Review Article | Published:

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

Nature Reviews Clinical Oncology volume 14, pages 4556 (2017) | Download Citation

This article has been updated

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.

Key points

  • The diagnosis of cancer as an emergency is associated with a substantially worse prognosis; however, this represents an understudied problem, with evidence examining its frequency and aetiology limited to a few developed countries

  • Most available evidence defines diagnosis of cancer as an emergency contextually instead of employing clinical criteria regarding presentation severity, and uses administrative data as opposed to reviews of medical records

  • An emergency diagnosis of cancer often has a complex aetiology, involving tumour, patient and health-care related factors; evidence on the role of tumour and health-care related factors is particularly sparse

  • Studying variations in the risk of emergency presentations by prior health-care use and related symptoms can elucidate how some emergency presentations could potentially be prevented

  • Sociodemographic inequalities in the risks of emergency presentation underline the contribution of psychosocial factors and the potential for targeting of public health campaigns regarding cancer symptoms

  • Optimising screening can help to reduce emergency presentations of patients with colorectal cancer

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.

from$8.99

All prices are NET prices.

Change history

  • 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.

References

  1. 1.

    et al. Association between patient and general practice characteristics and unplanned first-time admissions for cancer: observational study. Br. J. Cancer 107, 1213–1219 (2012).

  2. 2.

    et al. Identifying patients at risk of emergency admission for colorectal cancer. Br. J. Cancer 111, 577–580 (2014).

  3. 3.

    , , , & Missed opportunities: racial and neighborhood socioeconomic disparities in emergency colorectal cancer diagnosis and surgery. BMC Cancer 14, 927 (2014).

  4. 4.

    Cancer diagnosis and outcomes in Michigan emergency departments versus other settings. Ann. Emerg. Med. 56, S92 (2010).

  5. 5.

    et al. Routes to diagnosis for cancer–determining the patient journey using multiple routine data sets. Br. J. Cancer 107, 1220–1226 (2012).

  6. 6.

    & Emergency presentation of colorectal cancer is associated with poor 5-year survival. Br. J. Surg. 91, 605–609 (2004).

  7. 7.

    National Cancer Intelligence Network. Major resections by routes to diagnosis (2006 to 2010; England). Public Health England (2015).

  8. 8.

    et al. Impact of route to diagnosis on treatment intent and 1-year survival in patients diagnosed with oesophagogastric cancer in England: a prospective cohort study. BMJ Open 3, e002129 (2013).

  9. 9.

    , , , & The effect of emergency presentation on surgery and survival in lung cancer patients in England, 2006–2008. Cancer Epidemiol. 39, 612–616 (2015).

  10. 10.

    et al. Causes and outcomes of emergency presentation of rectal cancer. Int. J. Cancer 139, 1031–1039 (2016).

  11. 11.

    , & Risk factors and survival outcome for non-elective referral in non-small cell lung cancer patients–analysis based on the National Lung Cancer Audit. Lung Cancer 83, 396–400 (2014).

  12. 12.

    et al. Heterogeneity of colon cancer patients reported as emergencies. World J. Surg. 38, 1819–1826 (2014).

  13. 13.

    et al. Management and prognosis of primary tracheal cancer: a national analysis. Laryngoscope 124, 145–150 (2014).

  14. 14.

    et al. Factors affecting short-term mortality in women with ovarian, tubal, or primary peritoneal cancer: population-based cohort analysis of English National Cancer Registration data. Int. J. Gynecol. Cancer 26, 56–65 (2016).

  15. 15.

    et al. Emergency presentation of cancer and short-term mortality. Br. J. Cancer 109, 2027–2034 (2013).

  16. 16.

    Quality Health. Cancer Patient Experience Survey 2014 National Report. (2014).

  17. 17.

    , & Are emergency diagnoses of cancer avoidable? A proposed taxonomy to motivate study design and support service improvement. Future Oncol. 10, 1329–1333 (2014).

  18. 18.

    & Saving 5,000 Lives Project -Cancer Networks Supporting Primary Care. Thames Valley Cancer Network, 2013.

  19. 19.

    et al. Patients' experiences of cancer diagnosis as a result of an emergency presentation: a qualitative study. PLoS ONE 10, e0135027 (2015).

  20. 20.

    , , & The role of primary care in cancer diagnosis via emergency presentation: qualitative synthesis of significant event reports. Br. J. Cancer 112, S50–S56 (2015).

  21. 21.

    et al. Do colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms? A longitudinal data-linkage study in England. Br. J. Cancer 115, 866–875 (2016).

  22. 22.

    , , , & Assessing the impact of an English national initiative for early cancer diagnosis in primary care. Br. J. Cancer 112, S57–S64 (2015).

  23. 23.

    et al. Assessing the preventability of emergency hospital admissions: a method for evaluating the quality of medical care in a primary care facility. Am. J. Med. 83, 1031–1036 (1987).

  24. 24.

    , & Preventability of emergent hospital readmission. Am. J. Med. 90, 667–674 (1991).

  25. 25.

    , , & The Andersen Model of Total Patient Delay: a systematic review of its application in cancer diagnosis. J. Health Serv. Res. Policy 17, 110–118 (2012).

  26. 26.

    National Cancer Intelligence Network. Routes to diagnosis 2006–2013, preliminary results. Public Health England (2015).

  27. 27.

    , , , & Cancer-specific variation in emergency presentation by sex, age and deprivation across 27 common and rarer cancers. Br. J. Cancer 112, S129–S136 (2015).

  28. 28.

    National Cancer Intelligence Network. Routes to diagnosis of cancer by stage, 2012-2013. Public Health England (2016).

  29. 29.

    National Cancer Intelligence Network. Routes to diagnosis 2006–2013 workbook. Public Health England (2015).

  30. 30.

    Emergency admissions of cancer as a marker of diagnostic delay. Br. J. Cancer 107, 1205 (2012).

  31. 31.

    National Cancer Intelligence Network. Routes to diagnosis: exploring emergency presentations. Public Health England (2013).

  32. 32.

    & Pathways to the diagnosis of lung cancer in the UK: a cohort study. BMC Fam. Pract. 9, 31 (2008).

  33. 33.

    , , & Pathways to the diagnosis of colorectal cancer: an observational study in three UK cities. Fam. Pract. 23, 15–19 (2006).

  34. 34.

    , , , & Pathways to the diagnosis of ovarian cancer in the UK: a cohort study in primary care. BJOG 117, 610–614 (2010).

  35. 35.

    Diagnosing symptomatic cancer in the NHS. BMJ 351, h5311 (2015).

  36. 36.

    , , & Comparing primary and secondary health-care use between diagnostic routes before a colorectal cancer diagnosis: cohort study using linked data. Br. J. Cancer 111, 1490–1499 (2014).

  37. 37.

    et al. Symptom appraisal and healthcare-seeking for symptoms suggestive of colorectal cancer: a qualitative study. BMJ Open 5, e008448 (2015).

  38. 38.

    , & Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process. Emerg. Med. J. 31, 448–452 (2014).

  39. 39.

    , & Risk factors for obstruction, perforation, or emergency admission at presentation in patients with colorectal cancer: a population-based study. Am. J. Gastroenterol. 101, 1098–1103 (2006).

  40. 40.

    , , & Clinical features of colorectal cancer before emergency presentation: a population-based case-control study. Fam. Pract. 24, 3–6 (2007).

  41. 41.

    , , & Cancer diagnosed by emergency admission in England: an observational study using the general practice research database. BMC Health Serv. Res. 13, 308 (2013).

  42. 42.

    et al. Variation in gastroscopy rate in English general practice and outcome for oesophagogastric cancer: retrospective analysis of Hospital Episode Statistics. Gut 63, 250–261 (2014).

  43. 43.

    et al. The effects of population-based faecal occult blood test screening upon emergency colorectal cancer admissions in Coventry and north Warwickshire. Gut 57, 218–222 (2008).

  44. 44.

    & Dukes staging in screen-detected and symptomatic cases of colorectal cancer in the West Midlands region. (2012).

  45. 45.

    et al. Temporal trends in mode, site and stage of presentation with the introduction of colorectal cancer screening: a decade of experience from the West of Scotland. Br. J. Cancer 113, 556–561 (2015).

  46. 46.

    National Cancer Intelligence Network. Cancer outcomes: stage at diagnosis and emergency presentations. Public Health England (2016).

  47. 47.

    , , & Temporal trends in new diagnoses of colorectal cancer with obstruction, perforation, or emergency admission in Ontario: 1993–2001. Am. J. Gastroenterol. 100, 672–676 (2005).

  48. 48.

    et al. How might healthcare systems influence speed of cancer diagnosis: a narrative review. Soc. Sci. Med. 116, 56–63 (2014).

  49. 49.

    , & Emergency presentation and socioeconomic status in colon cancer. Eur. J. Surg. Oncol. 39, 831–836 (2013).

  50. 50.

    et al. Social variations in access to hospital care for patients with colorectal, breast, and lung cancer between 1999 and 2006: retrospective analysis of hospital episode statistics. BMJ 340, b5479 (2010).

  51. 51.

    National Cancer Intelligence Network. Routes to diagnosis: investigating the different pathways for cancer referrals in England for teenagers and young adults. Public Health England (2013).

  52. 52.

    , & Risk factors for emergency presentation with lung and colorectal cancers: a systematic review. BMJ Open 5, e006965 (2015).

  53. 53.

    , , , & Gender inequalities in the promptness of diagnosis of bladder and renal cancer after symptomatic presentation: evidence from secondary analysis of an English primary care audit survey. BMJ Open 3, e002861 (2013).

  54. 54.

    , , , & Cancer fatalism: deterring early presentation and increasing social inequalities? Cancer Epidemiol. Biomarkers Prev. 20, 2127–2131 (2011).

  55. 55.

    & Psychological factors related to delay in consultation for cancer symptoms. Psycho-oncology 14, 339–350 (2005).

  56. 56.

    et al. Responding to symptoms suggestive of lung cancer: a qualitative interview study. BMJ Open Respir. Res. 1, e000067 (2014).

  57. 57.

    et al. Emergency diagnosis of lung cancer: an international problem [abstract]. J. Clin. Oncol. 33, 6536 (2015).

  58. 58.

    et al. An evaluation of the impact of large-scale interventions to raise public awareness of a lung cancer symptom. Br. J. Cancer 112, 207–216 (2014).

  59. 59.

    Cancer Research UK. Be Clear on Cancer (2016).

  60. 60.

    , , & Suspected cancer (part 2—adults): reference tables from updated NICE guidance. BMJ 350, h3044 (2015).

  61. 61.

    et al. Cancer symptom awareness and barriers to symptomatic presentation in England—are we clear on cancer. Br. J. Cancer 113, 533–542 (2015).

  62. 62.

    et al. Public awareness of cancer in Britain: a population-based survey of adults. Br. J. Cancer 101, S18–S23 (2009).

  63. 63.

    , , , & The association between fatalistic beliefs and late stage at diagnosis of lung and colorectal cancer. Cancer Epidemiol. Biomarkers Prev. 24, 720–726 (2015).

  64. 64.

    et al. 'This isn't what mine looked like': a qualitative study of symptom appraisal and help seeking in people recently diagnosed with melanoma. BMJ Open 4, e005566 (2014).

  65. 65.

    et al. Differences in cancer awareness and beliefs between Australia, Canada, Denmark, Norway, Sweden and the UK (the International Cancer Benchmarking Partnership): do they contribute to differences in cancer survival? Br. J. Cancer 111, 2382 (2014).

  66. 66.

    National Cancer Intelligence Network. Routes to diagnosis: comparing multiple studies. NCIN (2013).

  67. 67.

    , & Accelerate, Coordinate, Evaluate Programme: a new approach to cancer diagnosis. Br. J. Gen. Pract. 66, 176–177 (2016).

  68. 68.

    , & Preventing overdiagnosis: how to stop harming the healthy. BMJ 344, e3502 (2012).

  69. 69.

    et al. Social and geographic disparities in access to reference care site for patients with colorectal cancer in France. Br. J. Cancer 92, 1842–1845 (2005).

Download references

Acknowledgements

Y. Z. acknowledges an Academic Clinical Fellowship in General Practice funded by Health Education East of England. F.M.W. acknowledges funding from a UK National Institute for Health Research Clinician Scientist award. G.L. acknowledges funding from Cancer Research UK (Advanced Clinican Scientist Fellowship Award, grant number A18180).

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

Authors

  1. Search for Yin Zhou in:

  2. Search for Gary A. Abel in:

  3. Search for Willie Hamilton in:

  4. Search for Kathy Pritchard-Jones in:

  5. Search for Cary P. Gross in:

  6. Search for Fiona M. Walter in:

  7. Search for Cristina Renzi in:

  8. Search for Sam Johnson in:

  9. Search for Sean McPhail in:

  10. Search for Lucy Elliss-Brookes in:

  11. Search for Georgios Lyratzopoulos in:

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

The authors declare no competing financial interests.

Corresponding author

Correspondence to Georgios Lyratzopoulos.

Supplementary information

PDF files

  1. 1.

    Supplementary information S1 (table 1)

    Frequency of emergency presentation for different cancers

  2. 2.

    Supplementary information S2 (table 2)

    Descriptions of included studies / sources of evidence

  3. 3.

    Supplementary information S3 (table 3)

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

About this article

Publication history

Published

DOI

https://doi.org/10.1038/nrclinonc.2016.155

Further reading