The lung cancer patient at the emergency department: a three-year retrospective study

Development of a claims-based risk-scoring model to predict emergency department visits in older patients receiving anti-neoplastic therapy

This study developed and validated a risk-scoring model, with a particular emphasis on medication-related factors, to predict emergency department (ED) visits among older Korean adults (aged 65 and older) undergoing anti-neoplastic therapy. Utilizing national claims data, we constructed two cohorts: the development cohort (2016-2018) with 34,642 patients and validation cohort (2019) with 10,902 patients. The model included a comprehensive set of predictors: demographics, cancer type, comorbid conditions, ED visit history, and medication use variables. We employed the least absolute shrinkage and selection operator (LASSO) regression to refine and select the most relevant predictors. Out of 120 predictor variables, 12 were integral to the final model, including seven related to medication use. The model demonstrated acceptable predictive performance in the validation cohort with a C-statistic of 0.76 (95% CI 0.74-0.77), indicating reasonable calibration. This risk-scoring model, after further clinical validation, has the potential to assist healthcare providers in the effective management and care of older patients receiving anti-neoplastic therapy.

A cognitive-behavioral model of dyspnea: Qualitative interviews with individuals with advanced lung cancer

OBJECTIVES

Shortness of breath, or dyspnea, is the subjective experience of breathing discomfort and is a common, distressing, and debilitating symptom of lung cancer. There are no efficacious pharmacological treatments, but there is suggestive evidence that cognitive-behavioral treatments could relieve dyspnea. For this, understanding the psychological, behavioral, and social factors that may affect dyspnea severity is critical. To this end, patients with dyspnea were interviewed with questions framed by the cognitive-behavioral model-emphasizing thoughts, emotions, and behaviors as contributors and outcomes of dyspnea.

METHODS

Two trained individuals conducted semi-structured interviews with lung cancer patients (N = 15) reporting current dyspnea. Interviews assessed patients' cognitive-behavioral experiences with dyspnea. Study personnel used a grounded theory approach for qualitative analysis to code the interviews. Inter-rater reliability of codes was high (κ = 0.90).

RESULTS

Thoughts: Most common were patients' catastrophic thoughts about their health and receiving enough oxygen when breathless. Emotions: Anxiety about dyspnea was the most common, followed by anger, sadness, and shame related to dyspnea. Behaviors: Patients rested and took deep breaths to relieve acute episodes of dyspnea. To reduce the likelihood of dyspnea, patients planned their daily activity or reduced their physical activity at the expense of engagement in hobbies and functional activities.

SIGNIFICANCE OF RESULTS

Patients identified cognitive-behavioral factors (thoughts, emotions, and behaviors) that coalesce with dyspnea. The data provide meaningful insights into potential cognitive-behavioral interventions that could target contributors to dyspnea.

Risk Factors for Return to the Emergency Department and Readmission in Patients With Hospital-Diagnosed Advanced Lung Cancer

BACKGROUND

Advanced lung cancer (ALC) is a symptomatic disease often diagnosed in the context of hospitalization. The index hospitalization may be a window of opportunity to improve care delivery.

OBJECTIVES

We examined the patterns of care and risk factors for subsequent acute care utilization among patients with hospital-diagnosed ALC.

RESEARCH DESIGN, SUBJECTS, AND MEASURES

In Surveillance, Epidemiology, and End Results-Medicare, we identified patients with incident ALC (stage IIIB-IV small cell or non-small cell) from 2007 to 2013 and an index hospitalization within 7 days of diagnosis. We used a time-to-event model with multivariable regression to identify risk factors for 30-day acute care utilization (emergency department use or readmission).

RESULTS

More than half of incident ALC patients were hospitalized around the time of diagnosis. Among 25,627 patients with hospital-diagnosed ALC who survived to discharge, only 37% ever received systemic cancer treatment. Within 6 months, 53% had been readmitted, 50% had enrolled in hospice, and 70% had died. The 30-day acute care utilization was 38%.Small cell histology, greater comorbidity, precancer acute care use, length of index stay >8 days, and prescription of a wheelchair were associated with higher risk of 30-day acute care utilization. Age >85 years, female sex, residence in South or West regions, palliative care consultation, and discharge to hospice or a facility were associated with lower risk.

CONCLUSIONS

Many patients with hospital-diagnosed ALC experience an early return to the hospital and most die within 6 months. These patients may benefit from increased access to palliative and other supportive care during index hospitalization to prevent subsequent health care utilization.

Lung cancer in the emergency department

Background

Though decreasing in incidence and mortality in the USA, lung cancer remains the deadliest of all cancers. For a significant number of patients, the emergency department (ED) provides the first pivotal step in lung cancer prevention, diagnosis, and management. As screening recommendations and treatments advance, ED providers must stay up-to-date with the latest lung cancer recommendations. The purpose of this review is to identify the many ways that emergency providers may intersect with the disease spectrum of lung cancer and provide an updated array of knowledge regarding detection, management, complications, and interdisciplinary care.

Findings

Lung cancer, encompassing 10-12% of cancer-related emergency department visits and a 66% admission rate, is the most fatal malignancy in both men and women. Most patients presenting to the ED have not seen a primary care provider or undergone screening. Ultimately, half of those with a new lung cancer diagnosis in the ED die within 1 year. Incidental findings on computed tomography are mostly benign, but emergency staff must be aware of the factors that make them high risk. Radiologic presentations range from asymptomatic nodules to diffuse metastatic lesions with predominately pulmonary symptoms, and some may present with extra-thoracic manifestations including neurologic. The short-term prognosis for ED lung cancer patients is worse than that of other malignancies. Screening offers new hope through earlier diagnosis but is underutilized which may be due to racial and socioeconomic disparities. New treatments provide optimism but lead to new complications, some long-term. Multidisciplinary care is essential, and emergency medicine is responsible for the disposition of patients to the appropriate specialists at inpatient and outpatient centers.

Conclusion

ED providers are intimately involved in all aspects of lung cancer care. Risk factor modification and referral for lung cancer screening are opportunities to further enhance patient care. In addition, with the advent of newer cancer therapies, ED providers must stay vigilant and up-to-date with all aspects of lung cancer including disparities, staging, symptoms of disease, prognosis, treatment, and therapy-related complications.

Predictors of Urgent Cancer Care Clinic and Emergency Department Visits for Individuals Diagnosed with Cancer

In 2013, CancerCare Manitoba (CCMB) launched an urgent cancer care clinic (UCC) to meet the needs of individuals diagnosed with cancer experiencing acute complications of cancer or its treatment. This retrospective cohort study compared the characteristics of individuals diagnosed with cancer that visited the UCC to those who visited an emergency department (ED) and determined predictors of use. Multivariable logistic mixed models were run to predict an individual’s likelihood of visiting the UCC or an ED. Scaled Brier scores were calculated to determine how greatly each predictor impacted UCC or ED use. We found that UCC visits increased up to 4 months after eligibility to visit and then decreased. ED visits were highest immediately after eligibility and then decreased. The median number of hours between triage and discharge was 2 h for UCC visits and 9 h for ED visits. Chemotherapy had the strongest association with UCC visits, whereas ED visits prior to diagnosis had the strongest association with ED visits. Variables related to socioeconomic status were less strongly associated with UCC or ED visits. Future studies would be beneficial to planning service delivery and improving clinical outcomes and patient satisfaction.

Cancer related emergencies with the chief complaint of pain: Incidence, ED recognition, and quality of care

BACKGROUND

Pain is the most common reason for cancer-related emergency department (ED) visits and a precursor of the urgency of oncological emergencies.

PURPOSE

To identify the incidence of oncological emergencies with the chief complaint of pain and evaluate ED recognition and quality of care in managing the associated emergency.

METHODS

This was a retrospective observational study of cancer patients presented to three EDs during the four-year study period.

RESULTS

The study's sample consisted of 252 patients admitted with oncological emergencies with a chief complaint of pain. Some oncological emergencies were more likely to be prioritized appropriately, such as febrile neutropenia and increased intracranial pressure. However, most patients with spinal cord compression and cardiac tamponade were more likely to be triaged to less urgent triage categories. Timeliness of ED care was suboptimal for most patients, particularly among those assigned to less urgent triage categories. Indicators for the low quality of care extended beyond ED with multiple adverse events in the hospital.

CONCLUSION

Triage nurses are expected to use the oncological emergencies' prevalent symptoms to allocate the patients to high triage urgency accurately. Patient waiting to be seen expected to be reassessed periodically to ensure waiting remain safe. Hospitals can adopt or establish pathways, protocols, or standardized order sets to fast-track patients with oncological emergencies. The health information system should be available to monitor and improve the delivered care continuously.

Gender-specific differences in care-seeking behaviour among lung cancer patients: a systematic review

BACKGROUND

In the literature, men are often described as unwilling to use healthcare services, whereas women as frequent users. We conducted a systematic literature review to examine the gender differences in healthcare utilisation of lung cancer patients. Our aim was to synthesise evidence to assess whether men and women utilise cancer diagnosis and treatments differently.

METHODS

The databases of PubMed, Scopus, Web of Science, EBSCO Host, Ovid nursing, and Cochrane was systematically searched. We used pre-defined eligibility criteria to identify peer-reviewed published literature that reported healthcare use of lung cancer patients. Two reviewers independently screened the title, abstract, full texts and retrieved relevant data.

RESULTS

A total of 42 studies met the eligibility criteria from 1356 potential studies. In these studies, the most commonly measured healthcare utilisation is surgery (n = 19), followed by chemotherapy (n = 13). All the studies were from developed countries and had a higher percentage of male participants. Substantial evidence of heterogeneity in the use of treatments by gender were found. In relation to diagnosis interval and stage of cancer diagnosis, it was found that women had longer diagnostic intervals. Nonetheless, women tend to get diagnosed at an earlier stage. Furthermore, women had a higher probability of using inpatient cancer-care services and surgical treatments. Conversely, men had greater risks of readmission after surgery and longer length of stay. Lastly, there were no significant gender differences in the likelihood of receiving chemotherapy and radiation therapy.

CONCLUSION

This study synthesised evidence of disparities in the use of lung cancer treatments based on gender in developed countries, with no evidence available from least-developed and developing countries. Further studies are required to understand this gender-specific inequality and to design interventions to improve the survival rate of lung cancer patients.

Clinical Characteristics of Patients with Cancer Presenting to the Emergency Department and Their Use of Emergency Medical Service Transport

Objectives: Although life-threatening emergencies for cancer patients are relatively rare, cancer patients often seek care in the emergency department. The use of emergency medical service (EMS) by these patients is not well studied. The aim of this study was to investigate the characteristics of cancer patients who present to the emergency department (ED) for care and compare characteristics of patients transported by EMS vs. those transported by private vehicle. Methods: Our retrospective cohort study was conducted in an EMS system with 21,070 annual transports and an academic ED with 129,263 annual visits. Our study consisted of patients with a new diagnosis of cancer between January 1 and July 1, 2015 who subsequently presented to the ED between January 1, 2015 and July 1, 2017. Study variables included patient demographics, mode of ED arrival, cancer type and treatment, patient clinical characteristics, and disposition. To describe differences in patient characteristics of EMS vs. private vehicle transport, we report variable frequencies and stratified them by mode of transport. Results: Of the 2,727 patients with a new diagnosis of cancer, 1,303 (47.8%) presented to the ED with a total of 3,590 visits in 30 months. EMS transported 22% of cancer patients to the ED vs. 78% transported by private vehicle. Thus, cancer patients would make up approximately 1.5% (781/52,675) of all EMS transports during the study period. For those transported by EMS, the most common chief complaints were respiratory distress (16.0%), pain (15.4%), and neurological symptoms (12.6%). Patients with cancer of the lung/respiratory tract (21.5%), upper GI (12.4%), and central nervous system (CNS) (11.0%) were most frequently transported by EMS. Older age, presence of CNS cancer, presentation with neurological or cardiovascular complaints, and higher acuity were significantly associated with EMS transport to ED, while gender and pain severity were not. Patients transported by EMS were more likely to be hospitalized and for greater than 2 days (p < 0.0001). Conclusions: Cancer patients frequently seek emergency care after initial diagnosis, most commonly present for symptom relief, and are often admitted. Patients transported by EMS are more likely to be admitted and for longer periods of time.

[Emergency room management of patients with lung cancer and organ failure]

BACKGROUND

When patients with lung cancer present to the emergency department with organ failure the question of admission to intensive care has to be considered. Our aim is to describe the process leading to the proposed management.

METHODS

Retrospectively, all patients admitted to the emergency room between December 2010 and January 2015 with a diagnosis of ICD-10 C34.9 (lung cancer) were reviewed. Those with at least one organ failure were included.

RESULTS

The records of 561 patients were reviewed, 79 (14%) had at least one organ failure. The majority of these patients received maximal medical care (59%), 25% exclusive palliative care, and 15% intensive care. Performance status, metastatic status and efficacy of anti-tumor treatment were recorded in the emergency medical record in 20%, 66% and 74% of cases, respectively. An opinion was obtained from the oncologist in 44% of cases and from the intensivist in 41% of cases. No external advice was provided in 27% of cases.

CONCLUSION

In the majority of cases, the decision on the intensity of care to be provided to patients with lung cancer and organ failure was made in a collective manner.

Initial presentation of lung cancer in the emergency department: a descriptive analysis

BACKGROUND

Guidelines aimed at improving care for lung cancer, the leading cause of cancer-related death in Canada and worldwide, require accurate knowledge of the diagnostic setting or pathway. We sought to determine how often lung cancer is initially diagnosed through the emergency department.

METHODS

We performed a descriptive study that included all cases of primary lung cancer diagnosed in residents of Nova Scotia in 2014. Cancer registry data included diagnostic data and date of death to Aug. 31, 2016. We reviewed linked hospital records, including laboratory and imaging results, to identify the first positive diagnostic study and the route of presentation (emergency department v. other). We evaluated time from diagnosis to death as a function of presentation route using Kaplan-Meier curves and Cox regression (hazard rate ratios [HRRs]).

RESULTS

Sufficient data were available for 946 of 951 cases identified, of which 336 (35.5%) were diagnosed through the emergency department. Cases diagnosed via the emergency department were more likely to be at an advanced stage (stage IV, 59.5% v. 43.4%), with patients experiencing shorter survival (1-yr survival, 28.4% v. 49.5%), including stage-specific survival. Mortality for cases diagnosed in the emergency department was 54% higher than for the non-emergency department group after adjusting for age and stage (HRR 1.54, 95% confidence interval 1.32-1.81). Few patients (7.1%, n = 24) who presented to the emergency department reported having no family physician.

INTERPRETATION

The emergency department is a common route of presentation for lung cancer and is associated with advanced stage at diagnosis and reduced survival time. Strategies are needed to encourage pre-emergent diagnosis and to ensure that emergency providers are supported in the initial care of patients with lung cancer.

Oncologic emergencies in a cancer center emergency department and in general emergency departments countywide and nationwide

Background

Although cancer patients (CPs) are increasingly likely to visit emergency department (ED), no population-based study has compared the characteristics of CPs and non-cancer patients (NCPs) who visit the ED and examined factors associated with hospitalization via the ED. In this study, we (1) compared characteristics and diagnoses between CPs and NCPs who visited the ED in a cancer center or general hospital; (2) compared characteristics and diagnoses between CPs and NCPs who were hospitalized via the ED in a cancer center or general hospital; and (3) investigated important factors associated with such hospitalization.

Methods and findings

We analyzed patient characteristic and diagnosis [based on International Classification of Diseases-9 (ICD-9) codes] data from the ED of a comprehensive cancer center (MDACC), 24 general EDs in Harris County, Texas (HCED), and the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1/1/2007–12/31/2009. Approximately 3.4 million ED visits were analyzed: 47,245, 3,248,973, and 104,566 visits for MDACC, HCED, and NHAMCS, respectively, of which 44,143 (93.4%), 44,583 (1.4%), and 632 (0.6%) were CP visits. CPs were older than NCPs and stayed longer in EDs. Lung, gastrointestinal (excluding colorectal), and genitourinary (excluding prostate) cancers were the three most common diagnoses related to ED visits at general EDs. CPs visiting MDACC were more likely than CPs visiting HCED to be privately insured. CPs were more likely than NCPs to be hospitalized. Pneumonia and influenza, fluid and electrolyte disorders, and fever were important predictive factors for CP hospitalization; coronary artery disease, cerebrovascular disease, and heart failure were important factors for NCP hospitalization.

Conclusions

CPs consumed more ED resources than NCPs and had a higher hospitalization rate. Given the differences in characteristics and diagnoses between CPs and NCPs, ED physicians must pay special attention to CPs and be familiar with their unique set of oncologic emergencies.

Presenting Symptoms in the Emergency Department as Predictors of Intensive Care Unit Admissions and Hospital Mortality in a Comprehensive Cancer Center

PURPOSE

The identification of patients at high risk for poor outcomes may allow for earlier palliative care and prevent futile interventions. We examined the association of presenting symptoms on risk of intensive care unit (ICU) admission and hospital death among patients with cancer admitted through an emergency department (ED).

METHODS

We queried MD Anderson Cancer Center databases for all patients who visited the ED in 2010. Presenting symptoms, ICU admissions, and hospital deaths were reviewed; patient data analyzed; and risk factors for ICU admission and hospital mortality identified.

RESULTS

The main presenting symptoms were pain, fever, and respiratory distress. Of the patients with cancer who visited the ED, 5,362 (58%) were admitted to the hospital at least once (range, 1 to 13 admissions), 697 (13%) were admitted to the ICU at least once, and 587 (11%) died during hospitalization (31% of 233 patients with hematologic malignancies and 27% of 354 patients with solid tumors died in the ICU; P < .001). In multivariable logistic regression, presenting symptoms of respiratory distress or altered mental status; lung cancer, leukemia, or lymphoma; and nonwhite race were independent predictors of hospital death. Patients who died had a longer median length of hospital stay than patients discharged alive (14 v 6 days for hematologic malignancies and 7 v 5 days for solid tumors; P < .001).

CONCLUSION

Patients with cancer admitted through an ED experience high ICU admission and hospital mortality rates. Patients with advanced cancer and respiratory distress or altered mental status may benefit from palliative care that avoids unnecessary interventions.

[The Glasgow inflammatory score and lung cancer: A predictor of admissions to emergency units]

INTRODUCTION

In a first study, we found predictive factors for hospital admission in lung cancer patients consulting at the emergency department. Knowing that systemic inflammation is a prognostic factor in cancer patients, the goal of our study was to determine whether systemic inflammation measured using the modified Glasgow prognostic score can improve the predictive value of our previous model.

METHODS

We conducted a retrospective study including all patients with lung cancer consulting at the emergency department of an oncology hospital between January 1st 2008 and December 31st 2010.

RESULTS

Of the 548 emergency department visits, C-reactive protein and albumin needed for calculating the Glasgow score, were available for 291 visits. Multivariate analysis identified three predictors of hospitalization subsequent to a visit at the emergency ward: the Modified Glasgow Prognostic Score (mGPS) (OR=2.72; P<0.0001), arrival by ambulance (odds ratio [OR]=21.38; P<0.0001) and the presence of physical signs associated with the complaint (OR=2.72; P<0.05).

CONCLUSION

The mGPS is an independent predictor for hospitalization in patients with lung cancer consulting at the emergency department.

Presentation patterns and outcomes of patients with cancer accessing care in emergency departments in Victoria, Australia

PURPOSE

People with cancer attend emergency departments (EDs) for many reasons. Improved understanding of the specific needs of these patients may assist in optimizing health service delivery. ED presentation and hospital utilization characteristics were explored for people with cancer and compared with those patients without cancer.

METHODS

This descriptive, retrospective, multicentre cohort study used hospital administrative data. Descriptive and inferential statistics were used to summarise and compare ED presentation characteristics amongst cancer and non-cancer groups. Predictive analyses were used to identify ED presentation features predictive of hospital admission for cancer patients. Outcomes of interest were level of acuity, ED and inpatient length of stay, re-presentation rates and admission rates amongst cancer patients and non-cancer patients.

RESULTS

ED (529,377) presentations occurred over the 36 months, of which 2.4% (n = 12,489) were cancer-related. Compared with all other attendances, cancer-related attendances had a higher level of acuity, requiring longer management time and length of stay in ED. Re-presentation rates for people with cancer were nearly double those of others (64 vs 33%, p < 0.001), with twice the rate of hospital admission (90 vs 46%, p < 0.001), longer inpatient length of stay (5.6 vs 2.8 days, p < 0.001) and had higher inpatient mortality (7.9 vs 1.0%, p < 0.001). Acuity and arriving by ambulance were significant predictors of hospital admission, with cancer-related attendances having ten times the odds of admission compared to other attendances (OR = 10.4, 95% CI 9.8-11.1).

CONCLUSIONS

ED presentations by people with cancer represent a more urgent, complex caseload frequently requiring hospital admission when compared to other presentations, suggesting that for optimal cancer care, close collaboration and integration of oncology, palliative care and emergency medicine providers are needed to improve pathways of care.

Rate and patterns of ICU admission among colorectal cancer patients: a single-center experience

PURPOSE

The purposes of this study were to evaluate, in colorectal cancer patients, the cause of ICU admission and to find predictors of death during and after hospitalization.

METHODS

This is a retrospective study including all patients with colorectal cancer admitted in the ICU of a cancer hospital from January 1st 2003 to December 31 2012.

RESULTS

Among 3721 ICU admissions occurring during the study period, 119 (3.2 %) admissions dealt with colorectal cancer, of whom 89 were eligible and assessable. The main reasons for admission were of metabolic (24 %), hemodynamic (19 %), cardiovascular (18 %), gastrointestinal (16 %), respiratory (13 %), or neurologic (6 %) origin. These complications were due to cancer in 43 %, to the antineoplastic treatment in 25 %, or were unrelated to the cancer or its treatment in 33 %. A quarter of the patients died during hospitalization. Independent predictors of death were the Sequential Organ Failure Assessment (SOFA) score (with risk of dying increasing by 42 % per unit of SOFA score), fever (with risk of dying multiplied by three per °C), and high values of GOT (with risk of dying multiplied by 1 % per unit increase), while cancer control (i.e., stage progression or not), compliance to the initial cancer treatment plan, and LDH ≤ median levels had prognostic significance for further longer survival after hospital discharge.

CONCLUSION

This is the first study looking at specific causes for unplanned ICU admission of patients with colorectal cancer. Hospital mortality was influenced by the characteristics of the complication that entailed the ICU admission while cancer characteristics retained their prognostic influence on survival after hospital discharge.

Evaluation of cancer patients admitted to the emergency department within one month before death in Turkey: what are the problems needing attention?

BACKGROUND

Although previously studies have reported that most patients with malignancy prefer to die at home, this is not the real situation in clinical practice.

AIM

In this study, we aimed to determine the characteristics of Turkish cancer patients admitted to the emergency department (ED) within one month before death.

MATERIALS AND METHOD

This descriptive retrospective study focused on questions about how often and why patients with cancer visited the ED before death. A total of 107 individuals with cancer were divided into 2 groups: Group 1, patients with at least one visit in the final 4 weeks; and Group 2, patients with no visit to ED. Demographic and clinical features were compared between the two groups.

STATISTICAL ANALYSES

Descriptive statistical methods, statistical analysis for correlation, Student's t-test, chi-square tests and logistic regression were used.

RESULTS

At least one visit to ED within one month before death was reported for 64 (60%) of the 107 cases. Of these 64 (Group 1), 38% (n=24) were discharged and 9% (n=6) died in the ED. The most common site of the primary tumor was the lung (n=24, 38%) and the most common symptom was dyspnea (92%). With the other 43 (40%) cancer patients not presenting to the ED within one month before death, they were more likely to be female with another type of cancer.

CONCLUSIONS

Guidelines are needed for better management of cancer patients benefiting from visits to ED within the last month of life .

Analysis of advanced lung cancer patients diagnosed following emergency admission

Data on prognosis and predictors of overall survival in advanced lung cancer patients diagnosed following emergency admission (DFEA) are currently lacking. We retrospectively analysed data from 771 patients with advanced nonsmall cell lung cancer between April 2004 and April 2012. Of the 771 patients, 103 (13%) were DFEA. DFEA was not an independent predictor of overall survival by multivariate Cox proportional hazard models, whereas good performance status (PS), epidermal growth factor receptor gene mutation, stage IIIB, adenocarcinoma and chemotherapy were independent predictors of overall survival (hazard ratio (95% CI) 0.36 (0.29-0.44), p<0.001; 0.49 (0.38-0.63), p<0.001; 0.64 (0.51-0.80), p<0.001; 0.81 (0.67-0.99), p=0.044; and 0.40 (0.31-0.52), p<0.001, respectively). Good PS just prior to opting for chemotherapy, but not at emergency admission, was a good independent predictor of overall survival in DFEA patients (hazard ratio (95% CI) 0.26 (0.12-0.55); p<0.001). DFEA is relatively common. DFEA and PS at emergency admission were not independent predictors of overall survival, but good PS just prior to opting for chemotherapy was an independent predictor of longer overall survival. Efforts to improve patient PS after admission should be considered vital in such circumstances.