal Access Health Care System?
abstract: BACKGROUND
  Detection of colorectal cancer ideally occurs at an early stage through proper screening. We sought to establish methods by which colorectal cancers are diagnosed within an equal access military health care population and evaluate the correlation between TNM stage at colorectal cancer diagnosis and diagnostic modality (i.e., symptomatic detection vs screen detection).
  
  
  METHODS
  A retrospective chart review of all newly diagnosed colorectal cancer patients from January 2007 to August 2014 was conducted at the authors' equal access military institution. We evaluated TNM stage relative to diagnosis by screen detection (fecal occult blood test, flexible sigmoidoscopy, CT colonography, colonoscopy) or symptomatic evaluation (diagnostic colonoscopy or surgery).
  
  
  RESULTS
  Of 197 colorectal cancers diagnosed (59 % male; mean age 62 years), 50 (25 %) had stage I, 47 (24 %) had stage II, 70 (36 %) had stage III, and 30 (15 %) had stage IV disease. Twenty-five percent of colorectal cancers were detected via screen detection (3 % by fecal occult blood testing (FOBT), 0.5 % by screening CT colonography, 17 % by screening colonoscopy, and 5 % by surveillance colonoscopy). One hundred forty-eight (75 %) were diagnosed after onset of signs or symptoms. The preponderance of these was advanced-stage disease (stages III-IV), although >50 % of stage I-II disease also had signs or symptoms at diagnosis. The most common symptoms were rectal bleeding (45 %), abdominal pain (35 %), and change in stool caliber (27 %). The most common overall sign was anemia (60 %). Screening FOBT (odds ratio (OR) 8.7, 95 % confidence interval (CI) 1.0-78.3; P = 0.05) independently predicted early diagnosis with stage I-II disease. Patient gender and ethnicity were not associated with cancer stage at diagnosis.
  
  
  CONCLUSIONS
  Despite equal access to colorectal cancer screening, diagnosis after development of symptomatic cancer remains more common. Fecal occult blood screen detection is associated with early stage at colorectal cancer diagnosis and is the focus for future initiatives.
authors.affiliation: Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA, 98431, USA. qhatch@gmail.com.
authors.forename: Quinton M
authors.initials: QM
authors.lastname: Hatch
authors.affiliation: Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA, 98431, USA.
authors.forename: Kevin R
authors.initials: KR
authors.lastname: Kniery
authors.affiliation: Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA, 98431, USA.
authors.forename: Eric K
authors.initials: EK
authors.lastname: Johnson
authors.affiliation: Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA, 98431, USA.
authors.forename: Shelly A
authors.initials: SA
authors.lastname: Flores
authors.affiliation: Northwest Permanente, Kaiser Permanente Northwest, Portland, OR, USA.
authors.forename: David L
authors.initials: DL
authors.lastname: Moeil
authors.affiliation: Northwest Permanente, Kaiser Permanente Northwest, Portland, OR, USA.
authors.forename: John J
authors.initials: JJ
authors.lastname: Thompson
authors.affiliation: Division of Colorectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA, USA.
authors.forename: Justin A
authors.initials: JA
authors.lastname: Maykel
authors.affiliation: Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, Tacoma, WA, 98431, USA.
authors.forename: Scott R
authors.initials: SR
authors.lastname: Steele
mesh_terms: D000328:Adult; D000368:Aged; D023881:Colonography, Computed Tomographic; D003113:Colonoscopy; D015179:Colorectal Neoplasms / Q000150:complications* / Q000175:diagnosis*; D055088:Early Detection of Cancer; D005243:Feces; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008403:Mass Screening; D008875:Middle Aged; D009367:Neoplasm Staging; D009780:Occult Blood; D012189:Retrospective Studies; D063189:Symptom Assessment
keywords: Colon cancer; Colorectal cancer; Equal access; Rectal cancer; Screening