Epidemiological Data from Patients Who Underwent Colonoscopy from High-Susceptibility Vacancies

Abstract

Objective The objective of this study was to analyze the epidemiological profile of patients to propose measures that facilitate regulation and access to diagnostic imaging exams.

Methods Data were collected from 157 scheduled exams for high-suspicion colonoscopy through regulation systems and electronic medical records from January to December 2023. Results: The data showed a higher rate of appointments among females, particularly in older age groups (71–80 years). There was a high rate of non-attendance on the day of the exam scheduled during the coldest months of the year. The most prevalent biopsy location was the colon region, with a predominance of low-grade adenomas and polyps.

Conclusion Facilitating access to diagnostic imaging exams includes regionalization in scheduling. Monitoring results allows for the tracking of family members, enabling preventive action and early diagnosis.

 

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Keywords

colorectal neoplasms - diagnosis - colonoscopy and service management

Introduction

Colorectal cancer (CRC) is a significant health concern, being the second most common cancer in women and the third in men. It ranks as the fourth leading cause of cancer-related deaths globally, accounting for 9.2% of such deaths.[1] [2] [3] In Brazil, CRC is the third most common type of tumor, with approximately 40,000 new cases diagnosed annually.[4] In 2020, there were 20,540 new cases of CRC in men and 20,470 in women.[4] [5] The forecast for new cases of CRC each year from 2023 to 2025 is 45,630 cases, corresponding to an estimated risk of 21.10 cases per 100,000 inhabitants.[4]

The incidence of CRC increases proportionally with age (≥ 50 years), male sex, and in people of African descent. It is related to a diet rich in saturated fats, excessive consumption of red and processed meat, low fiber intake, alcohol abuse, and smoking.[6] [7] Studies show that 75% of cases are sporadic, predominantly in men aged ≥ 50 years, regardless of symptoms; 20% are familial, and the remainder are secondary to inflammatory bowel disease and hereditary CRC syndromes.[8] [9]

CRC can be diagnosed based on the evaluation of symptomatic patients (blood in the stool, changes in bowel habits, abdominal pain, pale appearance, shortness of breath, and weight loss) or through screening.[9] The colon and rectum have high potential for primary and secondary prevention, based on family history and lifestyle, and are subject to screening actions. Detecting CRC in its asymptomatic phase enables early diagnosis, reducing morbidity and mortality related to the disease, and improving life expectancy and quality of life.[10]

Epidemiological studies increasingly show that early screening and treatment improve survival in CRC, with 5-year survival rates of approximately 90% for early-stage cancer patients, compared to 10% for those diagnosed with metastatic CRC.[11] [12] Screening in most countries targets men and women aged 50 to 75 years. A low-risk population includes individuals over 50 years without other risk factors for CRC. Moderate risk includes individuals with a family history of CRC in one or more first-degree relatives, a personal history of a polyp larger than one centimeter or multiple polyps of any size, and those with a personal history of CRC treated with curative intent. High-risk patients include those with a personal history of adenomatous polyps or colorectal, breast, endometrial, or ovarian neoplasia, inflammatory bowel disease, a family history of CRC or adenomatous polyps, and hereditary colorectal neoplasm syndromes.[12] [13]

Colonoscopy is the gold standard for diagnosing CRC, offering high diagnostic accuracy and precise tumor localization. It allows for simultaneous biopsy sampling, providing histological confirmation of the diagnosis and material for molecular profiling.[14] [15] The effectiveness of colonoscopy in reducing CRC incidence and mortality has been well demonstrated by the US National Polyp Study.[14] According to the World Health Organization (WHO), early cancer detection consists of two strategies: screening, which aims to find pre-clinical cancer or pre-cancerous lesions through routine examinations in a target population without symptoms, and early diagnosis, which seeks to identify cancer at an early stage in symptomatic individuals.[16] The slow progression of CRC, starting as a benign lesion and potentially evolving over 10 to 15 years, makes early detection highly favorable. Identifying and removing benign intestinal polyps can reduce cancer incidence, while early-stage detection and adequate treatment improve survival and reduce mortality.[17]

The State of São Paulo recognizes regulation as an essential management tool for the public health system, aiming for equitable access, implemented through dynamic actions coordinated by the State Department of Health (SES/SP) via its State Regulatory Complex, under the technical direction of the Regulation Group of the Health Regions Coordination.

Federal Law Number 13,896 dated October 30, 2019, mandates that necessary tests for diagnosing malignant neoplasms be performed within 30 days.[18] Therefore, the Health Planning Coordination of the State of São Paulo, through CIB Deliberation Number 53 of May 21, 2021, prepared the State Protocol for High Suspicion in Oncology, defining colonoscopy with biopsy as essential for the diagnostic investigation of CRC. These cases require prompt care, prioritizing diagnostic elucidation, and timely referral for treatment.[19]

Access Regulation Protocols provide guidelines for the appropriate and rational use of diagnostic and therapeutic technologies. Early diagnosis and treatment of CRC are crucial for reducing morbidity, mortality, and associated costs. This study aims to analyze data collected from appointments and exams performed for high-suspicion colonoscopy, as well as the epidemiological data of these cases, to outline the profile of these patients and propose ways to facilitate access to diagnostic imaging exams, including screening actions for family members, through demand management and the provision of colonoscopy services in a coverage area that includes 15 municipalities in the State of São Paulo.

 

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Methods

This study is a retrospective analysis of records of exams scheduled and carried out in a tertiary reference service in the city of Osasco, which provides outpatient and hospital care to an area covering the Mananciais Route and the Rota dos Bandeirantes. The Mananciais Route includes the municipalities of Cotia, Embu, Ibiúna, Embu Guaçu, Itapecerica da Serra, Juquitiba, São Lourenço da Serra, and Vargem Grande Paulista, with a total population of 918,166 inhabitants. The Rota dos Bandeirantes includes the municipalities of Barueri, Carapicuíba, Jandira, Itapevi, Osasco, Pirapora do Bom Jesus, and Santana de Parnaíba, with a total population of 1,971,307 inhabitants.

Epidemiological data were collected from appointments for high-suspicion colonoscopy from January to December 2023, as well as exams carried out in the CROSS-regulation systems and electronic medical records of the S4SP System. Epidemiological data from DATASUS regarding the incidence and deaths of colon and rectal cancer were also used.

The sample included 157 individuals of both sexes scheduled for colonoscopy in 2023. Of these, 17 were scheduled for January 17 in February 20 in March 17 in April 19 in May 12 in June 10 in July 12 in August 12 on September 8 on October 6 in November, and 7 in December.

The manuscript was approved by the Research Ethics Committee of Hospital Moriah under number 6.861.476, CAAE: 79690424.6.0000.8054, dated 05/10/2024. All authorizations and forms for analyzing system data and conducting the research were obtained from the service division directorate. Personal data was not the subject of the research, and confidentiality of information contained in medical records was guaranteed by the General Data Protection Law (LGPD).

 

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Results

The sample consisted of 157 individuals scheduled for high-suspicion colonoscopy slots, aged between 37 and 91 years (mean 70.24 ± 10.85). When stratifying ages below 50 years and then by decades, we noticed a greater participation of individuals aged 71 to 80 years (54 patients, mean 75.09 ± 2.72 years) with a statistically significant difference (p = 0.007). There was a female predominance (66.24%) compared to males (33.76%). The patients' weight ranged from 49 kg to 119 kg (mean 72.16 ± 15.0). Self-declared white (49.68%) and mixed race (38.22%) individuals predominated. Regarding marital status, 35.03% declared being married, 28.02% did not declare, 16.56% were single, 15.29% were widowed, and only 5.10% declared being separated, as shown in [Table 1].

Table 1 Profile of patients scheduled in 2023 for colonoscopy exams in high-suspicion spaces

	N	(%)
Sex
Woman	104	66,24
Man	53	33,76
Age (years)	70,24 ± 10,85
Weight (kg)	72,16 ± 15,0
Race
White	78	49,68
black	16	10,19
Brown	60	38,22
Yellow	03	1,91
Marital status
Single	26	16,56
Married	55	35,03
Divorced	08	5,10
Widower	24	15,29
Others/not informed	44	28,02

Data presented as absolute and relative frequency (%); mean and standard deviation.

Of the total number of patients scheduled for 2023, 44.59% underwent the exam, 43.31% were absent on the scheduled date, and 12.10% were dismissed on the day. We stratified by scheduling months and noticed that the highest number of appointments occurred in March (23 vacancies) and August (23 vacancies), while the lowest occurred in February, April, and November with 19 vacancies each. The highest attendance rates were in February (76.47%) and March (60%), while May had the highest absenteeism (63.16%). November (50%) and August (33%) showed the highest discharge rates among scheduled patients. This data is presented in [Graph 1].

Graph 1 Distribution of patients according to scheduling status (attended, absent, or dismissed)

We analyzed the regions from which patients came for high-suspicion colonoscopy examinations. Out of 157 scheduled patients, 46.50% came from Taboão da Serra, followed by SMS Diadema (20.38%), though specific data were not shown.

During 2023, we observed deaths among scheduled patients for colonoscopy exams, comparing this with data from DATASUS on the percentage of deaths among registered cases of colon and rectal cancer in 2022. No deaths occurred in January, February, March, May, July, or September. In June and August, the death rate matched that of DATASUS, while in April, October, and November, it exceeded it, as shown in [Graph 2].

Graph 2 Percentage of deaths of patients scheduled at the Hospital versus data on deaths from colon and rectal cancer from DATASUS

We analyzed patients who were dismissed on the day of their scheduled exam (19 patients). Of these, 8 were men and 11 were women, with a mean age of 76.68 ± 6.80 years. Eleven of these patients were rescheduled and underwent the exam at the same or another unit, 4 were rescheduled but did not attend, and 4 did not reschedule at all. Reasons for dismissal included 73.68% of patients lacking necessary exams, 5.26% lacking a medical referral, and 21.06% being unable to undergo the exam (data not shown).

Regarding patients who did not attend their appointments (68 patients), their mean age was 72.52 ± 9.87 years, with 44 women and 24 men. Among these, 42.65% were aged 71-80, and 20.29% were aged 81-91. Among them, 5 deaths occurred, 21 underwent exams elsewhere, and 42 did not undergo the exam.

Finally, we examined the locations and results of pathological anatomies. Out of 70 patients who underwent the exam, 33 (47.14%) underwent a biopsy. The colon region was most analyzed (43%), followed by rectosigmoid (27%) and rectum (15%), as shown in [Graph 3]. Biopsy results indicated malignancy or premalignancy in only 3% of cases, while the remaining 94% showed findings such as low-grade tubular adenoma (49%), polyps (21%), low-grade adenoma fragments (12%), inflammatory processes (6%), and colitis (6%), as detailed in [Graph 4].

Graph 3 Region of the fragment in the colonoscopy exam

Graph 4 Biopsy results

 

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Discussion

This study represents the first epidemiological analysis outlining the profile of patients scheduled, absent, and dismissed for high-susceptibility colonoscopy examinations for colorectal cancer (CRC) in Osasco.

Upon analyzing the results, we observed a higher prevalence of scheduled exams among females. This could be attributed to greater outpatient demand from female patients, particularly concerning gastrointestinal issues, which aligns with previous findings.[20] Another potential factor contributing to the female predominance is the demographic trend of aging, which shows a feminization pattern in older age groups.[21] [22]

Results were further stratified based on attendance or absence on the scheduled exam day, revealing a notable absenteeism rate, particularly during colder months such as May, June, and July. We hypothesize that discomfort associated with winter conditions among elderly patients, coupled with diseases prevalent during this period, may contribute to these absences. Literature supports various reasons for absenteeism including forgetfulness, communication lapses between service providers and users, symptom improvements, scheduling conflicts, transportation issues, and distance from healthcare facilities.[23] The absenteeism present in this study may be related to regions further away from the exam location. Addressing these factors is crucial to enhancing appointment adherence through improved service regulation. The geographical distribution of absenteeism suggests a need for regionalized healthcare services, especially for examinations requiring preparation and extended durations. This underscores the importance of local provision of diagnostic services and their equitable distribution, as highlighted in the State Protocol for High Suspicion in Oncology.[19]

The most frequent colonoscopy findings were adenomas and polyps, consistent with existing literature.[24] Malignancy was detected in 3% of cases, while pre-malignant conditions were observed in another 3%, aligning with reported incidence rates (between 2 and 9.4%).[24] [25] [26] Among malignant cases, there was an unexpected female predominance, contrary to general trends indicating higher CRC incidence among males.[27] This finding may be explained by the higher female participation in scheduled exams observed in this study.

Notably, the study identified a concerning rate of deaths among scheduled patients, reflecting the broader issue of rising CRC incidence and mortality in Latin American countries.[28] [29]

Based on our results, we note that CRC is an emerging problem in Brazil, with a warning of increasing annual deaths. Early diagnosis remains pivotal for effective treatment outcomes, underscoring the importance of timely referral to specialized oncological care. The importance of diagnosis lies not only in offering the most appropriate treatment for these patients but also in the possibility of preventing or diagnosing the presence of cancer in family members early, providing them with the best oncological results.

 

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Conclusion

Efforts to detect signs and symptoms suggestive of colorectal neoplasms should be prioritized within Primary Care settings through early detection strategies. Once individuals at risk are identified, prompt scheduling and monitoring of diagnostic exams are crucial to achieve early diagnosis or exclusion of CRC. This approach is pivotal in reducing morbidity and mortality associated with the disease, especially in populations with familial predispositions but without apparent symptoms.

Regionalization of healthcare services emerges as a critical strategy to mitigate absenteeism and ensure equitable access to diagnostic examinations. This study's findings advocate for targeted screening initiatives that leverage family history as a guide to identifying high-risk populations, thereby improving oncological outcomes through timely intervention and treatment.

 

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Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgment

Not applicable.

Author's Contribution

Ana Claudia Martins: contributed to the conception and design of the study, initial writing, methodology, interpretation of results, and critical review of the manuscript.

Vera Lúcia Miranda: contributed to the conception and design of the study, initial writing, and data collection.

Milton Brandão Monteiro Jr: contributed to the conception and design of the study, initial writing, and data collection.

Mayra dos Santos Silva: initial writing, methodology, analysis, and interpretation of results and contribution to the final writing and critical review of the manuscript.

Author Disclaimer

Each author of this manuscript warrants that this Work contains no libelous or unlawful statements and does not infringe or violate the publicity or privacy rights of any third party, libel or slander any third party, contain scandalous, obscene, or negligible prepared information, or infringe or violate any other personal or proprietary right of others. Each author also warrants that all statements contained in the Work purporting to be facts are true, and any formula or instruction contained in the Work will not, if followed accurately, cause any injury, illness, or damage to the user.

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Eingereicht: 21. Juni 2024

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