ABSTRACT

Conclusion:

The most common reasons for ED visits by cancer patients are pain, nausea and vomiting, abdominal pain, and shortness of breath. Oncology patients admitted to the ED have higher needs for laboratory tests, radiological imaging and consultation, and time to be followed in the emergency services.

Results:

Totally 265 patients with pathology reports for confirmed oncology diagnosis were included in the study. The most common reason was “pain” with a rate of 13.6% (n=36). Gastrointestinal system symptoms and respiratory system symptoms were the most common reasons for hospitalization in clinics and intensive care units and patients who had these symptoms died with the rates of 6.8% (n=18) and 33.3% (n=30), respectively, in clinics.

Materials and Methods:

Patients aged 18 years or older with clinical/pathological oncologic diagnoses, who applied to Tekirdağ Namık Kemal University Hospital Emergency Department between March 1^st 2018 and August 31^st 2018, were included in the study. The study was prospective and ethics committee approval was obtained prior to the study.

Aim:

Prolongation in the life span of cancer patients has resulted in increased number of cancer patients all over the world. However, this change is increasing the number of oncological patients admitted to the emergency departments every day. This study aimed to determine the reasons for admission to the emergency department (ED) for cancer patients and to examine the factors affecting the prognosis demographically.

INTRODUCTION

The number of cancer patients admitted to the emergency departments is increasing every day. There are several possible reasons for this increase. The improvement in living standards has resulted in an increase in the population aged over 65 years in parallel with an increase in the incidence of age-dependent oncological diseases. With the improvement in the quality of life, there has also been an increase in the prevalence of cancer in parallel with the increased population aged 60 years and over¹. However, with the improvements in patient care, the prolongation in the survival of cancer patients results in the increase in the number of cancer patients relatively in the society¹.

According to the data of the World Health Organization (WHO), cancers are the second most common reason for deaths worldwide and they were thought to be responsible for 9.6 million deaths in 2018². Globally, cancer types are the first or second common cause of premature deaths (between the ages of 30 and 69 years) in 134 out of 183 countries². The economic burden of cancer patients for countries is gradually increasing, and the total annual economic cost of cancer patients in 2010 was estimated to be 1.16 trillion USD².

Cancer is a chronic disease and cancer patients can apply to emergency services with a wide variety of complaints. These complaints can roughly be classified as conditions directly caused by the existing cancer (pain, compression, bleeding), conditions that develop due to chemotherapy treatment (tumor lysis, febrile neutropenia), and conditions indirectly caused by cancer (infectious, metabolic)³. Patients may apply to emergency services with only one or a combination of several of these above conditions. Many of these disease conditions are life threatening and require immediate diagnosis and treatment. Early diagnosis and appropriate treatment are effective in improving the comfort care of the patient⁴. The first application points of these patient groups in hospitals are frequently the emergency services. This situation increases the number of emergency service applications and intensities.

In this study, it was aimed to investigate the common reasons for admission, problems that were encountered, and demographic data of oncology patients admitted to an emergency department. Recognition of these situations will contribute to the emergency service workers’ realization of the potential risks in cancer patient groups and improve the regulation of the patience approach policies.

GİRİŞ

Acil servise başvuran kanser hastalarının sayısı gün geçtikçe artmaktadır. Bu artışın birkaç olası nedeni vardır. Yaşam standartlarında iyileşme 65 yaş ve üzerindeki nüfusun artmasına ve beraberinde yaşla birlikte artan onkolojik hastalıklarında görülme sıklığında artışa neden olmuştur. Yaşam kalitesinin artması ile birlikte 60 yaş ve üzeri nüfus sayısındaki artışa paralel olarak kanser prevalansında da artış saptanmaktadır¹. Bununla birlikte hasta bakımındaki iyileşmeler sayesinde kanser hastalarının sağkalımlarındaki uzamalar toplumda kanserli hasta sayısının göreceli olarak artmasına neden olmaktadır¹.

Dünya Sağlık Örgütü’nün (DSÖ) verilerine göre kanser küresel olarak ikinci en sık ölüm nedenidir ve 2018 yılında 9,6 milyon ölümden sorumlu olduğu düşünülmektedir². Global olarak, kanser, 183 ülkeden 134’ünde erken ölümlerin (30-69 yaş) en sık birinci veya ikinci nedenidir². Kanser hastalarının ülkelere ekonomik yükü gittikçe artmakta, 2010 yılında kanser hastalarının toplam yıllık ekonomik maliyetinin 1,16 trilyon Amerikan Doları olduğu tahmin edilmektedir².

Kanser kronik bir hastalıktır ve kanser hastaları acil servislere çok çeşitli yakınmalar ile başvurabilirler. Bu yakınmalar kabaca mevcut kanserin direkt neden olduğu durumlar (ağrı, bası, kanama), kemoterapi tedavisine bağlı gelişen durumlar (tümör lizis, febril nötropeni) ve kanserin dolaylı olarak neden olduğu durumlar (enfeksiyöz, metabolik) olarak sınıflandırılabilir³. Hastalar acil servislere yukarıdaki durumların herhangi biriyle başvurabildikleri gibi bazen de bu durumların birkaçının kombinasyonu ile de başvurabilirler. Bu hastalık durumlarının birçoğu yaşamı tehdit eder ve acil tanı ve tedavi gerektirir. Erken tanı ve etkin tedavi hastanın yaşam konforunun iyileştirilmesinde etkilidir⁴. Bu hasta gruplarının genel olarak hastanelerde ilk başvuru noktaları acil servisler olmaktadır. Bu durum da acil servis başvurularını ve yoğunluğunu artırmaktadır.

Bu çalışmada acil servise başvuran onkoloji hastalarının demografik verilerinin yanında sık başvuru nedenlerinin ve karşılaşılan problemlerin araştırılması amaçlanmıştır. Bu durumların bilinmesi acil servis çalışanlarının kanserli hasta gruplarında potansiyel riskleri daha iyi anlamalarına ve yaklaşım politikalarının düzenlenmesine katkı sağlayacaktır.

MATERIALS AND METHODS

Before the study, the approval from Namık Kemal University Non-Invasive Clinical Research Ethics Committee was obtained (approval number: 2018/19/02/04, date: 19.02.2018).

Studied Population

Patients with clinical/pathological oncological diagnosis, aged 18 years and over, who applied to Tekirdağ Namık Kemal University Emergency Service between March 1^st 2018 and August 31^st 2018 and who signed the “Volunteer Consent form” were included in the study. Patients with a clinical/pathological oncological diagnosis, whose complaint at admission to the emergency service was not related to oncological disease (such as having breast carcinoma but brought to the emergency room due to a traffic accident or having lung cancer but applying due to extremity trauma etc.), were excluded from the study.

Study Protocol

The data of the patients who met the study inclusion criteria and who signed the “Volunteer Consent form” were recorded in the patient data record form. The observation and inspection data, duration of stay in the emergency service and emergency/clinical outcomes of the patients whose treatments were completed in the emergency department were analyzed on the “Hospital Information Management System” and recorded in the study form.

Clinical Outcomes of the Study

The primary endpoint of our study was to define the reasons for admission to the emergency department for patients with oncological diagnosis, and the secondary endpoint was to determine the emergency room outcomes of the patients.

Statistical Analysis

The data obtained from the study were recorded in the standard software of “Statistical Package for Social Sciences for Windows 20.0” to conduct statistical analysis. The t-test was used for the comparison of the means, and the chi-square test was used to compare the variables determined by counting.

RESULTS

Totally 265 patients with oncology diagnosis confirmed by pathology reports were included in the study. The youngest and the oldest patients were 19 and 84 years old, respectively. 52.1% (n=138) of the patients were male. The mean age of the cases was 60±12 years, and the average age in women was 58±13 years. It was found that 87.9% (n=233) of the patients were self-applied to the emergency service and 12.1% (n=32) by 112 emergency ambulance (Table 1).

The most prevalent complaints of patients were gastrointestinal system (GIS) complaints with a rate of 40.8% (n=108), followed by respiratory system complaints with a rate of 15.8% (n=42). The most prevalent symptom was “pain” with the rate of 13.6% (n=36) (Table 2).

When the cancer classifications of the patients were examined, it was determined that the most common types were GIS malignancies with the rate of 31.7% (n=84), followed by respiratory system and intrathoracic organ neoplasms with the rate of 27.5% (n=73). It was found that 61.5% (n=163) of the patients were metastatic and 85.7% (n=227) of the patients were under medical follow-up by the Medical Oncology department. It was determined that 87.2% (n=231) and 30.6% (n=81) of the studied patients were previously given chemotherapy and radiotherapy, respectively. It was determined that 46.4% (n=123) of the patients undergone oncological surgery and 74.7% (n=198) had no known family history at 1^st and 2^nd degree relatives (Table 3).

When the conditions of the patients in the emergency service were examined, it was determined that laboratory examination was requested at the time of admission to the emergency department from 91.3% (n=242) of the 265 patients included in the study. When the outcomes of the patients were monitored in the emergency department, it was determined that 49.8% (n=132) of patients were consulted to the relevant units, 62.6% (n=166) were discharged from the emergency department and 34% (n=90) were admitted to the service and intensive care units. It was observed that 27.5% (n=73) of the patients were followed up in the emergency department for four hours or more (Table 4).

Among the patients who were admitted to clinics and intensive care units, the most common reasons for hospitalization were GIS pathologies and respiratory pathologies with 6.8% (n=18), followed by hematological problems with 5.7% (n=15). The most common reason for hospitalization was neutropenic fever in 9 patients (3.4%), followed by pain palliation in 7 patients (2.6%). It was determined that 63.3% (n=57) of the 90 hospitalized patients were discharged from the hospital and 33.3% (n=30) of the patients died in the clinics where they were hospitalized. Patients who died (23.3%, n=7) were found to be hospitalized for palliative purposes. Of the 30 patients who died, 40% (n=12) and 33.3% (n=10) were previously diagnosed with “respiratory and intrathoracic neoplasm” and “GIS malignancy”, respectively. It was observed that 25% (n=8) and 34.3% (n=11) of 32 patients which were brought to the emergency room by 112 ambulance were admitted to intensive care units and to service floors, respectively.

DISCUSSION

The yearly increases in oncology cases around the world has a reflection in emergency room admission numbers, which is becoming a serious problem for the management of emergency services that are currently very busy. According to WHO data, it is estimated that the number of active cancer patients in 2020 was over 19 million and 9.9 million (17.8%) of 55.4 million deaths in the world in 2019 were caused by cancer. Moreover, this number is expected to be over 16 million in 2040⁵. Of more than 10 million newly diagnosed cancer patients within a year, 53% are men and 47% are women⁴. Kerrouault et al.⁶ found that 65% of the patients with an oncological diagnosis, who applied to the emergency department, were male and the average age was 62 years. Kocak et al.⁴ found in their study that 58% of the patients were male. In our study, we found that 52.1% of the patients were male, 47.9% were female, the average age was 60 years, and we found that these findings were consistent with the literature.

Siegel and Bigeraw⁷ found that the importance of palliative care in emergency services was increasing, symptoms related to pain, nausea and shortness of breath were common especially at oncology patients in the last period of their life, and these type of patients applied to the emergency services for these symptoms⁷. In our study, we found that the most common symptom was “pain” (26.4%, n=70), followed by “nausea and vomiting” (13.2%, n=35) and “shortness of breath” (12.5%, n=33). Palliation of pain in oncology patients is difficult with non-opioid drugs due to its physiopathology and needs for opioids are frequent, which can be considered as another factor that increase the frequency of hospital admissions.

The most common type of cancer encountered in the emergency department was reported to be lung cancer in studies of Swenson et al.¹ (16%) and Yaylacı et al.⁸. In their study, Işıkber⁹ reported that the most common type of cancer was GIS tumors in the applications followed by lung cancer in the second order. In our study, we found that GIS malignancies were ranked first with a rate of 31.7% (n=84), followed by “respiratory system and intrathoracic organ neoplasms” with a rate of 27.5% (n=73).

In their study, Yaylacı et al.⁸ found that the most common complaint was pain and the second most common complaint was shortness of breath. In our study, we found that the most common complaint was pain, followed by nausea and vomiting, and then by dyspnea.

Işıkber⁹ reported in their study that 36% of the cases were metastatic at admission stage. Çoban³ reported in their study that 72% of patients were metastatic at the time of admission. In our study, we found that 61% of the cases were metastatic at the time of admission, which we associated this high value with the status of tertiary healthcare institution, admitting advanced and complicated cases.

Barrett and Hamilton¹⁰ reported in their study that 23% of lung cancer cases were hospitalized urgently. In our study, we found that 28 (38.3%) of 73 patients diagnosed with ”neoplasm of respiratory and intrathoracic organs” were hospitalized in service and intensive care units. We associated this high rate of hospitalization with the approach that the respiratory problems were the leading causes of mortality and morbidity in patients and therefore physicians had a lower hospitalization threshold for hospitalization.

Işıkber⁹ examined the emergency service outcomes of the patients and reported in their study that 70% of the patients were discharged from the emergency service and 23% were hospitalized. In our study, we observed that 62% of the patients were discharged from the emergency department, and 34% were admitted to the service and intensive care units. In other studies, hospitalization rates in the general patient population in tertiary emergency services were found to be reported between 12% and 13%^11,12. This shows that the hospitalization rate of oncology patients is high, compared to all admissions, due to the difficulty of pain palliation in cancer patients and the difficulty of home care for cancer patients.

Study Limitations

The limitation of this study should be considered when interpreting our results. First, the present study is a prospective study with relatively small sample size. Second, limited parameters were examined in a limited time period in this study. Therefore, our results should be verified in multi-center prospective longitudinal studies with larger sample size.

TARTIŞMA

Dünya üzerinde her yıl onkoloji olgularındaki artış acil servis başvurularına yansımakta ve oldukça yoğun olan acil servislerin yönetiminde ciddi bir sorun haline gelmektedir. DSÖ verilerine göre 2020 yılındaki aktif kanser hasta sayısı 19 milyonun üzerindedir ve 2019 yılında dünya üzerindeki 55,4 milyon ölümün 9,9 milyonuna (%17,8) kanser sebep olmuştur ve bu sayının 2040 yılında 16 milyonun üzerinde olacağı tahmin edilmektedir⁵. Bir yıl içerisinde yeni tanı alan 10 milyondan fazla kanser hastasının %53’ünü erkekler, %47’sini kadınlar oluşturmaktadır⁴. Kerrouault ve ark.⁶ çalışmalarında AS’ye başvuran onkolojik tanısı olan hastaların %65’inin erkek ve yaş ortalamalarının 62 yıl olduğunu saptamışlardır. Kocak ve ark.⁴ yaptıkları çalışmada hastaların %58’inin erkek olduğunu tespit etmişlerdir. Biz çalışmamızda hastaların %52,1’inin erkek, %47,9’unun kadın olduğunu, yaş ortalamasının 60 yıl olduğunu tespit ettik ve bu bulguların literatürle uyumlu olduğunu gördük.

Siegel ve Bigelow⁷ yaptıkları çalışmada palyatif bakımın AS’lerdeki öneminin arttığını, özellikle yaşamının son döneminde olan onkoloji hastalarında ağrı, bulantı ve nefes darlığı ile ilgili semptomların sık görüldüğünü ve hastaların bu semptomları için acil servislere başvurduklarını tespit etmişlerdir. Biz çalışmamızda en sık başvuru semptomunun %26,4 ile (n=70) “ağrı” olduğunu, bunu ikinci sırada %13,2 (n=35) ile “bulantı kusma” yakınmasının izlediğini ve üçüncü olarak da %12,5 (n=33) “nefes darlığı”nın izlediğini saptadık. Onkoloji hastalarında ağrının palyasyonu fizyopatolojisi itibari ile opioid dışı ilaçlarla zordur ve sıklıkla opioid gereksinimi oluşturur ve bu durum da hastaların hastaneye başvuru sıklığını arttıran bir başka faktör olarak değerlendirilebilir.

Swenson ve ark.¹ yaptıkları çalışmada AS’de en sık karşılaştıkları kanser türünün %16 ile akciğer kanseri olduğunu, Yaylacı ve ark.⁸ yaptıkları çalışmada da ilk sırada akciğer kanserinin yer aldığını bildirmektedirler. Işıkber⁹ yaptıkları çalışmada ise başvurularda en sık karşılaşılan kanser türünün GİS tümörleri olduğunu, bunu ikinci sıklıkla akciğer kanserinin takip ettiğini bildirmişlerdir. Bizim çalışmamızda %31,7 (n=84) ile GİS malignitelerinin birinci sırada olduğu, bunu %27,5 (n=73) ile “solunum sistemi ve intratorasik organ neoplazmlarının” izlediği görüldü.

Yaylacı ve ark.⁸ yaptıkları çalışmada en sık görülen başvuru yakınmasının ağrı, ikinci sıklıkla görülen yakınmanın ise nefes darlığı olduğunu tespit etmişlerdir. Çalışmamızda en sık başvuru yakınmasının ağrı olduğunu, bunu ikinci sıklıkla bulantı-kusma, üçüncü sıklıkla nefes darlığının izlediğini saptadık.

Işıkber⁹ çalışmalarında %36 olgunun başvuru esnasında metastatik olduğunu bildirmişlerdir. Yine Çoban³ ise çalışmalarında başvuru esnasında %72 hastanın metastatik olduğunu bildirmişlerdir. Çalışmamızda olguların %61’inin başvuru esnasında metastatik olduğunu saptadık ve bu yüksek değeri, üçüncü basamak sağlık kuruluşu olmamız sebebiyle kurumumuzca takibi yapılan olguların daha ileri evre ve daha komplike sayılan olgulardan oluşması ile ilişkilendirdik.

Barrett ve Hamilton¹⁰ yaptıkları çalışmada akciğer kanserli olguların %23’ünün acil olarak hastaneye yatırıldığını rapor etmişlerdir. Biz çalışmamızda 73 “respiratuvar ve intratorasik organların neoplazmı” tanılı hastanın 28’inin (%38,3) servis ve yoğun bakımlara yatırıldığını saptadık. Yatış oranındaki bu yüksekliği, respiratuvar problemlerin hastaların mortalite ve morbidite sebeplerinin başında geldiği ve bu sebeple hekimlerin hastaneye yatış konusunda daha düşük yatış eşiğine sahip olduğu düşüncesi ile ilişkilendirdik.

Hastaların acil servis sonlanımları incelendiğince Işıkber⁹ yaptıkları çalışmada hastaların %70’inin acil servisten taburcu edildiğini, %23 oranı ile hastaneye yatışlarının yapıldığını bildirmişlerdir. Çalışmamızda hastaların %62’sinin AS’den taburcu edildiği, %34’ünün servis ve yoğun bakımlara yatışının yapıldığı görülmüştür. Çalışmalara bakıldığında üçüncü basamak AS’lerde genel hasta popülasyonundaki yatış oranları %12-13 arasında bildirilmektedir^11,12. Bu da göstermektedir ki onkoloji hastalarının tüm başvurulara göre hastaneye yatış oranları yüksektir ve bu yüksekliğin nedenleri arasında kanser hastalarında ağrı palyasyonunun ve evde bakımın zorluğu sayılabilir.

Çalışmanın Kısıtlılıkları

Sonuçlarımız yorumlanırken bu çalışmanın sınırlılıkları göz önünde bulundurulmalıdır. İlk olarak, bu çalışma nispeten küçük örneklem büyüklüğüne sahip ileriye dönük bir çalışmadır. İkinci olarak, bu çalışmada sınırlı parametreler sınırlı bir zaman diliminde incelenmiştir. Bu nedenle, sonuçlarımız daha büyük örneklemli çok merkezli prospektif boylamsal çalışmalarda doğrulanmalıdır.

CONCLUSION

For many cancer patients, emergency services are the entrance point to the hospitals. Frequent applications of these patients increase the intensity in the emergency services. Morbidity and mortality of these patient groups are higher compared to other patient groups. Due to this reason, oncological patients should be investigated more detailed in emergency departments. Separating oncological patients from other groups of patients in the emergency rooms in a section may be useful to achieve this target. Multi-center studies with more detailed data on wider populations will be more beneficial and guiding.