Diagnosis of cancer in the Emergency Department: A scoping review

Registry versus claims-based index dates for studies of cancer diagnosis in administrative data

PURPOSE

Studies of healthcare encounters leading to cancer diagnosis have increased over recent years. While some studies examine healthcare utilization before the cancer registry date of diagnosis, relevant pre-diagnosis interactions are not always immediately prior to this date due to date abstraction guidelines. We evaluated agreement of a registry date with a claims-based index and examined Emergency Department (ED) involvement in cancer diagnosis as an example of possible pre-diagnostic healthcare misclassification that could arise from improper date choice.

METHODS

We implemented an algorithm to define a claims-based index as the date of the earliest International Classification of Diseases code for the cancer in Medicare and estimated agreement with the date of diagnosis from a North Carolina registry for patients diagnosed aged 66 or older with 16 cancer types from 2008 to 2017 (n = 92,056). We then classified whether each cancer was initially diagnosed through care originating in the ED using each date.

RESULTS

The index date was identical to the cancer registry date for 47% of patients and preceded the registry date for 28%, with extent of agreement varying by cancer- and patient-specific characteristics. Agreement in ED-involved diagnosis classification using each date varied by cancer site, with sensitivity of classifications using the registry date relative to the index having a minimum of 86% for prostate and kidney cancer.

CONCLUSION

Studies assessing healthcare utilization proximal to cancer diagnosis should carefully consider the relevant assessment window and be aware that the use of cancer registry versus claims-based dates may impact variable classification.

Implementing a pathway for patients diagnosed with cancer in the emergency department

Patients diagnosed with cancer or suspected cancer during an emergency department (ED) presentation are often signposted back to their GP for urgent referral to cancer services. However, this can result in delays in patients receiving specialist support, confirmation of diagnosis and, vitally, starting treatment. A quality improvement initiative that aimed to address these issues through the introduction of an ED suspected cancer diagnosis pathway was implemented by the acute oncology service in two EDs in Oxford University Hospitals NHS Foundation Trust in April 2023. Data collected during the first year of implementation of the pathway show there has been a significant increase in the numbers of patients meeting the NHS England 62-day referral to treatment standard and in the numbers of patients receiving support from an acute oncology named cancer clinical nurse specialist from the point of discharge from the ED. This article details the initiative, which is ongoing, and shares some of the results from the first year of data collection.

Current Challenges in Imaging-Based Cancer Screening, From the AJR Special Series on Screening

The early detection of cancer confers many significant benefits for patients, primarily by enabling less invasive and more effective treatments and thus lowering disease mortality. Radiology is integral to early cancer detection, playing either a primary or complementary role in screening programs. Imaging-based screening is often performed in conjunction with other screening tests and may involve multiple modalities depending on patient demographics and cancer type. When developing a screening program for cancer early detection, both its potential benefits and harms need to be assessed. These harms, although specific to the modality and cancer, often include overdiagnosis, overtreatment, and false-positive examinations. As radiology technology improves and new tools become available, the ratios of risk to harm of imaging-based screening will shift, and screening recommendations will need to adapt accordingly. Radiologists must be major partners in the development and execution of screening guidelines to ensure the highest quality of care for their patients. This review discusses the major challenges of cancer screening programs and guidelines, exploring sources of evidence as well as harms of overdiagnosis and overtreatment. The article focuses on the most common cancer types that incorporate imaging-based screening including lung cancer, breast cancer, colon cancer, prostate cancer, and hepatocellcular carcinoma.

Patterns in Symptoms Preceding Acute Care in Patients With Cancer

Importance

Patients with cancer frequently experience unplanned acute care with emergency department visits and hospitalization due to disease or treatment complications, which impacts outcomes, quality of life, and health care costs. There remains a knowledge gap in understanding patterns of symptoms that precede acute care events. Natural language processing (NLP) may enable greater understanding of the symptoms and identify differences across patient and cancer characteristics.

Objective

To characterize symptoms preceding acute care in patients with cancer and quantify differences in symptom documentation across sociodemographic and cancer histologic subgroups.

Design, Setting, and Participants

A cohort study in a single tertiary-care institution, including all acute care (emergency department and hospitalization) encounters for patients aged 18 years or older with a primary cancer diagnosis identified between January 1, 2013, and December 31, 2023.

Main Outcomes and Measures

Natural language processing was used to identify routine clinical documentation to characterize symptoms documented in the 30 days preceding acute care. Logistic regression analyses was used to examine the possible association between sex, age, race and ethnicity, insurance coverage, cancer histologic characteristics, and reported symptoms.

Results

Overall, 28 708 patients with cancer had 70 606 acute care visits with 854 830 associated preceding documented symptoms. Median age was 61 (IQR, 48-70) years. Men (37 861 encounters [53.62%]) and patients of White race (39 989 encounters [56.64%]) accounted for most acute care encounters. Pain (7.54% of documented symptoms), nausea (6.74%), and vomiting (5.79%) were the most frequently documented symptoms. Acute care encounters with patients who were female (adjusted odds ratio [AOR], 1.14; 95% CI, 1.10-1.18; P < .001), Asian (AOR, 1.22; 1.17-1.28; P < .001), Black (AOR, 1.17; 95% CI, 1.10-1.25; P < .001), American Indian or Alaska Native (AOR, 1.21; 95% CI, 1.01-1.44; P = .04), or Medicaid-insured (AOR, 1.10; 95% CI, 1.05-1.14; P < .001) were associated with a high documented symptom burden (>10 unique symptoms) preceding acute care visits. Patients aged 65 years or older (AOR, 0.96; 95% CI, 0.92-1.00; P = .04) or uninsured (AOR, 0.58; 95% CI, 0.45-0.76; P < .001) were less likely to have a high symptom burden documented before acute care events.

Conclusions and Relevance

The findings of this study highlight common symptoms preceding acute care as well as the need for further research on interventions to reduce patient burden, improve quality of life, and reduce the use of acute care in patients with cancer.

Outcomes for Emergency Presentations of Lung Cancer: A Scoping Review

BACKGROUND

Lung cancer is frequently detected during visits to the emergency department (ED). The ED is crucial for identifying likely cases of lung cancer and coordinating the subsequent care for these patients.

OBJECTIVES

This scoping review aims to explore the definitions of emergency presentations (EPs) of lung cancer, along with mortality rates, cancer stage, and treatments for patients diagnosed with lung cancer following an EP.

METHODS

We conducted a scoping review of the literature on EPs of lung cancer, identifying 27 relevant articles out of 1338 initially screened.

RESULTS

Most studies originated from the United Kingdom, collectively reporting over 270,000 EPs of lung cancer. The majority of included studies provided strong evidence. Key findings revealed higher mortality rates among patients diagnosed with lung cancer through emergency presentations, with a significant proportion presenting at advanced stages. Patients with EPs were less likely to undergo surgical removal or receive radiotherapy. Lastly, only 66.7% of the studies defined an EP, with great heterogeneity among EP definitions. Methodological differences precluded meta-analysis.

CONCLUSION

Despite methodological heterogeneity, our synthesis indicates that patients presenting acutely with undiagnosed lung cancer often present at advanced stages and experience high mortality rates. These findings underscore the need for further research to develop evidence-based interventions for improving outcomes among ED patients with suspected lung cancer.

Improving Cancer Diagnosis in Alberta, Canada: A Qualitative Study of Emergency Department Healthcare Providers' Perspectives on Diagnosing Cancer in the Emergency Setting

Cancer is the leading cause of death in Canada, with diagnoses increasing annually. In Alberta, many cancer cases are detected in emergency departments, often at advanced stages. Despite the significant role of emergency departments in cancer diagnosis, limited research exists on the experiences of healthcare providers in this context. This qualitative study aimed to explore the perspectives of physicians and nurses working in emergency departments in Edmonton and Calgary regarding cancer diagnosis. Semi-structured interviews were conducted with 17 physicians and nurses, recruited through convenience and snowball sampling. Data collection continued until thematic saturation was reached. Interviews were analyzed thematically using an inductive, iterative process. Three main themes emerged: the acute care focus of the emergency department, its unsuitability for cancer diagnosis, and the need for systemic improvements to better support patients with suspected cancer. Participants highlighted challenges related to high patient volumes, the emotional burden of delivering cancer diagnoses, and barriers to effective communication and patient interaction in a fast-paced, high-pressure environment. The findings suggest the need for systemic reforms, including stronger primary care and improved care coordination, to alleviate pressure on emergency departments and enhance both patient outcomes and healthcare provider well-being.

Pathways to cancer care after a suspected cancer diagnosis in the emergency department: a survey of emergency physicians across Ontario

INTRODUCTION

Little is known about how patients are managed after a suspected cancer diagnosis through the emergency department. The objective of this study was to examine the ED management, specifically referral practices, for ten suspected cancer diagnoses by emergency physicians across Ontario and to explore variability in management by cancer-type and centre.

METHODS

An electronic survey was distributed to emergency physicians across Ontario, asking about referral practices for patients who could be discharged from the ED with one of ten suspected cancer diagnoses. Options for referral included: in-ED consult, outpatient medical or surgical specialists, surgical or medical oncology, and specialized cancer clinics. Data were described using frequencies and proportions. Variance partition coefficients were calculated to determine variation in responses attributed to differences between hospitals, with physicians nested within hospitals.

RESULTS

262 physicians from 54 EDs responded. Across most cancers, emergency physicians would refer to surgical specialists for further work-up; however, this ranged from 30.2% for lung cancer to 69.5% for head and neck cancer. For patients with an unknown primary malignancy, most physicians would refer to internal medicine clinic (34.3%) or obtain an in-ED consult (25.0%). Few physicians would refer directly to surgical or medical oncology from the ED. Comments suggest this may be due to oncologists requiring tissue confirmation of malignancy. Most referrals to specialized clinics were for suspected lung (30.2%) or breast cancer (19.5%); however, these appear to only be available at some centres. Variance in referrals between hospitals was lowest for breast cancer (variance partition coefficient = 8.6%) and highest for unknown primary malignancies (variance partition coefficient = 29.8%).

INTERPRETATION

Physician management of new suspected cancer varies between EDs and is specific to cancer type. Strategies to standardize access to cancer care in a timely and equitable way for patients with newly suspected cancer in the ED are needed.

Emergency department use before cancer diagnosis in Ontario, Canada: a population-based study

BACKGROUND

Although suspicions of cancer may be raised in patients who visit the emergency department, little is known about emergency department use before a cancer diagnosis. We sought to describe emergency department use among patients in Ontario within the 90 days before confirmed cancer diagnosis and to evaluate factors associated with this emergency department use.

METHODS

We conducted a retrospective, population-based study of patients aged 18 years or older who had a confirmed cancer diagnosis in Ontario from 2014 to 2021 using linked administrative databases. The primary outcome was any emergency department visit within 90 days before the cancer diagnosis date. We used multivariable logistic regression to evaluate factors associated with emergency department use, such as demographics (e.g., age, sex, rurality, Ontario Health region, indicators of marginalization), comorbidities, previous emergency department visits and hospital admissions, continuity of primary care, type of cancer, and year of cancer diagnosis.

RESULTS

We included 651 071 patients with cancer. Of these, 229 683 (35.3%) had an emergency department visit within 90 days before diagnosis, 51.4% of whom were admitted to hospital from the emergency department. Factors associated with increased odds of emergency department use before cancer diagnosis included rurality (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.13-1.17), residence in northern Ontario (North East region OR 1.14, 95% CI 1.10-1.17 and North West region OR 1.27, 95% CI 1.21-1.32, v. Toronto region), and living in the most marginalized areas (material resources OR 1.37, 95% CI 1.35-1.40 and housing OR 1.09, 95% CI 1.06-1.11, v. least marginalized quintile). We observed significant variation in emergency department use by cancer type, with high odds of emergency department use among patients with intracranial, pancreatic, liver or gallbladder, or thoracic cancer.

INTERPRETATION

Emergency department use is common before cancer diagnosis, with about one-third of patients with cancer in Ontario using the emergency department before diagnosis. Understanding why patients visit the emergency department before cancer diagnosis is important, particularly for patients who live in rural or marginalized areas, or those who have specific cancer types.

Predictors and consequences of different pathways to emergency diagnosis of cancer in England: Evidence from linked national audit and cancer registration data

BACKGROUND

Diagnosis of cancer soon after emergency care use is associated with adverse prognosis. We aimed to more precisely explore different definitions of emergency diagnosis.

METHODS

For 43,383 patients in the National Cancer Diagnosis Audit and Routes to Diagnosis datasets, we defined two emergency care pathways: emergency referral (Type-A) and emergency hospital admission (Type-B). We examined patient and tumour factors associated with each pathway excluding the other, and in combination (Type-A+B), in particular their concordance and prognostic implications for short-term mortality.

RESULTS

One in five patients (19 %) were diagnosed following emergency care use: 4 % through Type-A only, 7 % through Type-B only, and 8 % through Type-A+B. Higher co-morbidity, deprivation, advanced stage and certain cancer sites were associated with greater risk of emergency diagnosis. Concordance of emergency diagnosis pathway between Type-A and Type-B increased with age, co-morbidity and certain cancer sites. Patients with non-alarm symptoms were more likely to self-refer (Type-A) to an Emergency Department than patients with alarm symptoms. Associations with higher short-term mortality were strongest for Type-A+B.

CONCLUSIONS

We profile different pathways to emergency diagnosis and identify opportunities to improve diagnostic processes for these patients.

Proportion trends, cancer stage, and survival of patients with cancer diagnosed through emergency and nonemergency departments: a nationwide cohort study

Introduction

To reduce mortality, the Taiwan government has vigorously promoted free cancer screening and preventive health screening services. Cancers are usually advanced by the time they are discovered in the emergency department. Through this study, we aimed to understand the characteristics of cancer patients diagnosed through the emergency department and thus identify high-risk populations by comparing cancer staging and survival rates in patients diagnosed in the emergency department and those diagnosed in the non-emergency department.

Methods

The retrospective study enrolled a total of 389,043 patients over the age of 20 who were newly diagnosed with one of the five major cancers (including lung cancer, colorectal cancer, breast cancer, prostate cancer, and oral cancer) between 2008 and 2017 and analyzed their diagnostic pathway, cancer stage at diagnosis, and survival time.

Results

Of the study participants, 59,423 patients (about 15.3%) were diagnosed with cancer through the emergency department. We found that a sizable proportion of older people and patients with low education and low incomes were diagnosed through emergency department visits, and those with a health condition comorbidity severity of 3 had the highest proportion diagnosed by the emergency department, advanced stages at diagnosis, and risk of death. These can be classified as high-risk groups. In addition, 76.4% of patients diagnosed in the emergency department had advanced cancer, and the risk of death was 1.46 times higher than that of patients diagnosed in the non-emergency department. Although cancer screening is available, it does not reduce the proportion of patients with advanced cancer who are diagnosed through or at the time of diagnosis in the emergency department.

Conclusions

The present study found that the government's cancer screening did not affect the proportion or number of cancers diagnosed through emergency department visits. Therefore, the government should focus on more cancer screening, health education in high-risk groups, and strengthening the link between emergency and oncology departments to reduce the risk of death for patients diagnosed through emergency department visits.

Minorities Face Delays to Pancreatic Cancer Treatment Regardless of Diagnosis Setting

INTRODUCTION

Our analysis was designed to characterize the demographics and disparities between the diagnosis of pancreas cancer during emergency presentation (EP) and the outpatient setting (OP) and to see the impact of our institutions pancreatic multidisciplinary clinic (PMDC) on these disparities.

METHODS

Institutional review board-approved retrospective review of our institutional cancer registry and PMDC databases identified patients diagnosed/treated for pancreatic ductal adenocarcinoma between 2014 and 2022. Chi-square tests were used for categorical variables, and one-way ANOVA with a Bonferroni correction was used for continuous variables. Statistical significance was set at p < 0.05.

RESULTS

A total of 286 patients met inclusion criteria. Eighty-nine patients (31.1%) were underrepresented minorities (URM). Fifty-seven (64.0%) URMs presented during an EP versus 100 (50.8%) non-URMs (p = 0.037). Forty-one (46.1%) URMs were reviewed at PMDC versus 71 (36.0%) non-URMs (p = 0.10). No differences in clinical and pathologic stage between the cohorts (p = 0.28) were present. URMs took 22 days longer on average to receive treatment (66.5 days vs. 44.8 days, p = 0.003) in the EP cohort and 18 days longer in OP cohort (58.0 days vs. 40.5 days, p < 0.001) compared with non-URMs. Pancreatic Multidisciplinary Clinic enrollment in EP cohort eliminated the difference in time to treatment between cohorts (48.3 days vs. 37.0 days; p = 0.151).

RESULTS

Underrepresented minorities were more likely to be diagnosed via EP and showed delayed times to treatment compared with non-URM counterparts. Our PMDC alleviated some of these observed disparities. Future studies are required to elucidate the specific factors that resulted in these findings and to identify solutions.

Current gaps in emergency medicine core content education for oncologic emergencies: A targeted needs assessment

Objective

The core content of emergency medicine (EM) residency training includes the management of oncologic emergencies; however, documented knowledge gaps continue to exist in this subtopic. This study represents a targeted needs assessment as indicated by Step 2 of Kern's curriculum design to determine the specific training gaps to be addressed within the oncologic EM curriculum.

Methods

A multi-institutional cross-sectional survey of oncologists (surgical and medical) and emergency physicians (attendings and residents) was conducted during 2023 at five institutions. The voluntary survey consisted of general and specialty-specific questions exploring gaps in oncologic emergency-specific training/education topics. Descriptive statistics reported responses as frequencies and percentages.

Results

Of the 833 surveys sent across the five sites, 302 (36.3%) were accessed by link; of these, 271 (89.7%) surveys were completed. There were no differences in the responses between early and later respondents and no differences in the characteristics of respondents between sites. A vast majority of the oncologist and EM groups (91.2% and 83.0%, respectively) reported a belief that emergency physicians would benefit from additional oncologic emergency training. Our survey identified 16 important topics for inclusion in an oncologic EM curriculum, including five topics not present on the 2022 Model of Clinical Practice of Emergency Medicine.

Conclusions

Based on this needs assessment, an oncologic EM curriculum should include the topics listed under oncologic emergencies in the 2022 Model of the Clinical Practice of Emergency Medicine along with our respondent-identified topics of radiation therapy adverse effects, stem cell transplant complications, and the management of cancer-specific postsurgical complications, pain, and common diseases in patients with cancer.

Understanding mechanisms of racial disparities in breast cancer: an assessment of screening and regular care in the Carolina Breast Cancer Study

PURPOSE

Screening history influences stage at detection, but regular preventive care may also influence breast tumor diagnostic characteristics. Few studies have evaluated healthcare utilization (both screening and primary care) in racially diverse screening-eligible populations.

METHODS

This analysis included 2,058 women age 45-74 (49% Black) from the Carolina Breast Cancer Study, a population-based cohort of women diagnosed with invasive breast cancer between 2008 and 2013. Screening history (threshold 0.5 mammograms per year) and pre-diagnostic healthcare utilization (i.e. regular care, based on responses to "During the past ten years, who did you usually see when you were sick or needed advice about your health?") were assessed as binary exposures. The relationship between healthcare utilization and tumor characteristics were evaluated overall and race-stratified.

RESULTS

Among those lacking screening, Black participants had larger tumors (5 + cm) (frequency 19.6% vs 11.5%, relative frequency difference (RFD) = 8.1%, 95% CI 2.8-13.5), but race differences were attenuated among screening-adherent participants (10.2% vs 7.0%, RFD = 3.2%, 0.2-6.2). Similar trends were observed for tumor stage and mode of detection (mammogram vs lump). Among all participants, those lacking both screening and regular care had larger tumors (21% vs 8%, RR = 2.51, 1.76-3.56) and advanced (3B +) stage (19% vs 6%, RR = 3.15, 2.15-4.63) compared to the referent category (screening-adherent and regular care). Under-use of regular care and screening was more prevalent in socioeconomically disadvantaged areas of North Carolina.

CONCLUSIONS

Access to regular care is an important safeguard for earlier detection. Our data suggest that health equity interventions should prioritize both primary care and screening.

Shared decision-making needs, barriers, and facilitators of patients with newly diagnosed advanced cancer in the hospital: a multi-level, mixed-methods study

PURPOSE

Little is known about the shared decision-making (SDM) needs, barriers, and facilitators of patients with newly diagnosed advanced cancer in the hospital. Understanding this may improve SDM and cancer care quality in this vulnerable population.

METHODS

A single-site, mixed-methods study of hospitalized patients with newly diagnosed advanced cancer, caregivers, and oncologists was conducted. After discharge, patient ± caregiver semi-structured interviews exploring SDM needs, barriers, and facilitators regarding their most important upcoming cancer-related decision were conducted. Oncologists were surveyed about patient knowledge and SDM needs using closed- and open-ended questions, respectively. Thematic analysis was performed for qualitative data with a focus on themes unique to or amplified by hospitalization. Descriptive statistics and the Chi-squared test were performed for quantitative data.

RESULTS

Patients and caregivers reported high SDM needs surrounding treatment and prognostic information, leading to decisional conflict. Eight themes emerged: anticipated cancer treatment decisions, variable control preferences in decision-making, high cancer-related information needs and uncertainty, barriers and facilitators to information gathering during and post hospitalization, and decision-making facilitators. Among 32 oncologists, most (56%) reported patients were poorly informed about treatment and prognosis. Oncologists reported variable expectations about patient knowledge after hospitalization, facilitators to patient decision-making, and patient uncertainty while awaiting an outpatient oncologist appointment.

CONCLUSION

Patients newly diagnosed with advanced cancer in the hospital have high SDM needs and experience decisional conflict. This may be due to barriers unique to or exacerbated by hospitalization. Further research is needed to develop strategies to address these barriers and enhance the facilitators identified in this study.

BrainNet: Precision Brain Tumor Classification with Optimized EfficientNet Architecture

Brain tumors significantly impact human health due to their complexity and the challenges in early detection and treatment. Accurate diagnosis is crucial for effective intervention, but existing methods often suffer from limitations in accuracy and efficiency. To address these challenges, this study presents a novel deep learning (DL) approach utilizing the EfficientNet family for enhanced brain tumor classification and detection. Leveraging a comprehensive dataset of 3064 T1‐weighted CE MRI images, our methodology incorporates advanced preprocessing and augmentation techniques to optimize model performance. The experiments demonstrate that EfficientNetB(07) achieved 99.14%, 98.76%, 99.07%, 99.69%, 99.07%, 98.76%, 98.76%, and 99.07% accuracy, respectively. The pinnacle of our research is the EfficientNetB3 model, which demonstrated exceptional performance with an accuracy rate of 99.69%. This performance surpasses many existing state‐of‐the‐art (SOTA) techniques, underscoring the efficacy of our approach. The precision of our high‐accuracy DL model promises to improve diagnostic reliability and speed in clinical settings, facilitating earlier and more effective treatment strategies. Our findings suggest significant potential for improving patient outcomes in brain tumor diagnosis.

Impact of the COVID-19 Pandemic on the Treatment of Cancer Patients at a Hospital in Peru

BACKGROUND

The appearance of the new coronavirus, SARS-CoV-2, in Wuhan - China, in 2019 led to the declaration of a COVID-19 pandemic by the World Health Organization. Peru confirmed its first case on March 6, 2020, prompting a significant change in medical care.

PURPOSE

Our objective was to determine the impact of the COVID-19 pandemic on cancer treatment in Peru.

METHODS

A retrospective analysis of hospital data from the National Institute of Neoplastic Diseases revealed substantial decreases in oncological treatments in 2020 compared to 2019.

RESULTS

Oncological treatments involving bone marrow transplantation had a greater impact between the months of April and September, at -100% (p=0.003). However, treatments involving surgery in April (-95% [p≤0.001]), radiotherapy in May (-76% [p=0.002]) and chemotherapy in June (-71% [p≤0.001]) also showed significant impacts. Comparative analysis with international data revealed similar trends in cancer care interruptions in different countries. However, variations in the magnitude of the impact were observed, influenced by regional health policies and the severity of the pandemic.

CONCLUSIONS

The findings underscore the challenges cancer care providers face during public health crises, requiring adaptive strategies to ensure continued access to essential treatments. Addressing these challenges requires comprehensive public health responses to mitigate the impact of future crises on cancer care systems.

Retrospective review of patients with lung cancer presenting emergently

BACKGROUND

A significant proportion of lung cancer patients receive their diagnosis as part of an emergency presentation (EPs) to emergency departments (EDs).

OBJECTIVES

This study aimed to describe EPs of lung cancer at a safety-net hospital system.

METHODS

We conducted a retrospective analysis of patients with lung cancer at a safety-net ED. EP was defined as a diagnosis of lung cancer due to an acute presentation with symptoms of undiagnosed lung cancer (e.g., cough, hemoptysis, shortness of breath). Non-EPs were the result of either incidental findings (trauma pan-scan) or as part of lung cancer screening.

RESULTS

A total of 333 patient charts were reviewed who had lung cancer. Of those, 248 (74.5%) were defined as having an EP. EPs were more likely stage IV than non-EPs (50.4% vs 32.9%). The percent mortality was higher for EP versus non-EP, 60.0% vs 49.4%. which is driven by a high mortality rate for stage IV EPs (77.5%). Most patients with an EP were seen in the ED (177, 71.4%) as the location of initial visit that had a workup concerning for lung cancer. Most of the EPs were admitted for completion of either their diagnostic work up and/or for symptom management (117, 66.5%). Logistic regression identified significant predictors for an EP including stage IV at diagnosis (OR 2.49, 95% CI 1.39-4.48) and lack of primary care (OR 0.07, 95% CI 0.009-0.53).

CONCLUSION

Most patients with lung cancer present acutely as an EP with advanced stage in a safety-net health care setting. The ED plays an important role in the initial diagnosis of lung cancer and coordinating subsequent cancer care.

Retrospective study of cancer patients' predictive factors of care in a large, Hungarian tertiary care centre

OBJECTIVES

To identify predictive factors of multiple emergency department (ED) visits, hospitalisation and potentially preventable ED visits made by patients with cancer in a Hungarian tertiary care centre.

DESIGN

Observational, retrospective study.

SETTING

A large, public tertiary hospital, in Somogy County, Hungary, with a level 3 emergency and trauma centre and a dedicated cancer centre.

PARTICIPANTS

Patients above 18 years with a cancer diagnosis (International Classification of Diseases, 10th Revision codes of C0000-C9670) who visited the ED in 2018, who had received their diagnosis of cancer within 5 years of their first ED visit in 2018 or received their diagnosis of cancer latest within the study year. Cases diagnosed with cancer at the ED (new cancer diagnosis-related ED visits) were also included, constituting 7.9% of visits.

PRIMARY OUTCOME MEASURES

Demographic and clinical characteristics were collected and the predictors of multiple (≥2) ED visits within the study year, admission to inpatient care following the ED visit (hospitalisation), potentially preventable ED visits and death within 36 months were determined.

RESULTS

2383 ED visits made by 1512 patients with cancer were registered. Predictive factors of multiple (≥2) ED visits were residing in a nursing home (OR 3.09, 95% CI 1.88 to 5.07) and prior hospice care (OR 1.87, 95% CI 1.05 to 3.31). Predictive factors for hospitalisation following an ED visit included a new cancer diagnosis-related visit (OR 1.86, 95% CI 1.30 to 2.66) and complaint of dyspnoea (OR 1.61, 95% CI 1.22 to 2.12).

CONCLUSIONS

Being a resident of a nursing home and receiving prior hospice care significantly increased the odds of multiple ED visits, while new cancer-related ED visits independently increased the odds of hospitalisation of patients with cancer. This is the first study to report these associations from a Central-Eastern European country. Our study may shed light on the specific challenges of EDs in general and particularly faced by countries in the region.

Diagnosis of cancer in the Emergency Department: A scoping review

BACKGROUND

The Emergency Department (ED) plays a key role in the identification and care of acute medical conditions, including cancer. In this scoping review, we aimed to determine the role of the ED in the acute diagnosis of cancer.

METHODS

We conducted a scoping review of articles according to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) using PubMed and Google Scholar. We screened studies of adults with a new diagnosis of cancer in the ED. We included randomized control trials, prospective, retrospective, and cross-sectional observational studies, and case reports published in English since 2000. We grouped the articles into categories based on their objectives and findings.

RESULTS

Of the 4459 articles, we included 47 in the review. The identified studies fell into three major categories: (1) studies describing the incidental diagnosis of cancer in the ED (n = 11, 23%), (2) studies characterizing the acute initial presentation of cancer in the ED (n = 19, 41%), and (3) studies describing the ED as a pathway to cancer diagnosis in the healthcare system (n = 17, 36%). Across the studies, cancer diagnoses in the ED were more likely in patients with higher comorbidities, occurred at later stages, and resulted in worse survival rates.

CONCLUSIONS

The ED plays a prominent role in the initial diagnosis of cancer. Efforts must be made to integrate the ED within the cancer care continuum.