Lung cancer diagnosis in the emergency department

Investigating socioeconomic disparities in lung cancer diagnosis, treatment and mortality: an Italian cohort study

BACKGROUND

Lung cancer is one of the most lethal cancers worldwide and patient clinical outcomes seem influenced by their socioeconomic position (SEP). Since little has been investigated on this topic in the Italian context, our aim was to investigate the role of SEP in the care pathway of lung cancer patients in terms of diagnosis, treatment and mortality.

METHODS

This observational retrospective cohort study included patients discharged in the Lazio Region with a lung cancer diagnosis between 2014 and 2017. In the main analysis, educational level was used as SEP measure. Multivariate models, adjusted for demographic and clinical variables, were applied to evaluate the association between SEP and study outcomes, stratified for metastatic (M) and non-metastatic (NM) cancer. We defined a diagnosis as 'delayed' when patients received their initial cancer diagnosis after an emergency department admission. Access to advanced lung cancer treatments (high-cost, novel and innovative treatments) and mortality were investigated within the 24-month period post-diagnosis. Moreover, two additional indicators of SEP were examined in the sensitivity analysis: one focusing on area deprivation and the other on income-based exemption.

RESULTS

A total of 13,251 patients were identified (37.3% with metastasis). The majority were males (> 60%) and over half were older than 70 years. The distribution of SEP levels among patients was as follow: 31% low, 29% medium-low, 32% medium-high and 7% high. As SEP increased, the risks of receiving a delayed diagnosis ((high vs low: M: OR = 0.29 (0.23-0.38), NM: OR = 0.20 (0.16-0.25)) and of mortality ((high vs low M: OR = 0.77 (0.68-0.88) and NM: 0.61 (0.54-0.69)) decreased. Access to advanced lung cancer treatments increased in accordance with SEP only in the M cohort (high vs low: M: OR = 1.57 (1.18-2.09)). The primary findings were corroborated by sensitivity analysis.

CONCLUSIONS

Our study highlighted the need of public health preventive and educational programs in Italy, a country where the care pathway of lung cancer patients, especially in terms of diagnosis and mortality, appears to be negatively affected by SEP level.

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.

Retrospective review of patients with lung cancer identified in the emergency department

BACKGROUND

Obtaining a diagnosis of cancer following an emergency department (ED) visit is associated with poor outcomes and advanced stage. Limited data is available from EDs in the United States. We describe a cohort of patients that obtained a diagnosis of lung cancer because of an ED visit.

METHODS

This is a single center, retrospective cohort of patients with lung cancer who presented to the ED between December 2016 and December 2019. We investigated demographics, access to primary care, previous cancer screening, cancer type/stage, mortality, and imaging study that suggested cancer. The primary outcome is the percentage of lung cancer diagnoses over a 4-year period that resulted from an ED visit.

RESULTS

Among the 268 patients with lung cancer, 152 patients (57.6%) had presented to the ED with a workup that was concerning for lung cancer. Patients were generally elderly (median 62-years old), African American (n = 77, 51%), and smokers (n = 145, 95.4%) with a median smoking pack years of 40. Only 24 patients (15.8%) had seen a primary care physician within 1 year of diagnosis, and only 8 patients were appropriately screened for lung cancer. The most common type of cancer was non-small-cell carcinoma (111, 73.0%), with 61.3% of those being adenocarcinoma (n = 68). Patients were most likely to be stage IV (n = 86, 56.6%), and the overall mortality was 53.3% (n = 81, 1 year follow-up). Most patients (88/152, 57.9%) of patients were admitted to the hospital, and Medicare patients (OR 2.7, 95% CI 1.37-5.23) and patients with stage IV disease (OR 2.22, 95% CI1.15-4.29) were more likely to be admitted. Patients were more likely to have a concerning finding on computed tomography (CT) versus chest x-ray (55.9% versus 36.8%, respectively). CT scan reports were more likely to mention malignancy (OR 5.9, 95% CI 2.5-14.0) or metastasis (OR 30, 95% CI 7.1-127.1) than chest x-ray.

CONCLUSION

Patients that have lung cancer diagnosed through the ED are more likely to be advanced stage at time of diagnosis and are more likely to have CT scans demonstrate concerning findings. Given the lack of previous cancer screening, the advanced stage at presentation of lung cancer to the ED, and high mortality rates, the ED may serve a public health role in addressing lung cancer screening.