Open Access Highly Accessed Research article

Most bowel cancer symptoms do not indicate colorectal cancer and polyps: a systematic review

Barbara-Ann Adelstein16*, Petra Macaskill2, Siew F Chan3, Peter H Katelaris4 and Les Irwig5

Author Affiliations

1 Prince of Wales Clinical School, Faculty of Medicine, University of NSW, Sydney, Australia

2 associate professor, STEP, School of Public Health, University of Sydney, Australia

3 biostatistician, STEP, School of Public Health, University of Sydney, Australia

4 gastroenterologist, Concord Repatriation General Hospital, University of Sydney, Australia

5 professor of epidemiology, STEP, School of Public Health, University of Sydney, Australia

6 Screening and Test Evaluation (STEP) Program, School of Public Health, University of Sydney, NSW 2006, Australia

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BMC Gastroenterology 2011, 11:65  doi:10.1186/1471-230X-11-65

Published: 30 May 2011



Bowel symptoms are often considered an indication to perform colonoscopy to identify or rule out colorectal cancer or precancerous polyps. Investigation of bowel symptoms for this purpose is recommended by numerous clinical guidelines. However, the evidence for this practice is unclear. The objective of this study is to systematically review the evidence about the association between bowel symptoms and colorectal cancer or polyps.


We searched the literature extensively up to December 2008, using MEDLINE and EMBASE and following references. For inclusion in the review, papers from cross sectional, case control and cohort studies had to provide a 2×2 table of symptoms by diagnosis (colorectal cancer or polyps) or sufficient data from which that table could be constructed. The search procedure, quality appraisal, and data extraction was done twice, with disagreements resolved with another reviewer. Summary ROC analysis was used to assess the diagnostic performance of symptoms to detect colorectal cancer and polyps.


Colorectal cancer was associated with rectal bleeding (AUC 0.66; LR+ 1.9; LR- 0.7) and weight loss (AUC 0.67, LR+ 2.5, LR- 0.9). Neither of these symptoms was associated with the presence of polyps. There was no significant association of colorectal cancer or polyps with change in bowel habit, constipation, diarrhoea or abdominal pain. Neither the clinical setting (primary or specialist care) nor study type was associated with accuracy.

Most studies had methodological flaws. There was no consistency in the way symptoms were elicited or interpreted in the studies.


Current evidence suggests that the common practice of performing colonoscopies to identify cancers in people with bowel symptoms is warranted only for rectal bleeding and the general symptom of weight loss. Bodies preparing guidelines for clinicians and consumers to improve early detection of colorectal cancer need to take into account the limited value of symptoms.

colorectal cancer; colorectal polyps; bowel symptoms; rectal bleeding; change in bowel habit