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

The Effective and Efficient
Management of Patients with
Rectal Bleeding to Identify the
Few with Cancer
Michael R. Thompson, Edwin T. Swarbrick, Brian G. Ellis,
Iona C. Heath, L. FauldsWood, and Wendy S.Atkin
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
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