Colorectal Cancer Diagnosis: Tumor Stage of Screened vs. Symptomatic Patients

Abstract

Objective This study aims to evaluate the utilization of colorectal cancer (CRC) screening in Monmouth County, NJ, and to compare tumor stages between patients diagnosed through screening and those presenting with symptoms. The role of nurse navigators in enhancing screening adherence and patient care was also examined.

Material and Methods A retrospective chart review was conducted on 118 patients diagnosed with CRC at Jersey Shore University Medical Center (JSUMC) between January 2020 and July 2021. Data collected included initial symptoms, hemoglobin levels, age at diagnosis, screening history, cancer stage, nurse navigator involvement, and 24-month survival.

Results Among patients diagnosed by symptoms (n = 83), 40% were diagnosed with Stage IV CRC versus 14% for screened patients. Of the screened patients (n = 15), 86% were alive 24 months post-diagnosis compared to 67% of symptomatic patients. Notably, 73% of all patients had never undergone CRC screening, indicating a significant gap in adherence to recommended guidelines. Only 25% of patients were assigned a nurse navigator, suggesting limited utilization of this support.

Conclusions The findings demonstrate that CRC screenings were underutilized, contributing to a higher incidence of advanced-stage diagnoses and lower survival rates among symptomatic patients. Enhancing public awareness about the importance of screening, along with expanding the role of nurse navigators, may significantly improve patient outcomes and reduce the burden of advanced colorectal cancer.

Keywords

screening - CRC - symptoms - navigators

Background and Significance

Colorectal cancer (CRC) ranks as the third most prevalent cancer diagnosis and stands as the second highest contributor to cancer-related mortality in the United States when considering both male and female populations.[1] Risk for developing colorectal cancer increases with age.

Adenocarcinoma of the colon or rectum can be detected via screening using stool DNA tests, stool for blood tests, sigmoidoscopy, or colonoscopy for early-stage diagnosis. The United States Preventive Services Task Force (USPSTF) provides a Grade A recommendation for colorectal cancer screening ranging from ages 50 to 75, a Grade B recommendation from ages 45-49, and a Grade C recommendation from ages 76-85. The USPSTF suggests a screening colonoscopy once every 10 years. Those with a strong family or personal history of the disease are advised to screen more frequently and for a longer period.[2]

Nurse navigators can help guide patients through available medical, insurance, and social support systems via recurring phone calls or meetings.[3] Nurse navigators play a crucial role in cancer patient care, acting as guides and advocates throughout the complex healthcare journey. Their responsibilities encompass a spectrum of supportive and coordination tasks aimed at enhancing patients' experiences and improving outcomes. These roles often include providing education and emotional support to patients and their families, facilitating communication between healthcare providers, coordinating appointments and treatments, and assisting with navigating the healthcare system. Nurse navigators serve as a central point of contact, offering personalized assistance tailored to the individual needs of each patient. Additionally, they help patients access resources such as financial assistance programs or support groups, further bolstering comprehensive care.[4]

Colorectal cancer screening has shown to be effective in preventing patients from presenting with late-stage CRC, thereby ensuring that those at increased risk of developing CRC are acting according to national health guidelines and receiving requisite care.[5] [6] This study reviews the percentage of patients at Jersey Shore University Medical Center who were diagnosed by screening as opposed to those diagnosed when patient symptoms were evaluated. Additionally, the role and frequency of nurse navigation assignments were analyzed.

Objectives

Our primary hypothesis was that colon cancer screenings used by the citizens of Monmouth County, New Jersey were not being utilized as recommended, which led to patients presenting with more advanced stages of colorectal cancers. Our secondary hypothesis was that nurse navigators can play a key role in promoting cancer screening, following up on results, and guiding patients through various support systems while under care. Our results were compared to national and county data.[7] [8]

Methods

Our study was a retrospective chart review. A list of 525 patients from the Jersey Shore University Medical Center (JSUMC) Tumor Registry diagnosed with CRC from 2016 through 2021 was obtained. Approximately 118 electronic medical charts were reviewed of patients with adenocarcinoma of the colon admitted from 1/7/2020 - 7/28/2021. Variables recorded included initial symptoms, hemoglobin level, age at diagnosis, screening history, family history of colorectal cancer, cancer stage, nurse navigator role, and current patient status.

Results

Identifying the most common occurring symptoms allows for better identification and quicker treatment of disease. We found that 44% of symptomatic patients presented with a change in bowel habits or reported bloody stools. Another 52% of patients complained of abdominal cramping and another 50% of patients were seen to be anemic upon hospital admission.

The age at diagnosis for patients that presented with symptomatic CRC and asymptomatic CRC detected via screening, was also collected. The average age for symptomatic patients was 69.5 and the average age for screened patients was 68.6. (See [Figs. 1] and [2])

Fig. 1 Symptomatic Patients: Age Distribution.

Fig. 2 Asymptomatic Patients: Age Distribution.

For patients presenting with symptoms, cancer staging was determined by reviewing clinical, laboratory, radiological, surgical, and pathology reports. Of the pool of symptomatic patients (n = 83), 8% were diagnosed with Stage I CRC, another 24% with Stage II, 26% with Stage III and 40% with Stage IV colorectal cancer. See [Figs. 3] and [4].

Fig. 3 Cancer Staging for Symptomatic CRC Patients.

Fig. 4 Cancer Staging for Asymptomatic CRC Patients.

The CRC screening history of all patients (n = 118) was considered to be a gauge of our patients' awareness of the danger of CRC. 12% of patients were considered routine screeners, meaning their last CRC screen was within a year of their hospital admission. Patients who had been screened from 1-5 years and 5-10 years before CRC discovery each represented 2% of the group, respectively. 11% of the patient population reported to have been screened over 10 years prior and 73% had never been screened in their lifetime.

Each patient's family history of cancer was also recorded upon admission to the hospital. Of the 114 patients, 54% had no familial history of cancer. 33% of subjects reported an immediate family member having a cancer that was not colorectal cancer, while another 3% of patients had a secondary family member contract a non-CRC form of cancer. Lastly, 8% of subjects had an immediate family member who contracted a form of colorectal cancer.

The role of nurse navigators as facilitators of patient care was collected and categorized. From the entire patient population, 60% were not assigned a nurse navigator in any capacity. 14% of patients declined navigation assistance in any capacity and the remaining 25% requested and subsequently received assistance in multiple forms. The use of nurse navigation within the group of interest is outlined in [Fig. 5].

Fig. 5 Nurse Navigation Assistance.

We were able to review two years of follow-up in both patient cohorts. Of the symptomatic CRC patients (n = 103), 26% expired within 12 months, and another 3% expired between 12 and 24 months. Conversely, 67% of the patients presenting with symptoms remained alive after 24 months post-diagnosis. Meanwhile, 7% of asymptomatic screening patients expired within 12 months while another 7% expired between 12- and 24-months post-diagnosis. The other 86% of this group remained alive after 24 months.

Discussion

By removing benign polyps, colonoscopies significantly reduce the risk of colorectal cancer. Polyps are abnormal growths in the colon that can eventually become cancerous if left untreated. By detecting and removing these polyps early during a colonoscopy, the progression to colorectal cancer is prevented, effectively lowering cancer incidence. This preventive action is a key benefit of regular colonoscopy screenings.[9]

A significant portion of the patients (73%) reported having never been screened for colorectal cancer, likely contributing to the high incidence of late-stage cancer diagnoses. This may indicate a gap in adherence to national screening guidelines, especially given the USPSTF recommendations for regular screening between ages 50 to 75. The national CRC screening rates in 2021 were 71.8% while the Monmouth County 2020 screening rate was 72.0%, respectively. Though these averages are on par with one another, many symptomatic patients report not having been screened for CRC in any capacity in their lifetime. Therefore, it can be concluded that lower CRC screening incidence contributed to the late-stage identification of their diseases. Moreover, a substantial number of symptomatic patients were diagnosed at advanced stages, with over 40% of symptomatic patients presenting with Stage IV CRC, correlating with the low screening rates. Early-stage diagnosis was far less common, highlighting the importance of routine screenings for early detection and better prognosis.

The survival analysis indicated that patients diagnosed through screening had better outcomes, with 86% of patients alive after 24 months, compared to 67% of patients alive after 24 months after presenting with symptoms. Mortality rates among symptomatic patients were also higher. This further highlights the significance of late-stage CRC presentations in the absence of regular screenings.

A notable portion of patients (54%) had no familial history of cancer, suggesting that while family history is an important risk factor, many CRC cases occur in individuals without a genetic predisposition. Age in symptomatic patients as opposed to asymptomatic screening patients did not seem to play a large factor, as the average ages were quite similar.

Nurse navigator involvement was limited, with 60% of patients did not assign a navigator. However, 25% of patients who utilized nurse navigation services had better access to information and emotional support.

Conclusions

Our conclusion is that colon cancer screening leads to a diagnosis at an earlier stage than for patients diagnosed after the occurrence of symptoms. Strengthening public health education can raise awareness about the importance of regular screenings for colon cancer. An additional benefit is that the excision of colonic adenomas with colonoscopy, reduces the incidence of colon cancer.

Expanding the role and availability of nurse navigators could help guide patients through the screening process and offer support. These efforts may encourage individuals to prioritize their colorectal health and can spread the idea of colon cancer screening. By emphasizing the potential benefits of early detection and treatment, these campaigns may motivate proactive steps toward prevention, detection, and early intervention. Our analysis suggests that CRC screenings might not be utilized as recommended, potentially leading to patients presenting advanced stages of the disease. The importance of nursing navigators lies in promoting screenings and offering support to CRC patients. Ultimately, a comprehensive strategy that integrates public education, nurse navigation, and early detection efforts can significantly improve CRC screening rates and reduce the burden of advanced colon cancer.

Conflicts of Interest

The authors declare no conflicts of interest related to the content of this manuscript.

Authors' Contribution

Joseph Segal obtained the data by reviewing the charts and drafting a preliminary version of the manuscript. Arthur Topilow developed the project idea and guided Segal on how to collect the data. Topilow reviewed the data and made revisions and corrections to the manuscript. Glenn Parker, along with Topilow, developed the project idea, reviewed the data, and conducted an extensive review of the manuscript.

Ethics Approval

This study was reviewed and approved by the JSUMC Institutional Review Board.

• References

• 1 Edwards BK, Ward E, Kohler BA. et al. Annual report to the nation on the status of cancer, 1975-2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer 2010; 116 (03) 544-573
• 2 US Preventive Services Task Force. Colorectal cancer: Screening. 2021 May 18. Available from: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening
• 3 County Health Rankings & Roadmaps. Patient navigators. Available from: https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/strategies/patient-navigators
• 4 Temucin E, Nahcivan NO. The effects of the nurse navigation program in promoting colorectal cancer screening behaviors: A randomized controlled trial. J Cancer Educ 2020; 35 (01) 112-124
• 5 Brenner H, Jansen L, Ulrich A, Chang-Claude J, Hoffmeister M. Survival of patients with symptom- and screening-detected colorectal cancer. Oncotarget 2016; 7 (28) 44695-44704
• 6 Bretthauer M, Løberg M, Wieszczy P. et al; NordICC Study Group. Effect of colonoscopy screening on risks of colorectal cancer and related death. N Engl J Med 2022; 387 (17) 1547-1556
• 7 Cancer trends progress report. Colorectal cancer screening. [cited 2021]. Available from: https://progressreport.cancer.gov/detection/colorectal_cancer#:~:text=In%202021%2C%2071.8%25%20of%20adults,on%20the%20most%20recent%20guidelines
• 8 New Jersey Department of Health. New Jersey State Health Assessment Data. NJSHAD - Community health highlights report indicator page - Monmouth, Percent of adults ages 50–75 who are current with colorectal cancer screening recommendations. Available from: https://www-doh.state.nj.us/doh-shad/community/highlight/profile/FOBTSigmoid.Count y/GeoCnty/13.html
• 9 Zauber AG, Winawer SJ, O'Brien MJ. et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 366 (08) 687-696

Publication History

Received: 01 November 2024

Accepted: 09 January 2025

Article published online:
17 April 2025