Rectal Bleeding Patient Delay in Presentation OWEN F. DENT, M.A. PH.D.,* KERRYJ. GOULSTON, F.R.A.C.P., M.D.,t CHRISTOPHERC. TENNANT, F.R.A.N.Z.C.P., M.D.,~ PAULINE LANGELUDDECKE,M.A., PH.D.,~ ANDREA MANT, F.R.A.C.G.P., M.A.,w PIERRE H. CHAPUIS, F.R.A.C.S., D.S., II MARGARETWARD, B. APPL. SCI., E. LESLIE BOKEY F.R.A.C.S., M.S. ii
From the Australian National University, Canberra,* the Repatriation General Hospital, Concord, Sydney,~ Sydney University, Department of Psychiatry, Royal North Shore Hospital, Sydney,$ Royal Australian College of General Practitioners, Sydney,w Colorectal Unit, Sydney University Department of Surgery, Repatriation General Hospital, Concord, Sydney," and the Medical Records Office, Repatriation General Hospital, Concord, Sydney82
Dent OF, Goulston KJ, Tennant CC, Langeluddecke P, Mant A, Chapuis PH, Ward M, Bokey EL. Rectal bleeding: patient delay in presentation. Dis Colon Rectum 1990;33:851-857. Patient delay in presentation of rectal bleeding has been identified as a factor in delayed diagnosis among patients with colorectal cancer. The aim of this study was to identify demographic or psychological factors, or beliefs or behaviors related to delay in presentation of rectal bleeding. In 93 patients presenting with this symptom to their general practitioner, delay ranged from 0 to 249 days with a median of 7 days; 27 (29 percent) delayed more than 14 days. Delay was unrelated to age, sex, ethnic origin, competence in English, length of schooling, social status, availability of social support, measured psychologic traits, and to the belief that the cause might be cancer. The proportions delaying more than 14 days were statistically significantly elevated among those who were not worried by the bleeding (47 percent delayed); those who did not regularly look at their feces or the toilet paper after use (37 percent); and those who took some other action before presenting to their general practitioner (43 percent). [Key words: Rectal bleeding; Patient delay; Colorectal cancer; Public cancer education]
IN THIS STUDY we use the t e r m "new rectal bleeding" to mean an episode of rectal bleeding for which the patient was not currently receiving treatment and which caused the patient to seek medical help. In people older than 40 years of age, rectal Work was conducted at Repatriation General Hospital, Concord, New South Wales, Australia. Study was supported by a grant from the New South Wales State Cancer Council. Address reprint requests to Dr. Dent: Department of Sociology, The Faculties, The Australian National University, P.O. Box 4, Canberra, A.C.T. 2601, Australia.
851
bleeding may be a symptom of colorectal cancer or of polyps that may be premalignant.1 A high prevalence of polyps (24 percent) and colorectal cancer (10 percent) has been found in patients aged 40 years and older presenting to their doctor with new rectal bleeding, and a large proportion of colorectal cancer in these patients was confined to the bowel wall (67 percent), promising a good prognosis after bowel resection, z This prevalence of early-stage colorectal cancer is higher than that reported in published series of symptomatic colorectal cancer patients and approaches the prevalence reported in screening asymptomatic individuals for colorectal c a n c e r ? Thus, new rectal bleeding in people aged 40 years and older is a significant symptom, which the public should be encouraged to report to their doctor immediately after it occurs, despite reservations expressed by some 4 that a reduction in delay in diagnosing symptomatic colorectal cancer may have no impact on lengthening survival. 5 Rectal bleeding arises far more frequently from anal lesions or from benign colorectal conditions than from colorectal cancer. Without full colonic investi-
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gation it is difficult for both general practitioners and specialists to differentiate between bleeding from a colorectal cancer or polyp and bleeding from other lesions. 2 Clinical features of the bleeding and other bowel symptoms are largely unhelpful to the general practitioner in forming a provisional diagnosis 6 and it has been advocated that such patients should be referred for full colonic assessment. 2 Rectal bleeding occurs frequently in the adult population. 7,s In a random community survey of people aged 30 years and older, three of the present authors found that 16 percent had experienced rectal bleeding during the preceding six months. 9 This figure was replicated in a survey of Australian male World War II veterans, l~ There is a need for public education on the importance of new rectal bleeding for early diagnosis of colorectal cancer, but little is known of how this symptom is regarded by the public or how quickly or in what m a n n e r the public responds when it occurs. We do not know how long people delay before presenting to their doctor with rectal bleeding; what they think the source of the bleeding might be; how seriously they regard it; whether they engage in self-treatment; and whether their behavior with regard to the bleeding is related to their demographic characteristics, psychological traits, or socioeconomic variables. Information on these matters could aid in targeting education about rectal bleeding to categories of people most in need of it or most likely to benefit from it. The ideal study to answer these questions would involve sampling from a population defined as all members of a community who were aged 40 years and older and who had experienced a new occurrence of rectal bleeding within a given period. This was not feasible because, apart from calling for community volunteers, there was no way of compiling a population list of this kind. We therefore conducted a study of patients presenting with rectal bleeding to a sample of general practitioners in the northwestern suburbs of Sydney. The patients were interviewed as soon as possible after the initial consultation and before a definitive diagnosis had been made. The aim of the study was to measure the length of patient delay in presenting with newly occurring rectal bleeding to a general practitioner; to determine whether delay was related to any of a range of sociodemographic, psychological, and symptom-related factors; and to determine whether any such relationships could be used in directing public education about rectal bleeding to categories of people most prone to delay. Patients and Methods
Eleven local government areas (LGAs) in the northwestern suburbs of Sydney were selected as a sam-
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piing frame. All were within a 12-km radius of Concord Hospital. For reasons of travel time and interviewing cost, it was not feasible to sample from the entire Sydney metropolitan area. The total population of these LGAs was 496,102 at the 1986 census and their population was broadly representative of the entire Sydney metropolitan area in terms of demographic characteristics, socioeconomic status, and ethnic composition. All Australia Post postcode districts within these local government areas were identified. The Royal Australian College of General Practitioners provided a current list of all general practitioners in Sydney. From this list, a random sample was drawn of general practitioners having addresses with the chosen postcodes. Each sampled general practitioner was contacted and invited to take part in the study. Sampling continued until 58 general practitioners had agreed to recruit patients for the study. A general briefing session on the study was held for participants, and individual briefing was also conducted by the project research assistant. The general practitioners were asked to invite all patients aged 35 years and older for whom rectal bleeding was the reason for the consultation to take part in the study. Patients were excluded if the bleeding was massive hemorrhage or melena, if the patient was undergoing treatment for rectal bleeding, if the patient was known to have inflammatory bowel disease, polyposis coli, or colorectal cancer, if the general practitioner judged it inappropriate to include the patient because of their physical condition, mental state, o r advanced age. The general practitioner obtained provisional informed consent and completed a standard form recording the patient's age and sex, the date of the consultation, the date of onset of the rectal bleeding, whether the rectal bleeding was the presenting symptom or incidental to another reason for the consultation, and whether the general practitioner believed the patient should have presented sooner. To enable comparisons to be made between participating and nonparticipating patients, the same background data were collected on eligible patients who refused to be interviewed. Immediately after each patient was recruited, the general practitioner notified the project research assistant who arranged a personal interview with the patient as soon as possible after the initial consultation and obtained written informed consent. The interview lasted approximately 30 minutes and included questions on when and how the rectal bleeding was first noticed; whether rectal bleeding had ever occurred previously; how worried the patient was by the bleeding; what the patient believed might have been the cause of the bleeding; what action the patient had taken after noticing the bleeding;
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whether the patient had consulted another general practitioner or other health service provider; what factors had contributed to delayed or prompt presentation; and demographic and socioeconomic status measures. Occupational ranking was measured by the A N U II occupational prestige scale. 11 Also included was a short scale to measure social support, scored in three ways to measure 1) the variety of sources within a person's social support network; 2) the average amount of perceived support from available sources; and 3) the average amount of perceived support from all sources considered. 12 The patient also completed the following psychologic scales: a hypochondriasis scale;13 the Spielberger state-trait anxiety inventory; 14 the Spielberger state-trait anger scale; 15 a self-report symptom rating scale to measure depression; 16 the Courtald emotional control scale; 17 extraversion and neuroticism scales from the Eysenck personality inventory; TM and a checklist of ways of coping with adversity. 19 The interview did not ask questions about cancer because we believed that it would be ethically improper to provoke anxiety in patients who had not received a diagnosis before they were interviewed by our research assistant. However several patients mentioned cancer in response to open-ended questions during the interview. The data were coded numerically for computer analysis, for which a standard statistical package was used. 2~ The chi-square test was used to assess the statistical significance of differences in contingency tables. Comparisons between means employed Student's t distribution. The Mann-Whitney U test was used to compare distributions where the assumptions of the t-test were not satisfied. Logistic regression was u s e d to assess the independent effect of predictor variables on delay, which was dichotomized at 0 to 14 days v s . 15 days or longer. The statistical significance level was set at 0.05. Confidence intervals for percentages are given at the 95 percent confidence level. Results
Over the period from May 1987 to January 1988, 58 general practitioners invited 136 patients to participate in the study and 106 agreed. O f the 33 who did not participate, 10 declined without reason; 9 were not asked because of their age, mental state, or medical condition; 6 said they did not have time; 5 said they were too anxious; 1 had insufficient command of English to be interviewed; and for 2 the general practitioner did not give a reason. There were no statistically significant differences between the participants and the nonparticipants in respect to age, sex, birthplace, whether the episode of rectal bleeding was the first occurrence ever for the patient,
BLEEDING
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and whether the general practitioner believed the patient should have presented sooner. Thirteen otherwise eligible patients were excluded because rectal bleeding was not the main presenting symptom; it had been discovered by the general practitioner during a consultation for another problem. Fifty of the 93 remaining patients were male and 43 were female. Their ages ranged from 35 to 85 years with a mean and median of 55 years. The period between the onset of symptoms and the general practitioner consultation ranged from 0 to 249 days with a median of 7 days and had a J-shaped distribution. Twenty-seven patients (29 percent) had delayed for more than 14 days. The general practitioner considered that 28 patients (32 percent) should have presented earlier. The median delay for these patients was 31 days compared with 3 days for the remaining 60 (P < 0.0001) (the general practitioner did not give an opinion on 5 patients). O f the 63 patients who had presented within 14 days, the general practitioner believed that 11 (18 percent) should have presented earlier; of the 25 patients who delayed for 15 days or longer, the general practitioner believed that 68 percent should have presented earlier (P < 0.0001). A delay of more than 14 days in presenting rectal bleeding was not associated with age or sex. Forty-six patients (50 percent) said that this was not their first occurrence of rectal bleeding and 35 of these said that previous bleeding had happened only "once or twice" or "occasionally." Those who had not had previous occurrences were more likely to have delayed than those who had (Table 1).Thirty-seven patients (40 percent) said that they always looked at their feces in the toilet bowl and 43 (46 percent) said that they always looked at the toilet paper. In contrast, 34 patients (37 percent) said that they looked at their feces less than half the time and 35 (38 percent) said that they looked at the toilet paper less than half the time. The 63 patients who said that they always looked at either the toilet paper or at their feces were less likely to have delayed than other patients (Table 1). T h e r e was no association between delay and whether the blood was first seen on the toilet paper or in the toilet bowl or both and no association with whether the blood was separate from or mixed with feces. At the onset of bleeding, 16 patients had engaged in some form of self-treatment, and these patients tended to delay longer than others, but this difference was not statistically significant (Table 1). Sixteen patients had consulted a person other than a medical practitioner about their bleeding, and these patients tended to delay longer than others, but again the difference was not statistically significant (Table 1). No patient had consulted a pharmacist or a practitioner
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TABLE1. Association Between Delay and Other Variables
Had rectal bleeding previously Look at toilet paper or feces every time Self-treated at onset bleeding Consulted someone other than a doctor Took some other action before seeing doctor Tertiary education Embarrassed by rectal bleeding* Thought bleeding might be caused by hemorrhoids Thought bleeding might be caused by cancer
No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes
n
Percent delaying (15 + days)
95 Percent Confidence Interval
47 46 63 30 82 11 77 16 63 30 53 40 69 20 41 52 62 31
38.3 19.6 36.5 13.3 26.8 45.5 27.3 37.5 22.2 43.3 37.3 17.5 30.4 25.0 19.5 36.5 32.3 22.6
24.4-52.2 8.1-31.0 24.6-48.4 1.2-25.5 17.2-36.4 16.0-74.9 17.3-37.2 13.8-61.2 12.0-32.5 25.6-65.1 24.7-50.8 5.7-29.3 19.6~41.3 6.0-44.0 7.4-31.6 23.5-49.6 20.6--43.9 7.9-37.3
P 0.047 0.021 0.2 0.6 0.036 0.033 0.6 0.07 0133
*Four patients did not answer. o f alternative medicine. Patients whose only action after the onset o f bleeding was to consult their general practitioner delayed less than those who took some o t h e r action as well (Table 1). Ethnic origin was not associated with delayed presentation; patients b o r n in a n o n - A n g l o p h o n e country o r whose parents were b o r n in a n o n - A n g l o p h o n e c o u n t r y were no m o r e or less likely to delay than o t h e r patients. For patients b o r n in n o n - A n g l o p h o n e countries t h e r e was no association between delay and their perceived c o m p e t e n c e in written or spoken English. T h e r e was no association between delay and years o f schooling c o m p l e t e d , occupational rank, or income. Patients with little o r n o tertiary e d u c a t i o n were m o r e likely to have delayed than those who had c o m p l e t e d a trade course or equivalent or a recognized diploma or d e g r e e (Table 1). Delay was u n r e l a t e d to the d e g r e e o f social s u p p o r t patients perceived themselves as having and unrelated to marital status. T h e r e was no association between any o f the psychologic measures and delay. T w e n t y patients said they were embarrassed by the bleeding, but they were no m o r e likely to have delayed than the others. T w e n t y - s e v e n patients (29 percent) recalled having seen a television p r o g r a m or news item about rectal bleeding and 29 (31 percent) recalled having read something about this condition, but in neither case was t h e r e any association with p r o m p t vs. delayed presentation. T h e p r o p o r t i o n o f patients delaying for m o r e than two weeks decreased as their worry about the bleed-
ing increased (Table 2). Patients who believed thai the bleeding was caused by h e m o r r h o i d s delayed m o r e than others, although this d i f f e r e n c e did not reach the r e q u i r e d level o f statistical significance (Table 1). Delay was u n r e l a t e d to w h e t h e r the patient believed the bleeding might be d u e to cancer (Table 1). A logistic regression m o d e l with delay o f u p to 14 days vs. delay o f 15 days or m o r e as the d e p e n d e n t variable and the five variables that had statistically significant z e r o - o r d e r associations with delay as indep e n d e n t variables showed that only t h r e e o f these had statistically significant i n d e p e n d e n t effects o n delay (Table 3). T h e s e were w o r r y a b o u t the bleeding; regular vs. i r r e g u l a r inspection o f the feces or toilet paper; and w h e t h e r the patient had taken some o t h e r action b e f o r e seeing their general practitioner. In an o p e n - e n d e d question, patients who had presented within 14 days were asked why they had presented p r o m p t l y and those who took l o n g e r than 14 days were asked what had c o n t r i b u t e d to their delay. Up to t h r e e reasons were given by patients in answer to each o f these questions. C o n c e r n that the cause o f bleeding might be cancer or some serious condition TABLE2. Delay by Worry about Bleeding Not Worried
A Little Very Extremely Worried Worried Worried
n 33 41 16 Percent delaying more than 14 days 46.7 25.0 23.5 95 Percent confidence interval 28.5-64.5 10.9-39.1 3.4--43.7
10 0.0 --
Chi-square = 9.15, degrees of freedom = 3, P = 0.027.
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TABLE3. Logistic Regression with Delay as the Dependent Variable Coefficient Worry about the bleeding Took some other action before seeing doctor Always looks at feces or toilet paper Had rectal bleeding previously Tertiary eduction Intercept
Standard Error 0.19
2.78
0.75
0.31
2.38
0.73
0.35
2.07
0.51 0.03 2.36
0.30 0.31 0.58
1.73 0.10 4.09
were by far the most c o m m o n reasons for p r o m p t n e s s (Table 4). T h e presence o f o t h e r symptoms and the bleeding itself being alarming were also important. T h e main reasons given for delay were that the patient believed the bleeding was caused by h e m o r rhoids; that they believed it was o f aninor concern; and that it was not convenient to see a d o c t o r when the b l e e d i n g first o c c u r r e d (Table 5). Embarrassment, fear, and fatalism were m e n t i o n e d by very few patients. Discussion T h e p u r p o s e o f this study was to discover w h e t h e r patient delay in presenting new rectal bleeding was associated with any o f a r a n g e o f sociodemographic, psychologic, and symptom-related factors and to det e r m i n e w h e t h e r any such relationships could be used in directing public education about rectal bleeding to categories o f people most in need o f it. T h e desire to e n c o u r a g e p r o m p t presentation o f new rectal bleeding stems f r o m the f r e q u e n t occurrence o f this s y m p t o m in colorectal cancer. Previous studies o f delay in diagnosis o f colorectal cancer have retrospectively reviewed delay f r o m the first occurr e n c e o f symptoms t h r o u g h to the confirmation o f a diagnosis o f cancer and have identified three main phases: patient delay, d o c t o r delay, and diagnostic TABLE 4. Reason for Prompt Presentation Given by Patients who
Presented Within 14 Days
Reason Thought bleeding might be from a cancer Thought the cause might be serious Had other associated symptoms that were compelling Bleeding was alarming Relative or friend urged prompt presentation Bleeding coincided with planned visit to doctor Thought bleeding mith be from hemorrhoids *Patients gave u p to three reasons.
TABLE5. Reasons for Delay Given by Patients who Delayed 15 Days or Longer
Coefficient SE
0.53
Number of Patients* 33 16 10 9 4
855
Reason
Number of Patients*
Thought bleeding was caused by hemorrhoids Thought the bleeding was minor or insignificant Inconvenient to present sooner The bleeding occurred infrequently Embarrassment Thought the bleeding might cease Fatalistic--thought nothing could be done Afraid the cause was serious Waited till a regular appointment with doctor *Patients gave u p to t h r e e reasons.
delay. 21-25 A significant limitation o f these studies is that they have necessarily e x c l u d e d patients who exp e r i e n c e d a given s y m p t o m (for e x a m p l e , rectal bleeding) but were not ultimately diagnosed as having colorectal cancer. F u r t h e r m o r e , patients in previous studies were interviewed at a relatively late diagnostic stage when m e m o r y lapses, selective recall, and anxiety f r o m knowing that they h a d cancer may have influenced their accounts o f timing and events in the early symptomatic stage. It is reasonable to believe that public e d u c a t i o n should be based o n and directed toward the stage w h e n a p e r s o n is considering what to do about a s y m p t o m r a t h e r than at the point when they have b e e n given a definitive diagnosis. O u r study enlisted patients w h e n they first p r e s e n t e d with rectal bleeding to the participating general practitioner. Various studies have r e p o r t e d d i f f e r i n g periods o f delay between the onset o f symptoms o f colorectal cancer and presentation to a general practitioner, alt h o u g h we are not aware o f any study r e p o r t i n g delay specifically for rectal bleeding. Comparisons are complicated by inconsistency in the statistical m e t h o d s used to r e p o r t delay. For colon cancer, a m e d i a n total delay o f 11 weeks has b e e n r e p o r t e d f r o m an American study 2x and 22 weeks f r o m a British series. 22 For rectal cancer the respective total delays were 13.5 weeks and 31.5 weeks. T h e latter study gave average patient delays o f 12.7 weeks for colon cancer and 16.2 weeks for rectal cancer. 22 M a c A r t h u r and Smith rep o r t e d a m e d i a n patient delay o f 31.5 days 25 for colorectal cancer. T h e m e d i a n o f only 7 days f o u n d in the c u r r e n t study may have b e e n d u e to o u r focus on the single, compelling s y m p t o m o f rectal bleeding or may reflect g r e a t e r public awareness o f the significance o f this symptom, easier access to medical services, o r a quicker patient response in Australia comp a r e d with o t h e r countries. A n o t h e r possibility was
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that delay had diminished over the period of 10 years or longer between previous reports and our study. The effects of several classes of variables on delay in presentation of cancer symptoms have been reviewed by Antonovsky and Hartman. 26 These variables were: 1) sociodemographic factors including age, sex, ethnicity, education, marital status, occupation, and income; 2) knowledge about cancer, previous experience of cancer in oneself and others, and affective reactions to cancer such as embarrassment, fear, fatalism, and denial; 3) personality traits and more general psychologic factors going beyond affective reaction to cancer and including intellectual capacity, hypochondriasis, body image, emotional stability, and coping styles; 4) sociocultural factors such as learned dispositions toward health care and preventive behavior, and attitudes of significant others and the pressures they exert; 5) relationships between the patient and health care providers including the availability of doctors, diagnostic services, and health i n s u r a n c e schemes. A n t o n o v s k y a n d H a r t m a n showed that, almost without exception, different studies had reported differing conclusions on the effects of these variables on delay. Furthermore, most studies reported zero-order relationships only without attempting to control for correlations between predictor variables. We found very few associations between delay and the numerous variables from within these categories that we examined. The list was further reduced when correlations between the predictor variables were controlled by logistic regression. Patients who delayed were not worried about the bleeding; they did not look regularly at the toilet paper or their feces, and they had tended to take some other action such as self-treatment or consultation with a relative or friend before presenting to a general practitioner. The negative results of this study in regard to psychosocial factors are significant. Disabling fear, fatalism, denial, embarrassment, and lack of social support did not appear to have engendered delay except in isolated cases. Instead, worry about their rectal bleeding was the force driving early presentation in a substantial majority of patients. Those who delayed did so largely because they believed the bleeding was due to hemorrhoids or to an insignificant cause, because it was infrequent, or for reasons of inconvenience. The important message here is' that complex nonrational factors may be ignored in preparing and delivering public education about rectal bleeding, and that education should concentrate on simple factual information. Notwithstanding the short average delay found in this study, participating general practitioners consid-
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ered that one in three patients should have presented sooner. Therefore, we conclude that there is scope for public education on prompt presentation of rectal bleeding, although we have not been able to identify particular groups who are at risk of delaying and who are more in need of information about rectal bleeding than others. Public education should encourage all adults to look at their feces regularly, to avoid self-diagnosis and self-treatment, to present new episodes of rectal bleeding promptly to their general practitioner, and should stress the importance of this symptom in people aged 40 and older.
Acknowledgments A list of general practitioner's for sampling purposes was provided by the Royal Australian College of General Practitioners. We are most grateful to the general practitioners who enlisted patients for the study.
References 1. Silman AJ, Mitchell P, Nicholls RJ, et al. Self-reported dark red bleeding as a marker comparable with occult blood testing in screening for large bowel neoplasms. Br J Surg 1983;70: 721--4. 2. Goulston KJ, Cook I, Dent OF. How important is rectal bleeding in the diagnosis of howe1 cancer and polyps? Lancet 1986;2:261-3. 3. Hardcastle JD, Farrands PA, Balfour TW, et al. Controlled trial of faecal occult blood testing in the detection of colorectal cancer. Lancet 1983;2:2-4. 4. McDermott FT, Hughes ES, Phil E, et al. Symptom duration and survival prospects in carcinoma of the rectum. Surg Gynecol Obstet 1981;153:321-6. 5. Dent OF, Chapuis PH, Goulston KJ. Relationship of survival to stage of the tumour and duration of symptoms in colorectal cancer. Med J Aust 1983; 1:274-5. 6. Mant A, Bokey EL, Chapuis PH, et al. Rectal bleeding: do other symptoms aid in diagnosis? Dis Colon Rectum 1989 (in press). 7. Jones IS. An analysis of bowel habit and its significance in the diagnosis of carcinoma of the colon. Am J Proctol 1976; 27:45-56. 8. Farrands PA, Hardcastle JD. Colorectal screening by a selfcompleted questionnaire. Gut 1984;25:445-7. 9. Dent OF, Goulston KJ, Zubrzycki J, Chapuis PH. Bowel symptoms in an apparently well population. Dis Colon Rectum 1986;29:243-7. 10. Chapuis PH, Goulston KJ, Dent OF. Predictive value of rectal bleeding in screening for rectal and sigmoid polyps. Br Med J 1985;290:1546-8. 11. Broom L, Duncan-Jones P, Jones FL, McDonnell P. Investigating social mobility. Canberra: The Australian National University, Research School of Social Sciences, 1977; Department of Sociology, Departmental Monograph No. 1. 12. Funch DP, Marshall JR, Gebhardt general practitioner. Assessment of a short scale to measure social support. Soc Sci Med 1986;23:337-44. 13. Pilowsky I. Dimensions of hypochondriasis. Br J Psychiatry 1967; 113:89-93. 14. Spielberger CD. Manual for the state-trait anxiety inventory. Palo Alto: Consulting Psychologists' Press Inc., 1983. 15. Spielberger CD, Jacobs G, Russell S, Crane R. Assessment of anger: the state-trait anger scale. In: Butcher JN, Spielberger CD, eds. Advances in personality assessment. Vol 2. Hillsdale, NJ: Lea & Febiger, 1983. 16. Weissmau MM, Sholomskas D, Pottenger M, Prusoff BA,
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Locke BZ. Assessing depressive symptoms in five psychiatric populations: a validation study. Am J Epidemiol 1977;106: 203-14. Watson M, Greer S. Development of a questionnaire measure of emotional control. J Psychosom Res 1983;27:299-305. Grayson DA. A latent trait analysis of the Eysenck personality inventory. J Psychiatr Res 1986;20:217-35. Folkman S, Lazarus RS. If it changes it must be process: a study of emotions and coping during three stages of a college examination. J Pers Soc Psychol 1985;48:150-70. SPSS Inc. Statistical package for the social sciences. Chicago: SPSS Inc, 1988. Hackett TP, Cassem NH, Raker JW. Patient delay in cancer. N Engl J Med 1973;289:14-20.
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22. Holliday HW, HardcastleJD. Delay in diagnosis and treatment of symptomatic colorectal cancer. Lancet 1979; 1:309-11. 23. MacAdam DB. A study in general practice of the symptoms and delay patterns in the diagnosis of gastrointestinal cancer. J R Coll Gen Pract 1979;29:723-9. 24. Nilsson E, Bolin S, Sjodahl R. Carcinoma of the colon and rectum: delay in diagnosis. Acta Chir Scand 1982;148:61722. 25. MacArthur C, Smith A. Factors associated with speed of diagnosis, referral and treatment in colorectal cancer. J Epidemiol Community Health 1984;38:122-6. 26. Antonovsky A, Hartman H. Delay in the detection of cancer: a review of the literature. Health Education Monographs 1974;2:98-128.
From the Australian National University, Canberra,* the Repatriation General Hospital, Concord, Sydney,~ Sydney University, Department of Psychiatry, Royal North Shore Hospital, Sydney,$ Royal Australian College of General Practitioners, Sydney,w Colorectal Unit, Sydney University Department of Surgery, Repatriation General Hospital, Concord, Sydney," and the Medical Records Office, Repatriation General Hospital, Concord, Sydney82
Dent OF, Goulston KJ, Tennant CC, Langeluddecke P, Mant A, Chapuis PH, Ward M, Bokey EL. Rectal bleeding: patient delay in presentation. Dis Colon Rectum 1990;33:851-857. Patient delay in presentation of rectal bleeding has been identified as a factor in delayed diagnosis among patients with colorectal cancer. The aim of this study was to identify demographic or psychological factors, or beliefs or behaviors related to delay in presentation of rectal bleeding. In 93 patients presenting with this symptom to their general practitioner, delay ranged from 0 to 249 days with a median of 7 days; 27 (29 percent) delayed more than 14 days. Delay was unrelated to age, sex, ethnic origin, competence in English, length of schooling, social status, availability of social support, measured psychologic traits, and to the belief that the cause might be cancer. The proportions delaying more than 14 days were statistically significantly elevated among those who were not worried by the bleeding (47 percent delayed); those who did not regularly look at their feces or the toilet paper after use (37 percent); and those who took some other action before presenting to their general practitioner (43 percent). [Key words: Rectal bleeding; Patient delay; Colorectal cancer; Public cancer education]
IN THIS STUDY we use the t e r m "new rectal bleeding" to mean an episode of rectal bleeding for which the patient was not currently receiving treatment and which caused the patient to seek medical help. In people older than 40 years of age, rectal Work was conducted at Repatriation General Hospital, Concord, New South Wales, Australia. Study was supported by a grant from the New South Wales State Cancer Council. Address reprint requests to Dr. Dent: Department of Sociology, The Faculties, The Australian National University, P.O. Box 4, Canberra, A.C.T. 2601, Australia.
851
bleeding may be a symptom of colorectal cancer or of polyps that may be premalignant.1 A high prevalence of polyps (24 percent) and colorectal cancer (10 percent) has been found in patients aged 40 years and older presenting to their doctor with new rectal bleeding, and a large proportion of colorectal cancer in these patients was confined to the bowel wall (67 percent), promising a good prognosis after bowel resection, z This prevalence of early-stage colorectal cancer is higher than that reported in published series of symptomatic colorectal cancer patients and approaches the prevalence reported in screening asymptomatic individuals for colorectal c a n c e r ? Thus, new rectal bleeding in people aged 40 years and older is a significant symptom, which the public should be encouraged to report to their doctor immediately after it occurs, despite reservations expressed by some 4 that a reduction in delay in diagnosing symptomatic colorectal cancer may have no impact on lengthening survival. 5 Rectal bleeding arises far more frequently from anal lesions or from benign colorectal conditions than from colorectal cancer. Without full colonic investi-
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gation it is difficult for both general practitioners and specialists to differentiate between bleeding from a colorectal cancer or polyp and bleeding from other lesions. 2 Clinical features of the bleeding and other bowel symptoms are largely unhelpful to the general practitioner in forming a provisional diagnosis 6 and it has been advocated that such patients should be referred for full colonic assessment. 2 Rectal bleeding occurs frequently in the adult population. 7,s In a random community survey of people aged 30 years and older, three of the present authors found that 16 percent had experienced rectal bleeding during the preceding six months. 9 This figure was replicated in a survey of Australian male World War II veterans, l~ There is a need for public education on the importance of new rectal bleeding for early diagnosis of colorectal cancer, but little is known of how this symptom is regarded by the public or how quickly or in what m a n n e r the public responds when it occurs. We do not know how long people delay before presenting to their doctor with rectal bleeding; what they think the source of the bleeding might be; how seriously they regard it; whether they engage in self-treatment; and whether their behavior with regard to the bleeding is related to their demographic characteristics, psychological traits, or socioeconomic variables. Information on these matters could aid in targeting education about rectal bleeding to categories of people most in need of it or most likely to benefit from it. The ideal study to answer these questions would involve sampling from a population defined as all members of a community who were aged 40 years and older and who had experienced a new occurrence of rectal bleeding within a given period. This was not feasible because, apart from calling for community volunteers, there was no way of compiling a population list of this kind. We therefore conducted a study of patients presenting with rectal bleeding to a sample of general practitioners in the northwestern suburbs of Sydney. The patients were interviewed as soon as possible after the initial consultation and before a definitive diagnosis had been made. The aim of the study was to measure the length of patient delay in presenting with newly occurring rectal bleeding to a general practitioner; to determine whether delay was related to any of a range of sociodemographic, psychological, and symptom-related factors; and to determine whether any such relationships could be used in directing public education about rectal bleeding to categories of people most prone to delay. Patients and Methods
Eleven local government areas (LGAs) in the northwestern suburbs of Sydney were selected as a sam-
AL.
Dis. Col. & Rect. October 1990
piing frame. All were within a 12-km radius of Concord Hospital. For reasons of travel time and interviewing cost, it was not feasible to sample from the entire Sydney metropolitan area. The total population of these LGAs was 496,102 at the 1986 census and their population was broadly representative of the entire Sydney metropolitan area in terms of demographic characteristics, socioeconomic status, and ethnic composition. All Australia Post postcode districts within these local government areas were identified. The Royal Australian College of General Practitioners provided a current list of all general practitioners in Sydney. From this list, a random sample was drawn of general practitioners having addresses with the chosen postcodes. Each sampled general practitioner was contacted and invited to take part in the study. Sampling continued until 58 general practitioners had agreed to recruit patients for the study. A general briefing session on the study was held for participants, and individual briefing was also conducted by the project research assistant. The general practitioners were asked to invite all patients aged 35 years and older for whom rectal bleeding was the reason for the consultation to take part in the study. Patients were excluded if the bleeding was massive hemorrhage or melena, if the patient was undergoing treatment for rectal bleeding, if the patient was known to have inflammatory bowel disease, polyposis coli, or colorectal cancer, if the general practitioner judged it inappropriate to include the patient because of their physical condition, mental state, o r advanced age. The general practitioner obtained provisional informed consent and completed a standard form recording the patient's age and sex, the date of the consultation, the date of onset of the rectal bleeding, whether the rectal bleeding was the presenting symptom or incidental to another reason for the consultation, and whether the general practitioner believed the patient should have presented sooner. To enable comparisons to be made between participating and nonparticipating patients, the same background data were collected on eligible patients who refused to be interviewed. Immediately after each patient was recruited, the general practitioner notified the project research assistant who arranged a personal interview with the patient as soon as possible after the initial consultation and obtained written informed consent. The interview lasted approximately 30 minutes and included questions on when and how the rectal bleeding was first noticed; whether rectal bleeding had ever occurred previously; how worried the patient was by the bleeding; what the patient believed might have been the cause of the bleeding; what action the patient had taken after noticing the bleeding;
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whether the patient had consulted another general practitioner or other health service provider; what factors had contributed to delayed or prompt presentation; and demographic and socioeconomic status measures. Occupational ranking was measured by the A N U II occupational prestige scale. 11 Also included was a short scale to measure social support, scored in three ways to measure 1) the variety of sources within a person's social support network; 2) the average amount of perceived support from available sources; and 3) the average amount of perceived support from all sources considered. 12 The patient also completed the following psychologic scales: a hypochondriasis scale;13 the Spielberger state-trait anxiety inventory; 14 the Spielberger state-trait anger scale; 15 a self-report symptom rating scale to measure depression; 16 the Courtald emotional control scale; 17 extraversion and neuroticism scales from the Eysenck personality inventory; TM and a checklist of ways of coping with adversity. 19 The interview did not ask questions about cancer because we believed that it would be ethically improper to provoke anxiety in patients who had not received a diagnosis before they were interviewed by our research assistant. However several patients mentioned cancer in response to open-ended questions during the interview. The data were coded numerically for computer analysis, for which a standard statistical package was used. 2~ The chi-square test was used to assess the statistical significance of differences in contingency tables. Comparisons between means employed Student's t distribution. The Mann-Whitney U test was used to compare distributions where the assumptions of the t-test were not satisfied. Logistic regression was u s e d to assess the independent effect of predictor variables on delay, which was dichotomized at 0 to 14 days v s . 15 days or longer. The statistical significance level was set at 0.05. Confidence intervals for percentages are given at the 95 percent confidence level. Results
Over the period from May 1987 to January 1988, 58 general practitioners invited 136 patients to participate in the study and 106 agreed. O f the 33 who did not participate, 10 declined without reason; 9 were not asked because of their age, mental state, or medical condition; 6 said they did not have time; 5 said they were too anxious; 1 had insufficient command of English to be interviewed; and for 2 the general practitioner did not give a reason. There were no statistically significant differences between the participants and the nonparticipants in respect to age, sex, birthplace, whether the episode of rectal bleeding was the first occurrence ever for the patient,
BLEEDING
853
and whether the general practitioner believed the patient should have presented sooner. Thirteen otherwise eligible patients were excluded because rectal bleeding was not the main presenting symptom; it had been discovered by the general practitioner during a consultation for another problem. Fifty of the 93 remaining patients were male and 43 were female. Their ages ranged from 35 to 85 years with a mean and median of 55 years. The period between the onset of symptoms and the general practitioner consultation ranged from 0 to 249 days with a median of 7 days and had a J-shaped distribution. Twenty-seven patients (29 percent) had delayed for more than 14 days. The general practitioner considered that 28 patients (32 percent) should have presented earlier. The median delay for these patients was 31 days compared with 3 days for the remaining 60 (P < 0.0001) (the general practitioner did not give an opinion on 5 patients). O f the 63 patients who had presented within 14 days, the general practitioner believed that 11 (18 percent) should have presented earlier; of the 25 patients who delayed for 15 days or longer, the general practitioner believed that 68 percent should have presented earlier (P < 0.0001). A delay of more than 14 days in presenting rectal bleeding was not associated with age or sex. Forty-six patients (50 percent) said that this was not their first occurrence of rectal bleeding and 35 of these said that previous bleeding had happened only "once or twice" or "occasionally." Those who had not had previous occurrences were more likely to have delayed than those who had (Table 1).Thirty-seven patients (40 percent) said that they always looked at their feces in the toilet bowl and 43 (46 percent) said that they always looked at the toilet paper. In contrast, 34 patients (37 percent) said that they looked at their feces less than half the time and 35 (38 percent) said that they looked at the toilet paper less than half the time. The 63 patients who said that they always looked at either the toilet paper or at their feces were less likely to have delayed than other patients (Table 1). T h e r e was no association between delay and whether the blood was first seen on the toilet paper or in the toilet bowl or both and no association with whether the blood was separate from or mixed with feces. At the onset of bleeding, 16 patients had engaged in some form of self-treatment, and these patients tended to delay longer than others, but this difference was not statistically significant (Table 1). Sixteen patients had consulted a person other than a medical practitioner about their bleeding, and these patients tended to delay longer than others, but again the difference was not statistically significant (Table 1). No patient had consulted a pharmacist or a practitioner
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TABLE1. Association Between Delay and Other Variables
Had rectal bleeding previously Look at toilet paper or feces every time Self-treated at onset bleeding Consulted someone other than a doctor Took some other action before seeing doctor Tertiary education Embarrassed by rectal bleeding* Thought bleeding might be caused by hemorrhoids Thought bleeding might be caused by cancer
No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes
n
Percent delaying (15 + days)
95 Percent Confidence Interval
47 46 63 30 82 11 77 16 63 30 53 40 69 20 41 52 62 31
38.3 19.6 36.5 13.3 26.8 45.5 27.3 37.5 22.2 43.3 37.3 17.5 30.4 25.0 19.5 36.5 32.3 22.6
24.4-52.2 8.1-31.0 24.6-48.4 1.2-25.5 17.2-36.4 16.0-74.9 17.3-37.2 13.8-61.2 12.0-32.5 25.6-65.1 24.7-50.8 5.7-29.3 19.6~41.3 6.0-44.0 7.4-31.6 23.5-49.6 20.6--43.9 7.9-37.3
P 0.047 0.021 0.2 0.6 0.036 0.033 0.6 0.07 0133
*Four patients did not answer. o f alternative medicine. Patients whose only action after the onset o f bleeding was to consult their general practitioner delayed less than those who took some o t h e r action as well (Table 1). Ethnic origin was not associated with delayed presentation; patients b o r n in a n o n - A n g l o p h o n e country o r whose parents were b o r n in a n o n - A n g l o p h o n e c o u n t r y were no m o r e or less likely to delay than o t h e r patients. For patients b o r n in n o n - A n g l o p h o n e countries t h e r e was no association between delay and their perceived c o m p e t e n c e in written or spoken English. T h e r e was no association between delay and years o f schooling c o m p l e t e d , occupational rank, or income. Patients with little o r n o tertiary e d u c a t i o n were m o r e likely to have delayed than those who had c o m p l e t e d a trade course or equivalent or a recognized diploma or d e g r e e (Table 1). Delay was u n r e l a t e d to the d e g r e e o f social s u p p o r t patients perceived themselves as having and unrelated to marital status. T h e r e was no association between any o f the psychologic measures and delay. T w e n t y patients said they were embarrassed by the bleeding, but they were no m o r e likely to have delayed than the others. T w e n t y - s e v e n patients (29 percent) recalled having seen a television p r o g r a m or news item about rectal bleeding and 29 (31 percent) recalled having read something about this condition, but in neither case was t h e r e any association with p r o m p t vs. delayed presentation. T h e p r o p o r t i o n o f patients delaying for m o r e than two weeks decreased as their worry about the bleed-
ing increased (Table 2). Patients who believed thai the bleeding was caused by h e m o r r h o i d s delayed m o r e than others, although this d i f f e r e n c e did not reach the r e q u i r e d level o f statistical significance (Table 1). Delay was u n r e l a t e d to w h e t h e r the patient believed the bleeding might be d u e to cancer (Table 1). A logistic regression m o d e l with delay o f u p to 14 days vs. delay o f 15 days or m o r e as the d e p e n d e n t variable and the five variables that had statistically significant z e r o - o r d e r associations with delay as indep e n d e n t variables showed that only t h r e e o f these had statistically significant i n d e p e n d e n t effects o n delay (Table 3). T h e s e were w o r r y a b o u t the bleeding; regular vs. i r r e g u l a r inspection o f the feces or toilet paper; and w h e t h e r the patient had taken some o t h e r action b e f o r e seeing their general practitioner. In an o p e n - e n d e d question, patients who had presented within 14 days were asked why they had presented p r o m p t l y and those who took l o n g e r than 14 days were asked what had c o n t r i b u t e d to their delay. Up to t h r e e reasons were given by patients in answer to each o f these questions. C o n c e r n that the cause o f bleeding might be cancer or some serious condition TABLE2. Delay by Worry about Bleeding Not Worried
A Little Very Extremely Worried Worried Worried
n 33 41 16 Percent delaying more than 14 days 46.7 25.0 23.5 95 Percent confidence interval 28.5-64.5 10.9-39.1 3.4--43.7
10 0.0 --
Chi-square = 9.15, degrees of freedom = 3, P = 0.027.
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TABLE3. Logistic Regression with Delay as the Dependent Variable Coefficient Worry about the bleeding Took some other action before seeing doctor Always looks at feces or toilet paper Had rectal bleeding previously Tertiary eduction Intercept
Standard Error 0.19
2.78
0.75
0.31
2.38
0.73
0.35
2.07
0.51 0.03 2.36
0.30 0.31 0.58
1.73 0.10 4.09
were by far the most c o m m o n reasons for p r o m p t n e s s (Table 4). T h e presence o f o t h e r symptoms and the bleeding itself being alarming were also important. T h e main reasons given for delay were that the patient believed the bleeding was caused by h e m o r rhoids; that they believed it was o f aninor concern; and that it was not convenient to see a d o c t o r when the b l e e d i n g first o c c u r r e d (Table 5). Embarrassment, fear, and fatalism were m e n t i o n e d by very few patients. Discussion T h e p u r p o s e o f this study was to discover w h e t h e r patient delay in presenting new rectal bleeding was associated with any o f a r a n g e o f sociodemographic, psychologic, and symptom-related factors and to det e r m i n e w h e t h e r any such relationships could be used in directing public education about rectal bleeding to categories o f people most in need o f it. T h e desire to e n c o u r a g e p r o m p t presentation o f new rectal bleeding stems f r o m the f r e q u e n t occurrence o f this s y m p t o m in colorectal cancer. Previous studies o f delay in diagnosis o f colorectal cancer have retrospectively reviewed delay f r o m the first occurr e n c e o f symptoms t h r o u g h to the confirmation o f a diagnosis o f cancer and have identified three main phases: patient delay, d o c t o r delay, and diagnostic TABLE 4. Reason for Prompt Presentation Given by Patients who
Presented Within 14 Days
Reason Thought bleeding might be from a cancer Thought the cause might be serious Had other associated symptoms that were compelling Bleeding was alarming Relative or friend urged prompt presentation Bleeding coincided with planned visit to doctor Thought bleeding mith be from hemorrhoids *Patients gave u p to three reasons.
TABLE5. Reasons for Delay Given by Patients who Delayed 15 Days or Longer
Coefficient SE
0.53
Number of Patients* 33 16 10 9 4
855
Reason
Number of Patients*
Thought bleeding was caused by hemorrhoids Thought the bleeding was minor or insignificant Inconvenient to present sooner The bleeding occurred infrequently Embarrassment Thought the bleeding might cease Fatalistic--thought nothing could be done Afraid the cause was serious Waited till a regular appointment with doctor *Patients gave u p to t h r e e reasons.
delay. 21-25 A significant limitation o f these studies is that they have necessarily e x c l u d e d patients who exp e r i e n c e d a given s y m p t o m (for e x a m p l e , rectal bleeding) but were not ultimately diagnosed as having colorectal cancer. F u r t h e r m o r e , patients in previous studies were interviewed at a relatively late diagnostic stage when m e m o r y lapses, selective recall, and anxiety f r o m knowing that they h a d cancer may have influenced their accounts o f timing and events in the early symptomatic stage. It is reasonable to believe that public e d u c a t i o n should be based o n and directed toward the stage w h e n a p e r s o n is considering what to do about a s y m p t o m r a t h e r than at the point when they have b e e n given a definitive diagnosis. O u r study enlisted patients w h e n they first p r e s e n t e d with rectal bleeding to the participating general practitioner. Various studies have r e p o r t e d d i f f e r i n g periods o f delay between the onset o f symptoms o f colorectal cancer and presentation to a general practitioner, alt h o u g h we are not aware o f any study r e p o r t i n g delay specifically for rectal bleeding. Comparisons are complicated by inconsistency in the statistical m e t h o d s used to r e p o r t delay. For colon cancer, a m e d i a n total delay o f 11 weeks has b e e n r e p o r t e d f r o m an American study 2x and 22 weeks f r o m a British series. 22 For rectal cancer the respective total delays were 13.5 weeks and 31.5 weeks. T h e latter study gave average patient delays o f 12.7 weeks for colon cancer and 16.2 weeks for rectal cancer. 22 M a c A r t h u r and Smith rep o r t e d a m e d i a n patient delay o f 31.5 days 25 for colorectal cancer. T h e m e d i a n o f only 7 days f o u n d in the c u r r e n t study may have b e e n d u e to o u r focus on the single, compelling s y m p t o m o f rectal bleeding or may reflect g r e a t e r public awareness o f the significance o f this symptom, easier access to medical services, o r a quicker patient response in Australia comp a r e d with o t h e r countries. A n o t h e r possibility was
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DENT, ET AL.
that delay had diminished over the period of 10 years or longer between previous reports and our study. The effects of several classes of variables on delay in presentation of cancer symptoms have been reviewed by Antonovsky and Hartman. 26 These variables were: 1) sociodemographic factors including age, sex, ethnicity, education, marital status, occupation, and income; 2) knowledge about cancer, previous experience of cancer in oneself and others, and affective reactions to cancer such as embarrassment, fear, fatalism, and denial; 3) personality traits and more general psychologic factors going beyond affective reaction to cancer and including intellectual capacity, hypochondriasis, body image, emotional stability, and coping styles; 4) sociocultural factors such as learned dispositions toward health care and preventive behavior, and attitudes of significant others and the pressures they exert; 5) relationships between the patient and health care providers including the availability of doctors, diagnostic services, and health i n s u r a n c e schemes. A n t o n o v s k y a n d H a r t m a n showed that, almost without exception, different studies had reported differing conclusions on the effects of these variables on delay. Furthermore, most studies reported zero-order relationships only without attempting to control for correlations between predictor variables. We found very few associations between delay and the numerous variables from within these categories that we examined. The list was further reduced when correlations between the predictor variables were controlled by logistic regression. Patients who delayed were not worried about the bleeding; they did not look regularly at the toilet paper or their feces, and they had tended to take some other action such as self-treatment or consultation with a relative or friend before presenting to a general practitioner. The negative results of this study in regard to psychosocial factors are significant. Disabling fear, fatalism, denial, embarrassment, and lack of social support did not appear to have engendered delay except in isolated cases. Instead, worry about their rectal bleeding was the force driving early presentation in a substantial majority of patients. Those who delayed did so largely because they believed the bleeding was due to hemorrhoids or to an insignificant cause, because it was infrequent, or for reasons of inconvenience. The important message here is' that complex nonrational factors may be ignored in preparing and delivering public education about rectal bleeding, and that education should concentrate on simple factual information. Notwithstanding the short average delay found in this study, participating general practitioners consid-
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ered that one in three patients should have presented sooner. Therefore, we conclude that there is scope for public education on prompt presentation of rectal bleeding, although we have not been able to identify particular groups who are at risk of delaying and who are more in need of information about rectal bleeding than others. Public education should encourage all adults to look at their feces regularly, to avoid self-diagnosis and self-treatment, to present new episodes of rectal bleeding promptly to their general practitioner, and should stress the importance of this symptom in people aged 40 and older.
Acknowledgments A list of general practitioner's for sampling purposes was provided by the Royal Australian College of General Practitioners. We are most grateful to the general practitioners who enlisted patients for the study.
References 1. Silman AJ, Mitchell P, Nicholls RJ, et al. Self-reported dark red bleeding as a marker comparable with occult blood testing in screening for large bowel neoplasms. Br J Surg 1983;70: 721--4. 2. Goulston KJ, Cook I, Dent OF. How important is rectal bleeding in the diagnosis of howe1 cancer and polyps? Lancet 1986;2:261-3. 3. Hardcastle JD, Farrands PA, Balfour TW, et al. Controlled trial of faecal occult blood testing in the detection of colorectal cancer. Lancet 1983;2:2-4. 4. McDermott FT, Hughes ES, Phil E, et al. Symptom duration and survival prospects in carcinoma of the rectum. Surg Gynecol Obstet 1981;153:321-6. 5. Dent OF, Chapuis PH, Goulston KJ. Relationship of survival to stage of the tumour and duration of symptoms in colorectal cancer. Med J Aust 1983; 1:274-5. 6. Mant A, Bokey EL, Chapuis PH, et al. Rectal bleeding: do other symptoms aid in diagnosis? Dis Colon Rectum 1989 (in press). 7. Jones IS. An analysis of bowel habit and its significance in the diagnosis of carcinoma of the colon. Am J Proctol 1976; 27:45-56. 8. Farrands PA, Hardcastle JD. Colorectal screening by a selfcompleted questionnaire. Gut 1984;25:445-7. 9. Dent OF, Goulston KJ, Zubrzycki J, Chapuis PH. Bowel symptoms in an apparently well population. Dis Colon Rectum 1986;29:243-7. 10. Chapuis PH, Goulston KJ, Dent OF. Predictive value of rectal bleeding in screening for rectal and sigmoid polyps. Br Med J 1985;290:1546-8. 11. Broom L, Duncan-Jones P, Jones FL, McDonnell P. Investigating social mobility. Canberra: The Australian National University, Research School of Social Sciences, 1977; Department of Sociology, Departmental Monograph No. 1. 12. Funch DP, Marshall JR, Gebhardt general practitioner. Assessment of a short scale to measure social support. Soc Sci Med 1986;23:337-44. 13. Pilowsky I. Dimensions of hypochondriasis. Br J Psychiatry 1967; 113:89-93. 14. Spielberger CD. Manual for the state-trait anxiety inventory. Palo Alto: Consulting Psychologists' Press Inc., 1983. 15. Spielberger CD, Jacobs G, Russell S, Crane R. Assessment of anger: the state-trait anger scale. In: Butcher JN, Spielberger CD, eds. Advances in personality assessment. Vol 2. Hillsdale, NJ: Lea & Febiger, 1983. 16. Weissmau MM, Sholomskas D, Pottenger M, Prusoff BA,
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Locke BZ. Assessing depressive symptoms in five psychiatric populations: a validation study. Am J Epidemiol 1977;106: 203-14. Watson M, Greer S. Development of a questionnaire measure of emotional control. J Psychosom Res 1983;27:299-305. Grayson DA. A latent trait analysis of the Eysenck personality inventory. J Psychiatr Res 1986;20:217-35. Folkman S, Lazarus RS. If it changes it must be process: a study of emotions and coping during three stages of a college examination. J Pers Soc Psychol 1985;48:150-70. SPSS Inc. Statistical package for the social sciences. Chicago: SPSS Inc, 1988. Hackett TP, Cassem NH, Raker JW. Patient delay in cancer. N Engl J Med 1973;289:14-20.
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22. Holliday HW, HardcastleJD. Delay in diagnosis and treatment of symptomatic colorectal cancer. Lancet 1979; 1:309-11. 23. MacAdam DB. A study in general practice of the symptoms and delay patterns in the diagnosis of gastrointestinal cancer. J R Coll Gen Pract 1979;29:723-9. 24. Nilsson E, Bolin S, Sjodahl R. Carcinoma of the colon and rectum: delay in diagnosis. Acta Chir Scand 1982;148:61722. 25. MacArthur C, Smith A. Factors associated with speed of diagnosis, referral and treatment in colorectal cancer. J Epidemiol Community Health 1984;38:122-6. 26. Antonovsky A, Hartman H. Delay in the detection of cancer: a review of the literature. Health Education Monographs 1974;2:98-128.
