Editorial

It has long been recognised that emergency presentation with colorectal cancer is associated with poorer outcomes than when management is elective. Two papers in this edition shine a spotlight on this issue once again. The study by Webster et al. [1] presents data from a 10-year period at single centre in the UK and compares outcomes in ‘young ‘and ‘elderly’ cohorts with emergency presentation of colorectal cancer. Those in the younger group (under 75 years) were more likely to undergo emergency curative surgery or receive adjuvant chemotherapy, but outcomes were similar in those that did undergo curative surgery, irrespective of age group. The other paper [2] from the Netherlands, conducted over a similar time period, found that undergoing emergency surgery for colon cancer was associated with higher longer term mortality (5-year mortality hazard ratio 1.79, 95% CI 1.28–2.51) in those who were successfully discharged for hospital, after correction for a number of potentially confounding variables, including tumour stage. So why do around 15%–25% of colorectal cancer patients still present acutely? There is some evidence of reduced incidence associated with the introduction of population screening for bowel cancer. A large study [3] from England showed an adjusted odds ratio for emergency admission in patients diagnosed 6 months or more after commencement of screening was 0.83 (CI 0.76–0.90). Even with the improved accuracy offered by faecal immunochemical testing (FIT), the current approach misses cancers and contributes little to prevention. The sensitivity threshold at which a FIT result triggers colonoscopy is arbitrarily determined, often set so as not to overwhelm current limited colonoscopy capacity. ‘Fast-track’ referral pathways are associated with a very low yield of colorectal cancer diagnoses, straining resources and creating a barrier to referral in the first place. Lowering this barrier can reduce the rate of emergency presentation. An example of this was the study by Davies et al. [4] in which the introduction of fast-track flexible sigmoidoscopy was followed by a reduction in the proportion of patients with colorectal cancer presenting as an emergency from 35.7% to 25.9%. A closer look at these emergency patients and their history is illuminating. They are more likely to be socioeconomically deprived and elderly, but many of them may not experience the classical ‘alarm’ symptoms of colorectal cancer. A study examining the consultation behaviours and symptoms reported by patients who subsequently presented as an emergency with colorectal cancer [5] found that ‘emergency presenters’ had similar background consultation history to ‘non-emergency presenters’ and that the tumours seemed to be associated with less typical symptoms. The authors concluded that opportunities for earlier diagnosis were present in only about a fifth of them. Finally, surgical sub-specialisation and the emergence of the ‘emergency surgeon’ raises questions about who should care for patients presenting acutely with colorectal cancer. A recent publication in this journal [6] reported that 30-day mortality after emergency colorectal resection (not all for cancer) was significantly lower (11.8% vs. 15.2%) if the responsible consultant was a colorectal surgeon rather than another general surgeon. We need to continue trying to reduce emergency presentation with colorectal cancer, and improve management when it occurs. This requires aggregated marginal gains, rather than fixation on one element to the exclusion of the others. Improvements in population screening uptake and process, and in management of symptomatic patients are areas of ongoing research and debate. Ensuring that patients are managed by the most appropriate teams when they do present should not be beyond us. Going back to ‘basics’ and looking in detail at the biology of these tumours, which still occur in a population with a well-established screening programme, and apparently without early symptoms, might also provide useful insight and expose potential diagnostic and therapeutic targets.