The Effective and Efficient Management of Patients with Rectal Bleeding to Identify the Few with Cancer

Abstract

There are currently insufficient resources to fully investigate all patients with rectal bleeding to exclude the small possibility of cancer, and this is the dominant factor in developing strategies for the management of rectal bleeding. However, even if there were unlimited resources it may not be desirable to investigate all patients because the small risks associated with the investigative procedure might outweigh the benefits, particularly in groups at very low risk of having cancer. The importance of efficient as well as effective delivery of healthcare was the subject of the Rock Carling Lectures delivered by Archie Cochrane in 1972 [1], and continues to be an essential aspect of clinical medicine. In the context of the management of rectal bleeding, effectiveness is achieved if all patients with colorectal cancer are promptly diagnosed, and efficiency is achieved by limiting the number of patients without cancer investigated. In view of the high prevalence of rectal bleeding in the community and the potential demand for its investigation, the efficient management of all patients presenting with rectal bleeding will profoundly affect the prompt diagnosis of those with cancer. The management of rectal bleeding as a symptom of bowel cancer begins with advice to the general public through disease awareness campaigns, proceeds through referral guidelines to general practitioners (GPs), and finishes with the efficient use of resources for its investigation. The varying prevalence and predictive value of rectal bleeding for cancer in different cohorts of patients is important to all stages of its management. Rectal bleeding is also important in the diagnosis of adenomatous polyps [2–7] and colitis [7] as well as colorectal cancer [2,4–11]. Overall, 40% of all colorectal cancers and 70%–80% of rectal and sigmoid cancers present with overt rectal bleeding [9–11]. It may be a sign of an early-stage curable cancer [12–15] and of large adenomatous polyps, which, with subsequent colonoscopic surveillance, may be a valuable way of reducing the prevalence and overall mortality from colorectal cancer [16]. It is perhaps not