Intervening factors for the initiation of treatment of patients with stomach and colorectal cancer 1

ABSTRACT Objective: to identify the time between symptoms, the request for care and the beginning of treatment in patients with stomach and colorectal cancer as well as the factors that interfere in these processes. Method: correlational descriptive study, including 101 patients diagnosed with stomach or colorectal cancer, treated in a hospital specialized in oncology. Results: the 101 patients investigated there was predominance of males, mean age of 61.7 years. The search for medical care occurred within 30 days after the onset of symptoms, in most cases. The mean total time between the onset of symptoms and the beginning of treatment ranged from 15 to 16 months, and the mean time between the search for medical care and the diagnosis was 4.78 months. The family history of cancer (p=0.008) and the implementation of preventive follow-up (p<0.001) were associated with shorter periods between the search for care and the beginning of treatment. Nausea, vomiting, hematochezia, weight loss and pain were associated with faster demand for care. Conclusion: the longer interval between the search for medical care and the diagnosis was possibly due to the non-association between the presented symptoms and the disease.


Introduction
Stomach and colorectal cancer stand out among the leading causes of cancer in men and women. An estimated 34,280 new cases of colorectal cancer and 20,520 new cases of stomach cancer happened in Brazil in 2016 (1) . Worldwide, colorectal cancer represents the third most common tumor and stomach cancer is the third leading cause of cancer death in both sexes (2) . pylori is pointed out as contributing factor as well as is for colorectal cancer the presence of polyps and history of inflammatory diseases such as ulcerative colitis or Crohn's disease (3)(4) .
However, most of the cases are diagnosed at an advanced stage, due to the non-specificity of the symptoms in the initial phase of the disease, such as diffuse abdominal pain, asthenia, anorexia and weight loss, compromising healing and reflecting in high morbidity and mortality rates, since the most radical surgery involves the total removal of the stomach (3) .
Regarding colorectal cancer, prevention is anchored in two main aspects: the primary prevention linked to education and lifestyle modification, and the secondary one, consisting in early detection, through the identification of signs and symptoms such as: Hematochezia, change in bowel habit (diarrhea or constipation), weight loss, incomplete intestinal emptying sensation and abdominal pain, together with tests such as fecal occult blood test, sigmoidoscopy and colonoscopy with subsequent biopsy (4) .
Depending on the staging of the disease, the main treatment is surgical. In colorectal cancer, the most radical surgery involves the removal of the large intestine and rectum, leading to the need for colostomy, which social, physical and psychological impact (5) .
Countries such as Japan, England, Canada and the United States of America (USA), which have established programs for the screening of stomach or colorectal cancer, have observed a significant decrease in morbimortality indexes associated with the disease due to the quality of their follow-up methods and the more efficient use of the available diagnostic tests, increasing the capacity of detection and removal of early adenomas and / or carcinomas (6)(7)(8) .
Diagnosis and staging are key for stomach and colorectal cancer treatment, and the mortality rate and quality of life impairments are directly linked to these two processes. Reaching out in an early stage for a network of health services providing specialized assistance, and the existence of an organized screening program with laboratory studies and procedures for early diagnosis contribute to increasing patients' recovery, avoiding more invasive and extensive procedures (4)(5)9) .
Ideally, the time from diagnosis to tumor surgery should take a maximum of six to eight weeks (10) .
However, due to the unequal distribution of healthcare resources and the large geographic extent of Brazil, health care conditions are very diverse, and frequently the demand is much higher than the services capacity, causing delays in diagnosis and treatment compromising the well-being and quality of patient recovery (9) Despite the existence of international studies that  (10) . Thus, despite the differences between tumor types, it was decided to use them, since it was considered that the system of public health care used by patients was the same, added to the fact that the cited research contained the necessary statistical data, allowing us to adequately estimate the number of observations to be made.
Thus, the sample calculation was based on the national study findings (10) in which the mean time

Results
A total of 101 patients investigated, a mean age of 61.7 years (SD=12.94 years), predominantly male (53.5%) ( Table 1) and residing in the city of São Paulo (43.6%). Staging of the tumors, by means of the classification system TNM ("T": information on the primary tumor; "N": Lymph node involvement, and; "M": Existence of metastases), revealed that the highest incidence were IA   Table 3.    The results concur with the scientific literature regarding the mean age of the patients and the predominance of this type of cancer among males (2,(12)(13) , alcohol and tobacco users (14)(15)(16) and with low educational level, as aspects associated with delays longer than 30 days until the first treatment, demonstrating that not www.eerp.usp.br/rlae 6 Rev. Latino-Am. Enfermagem 2017;25:e2879.
only clinical aspects, but also cultural factors interfere in the treatment search process (12) .
In the present investigation, most of the patients analyzed sought medical care up to 30 days after the onset of symptoms, however, the time between the search for medical care and the beginning of treatment occurred on average in 8.84 months. In this sense, in an effort to accelerate access to health services, several countries around the world have sought to implement specific screening programs for stomach and colorectal cancer.
In the 1990s, the Danish government began to implement a program that recommended that the time between suspected and performed exams in patients investigated for colorectal cancer should occur in a maximum of 14 days, plus a further 14 days between the diagnosis and treatment, thus totaling a period of 28 days between suspicion and treatment (17) . In the United Kingdom, as of 2000, the "two-week referral" recommendation was introduced for patients with suspected colorectal cancer, if they met predefined criteria for age, signs and symptoms (18) .

Recent research analyzing the implementation of the
British program showed that the number of diagnoses of colorectal cancer showed a significant increase, compared to periods before its beginning, however, no differences were found regarding the stage of the diagnosed tumors or the survival period in two years (18) .
This aspect differs from the implementation of screening programs for gastric cancer, especially in Asia, which has contributed to the diagnosis of the disease in the early stages and therefore increased the survival of these patients, thus generating better results than those obtained in the West, in relation to the same disease (19) .
Only recently, Brazil, through Law no. 12,732 (20) , enacted in 2012, recommended that cancer treatment, regardless of cancer type, should be started within 60 days after diagnosis. It is important to emphasize that the term recommended by Brazilian law takes into account only the period between admission and treatment of the patient in the institution specialized in oncology, therefore, does not evaluate the necessary referrals until this service.
The experiences of the patients investigated, the period between the diagnosis or suspected diagnosis and effective treatment took an average of four months.
It is important to highlight that, in the current study, the entire process of search for treatment reported by the patient, that is, from the first symptoms to the oncological treatment itself, is described in the specialized institution.
It is noteworthy that, although screening programs are capable of increasing the diagnostic capacity of oncological disease (18)(19) , different from that occurring in gastric tumors (19) , the scientific literature does not seem to be able to demonstrate the capacity of these initiatives to impact on the mortality associated with colorectal cancer (18,(21)(22) .
In this sense, there is evidence that independent of guarantees of equal access to the health system and diagnosis, through screening for the disease, most diagnoses are associated with the presence of signs and symptoms, especially rectal bleeding, abdominal pain, or change in bowel habits and fatigue, which seems to culminate in more advanced stages of colorectal neoplasia (21)(22) .
Recent literature review has indicated controversies in the analysis of the role of delayed diagnosis, colorectal cancer survival and disease stage (23) .  (23)(24) .
In this investigation, it was also observed that the time between presenting the first symptoms and  (13) . Regarding patients with gastric cancer, the five-year survival for the disease worldwide is 20%, while in Japan, for diseases diagnosed between stages I and II, the survival rate reaches 70% (25) .
In addition, it is interesting to note that another aspect that may have influenced the search for the health service may be linked to the frequency in men of stomach and colorectal cancer (2,(12)(13) as it is well known that women tend to adhere better to health programs, e.g. the breast cancer screening program.
It was also observed that aspects that collaborated in the agility of care were observed, such as the  (10) .
Recommendations on the need for a control program for gastric and colorectal cancer in Brazil have existed since the 1990s, however, the difficulties associated with the high cost of detection tests and their invasive nature can not be ignored, together with the need for training of health professionals beginning in their professional education, mainly those who work in primary care, in order to identify signs and symptoms of suspicion (9) .
Thus is evidenced the importance of launching a Another aspect to be pointed out is the lack of national studies that investigate the subject, especially among gastrointestinal tumors, which can also be presented as a limitation, since it weakens the comparisons of the results found to the national reality.
Thus, the need to carry out similar investigations in other regions of the country is reinforced, producing studies that will allow the identification of barriers and solutions, contributing to the elaboration of a wellstructured Brazilian public policy for the treatment of potential cases of stomach cancer and colorectal cancer.

Conclusion
The major cause of delay in the search for medical care was the non-association between the symptoms presented as cause of illness. Family history of cancer and preventive follow-ups were significantly related to shorter periods of search and initiation of treatment. The period between symptoms manifestation and getting treatment lasted on average 15.16 months, and this period may be justified due to the need in the majority of the sample, for at least one or two referrals to the place of effective treatment.