Journal of Behavioral Medicine

, Volume 37, Issue 4, pp 698–708 | Cite as

Appraisal of emerging symptoms of colorectal cancer: associations with dispositional, demographic, and tumor characteristics

  • Stephen L. RistvedtEmail author
  • Sandi L. Pruitt
  • Kathryn M. Trinkaus


The time it takes for individuals to realize that their emerging colorectal cancer (CRC) symptoms are serious is often an impediment to expeditious help-seeking. Tailored educational efforts to hasten symptom appraisal time would benefit from knowledge of the characteristics of individuals who tend to neglect their symptoms as well as the nature of symptoms that are most often neglected. In a sample of 112 CRC patients, we investigated associations between duration of symptom appraisal and: (1) trait anxiety, and (2) tumor location, which affects symptomatology. Symptom appraisal duration was associated with a sex-by-anxiety interaction (p = 0.007). The longest times (in weeks) were among high anxiety females (Mdn = 26.0) and low anxiety males (Mdn = 17.0), with shorter times among low anxiety females (Mdn = 9.0) and high anxiety males (Mdn = 2.0). Symptom appraisal times were also longer for patients with distal (vs. proximal) tumors (p = 0.036).


Colorectal cancer Symptom appraisal Trait anxiety Sex differences Common-sense model 



This research was supported in part by National Institute of Health grant CA102177 and the Barnes-Jewish Hospital Foundation (SLR), and a postdoctoral fellowship from the Alvin J. Siteman Cancer Center Prevention and Control Program (SLP) and career development award from the National Center for Research Resources Washington University-ICTS (KL2 RR024994) (SLP). The authors wish to acknowledge the support of the Biostatistics Core, Siteman Comprehensive Cancer Center and NCI Cancer Center Support Grant P30 CA091842.

Supplementary material

10865_2013_9519_MOESM1_ESM.docx (17 kb)
Supplementary material 1 (DOCX 17 kb)


  1. Adelstein, B. A., Macaskill, P., Chan, S. F., Katelaris, P. H., & Irwig, L. (2011). Most bowel cancer symptoms do not indicate colorectal cancer and polyps: A systematic review. BMC Gastroenterology, 11, 65.PubMedCentralPubMedCrossRefGoogle Scholar
  2. American Cancer Society. (2011). Colorectal cancer facts and figures 2011–2013. Atlanta, GA: American Cancer Society.Google Scholar
  3. Andersen, B. L., Cacioppo, J. T., & Roberts, D. C. (1995). Delay in seeking a cancer diagnosis: Delay stages and psychophysiological comparison processes. British Journal of Social Psychology, 34, 33–52.PubMedCrossRefGoogle Scholar
  4. Andersen, R. S., Vedsted, P., Olesen, F., Bro, F., & Sondergaard, J. (2009). Patient delay in cancer studies: A discussion of methods and measures. BMC Health Services Research, 9, 189.PubMedCentralPubMedCrossRefGoogle Scholar
  5. Astin, M., Griffin, T., Neal, R. D., Rose, P., & Hamilton, W. (2011). The diagnostic value of symptoms for colorectal cancer in primary care: A systematic review. The British Journal of General Practice, 61, e231–e243.PubMedCentralPubMedCrossRefGoogle Scholar
  6. Baumann, L. J., Cameron, L. D., Zimmerman, R. S., & Leventhal, H. (1989). Illness representations and matching labels with symptoms. Health Psychology, 8, 449–469.PubMedCrossRefGoogle Scholar
  7. Cacioppo, J. T., Andersen, B. L., Turnquist, D. C., & Petty, R. E. (1986). Psychophysiological comparison processes: Interpreting cancer symptoms. In B. L. Andersen (Ed.), Women with cancer: Psychological perspectives (pp. 141–171). New York: Springer.CrossRefGoogle Scholar
  8. Cain, K. C., Jarrett, M. E., Burr, R. L., Rosen, S., Hertig, V. L., & Heitkemper, M. M. (2009). Gender differences in gastrointestinal, psychological, and somatic symptoms in irritable bowel syndrome. Digestive Diseases and Sciences, 54, 1542–1549.PubMedCentralPubMedCrossRefGoogle Scholar
  9. Cameron, L. D. (2003). Anxiety, cognition, and responses to health threats. In L. D. Cameron & H. Leventhal (Eds.), The self-regulation of health and illness behaviour (pp. 157–183). New York: Routledge.Google Scholar
  10. Cameron, L., Leventhal, E. A., & Leventhal, H. (1993). Symptom representations and affect as determinants of care seeking in a community-dwelling, adult sample population. Health Psychology, 12, 171–179.PubMedCrossRefGoogle Scholar
  11. Carver, C. S., & White, T. L. (1994). Behavioral inhibition, behavioral activation, and affective responses to impending reward and punishment: The BIS BAS Scales. Journal of Personality and Social Psychology, 67, 319–333.CrossRefGoogle Scholar
  12. Courtney, R. J., Paul, C. L., Sanson-Fisher, R. W., Macrae, F., Attia, J., & McEvoy, M. (2012). Current state of medical-advice-seeking behaviour for symptoms of colorectal cancer: Determinants of failure and delay in medical consultation. Colorectal Disease, 14, e222–e229.PubMedCrossRefGoogle Scholar
  13. Esteva, M., Ramos, M., Cabeza, E., Llobera, J., Ruiz, A., Pita, S., et al. (2007). Factors influencing delay in the diagnosis of colorectal cancer: A study protocol. BMC Cancer, 7, 86.PubMedCentralPubMedCrossRefGoogle Scholar
  14. Ferlay, J., Shin, H. R., Bray, F., Forman, D., Mathers, C., & Parkin, D. M. (2010). Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. International Journal of Cancer, 127, 2893–2917.CrossRefGoogle Scholar
  15. Fritz, A., Percy, C., Jack, A., Shanmugaratnam, K., Sobin, L., Parkin, D. M., et al. (2000). International classification of diseases for oncology (3rd ed.). Geneva: World Health Organization.Google Scholar
  16. Gandhi, T. K., Kachalia, A., Thomas, E. J., Puopolo, A. L., Yoon, C., Brennan, T. A., et al. (2006). Missed and delayed diagnoses in the ambulatory setting: A study of closed malpractice claims. Annals of Internal Medicine, 145, 488–496.PubMedCrossRefGoogle Scholar
  17. Greene, F. L., & American Joint Committee on Cancer, & American Cancer Society. (2002). AJCC cancer staging manual (6th ed.). New York: Springer.CrossRefGoogle Scholar
  18. Howard, D. H., Richardson, L. C., & Thorpe, K. E. (2009). Cancer screening and age in the United States and Europe. Health Affairs, 28, 1838–1847.PubMedCrossRefGoogle Scholar
  19. Jones, A., & Zachariae, R. (2004). Investigation of the interactive effects of gender and psychological factors on pain response. British Journal of Health Psychology, 9, 405–418.PubMedCrossRefGoogle Scholar
  20. Knyazev, G. G., Slobodskaya, H. R., & Wilson, G. D. (2004). Comparison of the construct validity of the Gray-Wilson Personality Questionnaire and the BIS/BAS scales. Personality and Individual Differences, 37, 1565–1582.CrossRefGoogle Scholar
  21. Lee, W. E., & Ristvedt, S. L. (2010). Low trait anxiety may be particularly hazardous to young men. Unpublished manuscript, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO.Google Scholar
  22. Leventhal, H., Brissette, I., & Leventhal, E. A. (2003). The common-sense model of self-regulation of health and illness. In L. D. Cameron & H. Leventhal (Eds.), The self-regulation of health and illness behaviour (pp. 42–65). New York: Routledge.Google Scholar
  23. Leventhal, H., Leventhal, E. A., & Breland, J. Y. (2011). Cognitive science speaks to the “common-sense” of chronic illness management. Annals of Behavioral Medicine, 41, 152–163.PubMedCrossRefGoogle Scholar
  24. Majumdar, S. R., Fletcher, R. H., & Evans, A. T. (1999). How does colorectal cancer present? Symptoms, duration, and clues to location. American Journal of Gastroenterology, 94, 3039–3045.PubMedCrossRefGoogle Scholar
  25. Mayer, E. A., Naliboff, B., Lee, O., Munakata, J., & Chang, L. (1999). Review article: Gender-related differences in functional gastrointestinal disorders. Alimentary Pharmacology & Therapeutics, 13, 65–69.CrossRefGoogle Scholar
  26. McCaffery, K., Wardle, J., & Waller, J. (2003). Knowledge, attitudes, and behavioral intentions in relation to the early detection of colorectal cancer in the United Kingdom. Preventive Medicine, 36, 525–535.PubMedCrossRefGoogle Scholar
  27. Mitchell, E., Macdonald, S., Campbell, N. C., Weller, D., & Macleod, U. (2008). Influences on pre-hospital delay in the diagnosis of colorectal cancer: A systematic review. British Journal of Cancer, 98, 60–70.PubMedCentralPubMedCrossRefGoogle Scholar
  28. Phillips, R. L., Bartholomew, L. A., Dovey, S. M., Fryer, G. E., Miyoshi, T. J., & Green, L. A. (2004). Learning from malpractice claims about negligent, adverse events in primary care in the United States. Quality and Safety in Health Care, 13, 121–126.PubMedCentralPubMedCrossRefGoogle Scholar
  29. Pickett-Blakely, O., Lee, L. A., & Mullin, G. (2010). Gender differences in irritable bowel syndrome. In M. J. Legato (Ed.), Principles of gender-specific medicine (2nd ed., pp. 347–356). New York: Elsevier, Inc.CrossRefGoogle Scholar
  30. Ristvedt, S. L., & Trinkaus, K. M. (2005). Psychological factors related to delay in consultation for cancer symptoms. Psychooncology, 14, 339–350.PubMedCentralPubMedCrossRefGoogle Scholar
  31. Ristvedt, S. L., & Trinkaus, K. M. (2008). Sex differences in responding to rectal cancer symptoms. Psychology and Health, 23, 935–944.PubMedCentralPubMedCrossRefGoogle Scholar
  32. Robb, K., Stubbings, S., Ramirez, A., Macleod, U., Austoker, J., Waller, J., et al. (2009). Public awareness of cancer in Britain: A population-based survey of adults. British Journal of Cancer, 101, S18–S23.PubMedCentralPubMedCrossRefGoogle Scholar
  33. Singh, H., Daci, K., Petersen, L. A., Collins, C., Petersen, N. J., Shethia, A., et al. (2009). Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis. American Journal of Gastroenterology, 104, 2543–2554.PubMedCentralPubMedCrossRefGoogle Scholar
  34. Sobin, L. H., Wittekind, C., & International Union Against Cancer. (2002). TNM classification of malignant tumours (6th ed.). New York: Wiley-Liss.Google Scholar
  35. Takahashi, Y., Yamagata, S., Kijima, N., Shigemasu, K., Ono, Y., & Ando, J. (2007). Continuity and change in behavioral inhibition and activation systems: A longitudinal behavioral genetic study. Personality and Individual Differences, 43, 1616–1625.CrossRefGoogle Scholar
  36. USDA Economic Research Service. (2005). Measuring rurality: Rural-urban commuting area codes 2005 [Data file]. Retrieved from
  37. Weller, D., Vedsted, P., Rubin, G., Walter, F. M., Emery, J., Scott, S., et al. (2012). The Aarhus statement: Improving design and reporting of studies on early cancer diagnosis. British Journal of Cancer, 106, 1262–1267.PubMedCentralPubMedCrossRefGoogle Scholar
  38. Whisman, M. A., Richardson, E. D., & Smolen, A. (2011). Behavioral inhibition and triallelic genotyping of the serotonin transporter promoter (5-HTTLPR) polymorphism. Journal of Research in Personality, 45, 706–709.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Stephen L. Ristvedt
    • 1
    Email author
  • Sandi L. Pruitt
    • 2
  • Kathryn M. Trinkaus
    • 3
  1. 1.Department of PsychiatryWashington University School of MedicineSt. LouisUSA
  2. 2.Division of Outcomes and Health Services Research, Department of Clinical Sciences, Southwestern Medical CenterUniversity of TexasDallasUSA
  3. 3.Division of BiostatisticsWashington University School of MedicineSt. LouisUSA

Personalised recommendations