By James Hill, Clinical Professor of Colorectal Surgery

Litigation as a result of delay in the diagnosis and treatment of colorectal cancer and colorectal polyps is common.

Urgent or ‘two-week rule’ referral criteria for primary care doctors are well established. They are based on a combination of age, symptoms of change in bowel habit and rectal bleeding, signs of an abdominal or rectal mass and investigations, iron deficiency anaemia and blood in the faeces. Two-week rule patients with proven cancer should have their first treatment within 62 days of referral and all patients with colorectal cancer should have their first treatment within 31 days of diagnosis.

Standard methods of investigation are lower GI endoscopy or CT colonoscopy (virtual colonoscopy). Standard CT scanning is not sufficiently accurate to exclude a colorectal malignancy.

The progression of benign colorectal polyps to colorectal cancers is well established. Litigation resulting from delays in the treatment of proven colorectal polyps is often caused by administrative errors and patients being ‘lost in the system.’ Polyps grow and there is good evidence that polyp size is closely related to risk of cancer. For example, only 2% of polyps 6-15 mm in diameter are malignant and around 20% of polyps 16-25mm are malignant, on balance of probability polyps of this size are benign.

Thus, if a polyp of these dimensions is identified and treatment delayed such that at the time of treatment a cancer is diagnosed, it is possible to establish that on balance of probability the delay in treatment has worsened the prognosis.

For cancer cases, establishing that recommended time-lines have been breached is straightforward, establishing that the delays involved in a particular case have resulted in poorer outcomes for the patient is more difficult. Colorectal cancer can be simply staged as localised, regional or distant. Cure rates are 80-90% for localised disease, 60-70% for regional disease and around 15-20% distant disease. Standard treatments are; localised disease - surgery alone, regional disease - surgery and chemotherapy, distant disease – chemotherapy and in selected cases resection of the distant disease (metastectomy). Chemotherapy treatment options have increased and have improved survival times in those with incurable disease.

Delays in diagnosing colorectal cancer can lead to significant patient harm and subsequent legal action.

The biological behaviour of the cancer is the major factor determining the time to diagnosis and survival. Studies looking at early diagnosis have not demonstrated consistent findings of better outcomes, but there are large studies that have confirmed that there is a correlation between delay in diagnosis and both advanced colorectal cancer and death from colorectal cancer. In a study of 11 720 incident colorectal cancer patients attending primary care with symptoms before diagnosis, the odds of advanced colorectal cancer increased with longer primary care intervals and secondary care intervals.

A further population-based study of 39,000 patients showed risk of death was increased for delays of both 31-150 and >150 days compared to delays of <31 days.

Further, time to diagnosis following an initial indication for colonoscopy in a study of over 70, 000 patients showed that compared with colonoscopy within 8 to 30 days, risks of advanced stage disease were significantly higher for examinations at 10 to 12 months.

Most regions have experienced significant delays in provision of endoscopy services during the Covid pandemic. This has inevitably resulted in patients with colorectal cancer experiencing diagnostic delays. It will be interesting to know whether allowance is made for difficulties in service delivery as a result of the Covid pandemic and how this plays out in any subsequent medico-legal cases

About the Author:

Mr. James Hill is a Clinical Professor of Colorectal Surgery working at Manchester Royal Infirmary since 1995. Mr Hill qualified from Bristol and trained in Bristol Manchester and Harvard. He was the President Association of Coloproctology GB&I 2017-18 and is part of National Cancer Research Institute colorectal group,  Editorial board BJS and Chief investigator and co-investigator on multicentre UK trials in coloproctology.

He has been undertaking medico-legal work for over 15 years predominantly for the claimant with experience in preparing Joint Statements.

His areas of specialist interest include: Coloproctology, Colorectal Surgery, Colorectal cancer, IBD - inflammatory bowel disease, functional pelvic disorders, familial colorectal cancer, early rectal cancer, obstructing colorectal cancer.

Mr Hill can be contacted for all medico-legal work and to request his CV at jameshill@inneg.co.uk