Diagnosis of cancer as an emergency: a critical review of current evidence

Journal name:
Nature Reviews Clinical Oncology
Volume:
14,
Pages:
45–56
Year published:
DOI:
doi:10.1038/nrclinonc.2016.155
Published online
Corrected online

Abstract

Many patients with cancer are diagnosed through an emergency presentation, which is associated with inferior clinical and patient-reported outcomes compared with those of patients who are diagnosed electively or through screening. Reducing the proportion of patients with cancer who are diagnosed as emergencies is, therefore, desirable; however, the optimal means of achieving this aim are uncertain owing to the involvement of different tumour, patient and health-care factors, often in combination. Most relevant evidence relates to patients with colorectal or lung cancer in a few economically developed countries, and defines emergency presentations contextually (that is, whether patients presented to emergency health-care services and/or received emergency treatment shortly before their diagnosis) as opposed to clinically (whether patients presented with life-threatening manifestations of their cancer). Consistent inequalities in the risk of emergency presentations by patient characteristics and cancer type have been described, but limited evidence is available on whether, and how, such presentations can be prevented. Evidence on patients' symptoms and health-care use before presentation as an emergency is sparse. In this Review, we describe the extent, causes and implications of a diagnosis of cancer following an emergency presentation, and provide recommendations for public health and health-care interventions, and research efforts aimed at addressing this under-researched aspect of cancer diagnosis.

Change history

Corrected online 19 October 2016
An incorrect version of the supplementary information was originally published with this Review. The originally published supplementary information has now been replaced with the correct version of this information.

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Author information

Affiliations

  1. The Primary Care Unit, Department of Public Health and Primary Care, Institute of Public Health, Forvie Site, Robinson Way, University of Cambridge, Cambridge CB2 0SR, UK.

    • Yin Zhou,
    • Gary A. Abel,
    • Fiona M. Walter &
    • Georgios Lyratzopoulos
  2. University of Exeter, College House, St Luke's Campus, Exeter EX2 4TE, UK.

    • Gary A. Abel &
    • Willie Hamilton
  3. Institute of Child Health, University College London, 30 Guilford Street, London WC1N 1EH, UK.

    • Kathy Pritchard-Jones
  4. University College London Partners Academic Health Science Network, 170 Tottenham Court Road, London W1T 7HA, UK.

    • Kathy Pritchard-Jones
  5. Section of General Medicine, Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center, Yale University School of Medicine, New Haven, Connecticut 06519, USA.

    • Cary P. Gross
  6. Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London WC1E 7HB, UK.

    • Cristina Renzi &
    • Georgios Lyratzopoulos
  7. National Cancer Registration and Analysis Service, Public Health England Zone A, 2nd Floor, Skipton House, 80 London Road, London SE1 6LH, UK.

    • Sam Johnson,
    • Sean McPhail,
    • Lucy Elliss-Brookes &
    • Georgios Lyratzopoulos

Contributions

G.L. and Y.Z. researched data for this article and wrote the manuscript. All authors made substantial contributions to discussions of content, and reviewed and/or edited the manuscript before submission.

Competing interests statement

The authors declare no competing interests.

Corresponding author

Correspondence to:

Author details

  • Yin Zhou

    Yin Zhou is a NIHR School for Primary Care Research GP Career Progression Fellow at the University of Cambridge, UK. Following her MSc in Health, Population and Society at the London School of Economics, UK (2012), she completed an Academic Clinical Fellowship in General Practice (2012–2016), funded by Health Education East of England. Her research interests include diagnostic safety and quality in primary care, in particular relating to the early diagnosis of cancer.

  • Gary A. Abel

    Gary Abel is a Senior Lecturer in Medical Statistics at the University of Exeter Medical School, UK. He has previously (until 2016) worked for the Cambridge Centre for Health Services Research, University of Cambridge after completing an MSc in Medical Statistics at the London School of Hygiene and Tropical Medicine, UK. Before retraining as a statistician, he worked for 10 years as a physicist at the British Antarctic Survey and University College London (UCL), UK where he completed a PhD in space physics. He has a broad range of research interests, particularly focusing on health-services research, care quality and the early diagnosis of cancer.

  • Willie Hamilton

    Willie Hamilton is a professor of primary-care diagnostics at the University of Exeter, UK, as well as a practising general practitioner. His research is largely in the field of cancer diagnostics, funded by the UK Department of Health, the National Institute of Health Research and several cancer charities. He was the clinical lead on the 2015 revision of NICE guidance, NG12.

  • Kathy Pritchard-Jones

    Kathy Pritchard-Jones is chief medical officer of an integrated cancer system, London Cancer (www.londoncancer.org) developed within the UCL Partners' academic health science network. She has led the redesign of whole pathways of cancer care to improve early diagnosis of cancer and outcomes for a population of 3.5 million in North London and West Essex, UK. She practices as a consultant paediatric oncologist at Great Ormond Street Hospital, London, and is the chief investigator for the UK's participation in several international clinical trials in childhood renal tumours. In this context, she has analysed the differences in routes to diagnosis between the UK and Germany.

  • Cary P. Gross

    Cary P. Gross is a Professor of Medicine and Public Health at Yale University, USA, and is the founding Director of Yale's Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center. As a general internist, Professor Gross studies comparative effectiveness, quality, and population health, with a focus on cancer prevention and treatment. He and his colleagues focus on generating evidence that will support high value, patient-centred cancer care.

  • Fiona M. Walter

    Fiona M. Walter is a principal researcher in primary-care cancer research at the University of Cambridge, and holds honorary clinical associate professorships at the Universities of Melbourne and Western Australia, Australia. Her research is mainly focused on the earlier diagnosis of cancer. She chairs the Early Diagnosis subgroup of the UK National Cancer Research Institute Primary Care Clinical Studies Group, and also works as a general practitioner near Cambridge.

  • Cristina Renzi

    Cristina Renzi is a public health physician and epidemiologist with a specific research interest in the evaluation of diagnostic pathways and factors influencing timely cancer diagnosis. In her role as principal investigator on a Cancer Research UK Early Diagnosis Advisory Group grant and Senior Clinical Research Associate at UCL, her work has focused in particular on evaluating the opportunities for reducing emergency diagnosis of cancer.

  • Sam Johnson

    Sam Johnson is a cancer analyst based in London at Public Health England's National Cancer Registration and Analysis Service, having previously had a role in the quality assurance team of the National Bowel Cancer Screening Programme. His research surrounds earlier diagnosis and outcome trends, primarily using and expanding the Routes to Diagnosis study.

  • Sean McPhail

    Sean McPhail performed postdoctoral work in the physical sciences before transferring his research interest to cancer epidemiology. He has worked in cancer registration for the past 10 years and is currently a Senior Analyst within the National Cancer Registration and Analysis Service and Honourary Senior Research Associate at UCL.

  • Lucy Elliss-Brookes

    Lucy Elliss-Brookes leads the cancer analysis team at Public Health England's National Cancer Registration and Analysis Service. Her team undertakes studies measuring cancer outcomes across England and the UK and supporting national public health and health-care policies aimed at reducing mortality from cancer. Lucy was the initiator of the big data Routes to Diagnosis project, which algorithmically links data from different sources to assign patients to different healthcare pathways to a cancer diagnosis, and is the first author on its foundation research paper. She also holds an honorary position as a Senior Research Associate at UCL.

  • Georgios Lyratzopoulos

    Georgios Lyratzopoulos is a Reader (Associate Professor) in Cancer Epidemiology at UCL. He is also a Cancer Research UK Advanced Clinician Scientist Fellow (2015–2019) with part-time research commitments relating to his Fellowship at the University of Cambridge. He also serves as a Senior Cancer Epidemiologist at the National Cancer Registration and Analysis Service of Public Health England. He was previously a NIHR Post Doctoral Fellow (2012–2014, Cambridge) and has worked for the English NHS and NICE as a hospital doctor and public health physician.

Supplementary information

PDF files

  1. Supplementary information S1 (table 1) (203 KB)

    Frequency of emergency presentation for different cancers

  2. Supplementary information S2 (table 2) (176 KB)

    Descriptions of included studies / sources of evidence

  3. Supplementary information S3 (table 3) (173 KB)

    Population based studies on EP and types of variables considered/mentioned by each

Additional data