BMJ 2016;353:i3590 doi: 10.1136/bmj.
i3590 (Published 14 July 2016)
Practice
Colorectal adenocarcinoma: risks, prevention and
diagnosis
1 2
Sri G Thrumurthy honorary research fellow , Sasha S D Thrumurthy medical officer , Catherine E
3 4
Gilbert foundation year doctor , Paul Ross consultant medical oncologist , Amyn Haji consultant
5
colorectal surgeon
1
Department of Surgery, University College Hospital, London, UK; 2Department of General Medicine, Tan Tock Seng Hospital, Singapore; 3Department
of Surgery, Queen Elizabeth Hospital, London, UK; 4Department of Medical Oncology, Guy's & St Thomas' Hospital, London, UK; 5Department of
Surgery, King's College Hospital, London, UK
Colorectal cancer is the fourth most common cause of cancer
related mortality globally, with 1.4 million new cases and 700
000 deaths annually.1
What is colorectal cancer?
Colorectal cancer refers to tumours of the rectum or large bowel
(including the appendix) that arise from the colorectal mucosa
(fig 1⇓). Adenocarcinoma is the most common form of
colorectal cancer (>95%). Rarer subtypes include carcinoid
tumour, sarcoma, and lymphoma; these present differently from
adenocarcinoma1 and will not be discussed in this review.
How does colorectal adenocarcinoma
develop?
Colorectal cancer typically develops from adenomatous polyps
that undergo dysplastic changes to become cancerous (fig 2⇓).2
Tumours can occur sporadically, but there are some inherited
colorectal cancer syndromes (see table 1⇓). Several risk factors
are also recognised (see box 1).
Who gets colorectal cancer?
The incidence of colorectal cancer strongly increases after 50
years of age (fig 3⇓), and median age at diagnosis is about 70
years in developed regions.23 In 2012, age standardised incidence
rates were highest across Oceania (41.0 and 29.2 per 100 000
in men and women respectively), North America, and Europe,
and lowest across western Africa (4.5 and 3.8 per 100 000) and
south-central Asia (fig 4⇓).8 Previously low risk regions (such
as Spain and several countries in Eastern Europe and East Asia)
have seen rapid rises in incidence of colorectal cancer. This has
been attributed to the adoption of high fat diets heavy in red
and processed meats, physical inactivity, excessive alcohol
consumption, and smoking. The US and other high income
countries have seen a plateau or drop in disease incidence,
Corresponding author: A Haji amynhaji@nhs.net
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Page 1 of 12
PRACTICE
possibly due to an increased use of diagnostic endoscopy and
polypectomy.24 25
What are the risk factors for colorectal
cancer?
Most colorectal cancer cannot be attributed to any single risk
factor, although increasing age and male sex have consistently
shown strong associations with disease incidence in
epidemiological studies.23 The evidence for the other major risk
factors for colorectal cancer is summarised in box 1.
The key genetic syndromes associated with colorectal cancer
are summarised in table 1⇓; and the current UK
recommendations for screening and surveillance of
asymptomatic patients in moderate-risk family groups are
summarised in table 2⇓.26
How do patients present, and who should
be referred?
The commonest presenting features of colorectal cancer are
abdominal pain, change in bowel habit, rectal bleeding, and
microcytic anaemia, although these commonly feature in other
gastrointestinal diseases. Left sided colorectal tumours typically
present with altered bowel habit (such as loose stools, increased
frequency, and intestinal obstruction secondary to progressive
luminal narrowing), rectal bleeding or mucus, or tenesmus.
Right sided lesions may present more insidiously with weight
loss, abdominal pain or mass, or iron deficiency anaemia.27
Urgently investigate and refer men and non-menstruating women
with iron deficiency anaemia, as 10% of such patients will have
colorectal cancer.28 29
A UK population based case-control study of 2093 patients
aimed to quantify the pre-diagnostic features of colorectal cancer
(see table 3⇓ for details).30 The 2015 NICE guidelines for the
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BMJ 2016;353:i3590 doi: 10.1136/bmj.i3590 (Published 14 July 2016) Page 2 of 12

PRACTICE

What you need to know

• Colorectal cancer is the third most common cancer in men and the second most common cancer in women worldwide
• It is rare below 40 years of age
• Increasing age, male gender, and a family history of colorectal cancer are the greatest risk factors for the disease
• Patients presenting with suspicious symptoms and signs should be referred and investigated urgently in a specialised unit

Box 1: Risk factors for colorectal cancer

Sociodemographic factors
Older age
• In the UK from 2009 to 2011, 43% of colorectal cancer was diagnosed in people aged ≥75 years, and 95% in those aged ≥50 years7
• Age-specific incidence rates increase steeply after age 50, with the highest rates above age 85 years
Male sex
• A meta-analysis of 17 studies comprising 924 932 patients showed men were at significantly greater risk than women (relative risk 1.83 (95% CI 1.69
to 1.97)) at developing advanced colorectal cancer across all age groups8

Lifestyle factors
• Red meat and processed meat consumption
– A meta-analysis of 24 prospective studies found the relative risk of colorectal cancer for the highest versus the lowest intake of red or processed
meat in the pooled cohort was 1.22 (95% CI 1.11 to 1.34)9
– Relative risk for every 100 g/day increase in intake was 1.14 (1.04 to 1.24)
– Cancer risk increased linearly with increasing meat intake up to 140 g/day
• Obesity
– 13% of bowel cancers in the UK have been linked to obesity10
– A meta-analysis of 43 studies including nearly 9 000 000 individuals worldwide found a relative risk of 1.33 (1.25 to 1.42) in obese individuals (body
mass index >30) compared with those with normal BMI11
– Association with BMI is stronger in men than women,12 and in women it may vary with menopausal status and use of hormone replacement therapy13
• Alcohol
– 11% of bowel cancers in the UK have been linked to excessive alcohol consumption10
– A meta-analysis of 61 cohort and case-control studies found that, compared with infrequent or non-drinkers, those who consumed 1.6-6.2 British
alcohol units daily had a 21% higher risk (95% CI 1.13 to 1.28) of bowel cancer, and those who drank over 6.2 units daily had a 52% higher risk
(95% CI 1.27 to 1.81)14
– Overall, bowel cancer risk increased by 7% per unit of alcohol consumed daily
• Tobacco smoking
– 8% of bowel cancers in the UK have been linked to tobacco smoking10
– A meta-analysis of 28 prospective studies and 1 463 796 subjects suggests current cigarette smokers have a 20% higher risk of disease (95% CI
1.10 to 1.30) than people who have never smoked15
– A meta-analysis of 106 observational studies suggests that former smokers have a 18% higher risk of bowel cancer (95% CI 1.11 to 1.25) than never
smokers; and that bowel cancer risk rises by 7-11% per 10 cigarettes smoked daily16

Medical factors
Family history
• 20% of bowel cancers are associated with hereditary factors other than familial adenomatous polyposis (FAP) and hereditary non-polyposis colorectal
cancer (HNPCC)6
• A meta-analysis of 59 studies suggested that bowel cancer risk was 80% higher in people with an affected first degree relative.17 A population lifetime
risk of 1.8% for a 50 year old increased to 3.4% (95% CI 2.8 to 4.0%) with at least one affected relative or 6.9% (4.5 to 10.4%) with two or more relatives
• A meta-analysis of 27 studies suggested a relative risk of 3.87 (2.40 to 6.22) for patients with an affected relative who was diagnosed before the age
of 45 years18
Colorectal adenomas or polyps
• A pooled analysis of 8 prospective studies comprising 9167 patients revealed that 1% of patients with colorectal adenomas >20 mm diameter or with
high grade dysplasia develop cancer within 4 years of adenoma removal19
• A meta-analysis of 7 studies comprising 11 387 patients revealed that patients with low risk polyps detected at first colonoscopy had a 80% higher risk
of advanced cancer than those with no polyps detected20
Inflammatory bowel disease (IBD)
• A meta-analysis of population based cohort studies found that patients with IBD (ulcerative colitis or Crohn's colitis) have a 70% higher risk (95% CI
1.2 to 2.2) of developing colorectal cancer than the general population21
• This risk increases with the duration and extent of disease: those with IBD for >20 years have a 5% risk of developing bowel cancer21
Diabetes
• A meta-analysis of 15 studies including 2 593 935 patients found that diabetes was associated with a 30% higher risk of colorectal cancer (relative
risk 1.30 (1.20 to 1.40))22
• Diabetic patients also suffered greater mortality from bowel cancer (relative risk 1.26 (1.05 to 1.50)), but there was evidence for heterogeneity between
studies (P=0.04)

urgent referral of suspected colorectal cancer are summarised

in table 4⇓.31

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BMJ 2016;353:i3590 doi: 10.1136/bmj.i3590 (Published 14 July 2016)
How to investigate suspected colorectal
cancer
Advise patients that more than one investigation may be
necessary to confirm or exclude a diagnosis of colorectal
cancer.32
Colonoscopy is the recommended first line imaging for
suspected colon cancer in patients without major comorbidity.32
Bowel preparation with oral laxatives improves the diagnostic
yield of pan-colonic imaging. Biopsies are taken from any
suspicious lesions unless contraindicated (for example, in
coagulopathy) to confirm the diagnosis and degree of tumour
differentiation (well, moderately, or poorly differentiated) to
guide treatment. Patients who have undergone incomplete
colonoscopy (due to intra-procedural discomfort or poor bowel
preparation) may be offered repeat colonoscopy, computed
tomographic (CT) colonography, or barium enema. Patients
with major comorbidity and frail or elderly patients with poor
mobility and poor tolerance to bowel preparation may be offered
alternative imaging such as CT colonography or flexible
sigmoidoscopy in the first instance, followed by biopsy of
suspicious lesions.32
Colonoscopy
Colonoscopy is operator dependent and requires full bowel
preparation. Completion rates (that is, passage of colonoscope
to caecum) vary widely because of technical challenges, and
experienced endoscopists typically achieve completion rates of
98%. A 90% rate is considered acceptable.33 Histological
confirmation of malignancy requires multiple biopsies. Overtly
malignant lesions may be injected with dye contrast to mark
the area and facilitate subsequent surgical resection. Procedural
risks are mainly related to sedation and bowel perforation (table
5⇓).34 35 Prospective comparative studies have suggested that
patients are as comfortable with conventional colonoscopy as
CT colonography. Both of these investigations are preferred
over barium enema.36 37 Poor bowel preparation and incomplete
colonoscopy are the two main variables contributing to false
negative tumour detection.33
Box 2 lists advice for people referred for colonoscopy. If there
is a clear contraindication or more than one relative
contraindication to bowel preparation, offer admission on the
day before colonoscopy for inpatient preparation.
CT colonography
CT colonography (“virtual colonoscopy”) may be indicated
after failed colonoscopy, in light of patient preference, or when
a patient is deemed unsuitable for colonoscopy. Unlike
conventional colonoscopy, CT colonography allows intraluminal
visualisation of the colourectum without the need for sedation,
while it offers a similar sensitivity for cancer detection but a
lower specificity for polyp and tumour detection (table 5⇓).38
CT colonography may detect extraluminal pathology in patients
referred for weight loss or abdominal pain. Intravenous contrast
and oral faecal tagging agents (such as Gastrografin, which also
has a laxative effect) are used to differentiate stools and mass
lesions (polyps and cancers). CT colonography is not suitable
for pregnant patients. It is contraindicated in patients with iodine
allergies and may not be possible for those with impaired
swallowing or high aspiration risk. Tissue biopsy and polyp
removal are not possible with CT colonography, so any lesions
detected will require endoscopic evaluation to confirm a
histological diagnosis.
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Page 3 of 12
PRACTICE
As with colonoscopy, patients must be given comprehensive
information about stopping certain medications and adopting a
low residue diet in the days before the test. Special instructions
are provided for diabetic patients. Depending on hospital policy,
patients will be requested to take oral Gastrografin (with or
without an accompanying bowel cleansing agent) at set times
for one or two days before the procedure. The procedure lasts
about 30 minutes, during which a muscle relaxant (such as
buscopan) may be administered with intravenous contrast, while
the colon is gently insufflated with carbon dioxide gas via the
rectum, and scans obtained in various patient positions.
Double contrast barium enema
Double contrast barium enema is well tolerated and safe with
excellent completion rates, but its relative impracticality and
lower diagnostic yields compared with the above investigations
have resulted in its declining use across most UK centres.
Other tests
Testing for faecal occult blood (FOB) and serum tumour markers
(such as carcinoembryonic antigen) are not useful in the
investigation of suspected colorectal cancer. While FOB testing
is effective for population screening in asymptomatic cohorts,
it is too insensitive to guide the investigation of patients with
colorectal symptoms. Similarly, tumour markers lack sensitivity
and specificity but are useful in the follow-up of treated patients.
A negative FOB test or normal serum tumour markers should
not delay the referral of symptomatic patients.
What can be done to prevent colorectal
cancer?
Primary prevention
Diet
A meta-analysis of 25 prospective studies revealed a 10% risk
reduction in developing colorectal cancer for an extra 10 g of
total dietary fibre ingested daily. In particular, cereal fibre and
whole grains were associated with a reduction in colorectal
cancer risk.39
A meta-analysis of 19 cohort studies suggested that, for every
400 g of dairy products consumed daily, the risk of developing
colorectal cancer was significantly reduced (relative risk 0.83
(95% CI 0.78 to 0.88). Similarly, the daily consumption of 200
g of milk or 50 g of cheese was associated with a lower risk of
developing colorectal cancer.40
Another meta-analysis of 15 studies including 12 305 patients
revealed that every 300 mg of daily calcium intake (up to 1900
mg/day) reduced the risk of developing colorectal cancer.41
Physical activity
It is estimated that 5% of colon cancers (but not rectal cancers)
in the UK are linked to inadequate physical activity.42 43
Meta-analyses of cohort studies have revealed a 17-24% risk
reduction in colon cancer from the most to the least physically
active people.43-45
Pharmacological
Two large trials in the 1980s, designed to evaluate the prevention
of vascular events by aspirin, revealed a 37% risk reduction of
colorectal cancer in patients with a daily intake of 300 mg
aspirin for at least five years.46 Various observational studies
support the use of long term aspirin in the chemoprevention of
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BMJ 2016;353:i3590 doi: 10.1136/bmj.i3590 (Published 14 July 2016) Page 4 of 12

PRACTICE

Box 2: General advice for patients referred for colonoscopy

• All patients referred for colonoscopy should be sent comprehensive written instructions by their endoscopy unit, including the following:
– Deadline for stopping iron preparations, anti-diarrhoeal and codeine-containing preparations, and fibre-containing laxatives beforehand
– Consuming a specific low fibre diet and increasing fluid intake in the week before endoscopy
– Avoiding all solid food 24 hours before endoscopy, and taking an oral bowel cleansing preparation (such as macrogols or sodium
picosulfate with magnesium citrate) at fixed times during this period
• The main risks of bowel preparations are dehydration and electrolyte imbalance
• Absolute contraindications to the use of bowel cleansing preparations include allergies to these agents, bowel obstruction, perforation
or ileus, gastric emptying disorders, toxic megacolon, and certain drug-specific contraindications (such as macrogols for patients with
phenylketonuria or glucose-6-phosphate dehydrogenase deficiency)
• Relative contraindications include chronic renal failure, heart failure, dehydration, impaired swallow or increased risk of aspiration,
acute inflammatory bowel disease, patients who are frail or not self caring, and the use of any medication that may affect fluid or
electrolyte balance or are dangerous with hypokalaemia (such as diuretics, steroids, antidepressants, digoxin, carbamazepine, lithium)
• It is vital to consider drugs such as antiepileptics, where decreased absorption may cause clinical deterioration

colorectal cancer,47 and data from a large randomised controlled
trial revealed that taking 600 mg aspirin daily for two years led
to a risk reduction (hazard ratio 0.41) in colorectal cancer
incidence among patients with HNPCC.48 Non-steroidal
anti-inflammatory drugs (NSAIDs) have also been shown to
reduce colorectal cancer risk in various cohort studies and
case-control studies,49 and randomised controlled trials have
shown that COX-2 inhibitors reduce adenoma incidence (relative
risk 0.72 (0.68 to 0.77)), potentially reducing subsequent cancer
risk.49 A large, randomised, double-blind trial revealed that daily
supplementation with 1200 mg calcium reduced colorectal
adenoma recurrence (adjusted risk ratio 0.85 (0.74 to 0.98),
P=0.03).50
Despite insufficient evidence to recommend routine use of most
of the above agents for prevention of colorectal cancer, the US
Preventive Services Task Force recently recommended use of
low dose aspirin for the primary prevention of cardiovascular
disease and colorectal cancer in adults aged 50-59 years who
have a ≥10% 10-year risk of cardiovascular disease, are not at
increased risk for bleeding, have a life expectancy of ≥10 years,
and are willing to take low dose aspirin daily for ≥10 years.51
No similar recommendations exist in current British or European
guidelines.
family history of colorectal cancer (a single first degree relative
with colorectal cancer or advanced adenoma diagnosed at <60
years old, or two first degree relatives with colorectal cancer or
advanced adenomas)26 56; inflammatory bowel disease (ulcerative
or Crohn's colitis)56; and acromegaly.58 59
Contributors: SGT, SSDT, and CEG conceived the review, extracted
evidence, and drafted the manuscript. All authors helped write the article
(including article direction, interpreting the literature, and editing the
manuscript). AH is guarantor and has approved the final article.
Competing interests: We have read and understood the BMJ Group
policy on declaration of interests and have no relevant interests to
declare.
Provenance and peer review: Not commissioned; externally peer
reviewed.
1 Ferlay J, Soerjomataram I, Ervik M, et al. GLOBOCAN 2012 v1.0, Cancer Incidence and
2
Mortality Worldwide: IARC CancerBase No 11. 2013. http://globocan.iarc.fr.
Arnold CN, Goel A, Blum HE, Boland CR. Molecular pathogenesis of colorectal cancer:
implications for molecular diagnosis. Cancer 2005;104:2035-47. doi:10.1002/cncr.
21462 pmid:16206296.
3 Gala M, Chung DC. Hereditary colon cancer syndromes. Semin Oncol 2011;38:490-9.
doi:10.1053/j.seminoncol.2011.05.003 pmid:21810508.
4 Dunlop MG, Farrington SM, Carothers AD, et al. Cancer risk associated with germline
DNA mismatch repair gene mutations. Hum Mol Genet 1997;6:105-10. doi:10.1093/hmg/
6.1.105 pmid:9002677.
5 Galiatsatos P, Foulkes WD. Familial adenomatous polyposis. Am J Gastroenterol

Secondary prevention (screening) 6

Faecal occult blood (FOB) testing is based on the tendency of
cancer and polyps to bleed.52 A meta-analysis of randomised
2006;101:385-98. doi:10.1111/j.1572-0241.2006.00375.x pmid:16454848.
Fearnhead NS, Wilding JL, Bodmer WF. Genetics of colorectal cancer: hereditary aspects
and overview of colorectal tumorigenesis. Br Med Bull 2002;64:27-43. doi:10.1093/bmb/
64.1.27 pmid:12421723.
7 Office for National Statistics. www.ons.gov.uk/ons/search/index.html?

controlled trials suggested that FOB screening reduced colorectal 8

cancer mortality by 25% (relative risk 0.75 (0.66 to 0.84)) and
estimated that FOB screening prevented approximately 1 in 6
deaths from colorectal cancer.53 The NHS bowel cancer
screening programme currently offers FOB testing to patients
aged 60-74 years, of whom those with a positive FOB test are
offered colonoscopy.54
In a large randomised controlled trial across 14 UK centres, a
single flexible sigmoidoscopy between the ages of 55 and 64
years reduced colorectal cancer incidence by 23% (hazard ratio
0.77 (0.70 to 0.84)) and mortality by 31% (hazard ratio 0.69
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integrated into the NHS Bowel Cancer Screening Programme
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14 Fedirko V, Tramacere I, Bagnardi V, et al. Alcohol drinking and colorectal cancer risk: an

by 2018. overall and dose-response meta-analysis of published studies. Ann Oncol

US guidelines recommend various other screening strategies
for average risk patients from 50 years of age, including
five-yearly flexible sigmoidoscopy (with or without FOB
testing), double contrast barium enema, or 10-yearly
colonoscopy,56 all of which reduce mortality compared with no
screening. Specific colonoscopy based screening protocols exist
for patients at increased risk due to syndromes such as FAP,
HNPCC, and MYH-associated polyposis (MAP)56 57; a strong
2011;22:1958-72. doi:10.1093/annonc/mdq653 pmid:21307158.
15 Tsoi KK, Pau CY, Wu WK, Chan FK, Griffiths S, Sung JJ. Cigarette smoking and the risk
of colorectal cancer: a meta-analysis of prospective cohort studies. Clin Gastroenterol
Hepatol 2009;7:682-688.e1, 5. doi:10.1016/j.cgh.2009.02.016 pmid:19245853.
16 Botteri E, Iodice S, Bagnardi V, Raimondi S, Lowenfels AB, Maisonneuve P. Smoking
and colorectal cancer: a meta-analysis. JAMA 2008;300:2765-78. doi:10.1001/jama.2008.
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17 Butterworth AS, Higgins JP, Pharoah P. Relative and absolute risk of colorectal cancer
for individuals with a family history: a meta-analysis. Eur J Cancer 2006;42:216-27. doi:
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18 Johns LE, Houlston RS. A systematic review and meta-analysis of familial colorectal
cancer risk. Am J Gastroenterol 2001;96:2992-3003. doi:10.1111/j.1572-0241.2001.04677.
x pmid:11693338.

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BMJ 2016;353:i3590 doi: 10.1136/bmj.i3590 (Published 14 July 2016)
How patients were involved in the creation of this article
No patients were involved in the creation of this article.
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Tables

Table 1| Inherited syndromes predisposing to colorectal cancer

Syndrome Prevalence Genes Associated cancers Prognosis

Hereditary non-polyposis HNPCC accounts for 1-4% MSH2, MLH1, MSH6, Most common—colorectal cancer (often 90% of men and 70% of women
colorectal cancer (HNPCC) or of colon cancers3 PMS2 (autosomal right sided), endometrial cancer with HNPCC develop bowel
Lynch syndrome dominant) Less common—stomach, ovary, urogenital cancer by age 70 years
4

tract, gallbladder, brain cancers

Familial adenomatous
polyposis (FAP)
FAP accounts for <1% of
bowel cancers3
APC (autosomal Colorectal cancer Almost all FAP patients develop
dominant) >100 polyps (adenomas) that start to bowel cancer by age 405
develop in adolescence
May feature upper gastrointestinal tract
polyps

6
It is estimated that another 20% of bowel cancer is linked to hereditary factors not associated with FAP and HNPCC.

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Table 2| Summary of recommendations for colorectal cancer (CRC) screening and surveillance in moderate risk family groups (adapted
from Cairns et al26)

Screening recommended
Lifetime risk of colorectal
Family history of colorectal cancer cancer death without Age at initial screen
(CRC) surveillance Procedure (years) Screening interval
In 3 relatives in first degree kinship*, none ~1 in 6-10 Colonoscopy 50 Every 5 years to age 75 years
<50 years old
In 2 relatives in first degree kinship*, ~1 in 6-10 Colonoscopy 50 Every 5 years to age 75 years
mean age <60 years
In 2 first degree relatives ≥60 years old ~1 in 12 Colonoscopy 55 No follow-up if initial screen normal
In 1 first degree relative <50 years old ~1 in 12 Colonoscopy 55 No follow-up if initial screen normal
Other family history of CRC <1 in 12 None NA NA

*Relatives who are first degree relatives of each other and at least one is a first degree relative of the consultand. No affected relative <50 years old (otherwise
26
high risk criteria apply).

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Table 3| Pre-diagnostic features of colorectal cancer (adapted from Hamilton et al30)

Feature Positive predictive value (95% CI) (%) P value

Presenting symptoms
Rectal bleeding 2.4 (1.9 to 3.2) <0.001
Weight loss 1.2 (0.91 to 1.6) <0.001
Abdominal pain 1.1 (0.86 to 1.3) <0.001
Diarrhoea 0.94 (0.73 to 1.1) <0.001
Constipation 0.42 (0.34 to 0.52) <0.001
Examination and investigation findings
Abnormal rectal examination 4.0 (2.4 to 7.4) <0.001
Abdominal tenderness 1.1 (0.77 to 1.5) <0.001
Anaemia (serum haemoglobin <100 g/L) 2.3 (1.6 to 3.1) <0.001

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Table 4| Urgent referral criteria for suspected colorectal cancer for an appointment within two weeks (from National Institute for Health
and Care Excellence31)

Symptoms and signs Age threshold (years)

Unexplained weight loss and abdominal pain ≥40
Rectal bleeding ≥50
Iron deficiency anaemia, altered bowel habit*, or a positive faecal occult blood test† ≥60
Rectal bleeding plus any of: abdominal pain, altered bowel habit, weight loss, iron deficiency <50
anaemia
Palpable rectal or abdominal mass Any

*Change in bowel habit to looser stools or increased frequency of defecation, or both.

†Faecal occult blood testing should be offered to adults without rectal bleeding who are aged ≥50 with unexplained abdominal pain or weight loss; those aged
<60 with altered bowel habit or iron deficiency anaemia; and those aged ≥60 with anaemia (that is, even in the absence of iron deficiency).

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Table 5| Common methods of colonic imaging

Sensitivity for detection

Modality Sedation Perforation rate (diagnostic) Biopsy or polypectomy, or both Large polyps (>10 mm) Cancer
Endoscopic
Standard colonoscopy Usually 2:1000* Yes 98% 97%
Flexible sigmoidoscopy Rarely 1:10 000* Yes Examines left colon only
Radiological
Double contrast barium enema No 1:10 000 No 48% 83-94%
CT colonography No 5:10 000 No 59-85% 97%

*Highly operator dependent. Many endoscopists have lower rates than quoted in published series.

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Figures

Fig 1 Distribution of bowel cancer by anatomical site, UK (2007-09) (adapted from Cancer Research UK, bowel cancer
incidence statistics,
www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bowel-cancer/incidence)

Fig 2 Progression from colorectal polyp to cancer (adapted from Johns Hopkins Colon Cancer Center. Polyps 101.
www.hopkinscoloncancercenter.org/CMS/CMS_Page.aspx?CurrentUDV=59&CMS_Page_ID=744568E4-291E-4276-97C4-FA7A4EE02235)

Fig 3 Age specific incidence rates of colorectal cancer per 100 000 population, UK (2009-11) (adapted from Cancer Research
UK, bowel cancer incidence statistics,
www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bowel-cancer/incidence)

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Fig 4 Estimated worldwide age standardised (per 100 000) incidence of colorectal cancer in men in 2012 (adapted from
GLOBOCAN 20121)

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