Diagnosis of a cancer upon emergency department presentation was associated with an elevated mortality rate, which was consistent across 16 analyzed cancer types, according to new research findings published in the Journal of the National Cancer Institute.
“These gaps held up even after we accounted for age, cancer stage, other illnesses, and frailty,” said lead author Caroline Thompson, PhD, MPH, Associate Professor of Epidemiology at the University of North Carolina (UNC) Gillings School of Global Public Health and member of the UNC Lineberger Comprehensive Cancer Center. “How a cancer is found carries information about a patient’s outlook that goes beyond the tumor itself.”
Study Methods
Researchers analyzed individuals diagnosed with cancer in the emergency department and associated mortality after their emergency presentation across 16 cancers in a national Medicare cohort. They identified patients with high-burden cancers who were diagnosed between 2008 and 2017 (n = 929,378), based on SEER-Medicare data.
An emergency presentation was defined by an emergency department claim 30 days before the cancer claim. These presentations were classified as either inpatient or outpatient.
Survival probabilities and mortality risk ratios were estimated, and were also adjusted for demographics, tumor characteristics, comorbidity, frailty, and health-care utilization.
Key Findings
Twenty-eight percent of the patients diagnosed with high-burden cancers in the study period had an emergency presentation, including 22% inpatient and 6% outpatient. The most common cancers with an emergency presentation (> 40%) were liver, lung, stomach, colon, ovarian, and pancreatic cancers; cancers less likely (< 10%) to be diagnosed through an emergency presentation included breast and prostate cancer.
At 1 year, the survival rate was 81% for non–emergency presentations, 60% for outpatient presentation, and 36% for inpatient presentation. Inpatient emergency presentations had a nearly four-fold greater 30-day adjusted mortality than non–emergency presentations (risk ratio [RR] = 3.88; 95% confidence interval [CI] = 3.81–3.96). The risk ratios ranged from 2.1 for pancreatic cancer to 6.3 for lymphoma.
In patients who survived 90 days, inpatient emergency presentation was associated with a 51% higher mortality at 1 year (RR = 1.51; 95% CI = 1.49–1.52), ranging from a risk ratio of 1.1 for pancreatic cancer to 2.1 for lymphoma.
At 1 year, the mortality risk ratio for outpatient emergency presentations was 1.28 (95% CI = 1.26–1.30).
“These patients, sent home from the emergency department to finish their workup, are a distinctly American phenomenon that international definitions of emergency presentation miss entirely,” Dr. Thompson said. “And they were not disconnected from the health-care system. Their primary care use before diagnosis looked much like patients diagnosed the standard way. So, the story is not simply that these patients avoided doctors. Opportunities to diagnose them earlier may have been missed.”
“At the system level, the emergency department is where these patients surface, but it is not built to coordinate a cancer workup,” Dr. Thompson said. “Patients sent home with a suspected cancer can fall through the cracks between the emergency department and oncology. Building deliberate pathways to catch and move these patients quickly is a concrete opportunity to improve outcomes.”
The study authors concluded that routine emergency presentation monitoring could improve risk stratification and guide further efforts to reduce avoidable emergency department cancer diagnoses.
DISCLOSURES: For full disclosures of the study authors, visit academic.oup.com.
