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

Emergency Department Visits Before Cancer Diagnosis Among Women at Mayo Clinic

Objective

To determine associations of incident cancer diagnoses in women with recent emergency department (ED) care.

Patients and Methods

A retrospective cohort study analyzing biological females aged 18 years and older, who were diagnosed with an incident primary cancer (12 cancer types studied) from January 1, 2015, to December 31, 2021, from electronic health records. The primary outcome was a cancer diagnosis within 6 months of a preceding ED visit. Secondary outcomes included patient factors associated with a preceding ED visit.

Results

Of 25,736 patients (median age of 62 years, range 18-101) diagnosed with an incident primary cancer, 1938 (7.5%) had an ED visit ≤6 months before a diagnosis. The ED-associated cancer cases were highest in lung cancer (n=514, 14.7%) followed by acute lymphoblastic leukemia (n=22, 13.3%). Patient factors increasing the likelihood of ED evaluation before diagnosis included 18-50 years of age (OR=1.32; 95% CI, 1.09-1.61), Elixhauser score (measure of comorbidities) >4 (OR=17.90; 95% CI, 14.21-22.76), use of Medicaid or other government insurance (OR=2.10; 95% CI, 1.63-2.69), residence within the institutional catchment areas (OR=3.18; 95% CI, 2.78-3.66), non-Hispanic Black race/ethnicity (OR=1.41; 95% CI, 1.04-1.88), and established primary care provider at Mayo Clinic (OR=1.45; 95% CI, 1.28-1.65). The ED visits were more likely in those who died within 6 months of diagnosis (n=327, 37.8%) than those who did not die (n=1611, 6.5%).

Conclusion

Patient characteristics identified in this study offer opportunities to provide cancer risk assessment and health navigation, particularly among individuals with comorbidities and limited health care access.

Patient outcomes associated with cancer diagnosis through the emergency department: A systematic review

OBJECTIVE

Many patients are initially diagnosed with a new suspected cancer through the emergency department (ED). The objective of this systematic review was to compare stage of cancer and survival of patients diagnosed with cancer through the ED to patients diagnosed elsewhere.

METHODS

Electronic searches of Medline and EMBASE were conducted and reference lists were hand-searched. Studies comparing adult patients diagnosed with any type of cancer through the ED (ED diagnosis) to patients diagnosed elsewhere (non-ED diagnosis) were included. Two reviewers independently screened titles and abstracts, assessed quality of the studies, and extracted data. The risk of bias of included studies was assessed using the Newcastle-Ottawa Scale. Data pertaining to patient outcomes were summarized and pooled using random-effects models and reported as risk ratios (RRs) with 95% confidence intervals (CIs), where applicable.

RESULTS

Fourteen studies were included. There was an increased risk of more advanced/later stage cancer (Stage III/IV or late-stage vs. earlier stage) among patients with an ED diagnosis of cancer compared to a non-ED diagnosis of cancer (RR 1.30, 95% CI 1.39-1.58). Survival was lower for patients with an ED diagnosis of cancer compared to those diagnosed elsewhere (RR 0.61, 95% CI 0.49-0.75).

CONCLUSIONS

Patients with an ED diagnosis of cancer had more advanced/late stage of cancer at diagnosis and worse survival compared to patients diagnosed elsewhere. Future research examining patients diagnosed with cancer through the ED is required.

First-line osimertinib for patients with EGFR-mutated advanced non-small cell lung cancer: efficacy and safety during the COVID-19 pandemic

Background

The FLAURA trial demonstrated improved overall survival (OS) with first-line osimertinib for patients with epidermal growth factor receptor (EGFR)-mutated advanced non-small cell lung cancer (NSCLC). We studied the efficacy and safety of osimertinib in a cohort treated during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

Patients diagnosed with EGFR-mutated advanced NSCLC between 11 March 2020 to 31 December 2021 who received first-line osimertinib in British Columbia, Canada were identified retrospectively. Kaplan-Meier curves of OS and progression-free survival (PFS) from the start of osimertinib were plotted. The associations of baseline characteristics with PFS, and development of pneumonitis or dose reductions due to toxicity with OS were evaluated with hazard ratios estimated using univariable and multivariable Cox models.

Results

The cohort comprised 231 individuals. 58.7% of patients with de novo advanced NSCLC were initially diagnosed after presentation to the Emergency Room. At osimertinib initiation, 31.6% were aged ≥75 years and 45.5% had an Eastern Cooperative Oncology Group performance status (ECOG PS) ≥2. Median PFS and OS were 18.0 months [95% confidence interval (CI): 16.1-26.2] and 25.4 months (95% CI: 20.3-not reached), respectively. On multivariable analysis, age ≥75 years (vs. <75), ECOG PS 2/3 (vs. 0/1), ECOG PS 4 (vs. 0/1), current smokers (vs. never smokers), programmed death ligand 1 (PD-L1) expression ≥50% (vs. <1%), and L858R mutation (vs. exon 19 deletion) were associated with shorter PFS. Among 110 patients who progressed, 33.6% received subsequent therapy. A proportion of 16.5% of the cohort developed grade ≥3 adverse events. Pneumonitis from osimertinib (3.9% incidence) was weakly associated with shorter OS (hazard ratio: 2.59, 95% CI: 0.94-7.12, P=0.066); dose reductions were not associated with worse OS. 10.8% of patients developed COVID-19.

Conclusions

In a cohort receiving first-line osimertinib during the COVID-19 pandemic, ECOG PS ≥2 was observed in nearly half of patients at treatment initiation contributing to a median OS shorter than in FLAURA. The incidence of severe adverse events was low and dose reduction for drug toxicity did not impact OS. Identifying and reducing barriers to the diagnosis of NSCLC during the COVID-19 pandemic are required.

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.

Emergency surgical consultation for cancer patients: identifying the prognostic determinants of health

BACKGROUND

Patients with malignancy often require urgent surgical consultation for treatment or palliation of disease. The objective of this study is to explore the prognostic determinants affecting care in acute cancer-related surgical presentations and the effect on patient outcomes.

MAIN BODY

This is a retrospective review of patients referred to the acute general surgery (ACS) service at a tertiary hospital for management of cancer-related problem from July 2017 to September 2018. Patient demographics, course in hospital, and survival were recorded. Multivariant logistic regression and Kaplan-Meier estimates were performed. One hundred eighty-nine patients were identified (53% female) with a mean age of 65.9 years. Forty-two patients (22%) were newly diagnosed with cancer on presentation, and 94 (50%) patients had metastatic disease. Cancer staging was completed in 84% of patients, and 65% had multidisciplinary team (MDT) assessment during their hospital stay. Surgery was performed on 90 (48%) patients, of which 31.2% was with palliative intent. Overall mortality was 56% with 30- and 60-day mortality of 15% and 22%, respectively. The adjusted odds ratio (OR) for a 60-day mortality was high in patients presenting with new cancer diagnosis (OR 3.18, 95% CI 1.18-9.02, p=0.03), metastatic disease (OR 5.11, 95% CI 2.03-12.85, p=0.001), or systemic therapy on presentation (OR 3.46, 95% CI 1.30-9.22, p=0.013).

CONCLUSION

Emergency surgical referral is common in patients with malignancy. Surgical decision making can be challenging due to the heterogeneity of this population and their associated comorbidities. Optimizing prognostic determinants such as goal-directed palliative care, MDT discussions, and bridging to systemic therapy can improve patient outcomes.

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.

Factors associated with waiting time to breast cancer diagnosis among symptomatic breast cancer patients: a population-based study from Ontario, Canada

PURPOSE

A prolonged time from first presentation to cancer diagnosis has been associated with worse disease-related outcomes. This study evaluated potential determinants of a long diagnostic interval among symptomatic breast cancer patients.

METHODS

This was a population-based, cross-sectional study of symptomatic breast cancer patients diagnosed in Ontario, Canada from 2007 to 2015 using administrative health data. The diagnostic interval was defined as the time from the earliest breast cancer-related healthcare encounter before diagnosis to the diagnosis date. Potential determinants of the diagnostic interval included patient, disease and usual healthcare utilization characteristics. We used multivariable quantile regression to evaluate their relationship with the diagnostic interval. We also examined differences in diagnostic interval by the frequency of encounters within the interval.

RESULTS

Among 45,967 symptomatic breast cancer patients, the median diagnostic interval was 41 days (interquartile range 20-92). Longer diagnostic intervals were observed in younger patients, patients with higher burden of comorbid disease, recent immigrants to Canada, and patients with higher healthcare utilization prior to their diagnostic interval. Shorter intervals were observed in patients residing in long-term care facilities, patients with late stage disease, and patients who initially presented in an emergency department. Longer diagnostic intervals were characterized by an increased number of physician visits and breast procedures.

CONCLUSIONS

The identification of groups at risk of longer diagnostic intervals provides direction for future research aimed at better understanding and improving breast cancer diagnostic pathways. Ensuring that all women receive a timely breast cancer diagnosis could improve breast cancer outcomes.

The effect of diagnostic assessment programs on the diagnosis and treatment of patients with lung cancer in Ontario, Canada

INTRODUCTION

Diagnostic assessment programs (DAPs) were implemented in Ontario, Canada, to improve the efficiency of the lung cancer care continuum. We compared the efficiency and effectiveness of care provided to patients in DAPs relative to usual care (non-DAPs).

METHODS

Lung cancer patients diagnosed between 2014 and 2016 were identified from the Ontario Cancer Registry. Using administrative databases, we identified various health-care encounters 6 months before diagnosis until the start of treatment and compared utilization patterns, timing, and overall survival between DAP and non-DAP patients.

RESULTS

DAP patients were younger (P < 0.0001), had fewer comorbidities (P = 0.0006), and were more likely to have early-stage disease (36% vs. 25%) than non-DAP patients. Although DAP patients had a similar time until diagnosis as non-DAP patients, the time until treatment was 8.5 days shorter for DAP patients. DAP patients were more likely to receive diagnostic tests and specialist consultations and less likely to have duplicate chest imaging. DAP patients were more likely to receive brain imaging. Among early-stage lung cancers, brain imaging was high (74% for DAP and 67% for non-DAP), exceeding guideline recommendations. After adjustment for clinical and demographic factors, DAP patients had better overall survival than non-DAP patients (hazard ratio [HR]: 0.79 [0.76-0.82]), but this benefit was lost after adjusting for emergency presentation (HR: 0.96 [0.92-1.00]). A longer time until treatment was associated with better overall survival.

CONCLUSION

DAPs provided earlier treatment and better access to care, potentially improving survival. Quality improvement opportunities include reducing unnecessary or duplicate testing and characterizing patients who are diagnosed emergently.

An Audit of Opportunistic Lung Cancer Screening in a Canadian Province

OBJECTIVES

Lung cancer is a leading cause of cancer-related death in Canada. Early detection can improve outcomes and despite recommendations from the Canadian Task Force on Preventive Health Care to screen patients who are 55 to 74 years old and have a 30+ pack-year history, formal screening programs are rare in Canada. Our goal was to determine if screening is being performed in a representative Canadian population, if recommendations are being followed, and how screening impacts lung cancer stage at diagnosis and prognosis.

METHODS

A retrospective chart review was performed to identify patients either screened for lung cancer or imaged due to lung cancer symptoms in Eastern Newfoundland between 2015 and 2018. Age, smoking history, screening modality, diagnosis, cancer stage, and mortality were recorded.

RESULTS

Under 6.0% of the eligible population were screened for lung cancer with only 28.13% meeting age and smoking criteria and being screened appropriately with low-dose CT. However, 70% of patients that had lung cancers found by screening met age and smoking screening criteria. While lung cancer detection rates were similar, screening detected cancer in patients at an earlier stage (50% Stage 1) compared to patients who were not screened (20% Stage 1). Patients who were screened had an improved prognosis.

CONCLUSIONS

Physicians are opportunistically screening for lung cancer, but not consistently following screening guidelines. As screening is sensitive, leads to earlier stage diagnosis, and has a mortality benefit, implementation of an organized screening program could increase quality assurance and prevent many lung-cancer related deaths.