|Ahead of print publication
Oncological emergencies: Profile and patient awareness of treatment
Avanish Jha1, Sisha Liz Abraham2, Anna Mathew1, Areeba Ahmad1, Jeryl Chellappa Jacob1, Sudipti Shandilya1, Kundavaram Paul Prabhakar Abhilash1
1 Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Surgical Oncology, Cochin Cancer Research Centre, Ernakulam, Kerala, India
|Date of Submission||16-May-2022|
|Date of Decision||30-Nov-2022|
|Date of Acceptance||09-Dec-2022|
|Date of Web Publication||02-Mar-2023|
Kundavaram Paul Prabhakar Abhilash,
Department of Emergency, Christian Medical College, Vellore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Patients with malignancies present to the emergency department (ED) with a varied spectrum of presentations. Data on oncological emergencies are scant; hence, we aimed to determine the profile, outcome, and awareness of their treatment of patients with malignancies presenting to the ED.
Methodology: This prospective observational study was conducted in the adult ED of a large tertiary care hospital in South India between February and August of 2018. A convenient sample of patients presenting to the ED with a known or newly diagnosed malignancy was included in the study after obtaining written informed consent.
Results: During the study, we recruited 110 patients presenting to the ED. The mean age of the patients was 48 (15.9) years. There was a female preponderance (56.4%). A quarter of the patients had malignancy of the genitourinary tract while 10% had breast carcinoma and 9% had bronchogenic carcinoma. Vomiting (44%) was the most common symptom at presentation followed by fever (39%) and abdominal pain (38%). Anemia (81%) and hyponatremia (54.5%) were the most common laboratory abnormalities. Antiemetics (61%), antibiotics (32%), and nonsteroidal anti-inflammatory drugs (27%) were the most commonly used medications. Chemotherapy-related complications (35.5%) and mass effects (28%) were the most common reasons for ED visits. The majority (83%) were previously diagnosed with malignancies. Most patients were aware of the duration (86%) and common side effects of chemotherapy (79%). However, most were unaware of the chemotherapy drugs' names (25%) and how to manage side effects (54%). Sixty percent required admission and three patients died during their in-hospital stay.
Conclusion: Gastrointestinal symptoms and fever are the most common causes of presentation to the ED among patients with malignancies. Although most patients were aware of the duration and side effects of treatment, half of them were ignorant of the emergency first aid for side effects of the medications they were on.
Keywords: Cancer, chemotherapy, oncological emergencies, patient awareness, radiotherapy
|How to cite this URL:|
Jha A, Abraham SL, Mathew A, Ahmad A, Jacob JC, Shandilya S, Prabhakar Abhilash KP. Oncological emergencies: Profile and patient awareness of treatment. J Curr Res Sci Med [Epub ahead of print] [cited 2023 Mar 31]. Available from: https://www.jcrsmed.org/preprintarticle.asp?id=370923
| Introduction|| |
“Cancer” has become a term universally understood even by those who have never read an English word due to the overall increasing literacy rates and pervasiveness of Western medicine in India. As the documented oncological cases doubled over the last two decades, malignancies have been described as an epidemic, further impacting an already overburdened public and private health system. With such a dramatic increase in cases predicted over the next two decades, emergency departments (EDs) will surely be a route through which oncology patients present to the hospital, be it before diagnosis or following the initiation of therapy. A study done in North Carolina; USA found that a significant number of ED visits (37, 7600/4,190,911: 0.9%) were due to an oncological condition (0.9%).
Perennially plagued by long waiting times and lack of prompt specialty consultation, these EDs are a large source of immense physical, emotional, and psychological burdens on patients with cancer or cancer-related issues. Oncology patients are administered long, arduous treatment regimens, often a combination of multiple modalities, namely surgical, chemotherapy, and radiotherapy, and naturally each of these has its own set of complications. Therefore, oncological emergencies presenting to the ED fall into two categories: those due to tumors and those due to treatment. While certain cancers such as lung or colon cancer can present with sudden “alarm symptoms” such as hematochezia or hemoptysis, others such as prostate cancer and breast cancer can be less dramatic and found through adequate screening programs or routine visits to primary care physicians. Malignancies detected for the first time in the ED are more likely to be in significantly older patients, and eventually have an overall poorer survival rate. In addition, the administration of chemotherapy often leads to medical emergencies, including febrile neutropenia, tumor lysis syndrome, dyselectrolytemia, and hyperviscosity syndrome.
A study analyzing adult ED visits in the US between 2006 and 2012 showed that around 4.2% of visits were by patients with a diagnosis of malignancy presenting with features of pneumonia, nonspecific chest pain, and urinary tract infections, not dissimilar to the general population.
Oncological emergencies are acute, potentially life-threatening events related to a patient's malignancy or its treatment and require rapid intervention to avoid death or severe permanent damage. They can be classified into metabolic, hormonal (or paraneoplastic), hematological, structural, or side effects of chemotherapy. Treatment-related complications include tumor lysis syndrome, neutropenia, infection, pulmonary infiltrates, neutropenic enterocolitis, and hemorrhagic cystitis. The purpose of this study was to document the incidence of oncological patients presenting to the emergency, their severity of complaints, the emergent management, and whether they knew the side effects of the therapy they were currently taking. Emergency medicine is an emerging field in India and oncology does not have much representation in the ED. Hence, in India, oncological emergencies are not well documented and there is hardly any data on the same. There is also very poor awareness regarding these emergencies on the physician's side, especially considering that these emergencies require experience and good clinical judgment to identify and begin appropriate management.
Our hospital is a tertiary care center, receiving referrals from across India and neighboring countries, with annual ED visits of more than 75,000. This study aims to analyze the profile of patients presenting to the ED, both presenting for the first time as well as those with a prior oncological diagnosis. We also assessed patients' knowledge of the adverse effects of their chemotherapy or radiotherapy regimens.
| Materials and Methods|| |
This was a prospective cross-sectional study done between February and August 2018.
The study was conducted in the ED of a large tertiary care hospital in South India. The ED is a 49-bed department and tends to about 300 patients per day.
Patients presenting to the ED with a previously known or suspected malignancy (confirmed by tissue biopsy during the hospital admission following their ED visit) between 8 am and 6 pm were included in the study after obtaining informed written consent.
Pediatric malignancies and patients who refused to consent were excluded from this study.
After taking the patient's written informed consent in a language the patient understood, the predecided questionnaire was administered. The patient and his/her bystanders were asked the questions in a language they understood.
Patients were followed up till discharge from the hospital and a predecided questionnaire was used for collecting data. Patient profile details such as age, sex, state of origin, and other comorbidities were recorded. Patients were asked about their presenting complaints and duration of illness. Patients fell into two categories – those who had a documented diagnosis of malignancy and those who were clinically suspected to have cancer (patients were tentatively included until the diagnosis was confirmed through tissue biopsy on follow-up). If the patient had a prior diagnosis, they were asked about the type of malignancy, whether there was metastasis, and prior oncological treatment (chemotherapy, surgery, or radiotherapy). The questionnaire included an assessment of the patient's awareness of the chemotherapy and radiotherapy regimen recommended for them, i.e., whether the patient knew the name of the drug they took, the duration of treatment, the possible side effects, and the first-aid management of side effects.
The outcome measures were ED disposition and hospital outcome.
All patients underwent relevant laboratory investigations and relevant radiological imaging based on their presenting complaints as per ED protocol.
Statistical analysis was performed using Statistical Package for Social Sciences software for windows (SPSS Inc. Released 2007, version 16.0. Chicago, Illinois, USA). Mean standard deviation (SD) was calculated for the continuous variables and nominal variables were expressed as a percentage.
The study was approved by the institutional review board (IRB), minute number 11024 dated December 04, 2017, and patient confidentiality was maintained using unique identifiers and password-protected data entry software with restricted users.
| Results|| |
During the 6-month study, we recruited 110 patients with malignancies presenting to the ED [Figure 1].
The mean age (SD) of patients was 48.1 years (15.9) years with more women (n = 62, 56%) than men (n = 48, 44%) enrolled in the study. The most prevalent comorbidity was diabetes mellitus (25%, n = 27), with systemic hypertension (22%, n = 24) close behind. The baseline characteristics are shown in [Table 1].
Signs and symptoms
Sixteen percent (n = 18) of patients presented to the ED with significantly compromised vitals, requiring admission to the resuscitation room (priority 1 by triage). Vomiting (44%, n = 48) was the most common symptom at presentation followed by fever (39%, n = 43) and abdominal pain (38%, n = 42). Tachypnoea (78%, n = 86) and tachycardia (65%, n = 71) were the most common examination findings [Table 2].
|Table 2: Presenting complaints, examination findings and laboratory investigations (n=110)|
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Diagnosis and therapy before presentation
Malignancies of the genitourinary tract were most common overall (25.4%, n = 28) followed by gastrointestinal tract malignancies (22.7%, n = 25) breast carcinoma (10%, n = 11), musculoskeletal (10%, n = 10), pulmonary (10%, n = 10), head-and-neck malignancies (5.4%, n = 6), hematological, hepatobiliary, and central nervous system malignancies (4.6%, n = 5 each) and others (53.6%, n = 4) [Table 3]. Most of the patients had a documented diagnosis of malignancy (83%, n = 91/110), while the remaining patients (17%, n = 19/110) presented clinically suspected cases of malignancy, and later had a diagnosis confirmed by tissue biopsy. Almost half (46%, n = 51/110) of patients had metastatic disease at presentation to the ED. All patients (100%, n = 91/91) had received some form of treatment for their malignancy before presentation to ED. Chemotherapy (88%, n = 80/91) was near ubiquitous in the treatment modality received.
Management, emergency department disposition, and outcome
Almost half (52%, n = 57) of ED visits were related to complications in treatment while the rest were tumor related (42%, n = 46) or unsure (6%, n = 7). Complications secondary to chemotherapy (35%, n = 39/110) were the most common diagnosis (both among those receiving chemotherapy before the presentation and among the entire study population) followed by mass effect (28%, n = 31/110). Anemia (81%, n = 89/110) and hyponatremia (54.5%, n = 60/110) were the most common laboratory abnormalities. Antiemetics (61%, n = 67/110) and antibiotics (42%, n = 46/110) were most often prescribed in patients' emergent management [Table 4]. More than half of the patients (60%, n = 65/110) were admitted to wards from ED. There were no deaths in the ED but three patients (3%) admitted to the wards died during admission.
|Table 4: Details of past treatment and treatment and current treatment in the emergency department (n=110)|
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Patient's awareness of therapy
Patients' awareness regarding the names of their chemotherapy drugs (25%; 20/80) and self-management of the minor side effects of chemotherapy at home (54%, n = 43/80) were poor. Patients on radiotherapy had worse awareness of side effects (46%, n = 12/26) and self-management of minor complications (30%, n = 8/26) [Table 5].
| Discussion|| |
In our study's population, the top three reasons for visits to the ED were vomiting, fever, and abdominal pain. Most of these patients, 91 out of the 110 studied, had prior treatment in the form of chemotherapy, radiotherapy, surgery, or a combination of these. The two most common diagnoses given to patients were complications due to chemotherapy (35%) and mass effect secondary to tumors (28%). Gastrointestinal and genitourinary malignancies were of the highest frequency, combinedly representing nearly half of our study population.
As seen in our study, febrile neutropenia is one of the most common chemotherapy-related side effects. Previous studies from India from Bengaluru by Babu et al. showed the etiology to be predominantly Gram-negative organisms (58%), followed by Gram-positive organisms (40%) and fungi (2%). Simeon et al. from Vellore described severe neutropenia in 70.2% of patients and moderate neutropenia in 29.8% with diabetics at a higher risk of developing this emergency. This complication is associated with high mortality of up to 13.5% as reported by Lakshmaiah et al.
Rather than focusing on the incidence of specific metabolic or obstructive oncological emergencies, past studies have focused on possible risk factors for emergency presentation or management. One such retrospective study was done in Romania in the year 2011. This study focused on finding the proportion of known oncology patients who had metastatic disease and identifying what proportion of documented oncological emergencies were a result of newly diagnosed malignancy. In our study too, we looked at patients who had metastatic disease (46.36%) and the proportion of patients who were newly diagnosed (17.3%).
In a retrospective study done in Mumbai, 12% of oncological patients had syndromes requiring admission with 55.9% classified as avoidable, 33% as probably avoidable, and 7.4% as absolutely avoidable. This differs highly from our study's findings of 59% of our patients being admitted. This may be attributed to the fact that our center has a much more generous patient-bed ratio than theirs. In truth, our figures for hospital admission were similar to western studies.
All malignancy patients who presented to us already diagnosed received some form of therapy before visiting the ED. Most patients presented with treatment-related complications and more than half (59%) needed admission to wards or intensive care units. This reconfirms our approach to treating patients with malignancy as a priority.
In our study, we classified oncological emergencies as tumor related or treatment related. The emergency was considered to be treatment-related if it occurred within 24 h of a cycle of chemotherapy or radiation therapy.,, These include febrile neutropenia, metabolic complications, radiation, and surgery-related emergencies. If there was more than an 1-week gap between the patient receiving the therapy and presenting with symptoms, or if the patient had never received any form of therapy, the emergency was classified as tumor-related. These include tumor lysis syndrome and structural side effects. If there were more than 24 h, but less than an 1-week gap between chemotherapy or radiotherapy and the onset of symptoms, the emergency was classified as unsure. Almost half (52%) of ED visits were treatment complication related while the rest were tumor related (42%) or unsure (6%).
While early diagnosis, appropriate treatment measures, and prompt referral are crucial in the management of a cancer patient who presents to the ED, another important aspect of care is the patient's perspective on the management and outcome. In the onslaught of purely medical concerns, this is often ignored, neglected, and undocumented. While there are few studies on oncological presentations to the ED, fewer still look at this aspect of care. One such study was done in the year 2007, at Norfolk and Norwich University in which analysis showed a correlation between patient satisfaction and admission to the oncology ward. To achieve a holistic approach to the management of oncological emergencies, it is essential to take into account patient perspectives such as patient awareness about disease and treatment, and patient satisfaction with treatment.
India being a developing country, has a high proportion of people who are ignorant about several diseases and their presentations, including cancer. Further often due to lack of communication, the psychological burden due to financial constraints, and social stigma patients are found to have a poor understanding of their disease and the required treatment.
We found that patients' awareness regarding the names of the chemotherapeutic drugs administered to them (25%) and self-management of minor side effects to these chemotherapy drugs (54%) at home was poor. Patients on radiotherapy had even worse awareness of side effects (46%) and self-management of minor complications (30%). Patients' knowledge of these side effects and at-home management would reduce the burden of these cases on the ED, freeing up resources that would otherwise be spent on much sicker patients.
With these findings in mind, it becomes apparent that increasing awareness among oncological patients is of imperative value. This can be done with a variety of different methods. Naturally, with the inherent burden of any tertiary center in India, it is difficult to expect doctors to spend more time with patients regarding this. Instead, videos or pamphlets standardized to various chemotherapeutic or radiotherapeutic regimens, which they could carry back to their residences could educate them and prevent avoidable visits. Ideally, these would be in a language that the patient could understand on their own. Alternatively, a dedicated hotline could be initiated by the various departments in which common doubts or complications could be answered over the telephone. Third, the implementation of counselors or liaisons within offices could lead to easier access of patients to their treating doctors, thereby reducing patient load.
There was underreporting of hematological emergencies. Since a convenient sampling technique was used, some cases were missed. The tertiary-level nature of our hospital induces a referral bias and may not truly represent the burden on the community.
| Conclusion|| |
Gastrointestinal symptoms and fever were the most common causes of presentation to the ED among patients with malignancies. Most of the patients surveyed in this study had been previously diagnosed. Around half the patients had a treatment-related emergency, and the other half had a tumor-related emergency. More than half of the patients had a metastatic presentation of the disease. Although most patients were aware of the duration and side effects of treatment, around half of them were ignorant of the emergency first aid for side effects of the medications they were on. Patient education on these side effects and immediate emergent management, perhaps standardized to the therapy, they are receiving can reduce the burden on the ED and increase patient satisfaction with their healthcare provider.
Research quality and ethics statement
The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require IRB/Ethics Committee review, and the corresponding protocol/approval number is IRB Min. No. 11024 dated December 04, 2017. We also certify that we have not plagiarized the contents in this submission and have done a plagiarism check.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]